Source: Kenneth Cloke, Politics, Dialogue and the Evolution of Democracy: How to Discuss Race, Abortion, Immigration Gun Control, Climate Change, Same Sex Marriage and Other Hot Topics, GoodMedia Press (2018)
America’s healthcare system is neither healthy, caring, nor a system. ~Walter Cronkite
Doctors are men who prescribe medicines of which they know little to cure diseases of which they know less in human beings of whom they know nothing. ~Voltaire
There are crimes against humanity the magnitude and cold brutality of which cannot be understood, cannot be weighed or calculated on any scale or spreadsheet — crimes, the motives for which are as commonplace, as banal, as quarterly earnings and political careers. ~ Hannah Arendt
So far, we’ve been lucky. None of the health emergencies or potential pandemics we have been through in recent years has achieved its deadliest potential. These health crises have included outbreaks of bird flu, swine flu and Ebola; the spread of drug-resistant bacteria and mosquito-born diseases, such the Zika virus; and the gradually extending reach of other infectious and insect-borne diseases that easily cut across political borders. At the same time, we have seen how conflicted, bureaucratic, ineffective and “too-little-too-late” many government departments and nonprofits have been in response to these emergencies. Before the next outbreak or pandemic, it would be wise for us to consider why this has been, and what we might do instead.
The first reason we have responded so poorly to health crises is quite simple: infectious diseases do not respect sovereignty or national borders, and potentially threaten everyone everywhere. From this simple fact we can only conclude that any serious effort to block their spread has to be organized internationally and collaboratively, even if it means a loss of sovereignty by nation states, whose resources and responses necessarily stop at their borders. The same facts and conclusions can be reached regarding environmental disasters, migration, crime, terrorism, climate change and other global problems.
The second reason is also quite simple: no government wants to admit that it is experiencing a pandemic or outbreak of infectious disease. No government is willing to slash potential income from tourism and trade, or promote panic among its citizens, or look ineffective by publicizing its health problems. No government is prepared, especially in the beginning when it is most important, to warn others about the true potential danger, or accept that the spread of disease is beyond its control. No government is prepared to admit that it is desperate and in need of international assistance. No government is ready to give international aid organizations full permission to do whatever they think is necessary to contain the disease without obtaining permission beforehand from local political authorities and overcoming innumerable bureaucratic roadblocks, which can take considerable time, when time means lives that are lost to disease. No government wants to surrender its sovereignty to political forces that may be hostile or indifferent to it. No government is willing to admit that by delaying the process of controlling disease in these ways, it is directly responsible for unnecessary deaths and the spread of infection.
So what will happen, inevitably and predictably, when serious infectious diseases begin to spread and fearful or corrupt government officials deny that there is a problem, suppress critical information about health issues that impact everyone, and block aid from reaching those who are most in need? What will happen when international aid organizations such as the World Health Organization are kept underfunded, inadequately staffed and ineffectual by these same governments, and starved of the resources and information that are vital to preventing global pandemics, all in the entirely legitimate name of national sovereignty? The answers are both obvious and preventable.
The Ebola Outbreak
Consider, for example, the Ebola virus that erupted in West Africa in December 2013, but was not diagnosed until March 2014, after it had already spread across several national borders. The World Health Organization (WHO) was contacted and its Global Outbreak Alert and Response Network (GOARN) tried to help, but WHO’s already meager budget had been cut 20 percent in 2011, and emergency and epidemic funding was cut by 50 percent in 2012. Guinea and Sierra Leone tried to reassure foreign investors that all was well by denying its extent and minimizing its importance. Guinea only allowed GOARN to report confirmed cases, but laboratory and public cooperation were initially restricted and only about half of all suspected cases were confirmed. As a result, only those who had personal contact with confirmed cases could be tracked down and quarantined, and there was inadequate funding even for these limited efforts, allowing a small outbreak to escalate into an epidemic. Moreover, WHO’s offices are located in Geneva, far removed from the most common places where diseases emerge, with country and regional offices that are staffed by people who are generally appointed by, and loyal to, local politicians. WHO staff members who were critical of their local governments’ response to the epidemic and spoke out were reportedly silenced or sent back to Geneva. GOARN staff members also complained about obstructions, but were told there was no problem. In June 2014, aid groups declared the epidemic out of control and accused WHO of failing to respond. In August, WHO declared a global emergency and began to tackle the problem in earnest, eventually successfully controlling the disease. [See, e.g., report by Debora MacKenzie in New Scientist, 19-26 December 2015]
In The End of Epidemics: The looming threat to humanity and how to stop it, Jonathan D. Quick and Bronwyn Fryer identify seven steps that can be taken to reduce the threat of epidemics, among which are better communications and a stronger WHO, with reduced reliance on traditional “command and control” methods, all of which require more advanced skills. Peter Salama, who heads WHO’s Health Emergencies Programme, is reportedly moving the agency rapidly in this direction, and for the first time attempting to track all potentially severe health risks around the world, leading to earlier responses and improved prevention.
Conflicts Over Bird Flu
It is important for us to recognize that what happened in connection with Ebola is not unique or surprising or exceptional. The same pattern has played out over and over again in every country where potential pandemics, environmental catastrophes and similar problems have emerged. For example, consider what happened in connection with the H5N1 virus, otherwise known as avian influenza or bird flu.
It is predictable that the convergence of extreme poverty and reliance on poultry for survival anywhere in the world will create favorable conditions for avian diseases such as bird flu, to mutate into a form that can be transmitted by air between human beings, which will lead to a catastrophic crisis for which we are woefully unprepared. Scientists estimate that only two or three, or at most a mere handful of mutations or instances of viral gene swapping are needed to transform bird flu into a virulent, deadly human form similar to Spanish Influenza. The difficulties mentioned in connection with Ebola, combined with the ease of international travel, panic and a desire to escape infection will then allow the virus to spread rapidly to other countries, creating a global pandemic.
The process of preparing vaccines for bird flu happens, in a simplified version, like this. Blood samples are taken from infected individuals by local health officials wherever there are outbreaks. These samples are sent to the WHO for analysis and tracking. The samples are then sent to large pharmaceutical companies to prepare vaccines, which are then sold for a profit on the world market. WHO rules allow commercial firms to make vaccines and patent them without sharing the profits with the viruses' countries of origin, and national governments are not permitted to make cheap generic versions of these vaccines.
The difficulty with this process is that the countries where bird flu outbreaks occur most often cannot afford to vaccinate their poorest citizens. So, in 2007, Indonesia, which is a hot spot for bird flu outbreaks, stopped exporting blood samples to WHO labs, on the ground that they would be used to make vaccines that Indonesia and other poor countries could not afford and could not duplicate. In an article in New Scientist, Indonesian health minister Siti Fadillah Supari explained her refusal to provide further blood samples to WHO:
In 2005, when bird flu arrived, we needed Tamiflu [the antiviral drug that can cure H5N1]. We contacted Roche, [the Swiss company that holds the drug's patent and its only source at the time]. They said we couldn't have any, we would have to wait two years, because industrialised countries had already made advance purchase orders. At the time, countries such as the U.S. and the UK, fearing an H5N1 pandemic, had placed orders for millions of doses of Tamiflu to be stockpiled in case of global spread, which would take Roche years to manufacture. Other buyers had to get in line, yet the rich countries had no H5N1 cases and the poor countries couldn’t get the vaccine. "We already had 20 cases," said Supari. "That's unfair distribution." She argued that fair distribution of flu drugs and vaccines should be based on need, and on which country had actual outbreaks of the disease, rather than on profits, political power or wealth. The drug companies refused. Meanwhile, WHO officials feared that by the time this problem was worked out it could be too late to develop a vaccine for any pandemic that would emerge from Indonesia or elsewhere.
In April 2011, after years of impasse and unresolved conflicts between the parties, an agreement was finally reached in which poorer countries would receive help accessing vaccines and antiviral drugs in return for providing viral samples. The International Federation of Pharmaceutical Manufacturers and Associations, which represented 26 research-based drug manufacturers, pledged to donate drugs and technology covering half of the $58 million annual cost of boosting defenses in the poorest nations, and pledged to "reserve at least 10 percent of pandemic vaccine manufacturing capacity on a real-time basis, for donation to the WHO and/or supply at tiered prices, to developing countries.”
While clearly a step forward, it is obvious that these measures are still inadequate and unable to prevent a global pandemic. Since they stopped sending virus samples, more than 15 Indonesians died of the virus and many more fell ill, fortunately without it mutating into a pandemic form, yet every human infection represents an opportunity for the virus to adapt further, become airborne and spread to people, thereby becoming pandemic. Similarly, during the H1N1 swine flu pandemic in 2009–2010, many developing countries complained that they had no life-saving antivirals or vaccines to combat the new virus. WHO helped distribute 78 million vaccines, donated by rich nations and drug companies to 77 developing countries, but regulatory and other hurdles slowed the process, and again, we were lucky that the pandemic turned out not to be as destructive as it might have been. No one contends that the drug company agreement will prevent pandemics from spreading, or that these bird flu or swine flu response patterns will be enough to prevent a new pandemic from occurring, or that the present drug distribution system is going to work if it does. The drug companies, under the agreement, are able to choose between donations and sharing their intellectual property in vaccines, so that even if low-cost generics were available, it is likely that the poorest people in the poorest countries will not be adequately vaccinated beforehand or in time, allowing the virus to spread to pandemic proportions.
Without a coordinated international response, scientists are nearly unanimous in noting that significant outbreaks of infectious diseases will occur before the end of the century, causing global pandemics that will inundate our capacity to respond, triggering panic, mass migrations, heightened competition for scarce vaccines, militaristic responses and political polarizations that will result in widespread illness, massive deaths and enormous economic losses, making future health problems even more difficult to solve. As we grow more connected and interdependent globally, a health disaster anywhere on the planet can easily turn into a catastrophe elsewhere, making it clear that global problems require global solutions. As outbreaks of disease are naturally chaotic and unpredictable, even small, seemingly insignificant changes anywhere can produce vastly larger ones later.
What Is the Solution?
Violence, bitter conflicts and divisive attitudes are widespread over whether some of these problems even exist, who is responsible for them, and how to fix them. Our conflicting cultures, political and religious beliefs, attitudes, national processes and competitive economies, together with efforts to maintain power and control by means of hierarchy, autocracy, bureaucracy and national sovereignty are restraining us from reaching agreements, finding solutions and preventatively addressing these issues before they spiral out of control. How, then, do we solve these problems?
If military force, litigation and similar power- and rights-based processes will not work, and take too long even when they do, the only alternatives remaining are inclusive, international, interest-based solutions, including designing conflict resolution systems that encourage open and honest communications, informal problem-solving, public dialogues, collaborative negotiations, consensus building, prejudice reduction, conflict coaching, ombuds services and mediation. In the specific context of potential pandemics such as Ebola, bird flu, swine flu and similar outbreaks, a minimally effective start seems to me to include at least the following steps:
- Develop international treaty language that grants authority and strengthens the ability of WHO and GOARN to coordinate global efforts to eradicate and control the spread of infectious diseases
- Increase funding for the treatment of infectious diseases, including a “superfund” for pandemics
- Establish a special international fund based partly on profits made by pharmaceutical companies from sales to wealthy countries, for the rapid development of pandemic vaccines
- Require pharmaceutical companies to make vaccines for the treatment of diseases labeled “pandemic” by WHO available to countries in order of the number of infections in each country
- Require pharmaceutical companies to make all biomedical intellectual property acquired through international agencies open and available to the United Nations and its member states
- Fund and encourage the production of less costly generic vaccines
- Create regional medical “rapid response teams” in areas where pandemics are occurring, or can be predicted
- Attach a U.N. mediator, dialogue facilitator and/or ombuds staff member to every international medical response team to assist in resolving conflicts in the field, coordinate multinational efforts and facilitate community dialogues aimed at increasing understanding of what is being done to control the outbreak, coordinating community health efforts and reducing prejudice against those who have been infected
- Protect WHO and GOARN personnel who are critical of local efforts from being punished or transferred for their views
- Hire additional full-time professional mediators, facilitators and ombuds personnel at the U.N., WHO and GOARN to resolve conflicts between nation states and international authorities over differences regarding prevention and treatment protocols and facilitate local community dialogues, provide feedback and recommend improved responses
Other Global Problems We Are Now Required to Solve
More broadly, the difficulty is not just that individual nation states are prone to resist international coordination in responding to pandemics or health care emergencies, it is that the problems we face as a species are increasingly global in scope, requiring us to move beyond nationally organized response mechanisms and autocratically, hierarchically and bureaucratically imposed solutions that have evolved over the course of centuries, in order to solve them. The most critical and important of these problems, in my view, are:
- CO2 and methane emissions • Exhaustion of the oceans
- Species extinction • Decreasing bio-diversity
- Air and water pollution • Deforestation
- Terrorism • Nuclear proliferation
- Drug-resistant diseases • Global pandemics
- Overuse of fertilizers • Loss of arable land
- Religious intolerance • Biological weapons
- Torture • Sexual trafficking and abuse
- Genocide • “Ethnic cleansing”
- Prejudice and intolerance • Cyclical economic crises
- Narcotics smuggling • Organized crime
- Vaccinations for diseases • Over population
- Unregulated currency trading • Destructive technologies
None of these problems can be solved locally, or nationally, or even by a consortium of nation-states. Neither can they be solved using military force, litigation, rule making, hierarchical command structures, autocratic decision-making processes or bureaucratic rules and regulations. In other words, neither power- nor rights-based processes, neither nation-states nor international organizations as presently constituted, are capable of creating sustainable solutions or avoiding destructive outcomes.
Thus, our most powerful problem-solving institutions, including the nation-state, have been outpaced and eclipsed by the problems they are required to solve and the information needed to solve them. And what is worse, the borders we have created to keep these problems out have made collective action and interest-based processes more difficult to carry out or implement in time.
As Albert Einstein famously declared after atom bombs were detonated over Hiroshima and Nagasaki, “Everything has changed, except the way we think.” The potential for disaster, created by a combination of national borders and international problems, ease of travel and ease of transmission, vaccines for the wealthy and pandemics for the poor, increases every day, and it does not take great foresight to recognize that we are inadequately prepared for what is likely, at some point, to occur.
In the end, there are only two approaches we can take to solving these problems, and others like them: first, those in the wealthiest countries can hope and imagine that they will be able to isolate and selfishly defend themselves against these problems, and that those in the poorest countries will be the only ones to suffer and die; or second, we can agree to address these issues together in an intelligent way by increasing our skills and capacities to communicate across borders, collaboratively solve common problems, engage in dialogue over difficult issues and mediate our more imperative disputes.
To achieve these goals, we require not only advanced methods in science and technology, but equally advanced methods in effective communication, joint problem-solving, collaborative negotiation, dialogue and conflict resolution. These techniques and skills are currently available and skilled practitioners are ready to use them.
As Abraham Lincoln reminded us, “A house divided against itself cannot stand.” Nor can a nation, a species or any important relationship. There are thousands of ways we can listen and learn from each other, work together to solve our common problems and prepare for environmental crises and potential pandemics. It is essential for our survival that we fund them and make them a priority.