Even the U.S. Centers for Disease Control and Prevention, which maintains an emergency stockpile of critical childhood vaccines in the event of shortages, requires manufacturers to maintain possession of the vaccines until delivery is requested. This just-in-time stockpile is reasonable for items such as vaccines that require special handling and rotation due to expiration date, but begs the question of how accessible the stockpiles would be in the event of a global transportation emergency.

Why is this relevant to the discussion of avian influenza? During the SARS epidemic in 2003 the World Health Organization (WHO) issued isolated travel advisories designed to discourage travel to impacted regions. Enforcement of these regulations was voluntary, inconsistently applied and not always effective, suggesting that future disease outbreaks might require much more onerous protective barriers. The influenza virus is not only highly contagious but can remain infectious on surfaces long enough that, with modern shipping methods, it could circumnavigate the globe. The declaration of an influenza epidemic would create a strong incentive for border closures to limit the spread to uninfected shores. In the face of an evolving crisis, if a few governments were to close their borders, it is likely that many others would follow suit, effectively locking people and products in place. Closing down the world's ability to achieve just-in-time delivery would cause an unprecedented disturbance of the global economy.

A disruption of this nature would quickly become a destabilizing force in countries beyond the regions primarily impacted by the influenza pathogen. The inability to obtain items considered essential by citizens of developed countries would have a significant impact on everyday life. Products necessary for the prevention or treatment of influenza--face masks, respirators, medications--would be difficult if not impossible to construct, making the impact of an influenza outbreak even greater. Further, lifesaving medications or devices unrelated to the treatment of influenza could be in short supply, resulting in casualties even before the virus left foreign shores.

In a scenario such as this, return to normalcy would depend on the deployment of an effective vaccine or on the outbreak running its natural course, which is estimated at six months but could be 18 months or more. And the time frame for vaccine development is dependent on many factors and is therefore highly unpredictable. It is known, however, that expeditious production of a vaccine would be problematic with current global capacity limitations on manufacturing. Presently, about 300 million influenza vaccines are created globally each year, well under what would be needed to vaccinate a world population of over six billion. The infrastructure and techniques used in creating products of this nature are nearly impossible to scale up in the short term, leaving large gaps between demand and supply. As a further example of the many complications in this effort, the development of a vaccine for distribution in the United States would require access to pathogen samples imported from the affected region. Global transportation of biological materials is usually achieved through contracts with private transport companies. During the SARS outbreak, convincing carriers to move samples of a deadly and unknown pathogen was sometimes a challenge. At present--in non-crisis mode--there is only one global carrier who will accept highly pathogenic samples for international transit, and it is unclear what impact an epidemic would have on their willingness to engage in this activity.

In the face of a growing epidemic and a shortage of the supplies needed to protect against transmission, political officials will need to decide how to allocate valuable resources. There is little doubt that, in a crisis situation with closed borders, governments would hold products made within their borders for their own citizens. Presently, there is a concentration of production capacity for critical interventions in developed countries, leaving most of the developing world without the capacity to create products that might be the front line of defense against an epidemic. There are only nine countries--Australia, Canada, France, Germany, Italy, Japan, the Netherlands, the United Kingdom and the United States--that have existing infrastructure to make an influenza vaccine, and the much touted antiviral treatment Tamiflu is manufactured at a single plant in Switzerland. In a situation where the United States has enough antiviral therapy to treat only 1 percent of its citizens, would it be willing to donate doses to treat the citizens of other countries, even, minimally, foreign heads of state? What would be the political ramifications of denying such a request? Sharing coveted resources with countries experiencing the first wave of infections might be politically difficult to sell domestically, forcing leaders to decide between the appearance of protecting their coveted stocks or assisting neighbors in a crisis.

Protect Your Own?

With the prospect of a global health crisis, can states find a way to cooperate to stem a pandemic? The answer lies in how much preparation is put in place before the onset of a global emergency of this nature and scale. Unlike AIDS, which is crawling around the world leaving a predictable epidemiological footprint on ravaged developing countries, influenza will come as a tidal wave, quickly destroying many lives and economies in its wake. The scientific community now sits poised, waiting for the next mutation that will transform the current virus into a form that can be readily transmitted from human to human, the sign that the human epidemic has begun. However, the impact of an avian flu pandemic for international politics and the economy goes far beyond the health care burden. Global integration, increased reliance on just-in-time production and items sourced from China will make any sustained restrictions on international transportation extremely painful for many economies.

Merely blaming the Chinese for a lack of transparency is not a solution to the challenges faced when dealing with a disease such as avian influenza. China is not unique in needing to confront public health weaknesses, but the size, scope and nature of its domestic agricultural community make the challenge formidable. The avian influenza epidemic among poultry and wildlife in China is already gaining momentum, complicating any radical changes that could be undertaken even if there were the political desire to make them. It is imperative that support and pressure for needed reforms to the public health and agricultural systems be maintained. If the global community demands transparency from China, as it should, there must also be an agreement to help it bear the burden of battling the disease.

The people who sit at the table in any future deliberations surrounding the appropriate response to the threat of emerging infectious diseases such as avian influenza need to include many from beyond the public health community. National trade representatives, transportation representatives and controllers of national money supplies are some of the individuals who should be thinking about what to do in the event of a global influenza pandemic. Familiarizing all segments of society with the possible implications of this type of emergency will greatly aid in the event that tough decisions need to be made in very little time. Above all, the process needs to be seen as independent of political bias, recognizing that wielding influence will do little to prevent the free movement of the pathogen. Finally, efforts to arrest a developing pandemic demand containment of the virus at the front line--on foreign shores. This strategy may run counter to the perceived short-term national self-interest of developed countries but may also be the only way for the world to counter the power of the ever-agile Mother Nature.

1.  Interestingly, on June 24, 2005, the prime minister of Vietnam declared retroactive compensation for chickens culled in the name of disease prevention and payment for participation in the culling efforts. Vietnam is not the first country to implement such a measure, but it shows the growing appreciation for grassroots participation in disease detection.

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