Unequal deaths

As of 21 July, the World Health Organisation (WHO) reported a total of 700 deaths from 'swine flu', since the new virus was first identified in late April in North America, subsequently making headlines the world over. During the same period, in Nepal's mid-west, there have been over 200 diarrhoea deaths, more than 150 of them reported from a single district, Jajarkot. There are probably more unreported deaths due to diarrhoea, now suspected to be cholera, in the remote parts of the district, and the toll is rising every day due to lack of basic amenities and medicine. These deaths, however – easily preventable with clean water and sanitation – do not make even the national news for very long, leave aside the international. And leave aside the fact that globally, about two million children die every year due to diarrhoea.

Swine flu was quickly re-dubbed with the robotic moniker H1N1. This was apparently at the behest of the processed-meat industry, which felt that pork would get a bad name, and indeed it was true that the virus has nothing at all to do with pigs. Either way, the virus's newsworthiness lies in its ability to be easily transmitted across the world due to air travel. But perhaps an equally significant contribution to keeping the threat alive is the potential for pharmaceutical companies to make a killing – quite literally.

According to reports, most of those affected by H1N1 recover without any medical intervention whatsoever, taking precautions normally advised for any type of influenza. However, antiviral drugs such as Tamifu, produced by Roche Holding, or Relenza, produced by GlaxoSmithKline, are being widely prescribed and consumed. After all, not many would like to take risks after an esteemed body like the WHO went as far as declaring H1N1 a "global pandemic" in mid-June, escalating the alert level to Phase 6, the highest. Contrary to popular perception, however, this categorisation is actually descriptive of the spread of H1N1 (70 countries at the time), and not the severity of the illness it causes.

Treatment apart, the development of vaccines is another aspect that bears scrutiny. The WHO claims to be "working closely with manufacturers to expedite the development of a safe and effective vaccine". But the nature of this close partnership has been neither publicised nor scrutinised enough to ensure transparency. After all, illnesses labelled 'pandemics' mean massive moneymaking potential for some. As the WHO declared the H1N1 a pandemic, governments around the world automatically set aside billions of dollars for the development and purchase of a vaccine that would combat what was fast beginning, they were told, to assume the proportions of a deadly disease. The United States alone has reportedly pledged USD 8.5 billion, while the Netherlands has ordered 34 million doses and Australia 21 million more – whenever the vaccine is actually developed. Needless to say, the cost of vaccinating large populations is significantly more than the cost of drugs to treat the fewer who do need them.

When the French pharmaceutical company Sanofi-aventis announced, in mid-June, that it was donating 100 million doses of the vaccine to developing countries, generosity was perhaps not the only driving force. Sanofi produces 40 percent of the global supply of flu vaccines, and is doubtless looking ahead to this new opportunity. For, in the pharmaceutical industry, the goodwill of the WHO (which heartily and publicly welcomed Sanofi's gesture) and various governments, who control regulation and licensing, is crucial to ensure the widest possible marketing of a product.

Lucrative hype
From all accounts, it will take three or four months for the new vaccine specific to H1N1 to be developed. Significantly, even as the efficacy of the vaccine is yet to be proven, the standard safety testing will also not be possible if the immunisation is to begin in the fall – before the northern hemisphere's winter, when the virus is expected to spread more rapidly. With the world's first human trials on the vaccine currently underway in Australia, the drug itself is expected to be available in as little as two or three months. Such a bypassing of mandatory safety standards spawns other aberrations. For instance, manufacturers are demanding legal protection against vaccine-injury related claims.

Back in 1976, in a nationwide emergency immunisation programme in the US, about 45 million Americans were vaccinated following an epidemic of swine flu at the Fort Dix army base in New Jersey. Extraordinarily high numbers of those who had been vaccinated, however, subsequently reported the Guillain-Barre syndrome, a rare neurological disorder that can cause temporary paralysis. With about 5000 people eventually going in for legal action, almost USD 73 million were paid out as damages to affected parties.

Unlike in the US, in Canada, where there is no system of 'no-fault compensation' for vaccine-related injury, it will be harder to convince the public to go in for immunisation with an inadequately tested vaccine. And what of countries in Southasia, where the public health system is in shambles, and aggrieved parties have no hope of being compensated for potential injury by a vaccine whose efficacy and safety has not been adequately established?

Amidst the cacophony of H1N1 vaccination, it is worth remembering that the death toll due to the much-hyped avian (bird) flu (H5N1), as of 1 July this year is as low as 262. For the record, the less-glamorous seasonal influenza kills about 250,000 to 500,000 people worldwide every year. The rest who survive do so because of a natural immunity built up by good nutrition, healthy lifestyles and a clean environment. When more than half the population of Jajarkot District in west Nepal lives on less than a dollar a day, and have little to no access to clean drinking water and sanitation, one does not need to look far to identify the cause of death. And one cannot help but wonder whether all this scare-mongering is doing massive harm to the effort required to make the developing world a healthier place.