From global flu to global health

At least four features of the swine flu crisis in April 2009 relate directly to broader debates over global health.  Worldwide concern over the crisis abated by mid-May, but the wider fears and hopes about the implications of such pandemics for global health endure.  For the same  reason, I am now moving to what is envisioned as a more enduring longer term blog on Global Health.  Here, though, in this final post to the Global Flu blog I want to flag the four features of the swine flu crisis that lead most obviously into bigger questions about global health.

THE SPACE OF GLOBAL HEALTH The first big topic that the swine flu crisis has highlighted for work on global health more generally relates to the evolving conceptualization of global space itself.  Swine flu's emergence in 2009 has been geographically represented in ways that tell us a lot about how the global in 'global health' is being routinely imagined today. The repeated mapping of the disease on definitively global maps that are in turn widely disseminated and read on the world-wide web helps represent and thereby reterritorialize analysis of the disease as a truly global (not just national, not just regional nor just continental) threat to global health  (see From ghost maps to global maps).  In short, the geographical representation of the disease in both formal and informal forms of surveillance has been planetary from the start.  These global mappings clearly contrast with the blame geographies and origin stories that reterritorialize swine flu as the fault of Mexicans.  Such geographically limited representations too quickly lead to the public health conclusion that controlling the virus should simply be about (as the Chinese government seemed to think) controlling borders and the movements of Mexicans.  And such dangers are only further magnified, when, as Alan Ingram commented, such pathologization of people and place is tied to militaristic security discourses and geopolitical tropes that chart a so-called war against disease with territorial 'fronts' and 'battlegrounds'.   By contrast global mappings of the disease instead depict the challenges presented by H1N1 as planetary problems for a global population that shares, albeit very unevenly, a basic biological vulnerability to a fast-moving, globe-trotting virus.   More than this, the mapping of the disease as a global disease also makes it much easier to relate its molecular emergence to larger-scale border-crossing but political and economic processes that have made the viral breeding grounds and globe-trotting reassortment of swine flu a possibility in the first place.

ASYMMETRY AMIDST  INTERDEPENDENCY The second global health lesson of the swine flu crisis moves in the opposite direction. At the same time as the maps of H1N1 have vividly illustrated an evermore global sense of the whole planet as a community vulnerable to shared contagion, the actual experience of the disease on the ground, its surveillance by public health officials, and the sorts of emergency preparedness it has prompted  have all been marked by deep disparities and inequalities.  In the same way, the much mentioned interdependency of global health itself should be understood to operate in ways that are twisted and turned by powerful asymmetries and uneven development patterns too (and, as the PBS global health atlas shows very clearly, global maps can obviously chart this inequality too).  In the case of swine flu, the examples of such asymmetry amidst interdependency are many.  They include the heightened vulnerabilities of poor communities and slum dwellers for whom routine public health advice about hygiene and washing hands sounds like wishful thinking.  They extend to the massive inequalities in public health infrastructures themselves, along with all the problems of monitoring the spread of disease, doing clinical tests and getting out information about personal and institutional best practices. And perhaps most significantly in the case of swine flu preparedness, the inequalities in global health are made manifest at the level of access medicines.  It fast became clear during the initial weeks of crisis that access to anti-virals such as Tamiflu (as well as any vaccines that might be developed) is directly structured by access to economic resources.  Poor countries and communities are effectively locked out of what is a very limited global supply.  Researchers at the Third World Network, point out thus that:

"The swine flu outbreak is a stark reminder that if a deadly pandemic were to develop, there will be a desperate fight over limited supplies of anti-viral treatments and vaccines, in which the developing countries will be at a vast disadvantage. Today more than 90% of the global capacity for vaccine manufacturing is located in Europe and in North America. Developed countries through  'advance purchase agreements' with manufacturers have already reserved a good portion of the limited current manufacturing capacity.  Thus in the event of a pandemic, the world would be several billion doses short of the expected demand.  If there is a worldwide pandemic of a new deadly influenza billions of doses of anti-viral treatments and vaccines will be required in the developing world and manufacturers will only be able to supply a small portion of what is needed. The anti-virals and vaccines sold to developing countries are also likely to be expensive, making them unaffordable for those in need. "

DEPENDENCE ON BIG-PHARMA  The example of access to anti-viral medicine points in turn to the much wider problems for global health posed by reliance on for-profit drug development and delivery.  Tamiflu is distributed and sold globally by the Swiss company Roche, and business newspapers such as the Financial Times have excitedly reported increased sales and profits for Roche alongside the increased global angst about swine flu.  More than just revealing the money to be made in global health, though, the swine flu/Tamiflu ties also make manifest our global dependence on big pharma and the ways in which the trade rules protecting the private intellectual property rights of the big drug companies compromise the ability of governments, national public health agencies and the World Health Organization to work towards guaranteeing health for all (for more on IP controversies surrounding Tamiflu see the CPTech site).  It's true that the Financial Times also reports Roche donating 5.7 million treatments to the WHO for distribution to low income countries, but that's barely enough for one medium sized city, and meanwhile  the production of lower cost generics by an Indian company (itself threatened by big pharma's patent protections) hardly looks set to make up the global difference.  These basic questions about drug  access and global protection are important, but they barely begin to scratch the surface of the huge challenges to global health posed by a dependence on big pharma.  There are, for example, the problems of corporate profiteering surrounding the roll-out of vaccine and immunization campaigns in the global south; there are the problems of human subjects abuses in clinical trials off-shored to the global south;  there are the related problems of corrupted bioethics review processes in wealthy countries and universities; and, at an altogether more global institutional level, there are all the problems surrounding the shrinkage of the policy space of the WHO and its member governments  by the ways in which big pharma has locked in its monopolies in global trade regulations that are much more binding and effectively enforced than the international health regulations of the WHO itself.

GLOBAL HEALTH GOVERNANCE  The concern over policy-space vis-a-vis big pharma relates in turn to many other questions that continue to be posed about global health governance more generally.   The swine flu has highlighted some of these quite directly.  There are the questions about the role and authority of the WHO, its chronic underfunding, and its tiny size in relation to planetary health crises, as well as the persistent problems surrounding the ways in which its regulations are undermined by both the corporate interests of powerful countries and poor country resentment and resistance it inspires (the so-called viral globalism of David Brooks being indicative in this respect of a more general pattern in which market fundamentalists point to the need for global health leadership but simultaneously undermine it).  Then beyond the WHO itself there is the complex web of national agencies, philanthropies, NGOs, public-private partnerships that all interact to define the wider system of global health governance.  As Swiss-based global health policy consultant Illona Kickbusch explained back in 2003: “We are in transition from what seemed a relatively stable, state defined and structured world of international health to a diffuse political space of global health.  We need to analyse to what extent the political ecosystem that inhabits this space transfers power and to whom.  We need to map the epistemic communities and the multitude of networks and their spheres of influence.”  It is with a view to following this call to map the terrain of global health that the blog Geographies of Global Health has been started.  Moving from the swine flu crisis to the much more general and all-encompassing crisis of global health itself, the ongoing goal will be to track the relations between the actual geographies of disease and the diverse ways in which such geographies both reflect and reinforce the processes through which the political space of global health is itself being constructed, contested and remade (for more on the theoretical resources I am drawing on to frame these questions see my paper - 'Unpacking Economism and Remapping the Terrain of Global Health' on the resources site of the People's Health Movement). 

From ghost maps to model maps

Online attempts such as Flu Tracker's to map the swine flu outbreak globally are not only worth examining for their informational content (or lack of it), but also for what they tell us about the fast changing character of disease mapping and epidemiological surveillance in the age of the internet.  Ranging from the official WHO global atlas tool, to unofficial online newspaper  time series maps, to Flu Tracker's Google-Earth enabled hybrid map mash-ups of both, the global scale of the mapping and the consequent depiction of H1N1 as a global pandemic is as striking as the ease with which one can access all this geographic information in the first place.  So what do these global visualizations of the disease tell us about the changing character of disease mapping?

 In The Ghost Map, a widely acclaimed book on the epidemiological revolution represented by John Snow's mapping of cholera deaths in nineteenth century London, author Stephen Johnston  explains that the cartography was crucial. It served to debunk the miasmatic theory of cholera's etiology, and it also represented a revisioning of urban space itself as a community shaped by a geographically defined vulnerability to contagion.  This same geographic revisioning also served in turn as a geographic guide for public health interventions  (such as improvements in sanitation) at a distinctively urban scale.  Johnston concludes his book with some provocative reflections on how the geography of the urban scale may again be critical to public health today but this time in a twenty-first century of mega-slums and mega-cities tied together globally by the speedy cross-border movement of people and pathogens.  In this regard, the emerging maps of swine flu index some of the related changes in how global space is being conceptualized and represented in line with increasing awareness of both global vulnerabilities and the need for global action.  Moreover, by effectively replacing John Snow's hand-drawn map of London with an array of new, often internet-enabled or otherwise computer-algorithm-based mappings, today's maps illustrate the eclipse of the nineteenth century ghost map by a twenty-first century rise of model-mediated disease mapping.

The front-page of the New York Times for May 3rd 2009, for example, featured a story entitled "Predicting Flu with the Aid of (George) Washington".  The article is all about the ways in which computer models using spatial data  related to air traffic, cell-phone calls and even the movement of dollar bills can effectively generate predictive maps of the movement of the flu. Such predictive spatial modeling is similar in some respects to another approach used to model seasonal influenza that actually uses monetized incentives to create so-called 'prediction markets'.  These are designed to work like financial futures markets to predict outbreaks and their intensity based on the assumption that speculative activity in a market is a good way to pool heterogeneous data in a way that rewards good data and good predictions with a financial incentive. Given the widespread anxiety about the market failures of real financial derivatives in recent months, it seems that such a marketized approach to epidemiological planning is unlikely to find many followers.  Moreover, whereas prediction markets are used chiefly to generate temporal predictions (about the timing and intensity of disease outbreaks), it is the geographic patterning of vulnerability that tends to be of wider interest to the public as well as to public health officials interested in the geographic organization of pandemic preparedness.  In this respect, other model methodologies that generate actual maps look better set to set the new norms.

One such model-based mapping innovation that has been developed of late that does provide geographic information about seasonal influenza is Google's Flu Trends tool.  This tool uses internet query entry data matched with traditional CDC surveillance data to generate geographically predictive algorithms. Based on locational clusters of heightened use of key query entry terms (terms that tend statistically to be associated with heightened incidence of people experiencing flu symptoms), the algorithms are able to produce a state-by-state mapping of flu activity (and hence flu risk levels) across the US. The result is a form of what is called "syndromic surveillance" because it is based on data that reflect symptoms (in this case the use of certain tell-tale query terms that reflect google users' symptoms) rather than the actual clinically-proven experience of disease.  Freed thus from the practical complexities of on the ground clinical reporting and virological lab work, its big advantage is that it works much more speedily than traditional clinical surveillance.  However, as its developers have reported in Nature they do not see the tool as a replacement for clinical surveillance.  Instead,  working  10 to 14 days faster than the normal CDC surveillance methods, its speed provides an extra aid for making time-sensitive public health policy decisions, including possibly about where to move and stockpile anti-viral medicines such as Tamiflu.  Quite how well the Google Flu Trends tool might translate to the swine flu case is not yet clear, although the  site does now provide a link to a new "experimental" flu trends map of swine flu incidence in Mexico.  Questions linger, however, about how the digital divide between computer-using and non-using communities may skew such predictive model maps, as well as about how they might remain vulnerable to the sorts of false positives created by online panics and rumor-sharing cascades of bad data.

Yet another important online disease mapping development that has had a swine flu map added is Harvard's Health Maps project.  This is not a form of syndromic surveillance that uses models built around query entry data on the internet, but represents instead an attempt simply to use webcrawling technology to provide up-to-date global maps of news stories on particular diseases based on their place of publication.  The Swine Flu version of this project reveals both the extraordinary global scope of the resulting mapping, but also some of its limits insofar as stories linked to places in one part of the world (e.g. Mali) may actually be reporting on events elsewhere (e.g. Mexico).  These problems aside, what is telling about such mapping is the way in which it aspires to represent the whole of global space as a community that shares - albeit very unevenly - a common vulnerability to contagion.  

In such globalized 21st century revisions of John Snow's ghost map we can surely also see a revolution in public health cartography and epidemiological interpretation.  Gone are the ghosts of Londoners, and in their place are millions of stories, reports and algorithmic relays of reports from around the whole world.  Perhaps we can also see in these transformations one basis for more effective global planning and more globally redistributive public health infrastructure funding.  

Certainly the visualization of the whole globe as a community of contagion serves as a useful spur to reflect on how poor public health infrastructures and inadequate  epidemiological surveillance in poorer parts of the world translate into heightened and shared dangers for the whole planet.  Back in the age of John Snow's ghost map another physician -  William Budd - commenting on another disease - typhoid - made what are now world famous remarks about this kind of shared vulnerability.  Like today's flus, typhoid was much more lethal for the poor, and the point was not that everyone was equally doomed by the disease.  However, for Budd the ties between rich and poor still made typhoid a shared threat to all.

“The disease not seldom attacks the rich, but it thrives among the poor.  But by the reason of our common humanity we are all, whether rich or poor, more nearly related here than we are apt to think. The members of the great human family are, in fact, bound together by a thousand secret ties, of whose existence the world in general little dreams.  And he that was never yet connected with his poorer neighbor, by deeds of charity or love, may one day find, when it is too late, that he is connected with him by a bond which may bring them both, at once, to a common grave.” 

As histories of public health such as George Rosen's remind us, it was this sort of awareness of shared vulnerability that in turn inspired the development of public health planning and community-wide interventions, first at an urban scale in the nineteenth century, and then more and more at a national scale in the twentieth century. However, as Paul Farmer argues in his powerful preface to Dying for Growth, today in the era of neoliberal globalization we need to revise and rescale our geographic vision of community anew.

“The ‘thousand secret ties’ still connect the poor and the wealthy, despite all the barriers our age has set up to separate them.  They are, in fact, less secret (though for many, effectively censored into invisibility) in the age of telecommunications.” 

The global mapping of H1N1 is yet another reminder of such now-not-so-secret-ties; and while pointing to more danger in poor communities (in Mexico), it has also underlined that all the barriers, border fences and gated communities of today's world are easily transcended by jet traveling pathogens.  The global maps we see today of a global pandemic therefore really could inspire efforts to develop more globally-shared public health planning based on a heightened awareness of transnational, transclass and transcultural vulnerability.  They could in this way serve as model maps that also model a new more global approach to investing in global health as a collective planetary good. However, as the post on 'viral globalism' (below) highlighted, such awareness of shared global vulnerabilities does not always lead to shared global consensus on the need for globally organized and globally redistributive responses that address the needs of the poor.   Instead, talk of subsidiarity as the future for global public health planning  seems to be haunted by a different specter altogether, a specter, one might even argue, of  social justice haunting the world!

From viral globalism to global health

In a remarkable April 27th New York Times column entitled 'Globalism Goes Viral' David Brooks argues that the big lesson for planetary public health from the swine flu outbreak is that decentralized local responses are what we need for the 21st century. "Subsidiarity," he concludes, "works best."  What is so remarkable about this conclusion is not so much the way it invokes a fairly normalized neoliberal nostrum about bureaucratic best practice: viz. shift any role for active government - apart from enforcing market rules - downwards to the lowest, most easily marginalized and/or disciplined scale possible.  Indeed, it would have been very surprising  to see a 'big-government-is-bad' standard bearer suddenly detour from the usual 'globalist' vision (the vision of allowing different countries and cities to compete with each other in a race to the bottom of competitive deregulation disguised as policy innovation).  However, what is remarkable about this column by Brooks is that, before reaching the 'salvation through subsidiarity' denoument, he first comes so close to advocating a very different sort of global policy-making position. 

Reflecting on the obviously global scope of the swine flu outbreak, he begins his article by highlighting the ways in which it evidences the interdependencies of globalization.  The threats, he says, "grow out of the quickening pace of globalization and are magnified by it. Instant global communication and rapid international travel can sometime lead to universal, systemic shocks.  A bank meltdown or a virus will not stay isolated."  Yet having hereby effectively echoed the very same comparisons and conclusions made by the WHO's Margaret Chan in her speech in Istanbul on the very same day, and having also therefore led his readers to think that he was about to recommend beefing up the the WHO as an antidote to nationalistic trade restrictions and other sorts of border-building defensive responses to the crisis, Brooks suddenly and dramatically veers back towards the neoliberal development dictat that decentralization is best.  A global public health body would just be too cumbersome and slow-moving, you see, dragged down by bureaucratic red tape and internal disagreements.  And so we get to the salvation through subsidiarity appeal at the close, itself, for US readers at least, little more than a rehash of traditional conservative talking points about states' rights.

The parallel with states' rights discourse, though, can at least serve as a wake-up call to the sorts of double standards and denials of rights often involved in advocating for decentralization.  One does not have to be a legal or historical expert on the Dred Scott decision to understand the problems.  And again, the example of today's global flu outbreak is illustrative.  As Lawrence Gostin has explained in the Washington Post, exceptionalist American appeals to federalism have actually been one of the stumbling blocks frustrating efforts to make the WHO's new international health regulations globally enforceable. This, combined with chronic underfunding for public health surveillance and preparedness both globally and nationally (which is itself frequently justified using rhetorics of big bad government waste), hardly speaks well of decentralized innovation in public health planning.  Moreover, we also surely need to consider how appeals to decentralization may also serve to cover up basic global inequalities.  They distract from asking questions about whether poorer countries and communities will be able to access adequate supplies of anti-viral medicines; are they just experimenting with less?  Will they be more vulnerable to contagion in the first place because of cramped living conditions and underfunded public health infrastructures?  Indeed, will there be any public health official even around in these impoverished areas to begin the process of decentralized experimentation proposed by Brooks?  

These sorts of questions lead in turn to still larger ones about the prospects of global health security in the context of today's globe-trotting infectious diseases.  Alan Ingram, a British health geographer, has argued in this respect that swine flu shows how we need a complete paradigm-shift in the way in which global health security is imagined and made possible.  As such, his intervention offers the perfect antidote to Brooks. But where does his call for a recognition of health inequalities amidst interdependencies lead us in terms of planetary pandemic preparedness and response? Might the WHO's Social Determinants of Health report itself offer a basis for thinking through global health security with these sensitivities?  And, given how close he himself came to repeating the much more enlightened arguments of the WHO director-general on April 27th, how might David Brooks respond to these emergent visions of global health?

Remapping the viral breeding grounds

If the normal outbreak narrative localizes and exteriorizes the origins of disease with a simple geography of blame, how can such narratives be most usefully remapped?  Critical accounts of swine flu by Robert Wallace,  Mike Davis and Johann Hari indicate that one useful strategy is to map the emergence of today's global H1N1 virus in relation to the transnational networks of global capitalism.

  For Wallace this involves exploring how viral breeding grounds (in which the H1N1 virus has evolved through genetic reassortment) have been created by a mix of agricultural industrialization, transnational agribusiness movements, and, the related consolidation of huge global food networks in which pig and poultry products move through overlapping commodity chains that also make genetic reassortment possible .  

"Early reports have identified the sources of the new H1N1’s genome as strains that have infected humans, birds and pig populations from both North America and Europe. In an important way, then, ’swine flu’ is a misnomer. This influenza is a ’swine-bird-human’ reassortant. The extraordinarily complex origins of the new influenza—across so many host types and geographic regions—is telling us something about influenza’s present ability to cross host species and bridge great spatial distances between livestock populations."

This connection with avian flu connects in turn to Mike Davis's analysis which is itself built upon his excellent book-length account of  The Monster at the Door.  While Davis never shies away from apocalyptic argument, and while this may lead some to dismiss him as a scare-mongerer, his earlier work on avian flu has enabled him to very effectively connect the dangers posed by swine flu to the more general vulnerabilities produced by neoliberalized global capitalism.  In this way, he underlines how, in addition to deregulated agribusiness, another enabling factor in the emergence of new global flu strains is the undermining of public health and underfunding of disease surveillance that has resulted globally as a result of structural adjustment programs, free trade regimes and other forms of neoliberal entrenchment.

"The swine flu, in any case, may prove that the WHO/Centers for Disease Control (CDC) version of pandemic preparedness--without massive new investment in surveillance, scientific and regulatory infrastructure, basic public health and global access to lifeline drugs--belongs to the same class of Ponzified risk management as AIG derivatives and Madoff securities."

As governments around the world struggle to respond to swine flu, what questions does the comparison drawn by Davis pose for their chances of success?  And will any attention be paid to the critical maps of the viral breeding grounds sketched by Davis and Wallace?

Tracking outbreak narratives and blame geographies

As accounts of swine flu proliferate across the internet and through the media, we can usefully track them in terms of what Priscilla Wald calls 'the outbreak narrative'. Such narratives are commonly nationalistic, Wald argues, and they thus turn epidemiological evidence about border-crossing pathogens into territorialized tales about imagined immunities and biomedical bordering.

"Communicable diseases know no borders, and the global village is the biological scale on which all people and populations are connected. While emerging infections are inextricable from global interdependence in all versions of these accounts, however, the threat they pose requires a national response.  The community to be protected is therefore configured in cultural and political as well as biological terms: the nation as immunological ecosystem."

  Typically, says Wald, this involves stories of threats to national health security that are personalized as irresponsible 'bad guys' (e.g. carriers that are coded as 'superspreaders' and 'pestilent foreigners') as well as stories of national health security 'good guys' (normally national doctors or soldiers who battle the disease and protect the homeland). Most significantly, the outbreak narrative also always involves some sort of externalizing and projecting move that depicts the origins of a disease as located outside of the nation-state in a usually exoticized 'hot zone'. In this regard, her account is similar to that of Paul Farmer in his acclaimed book Aids and Accusation. 

The subtitle of Farmer's book says it all: "Haiti and the Geography of Blame". In this particular text the geography of blame in question is the one that - wrongly - imagines and/or depicts Haiti as the 'ground zero' or launching pad from where HIV first entered the US. Farmers shows how erroneous and tendentious this geography of blame is, but also makes clear how it has worked nonetheless to serve hegemonic interests.  He explains thus how it is caught up in other 'blame the victim' discourses that have allowed US health experts to tolerate or legitimate sub-standard care for Haitians.

Today the writings of Wald and Farmer serve as important reminders that we need to be alert for the ways in which outbreak narratives about swine flu may be used simply to blame Mexicans and Mexico (Wald has also reminded readers in an op-ed that they distract us from underlying problems of global poverty too). Examples of swine flu geographies of blame are proliferating fast and have already attracted critical commentary, including Michael Calderon-Zaks' useful review of how they relate to older examples of anti-Mexican public health racism in the US. Have you seen any geographies of blame? What do they look like? Are there any that complicate the sorts of examples discussed by Wald and Farmer?  For instance, what about stories and activist campaigns linking the swine flu outbreak to the US pork producer Smithfield and its operations in Mexico.  To be sure, such accounts still identify an external hot zone outside the U.S., and yet they also clearly implicate a US corporation, and, by extension, US consumers and the NAFTA-enabled transnationalization of industrial agriculture, in the creation of viral breeding grounds in the first place.  For more on this see the post on Wallace and Davis.