council of foreign relations november 2010

8/8/2019 Council of Foreign Relations November 2010

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November 2, 2010

Dear Friends and Colleagues;

It has been some time since our last Update from the Council on Foreign Relations Global Health

Program, and several important events meriting discussion have transpired. This Update will include:Recent and upcoming events at the Council;

President Barak Obamas development strategy revealed;

Globalization of recession and disappointment: Implications for Global Health;

Water;

The looming resource monopolization effort;

Monkeypox fills smallpox vacuum?Zoonosis news: Inhaled and swine H5N1, gorilla malaria, pig MRSA; horizontal gene transfer

in the oceans;NDM-1;

Surge in vaccine-preventable diseases;

Food price inflation again;

Bulldozers in Haiti finally;

MDG postscript.

As always, Loyal Readers, you may distribute these materials. Elements will also be posted on

www.cfr.organd you will be informed of the URL location.

Recent and upcoming events at the Council

Events that unfolded in Cuba in September startled the world, and bore

direct implications for the thesis laid out in Laurie Garretts Castrocarein Crisis published this year in Foreign Affairs. Earlier in the summer wegot clues to radical changes underway in Cuba when the individual that

had served as our minder during a November 2009 trek around the

countrys healthcare system turned up in Miami, defecting to the U.S. In

six months the individual had gone from serving as the official voice of thegovernment on all matters related to health, to a disillusioned physician

now toiling in Florida to obtain American medical credentials. The mid-

September announcement by Raul Castro that Cuba will soon shed 10

percent of its government workforce more than half a million jobs and allow limited
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entrepreneurial business development was stunning. Global advocates should pay close attention to

these developments, as some of the job-shedding will undoubtedly occur in the health sector it hasto, as health is the #1 employer in Cuba. This makes the warnings raised in Foreign Affairs all the more

pressing.

Ominously, the following brief appeared in the October 28 Havana Times:

Representatives of public health in Cuba expressed their backing for the reorganization of

the labor force, greater economic efficiency and improving services for the population when

speaking at the 10th Congress of the Public Health Trade Union, being held in the islands

capital, reported IPS. The Cuban authorities have begun a program of cutting back on

spending on health care to face the economic crisis.

For several months the Global Health Program has worked closely with the United Nations AIDSProgramme (UNAIDS), developing a declarative document to be released later this year by the

UNAIDS High Level Commission on HIV Prevention. Senior Fellow Laurie Garrett and Research

Associate Daniel Barker have produced multiple drafts, in coordination with the Scientific Advisory

Panel to the Commission. This effort (http://www.hivpreventioncommission.net ) has been extremelytime-consuming, as divisions within the HIV/AIDS community run quite deep regarding all aspects of

prevention of transmission and limitation of pandemic expansion.

Last week, Yanzhong Huang, CFRs new senior fellow for global health, launch ed the Global Health

Governance Roundtable Series. The first meeting in the series, titled The Challenge of Non -

communicable Disease in Emerging Powers featured Rachel Nugent, Deputy Director of Global

Health at the Center for Global Development, Derek Yach, Senior Vice President for Global HealthPolicy at PepsiCo, Inc., and Jean-Paul Chretien, Public Health Adviser to the Commanding General,

2nd Marine Expeditionary Force. The speakers discussed the economic, socio-political, and foreign

policy implications on the growing burden of non-communicable disease in rising powers with

particular attention paid to India and China.

The next meeting of the Global Health Governance roundtable series will focus on the relevancy and

effectiveness of the World Health Organization (WHO) in managing the growing public health

challenges in the transformed global governance landscape and will feature Ambassador Jack C.

Chow, former Assistant Director-General at WHO and Jennifer Ruger, Associate Professor at theYale School of Public Health. The series is closed to the public and over-subscribed, but earnest

queries may be directed to Daniel Barker([email protected]).

The Council on Foreign Relations recently hosted two events relevant to global health: A session on

the Millennium Development Goals, Evaluating Progress on the UN Millennium DevelopmentGoals, and another on Food Security, Global Food Security: Prospects for Investment andDevelopment, which was off the record.
http://www.hivpreventioncommission.net/http://www.hivpreventioncommission.net/http://www.hivpreventioncommission.net/mailto:[email protected]:[email protected]:[email protected]://www.cfr.org/publication/23105/evaluating_progress_on_the_un_millennium_development_goals.htmlhttp://www.cfr.org/publication/23105/evaluating_progress_on_the_un_millennium_development_goals.htmlhttp://www.cfr.org/publication/23105/evaluating_progress_on_the_un_millennium_development_goals.htmlhttp://www.cfr.org/publication/23105/evaluating_progress_on_the_un_millennium_development_goals.htmlhttp://www.cfr.org/publication/23105/evaluating_progress_on_the_un_millennium_development_goals.htmlhttp://www.cfr.org/publication/23105/evaluating_progress_on_the_un_millennium_development_goals.htmlmailto:[email protected]://www.hivpreventioncommission.net/


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President Obamas development strategy revealed

In a speech to the United Nations General Assembly on September 23rd President Barack Obama

detailed his administrations new set of foreign assistance policies, including those directly involving

health. The landmark and novel development framework follows an often frustrating 18 monthinternal debate in the administration that involved input from at least four branches of the Cabinet,

and a long list of federal agencies. The Presidents wordshad barely been uttered before most of the

leading development and global health oriented groups in the U.S. were lining up to sing PresidentObamas praise (except those focused on money-raising, which will be discussed further below). Thelargest umbrella of development-oriented organizations, think tanks, religious groups and advocates,

the Modernizing Foreign Assistance Network, declared the Obama administrations discourse, a

major victory, for poor people worldwide, signaling, Americas first development policy, which at

long last provides a roadmap for more strategic, effective, accountable U.S. foreign assistance.

Coinciding with the Presidents speech, which

was delivered during the Summit focused on thefive-year countdown for the Millennium

Development Goals, a slew of documents were

released by key US agencies, detailing their rolesin fulfilling the Administrations new mandates.

Perhaps the most critical theme of the Presidents

speech was Obamas belief that foreign

assistance cannot and should not be viewed as

charity. Rather, Obama insisted, it is afundamental element of US national security that

must have as its core goal nothing short of complete and permanent transformation of impoverished,

disease-ravaged societies: The purpose of development and whats needed most right now is

creating the conditions where assistance is no longer needed. So we will seek partners who want tobuild their own capacity to provide for their people. We will seek development that is sustainable.

Sources working on the long-awaited Quadrennial Departmental Development Review (QDDR) tellus the State Department will finally release its new scheme before Thanksgiving. Alongside the

various White House documents, the QDDR is expected to spell out in detail not only how and whythe US is going to be engaged in foreign assistance, but the hierarchy of responsibility for all aspects of

global health, climate change adaptation, food security and anti-poverty efforts. By all accounts theQDDR is an ambitious document that has entailed input from more than 1,500 people inside the

Executive Branch. As such, it will certainly represent the most over-arching game plan for foreign

assistance released by the US government since the 1963 Foreign Assistance Act, drafted by President

John F. Kennedys team.

The United States, Obama insisted in his speech, is changing the way we do business. Among the

changes detailed by the White House that will impact health programs are:

The metrics used to measure the effectiveness of US-funded programs will change. Gone will

be measured the numbers of pills handed out, or bed nets distributed: Now US agencies will beasking recipient governments and NGOs to show how many lives are saved, health

infrastructures developed, and fundamental, lasting change initiated.
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All programs including the Presidents Emergency Program for AIDS Relief (PEPFAR) and

Presidents Malaria Initiative (PMI) will have to integrate their efforts more closely with thoseexecuted by host governments, with a goal of increasing country ownership of health

efforts.

All health programs must demonstrate schemes for building now, towards a day of country

self-reliance and sustainability.

Health programs will align with cutting edge research, including from the Centers for DiseaseControl and Prevention (CDC) and the National Institutes of Health (NIH), aspiring to

innovate, test, and then expand the toolkits of disease prevention and treatment.In the Presidents words, As the final pillar of our new approach, well insist on more

responsibility from ourselves and others. Well insist on mutual accountability.

One White House Fact Sheet says that under the new framework of foreign assistance the US will,

Hold all recipients of U.S. assistance accountable for achieving development results. In a recentCenter for Global Development posting analyst Nandini Oomman looks at how this notion of

mutual accountability may affect relations between PEPFAR and the Global Fund to Fight AIDS,

Tuberculosis and Malaria. Also on CGDs website, Christina Droggitis comments on theoverwhelmingly positive assessment of PEPFAR recently released by the General Accounting Office,

indicating the accountability mechanism is already unfolding inside the Obama Administration.

Following on the heels of President Obamas UN appearance top global health

officials from CDC, PEPFAR and NIH testified before the Congressional

House Committee on Foreign Affairs on September 29th, detailing how thenew development principles and Obama Global Health Initiative were being

executed. CDC Director Tom Frieden offered a particularly sharp illustration:

The Kenya Demographic and Health Surveys (KAIS) of 2003 and 2007. The

CDC played the lead technical advisory role in KAIS, creating a database that is

strong enough to demonstrate changing trends in who is getting infected withHIV, and by what means. Thanks to KAIS, the Kenyan government has a

reasonable empiric basis for deciding how to use scarce HIV prevention resources.

The Obama Administration changes in global health priorities are not limited to obviously health-related agencies like CDC. On the eve of the Presidents UN speech the Dep artment of Defense

announced that $1 billion worth of bio-weapons funding given to DOD by Congress this year will bediverted to vaccine development and production to combat disease pandemics. Since the

disappointing experience of H1N1 vaccine production and global distribution, Defense Secretary

Robert Gates has quietly moved millions of DOD dollars into flu vaccine R&D programs.

President Obama has scant time now to focus on global health, or just about anything except theNovember 2nd Midterm Elections, which polls indicate may sweep his party out of majority positions

in both the House and Senate. Moreover, many of the winners in these Congressional races are likelyto come from the new Tea Party Movement, which is generally aligned with the Republican Party and

seeks massive cuts in Federal spending. Overall the GOP candidates have attacked the tax and spendliberals of the Democratic Party, and vowed drastic budget reductions. Once in power the new

Members of Congress will discover that very little fat in the federal budget can be cut without either

eliminating pet projects their constituencies favor, or taking on Medicare and Social Security.

Anybody paying attention to the riots in the streets of France or Greece in recent weeks knows that

attacking healthcare and pensions for retirees is rarely a popular option, in practice.
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Among the most vulnerable programs for budget-cutters are those that comprise the less-than-1-percent of the federal budget directed at global health, development and food relief: Account 150, in

budget parlance. After the newly-elected are sworn into office in January we will learn whether thespectacular increases in budget support these programs enjoyed under President George W. Bush

were genuinely backed by the Republican Party, or were merely the interests of a now-retired former

leader.

Globalization of recession and disappointment: Implications

for Global Health

A Carleton University team last month published a survey of 33 nations, comparing public trust,government performance in population health and social programs, and gaps in domestic personal

income levels. Overall, the Carleton group finds a strong correlation between population lifeexpectancy and the size of income gaps between richest and poorest members of the society. (See:

Elgar FJ (2010), Income Inequality, Trust, and Population Health in 33 Countries, Am J PublicHealth.2010; 100: 2311-2315.) Using classic measurements, such as Gini coefficient and

International Social Survey Program data, the Canadian team led by Frank Elgar shows an almost on-the-line charted correlation between widening wealth gaps and diminishing returns on life expectancy

and health. In the analysis, the US ends up closer to the Philippines and Portugal than to Germany,

Japan, the Scandinavians or even Poland and Croatia.

According to the U.S. Internal Revenue Service the gap between the richest and poorest Americans isnow wider than it was during the Great Depression of the 1930s. In 2005 the bottom half of the U.S.

population earned just 12 percent of American wealth, while the top 10 percent richest citizens earned

21 percent. That 2005 gap had widened significantly over 2004, with more of Americas wealth

ending up in the hands of the top 10 percent, and the middle class of the country losing wealth.

Chart from World Bank


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According to Rothkopf, the 2001 change in the U.S. tax code effectively shifted more wealth towards

the top 0.1 percent richest households; 90 percent of Americans gained only 2 percent from the taxchanges, with most of that evaporating amid the 2008-10 financial, employment and real estate crises.

In contrast, the top 1 percent richest Americans saw their incomes grow 57 percent after 2001; thetop 0.1 percent had an 85 percent wealth growth and for the top 0.001 percent richest a whopping

112 percent increase in personal wealth was realized.

None of this is unique to America. The superrich top 0.01 percent wealthiest saw their incomes

and net worth swell by 600 percent in the UK, and similarly breathtaking amounts all over the world.

Political scientists Jacob Hacker and Paul Pierson argue in their new book, Winner-Take-All Politics:How Washington Made the Rich Richer And Turned Its Back on the Middle Class, that debt is

strangling the middle classes in traditionally wealthy countries, dooming an entire generation of

college-educated households to monthly battles to pay the bills. Well before the 2008 financial crisis

and real estate collapse nearly one-out-of-five households in the U.S. had zero, or negative, net worth

due to personal debts. A train wreck was looming, as so many Americans were spending far more thanthey earned: All it took was the 2008 banking debacle to topple all those middle class households.

And the next looming crisis? Americans are shy $4.6 trillion to cover their retirements, according to

the Employee Benefit Research Institute. Many company pensions and personal retirement accounts

fell to shreds during the 2008-9 financial disaster, and most Americans (and Europeans) have used

their home ownership as their primary cash cow for the future. Now that real estate has collapsed, fewpeople over 55 years of age in Western Europe, Japan, or the U.S. have time to earn back their losses

and cover their retirements. Every traditionally wealthy nation faces the enormous challenge of

finding ways to cover retirement for the giant Baby Boom generation. If the flow of cash from rich

countries to poor looks tight in 2010, brace yourselves for 2020.

What does this have to do with global health? The strongest population health statistics generally

track, in capitalist countries, with the size and comparative wealth of the nations middle classes.

When the middle class shrinks, the tax base and election pressure also shrinks for such things as safedrinking water, nutritious school lunches in well-supported public schools, stress-relieving employer-paid vacation time, work hours that allow 8 hours of sleep out of every 24, and overall access to

affordable health care. Moreover, strong middle class societies tend to be more generous, providing

foreign assistance and philanthropic support for anti-poverty and health programs in poorer regions

of the world. When the middle class in a wealthy country feels confident with its economic future, it

tends to aspire to bring middle class possibilities or at least better-than-subsistence standards to

the rest of the world.

The ground is shifting beneath the middle classes in many countries. Unemployment is rising, anger at

the follies and greed of the banking and financial sectors has fostered riots in Paris and Athens, Tea

Party electioneering in the U.S., and rising anti-immigrant sentiments in much of Western Europe.

According to the OECD, healthcare costs are rising faster than inflation and in most cases more

rapidly than the price index in any other economic sector. All OECD nations are experiencing medical

inflation, though social democracies with single-payer systems absorb the costs into overall, also

soaring, government expense. In mixed medical economies, such as the U.S., costs are either being

absorbed by individual citizens, or people are forgoing procedures and check-ups to defer strain ontheir personal budgets. OECD says that across its member nations, healthcare costs inflated by 7.8


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percent in 2000, but by 9 percent in 2008. The worst inflation was in countries where government

provides all health care in such cases 2008 inflation topped 16 percent.

A week ago the G20 finance ministers met in South Korea to discuss ways to bring greater order tothe world economy, put caps on uncontrolled speculation and bring all nations out of the current

recessionary slump. As was the case in July when leaders met in Canada, little progress was made.

(Final Communiqu: http://www.g20.utoronto.ca/2010/g20finance101023.html .) The Ministersshook hands and agreed to be nice, and then left Korea chuckling that they had blind-sided the other

guys. The problem is that we are in the earlystages of a currency war, in which nations are

following China and Japan to deliberatelydevalue their own labor forces, pegging their

national currency below its real value in order to

attract manufacturers that seek cheap workers.

Rather than do anything about the

concentration of wealth in their Superclass,countries all over the world are trying to salvage

their economies by devaluing their currencies,

even at the risk of lowering the standard of

living and wages of the bottom 50-80 percent of

their populations. Photo from Africa Links

It is in this decidedly difficult economic environment that the world entered the five-year countdown

on the Millennium Development Goals, the Global Fund to Fight AIDS, Tuberculosis and Malaria

sought a $20 billion funding replenishment, and the World Bank warned that achievements in

poverty-reduction could easily slip back to levels not seen in decades if care is not given to easing the

world financial crisis impact on the bottom 2 billion poorest people on earth.

World Bank President Robert Zoellick set the tone for the September UN General Assembly focus on

the MDGs, warning that the road(s) out of poverty for the poorest nations and populations is nolonger as apparent as it seemed when the MDG targets were set in the 1990s. "Even before the crisisthere was a questioning of prevailing paradigms and a sense that development economics needed

rethinking," he said. "The crisis has only made that more compelling. The flow of knowledge is no

longer North to South, West to East, rich to poor. Rising economies bring new approaches and

solutions," Zoellick said.

One of those new solutions is creation of enormous sovereign wealth funds, controlled by nations

banks and growing thanks to resource gains (e.g. petrochemicals and crude oil) or debt servicing (suchas Chinas absorption of U.S. debt). According to the 2010 Preqin Sovereign Wealth Fund Review the

aggregate value of the worlds sovereign wealth funds (SWFs), now stand at $3.51 trillion, which

represents a 9 percent increase from last years figure, confirming that sovereign wealthfunds haveretained their collective significance in the world of institutional investors. The largest sovereignwealth funds each manage hundreds of billions of dollars.Although it has never released information

on its assets under management, Abu Dhabi Investment Authority is likely the largest SWF in the

world. The next two largest SWFs are Norways Government Pension Fund Global and Chinas

SAFE Investment Company. The three largest SWFs together are estimated to manage well over$1

trillion in assets.
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The world economy in 2009 was about $70 trillion U.S. (global GDP); If three and a half trillion is

locked up in sovereign wealth funds that means about 5 percent of global wealth is no longer traded orinvested in small and medium sized businesses. Some of the things countries are doing with SWFs

include purchasing millions of hectares of overseas arable land to grow crops on for their populationsconsumption, buying up water rights in developing countries, and investing in domestic infrastructure

projects.

On the eve of the UNGA Summit on the MDGs dozens of reports were released by UN agencies,nongovernmental groups, OECD, the EU and other interested parties spelling out what has, to date,

been achieved in the MDG struggle, and how much more money is needed to reach the 2015 targets.

Most institutions tried to find a balance, optimistically noting strong achievements made to date (See:http://press.thelancet.com/mdgwa.pdf), while spelling out grim resource needs for continued

progress:

The Results for Development Institute forecast the world will need to spend $400-to-$700

billion over the next 20 years on HIV prevention, to prevent 14 million new HIV infections;

UN Secretary-General Ban Ki-Moon said the world needed $45 billion to reach the 2015targets;

The Global Fund to Fight AIDS, Tuberculosis and Malaria said it needed an addition $20

billion to meet the HIV, malaria and TB MDG targets;In September Ban Ki-Moon called for a$40 billion maternal and child healthinitiative.

A team of Kenyan researchers determined that funding for malaria programs has increased

166 percent since 2007, but remains $3 billion shy of the amount needed to conquer the

disease.The overall theme of the MDG Summit was, Do more, do it better with less financial resources than

you claim to require.
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Total commitments from donors, both public and private, reached $40 billion for the next five years,

for all MDG efforts combined. Some recipient countries pledged to increase the percentage of theirnational budgets spent on health, education and development efforts. And the official spin from the

top tiers of the UN was that the world is on track to achieve the MDGs. Off the record, nobodybelieves that to be true.

Economist Jeffrey Sachs, Director of the Earth Institute at Columbia University, decried the modestfunding commitments, insisting that more than twice as much money will be needed, and morally

ought to be committed. But Sachs has come under attack from groups that charge his modelMillennium Villages projects lack rigorous metrics for measuring their success, and may actually fail to

serve as models for development. Center for Global Development analysts Gabriel Demombynes andMichael Clemens insist that the Millennium Villages programs havent do ne enough to build in ways

to measure the impact of the projects, and data derived from the programs is difficult to use in any

meaningful manner. Thus, they insist on the CGD website, the Villages cannot at this time serve as

models for development and health.

The GAVI Alliance, which is the largest purchaser/distributor of child vaccines in the world, came to

the MDG Summit hat in hand, crippled by an enormous multi-billion dollar budget shortfall. By early

October it seemed GAVI had found the resources to squeeze through its current crisis, but long term,

sustained funding is questionable. According to MSF, vaccine shortages are being experienced in

many locations worldwide, often resulting in outbreaks of measles and other childhood-preventable

diseases.

The biggest loser in this time of financial woe is the Global Fund to Fight AIDS, Tuberculosis and

Malaria (the Global Fund), which went through a bruising replenishment round on October 5th in

New York. The Global Fund leaders came to the meeting arguing that a minimum of $13 billion over

five years was necessary to merely stay the course, offering no new services to any of the worlds poor,but maintaining support for the currently serviced HIV, TB and malaria sufferers and communities. If

funding reached $20 billion, the Global Fund said, services could expand to save millions more lives,

stop mother-to-child transmission of HIV, slow the spread of drug-resistant TB and approachuniversal access to HIV treatment.

Politically, in the lead up to the October 5th meeting, most attention was focused on the Obama

Administration, which was already by far the major donor to the Global Fund. A fair amount of anger,

even vitriol, was directed at the White House by activists, leading academic figures, the Global F unds

main advocates and political groups worldwide. A stage was set for failure, frankly: President Obamas

hands are tied in Congress, his Party is running for its life, and budget constraints are enormous.

Nevertheless, the Obama Administration vowed to increase support of the Global Fund by $4 billion

for FY2011-13, a 38 percent increase in U.S. support. At this writing it is not clear how much of that

pledge is funds the Executive Branch is in a position to give to the Global Fund, versus funds thatrequire Congressional approval. Advocates that have been denouncing President Obama, andcharging that George Bush was a better friend of people with AIDS, will soon discover how much of

the Obama Administrations support for The Global Fund will actually be allocated by a GOP-

dominated Congress, after the Midterm Elections.


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Despite the U.S. pledge, The Global Fund fell FAR short of its minimal goal of $13 billion. Only $11.7

billion was pledged, by all donors combined, and at least $1 billion of that sum is decidedly softmoney, as it is predicated on expected future income from airport levies and other UNITAID forms of

money-raising, the RED Campaign sales of goods with donations attached, poor country government

promises to increase domestic spending, and vows to donate that were offered by sources that have, in

the past, failed to meet their commitments. Realistically, The Global Fund garnered less than $11billion, more than $2 billion shy of what it claims is the minimum necessary to stay the course.

Mdecins Sans Frontiers was quick to respond to the disappointing results, with Dr. Jennifer Cohn,

MSF HIV/AIDS policy advisor, charging, Today marks a sad turning point in the fight against AIDS,

TB, and malaria, as world leaders have officially underfinanced the Global Fund. This decision willresult in the death of millions of people from otherwise treatable diseases. Ambitious country

programs, which could mean the difference between life and death, may no longer be feasible. A crisisplan and additional contributions are now urgently needed in order to maintain current grants and

expand and improve promising treatment and prevention programs.

Michel Kazatchkine, executive director of the Global Fund, said, "Obviously, with less than the lowscenario ... the effort will now decelerate and not scale up at pace." Kazatchkine assured the New York

Times that no one who currently receives treatment will be cut off, but that future targets must belowered.

Now what?

Five days after the dismal replenishment meeting leaders gathered for the World Health Summit in

Berlin to discuss innovative financing of global health not just the Global Fund, but ALL global

health efforts. The Robin Hood Tax, which would leverage 0.005 percent charge on all large currencytransactions, garnering a projected $33 billion annually, was rejected as a new tax measure that

wont fly in most countries. Indeed, little enthusiasm for any innovative financing scheme was

expressed.

And meanwhile the momentum in support of health systems development is swelling, both on donor

and recipient sides of the equation. The latest issue of Health Policy and Planning (2010;111) offersseveral thoughtful, well-researched case studies on the impact of the Global Funds targeted diseaseprograms on general healthcare delivery inThailand,Papua New Guinea,Indonesia, andLaos, as well

as an analysis of possible metrics for measuring health systems development.

In an editorial on October 16(doi:10.1016/S0140-6736(10)61897) , The Lancet offers this summary:
http://heapol.oxfordjournals.org/content/25/suppl_1/i53.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i53.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i53.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i48.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i48.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i48.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i43.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i43.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i43.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i37.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i37.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i37.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i37.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i43.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i48.abstract?ct=cthttp://heapol.oxfordjournals.org/content/25/suppl_1/i53.abstract?ct=ct


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The funding shortfall partly reflects the effect of the global financial crisis, but more

than that it represents a collective failure of international cooperation at a time whenthe world needs global solidarity. The predicament faced by the Fund therefore bodes

badly for other health issues that demand multilateral solutions.

And finally, why does WHO stay silent? Those close to discussions about the Fund's

replenishment have often voiced surprise and sadness that WHO played little part ingalvanizing donor commitments to the Fund, viewing money going to the Fund as

money not going to WHO. Multilateral failures have been matched by failures in thegovernance of global health.

Water

Its hard to imagine anything more basic to human health than oxygen and water. As mentionedabove, Sovereign Wealth Funds are increasingly being put to use for purchase of egress to water,

either through guaranteed control of aquifers, construction of massive tunnel and aqueduct systems,

or outright land grabs to guarantee access to the water beneath. The SWFs are hardly alone in this.Newsweek (October 18, 2010) documents an enormous surge in private purchasing of water rights,

much of it intended to be sold inside plastic bottles, consumed by individuals that for various reasonsshun free tap water.

Shifts in spatial patterns of relative human water security threat after accounting for water

technology benefits. (Source: Nature, as described in text)


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In two landmark pieces in the September 30th volume of NATURE Margaret Palmer of the University

of Maryland and a list of authors from around the world, draw the connections between waterscarcity, shrinking global biodiversity and human health. The main message: 80% of the worlds

population is exposed to high levels of threat to water security.

The researchers find that most of the worlds water is locked up in the extreme polar regions of the

planet, and equatorial rain forests, all of which are diminishing. The band of the global ecology that is

facing absolute water deprivation is expanding beyond the traditional desert regions of the Sahara andNorth American southwest to now include most of northern China and Mongolia, more than 80% of

the Australian continent, nearly all of southern Africa and much of both Western and Eastern Europe.

The shrinking biodiversity question offers serious challenge to biologists that are trying to model

future threats to humanity. Agricultural experts have long recognized the dangers of practicing

monoculture, or planting vast hectares spreads with a genetically identical species. In such settings

evolution speeds up for predatory insects and plant diseases and for insect resistance to pesticides. In avery real sense the lowered plant diversity promotes agricultural pestilence and insect invasion. This is

overcome through large use of pesticides.

Heterogeneity is healthy; homogeneity in ecosystems is dangerous. Shrinking biodiversity is more

than just a tragic extinction issue: It is a challenge to the health of the planet, and of humanity.

In its July 22, 2009 issue Foreign Policy magazine published a quiz on the links between dwindling

water resources and world stability. Here is the final page with correct answers circled:

CONCLUSION?


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The looming resource monopolization effort

The water crisis, and associated land grabs, is part of a larger trend in globalization that can have

profound implications for human health. Governments and private investors recognize that many

essential resources are either diminishing rapidly, or constrained for other reasons: arable land, water,essential minerals, oil, uranium, productive fisheries, etc. The responding trend is monopolization of

resources. A dramatic case in point received strong attention from national security and financial

sectors recently: Rare Earth Elements, or REEs. Though in truth REEs are not rare, as trace amountsof most of these elements can be found in soil samples all over the world, extraction of these exoticchemicals is costly, both in monetary and environmental terms. None of this mattered much until the

computer, telecom and green industrial revolutions made compounds like europium essential. The

REEs compounds found at the unpronounceable bottom end of the periodic table are essential for

sufficient battery power to drive electric cars, transmission of mobile phone signals, missile guidance

systems, laptop computers, the iPad you may be reading this on, or the MP3 player youve got pluggedinto your ears right now.

More than a decade ago Chinese scientists and technical planners recognized that the entire solar or

wind forms of power generation, along with electric cars, had a shared critical flaw storage capacity.

Traditional copper or even lithium batteries are too heavy and inefficient to handle the 21st Century

green revolution. China invested heavily in development of novel methods of extracting REEs fromconcentrated soil and rock samples, found in locations the Chinese government has purchased all over

the world. The environmental contamination produced by extraction technology was not consideredconsequential. The Chinese effort was begun in 1986, when three leading chemists wrote Deng

Xiaoping, urging a massive increase in basic science R&D. Deng ordered Program 863, which

spanned initiatives in biology, physics and chemistry. From early stages rare earth elements were partof Program 863, according to Cindy Hurst of the Institute for the Analysis of Global Security. In

1997, as the government recognized the strategic importance of REEs, Program 973 was set up,

giving more funding and urgency to energy and chemistry research. The elderly inspiration for


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breakthrough research on REE extraction was Xu Guangxian, who previously pioneered nuclear

extraction for China.

Few companies or governments outside of China took the REE extraction problem seriously until aChinese fisherman strayed into Japanese territorial waters in the South China Sea in September,

sparking a dangerous diplomatic show down between the two nations. The saber-rattling cooled down

after Japan claimed that China cut off exports of REEs to Japan, reportedly bringing Toyota electriccar production to a halt. Though there is widespread skepticism about Japans claim of Chinese

government intervention in REE exports, the controversy spurred the rest of the world to wake up tothe issue, realizing that China controls about 97 percent of global REE production. In recent days

Germany has charged that China is manipulating the REE market, cutting supplies for Europeanelectric car and solar production by 40 percent. China has countered, saying it is trying to reduce the

environmental costs of REE extraction. Essentially China is telling Europe, North America and Japan,

Pay our price, live with our monopoly, or go out and pollute your own environments to extract

REEs.

There is considerable debate regarding China's actions over the last 6 weeks, amid allegations the Hu

Jintao government blocked export of REEs to Japan in a direct retaliatory action for the seizure of a

Chinese fishing boat in the South China Sea. Japan officially claims that such a move was made by

China, which would constitute a violation of the World Trade Organization. The New York Times has

offered several reports claiming that China cut off Japanese access to REEs in late September, and

then on October 18th drastically reduced exports to Western Europe and the United States.According to the New York Times, an embargo was on. But many China experts asserted no official

embargo was underway, and if the world was feeling under-supplied with REEs it merely reflected

domestic changes in Chinese mining and production standards.

Whatever the case, the "embargo" officially ended on October 28th, when Chinese Premier WenJiabao told South Korea's Kim Hee Jung that, China will continue to supply rare earths to the

international community. And China will work with major buyers in expanding the source of rare

earths and developing alternative minerals."

Dan Markey, Chair of the US Senate Select Committee on Energy Independence and Global

Warming, has demanded detailed information from the Obama Administration regarding the status of

U.S. reliance on Chinese REE supplies. And chills are running down spines in Washington thanks to a

remarkable ad that has become immensely popular in China:http://news.sohu.com/20101026/n276478103.shtml

Now India wants to get into the REE game:http://www.reuters.com/article/idUSTRE69Q1V320101027

Brazil has cornered the market on sugar-derived ethanol, which is the most efficient and leastenvironmentally damaging form of plant-made fuel currently available to power automobiles and

heavy machinery.

And now it appears China is moving in on the basics of the drug and pharmaceutical industry. Chinese

factories now produce most of the worlds supply of raw ingredients used for everything from aspirinto heparin, vitamin C to advanced psychoactive pharmaceuticals.
https://owa.cfr.org/owa/redir.aspx?C=e9f96d64d3e64b7dae6799a640af809f&URL=http%3a%2f%2fnews.sohu.com%2f20101026%2fn276478103.shtmlhttps://owa.cfr.org/owa/redir.aspx?C=e9f96d64d3e64b7dae6799a640af809f&URL=http%3a%2f%2fnews.sohu.com%2f20101026%2fn276478103.shtmlhttps://owa.cfr.org/owa/redir.aspx?C=e9f96d64d3e64b7dae6799a640af809f&URL=http%3a%2f%2fwww.reuters.com%2farticle%2fidUSTRE69Q1V320101027https://owa.cfr.org/owa/redir.aspx?C=e9f96d64d3e64b7dae6799a640af809f&URL=http%3a%2f%2fwww.reuters.com%2farticle%2fidUSTRE69Q1V320101027https://owa.cfr.org/owa/redir.aspx?C=e9f96d64d3e64b7dae6799a640af809f&URL=http%3a%2f%2fwww.reuters.com%2farticle%2fidUSTRE69Q1V320101027https://owa.cfr.org/owa/redir.aspx?C=e9f96d64d3e64b7dae6799a640af809f&URL=http%3a%2f%2fnews.sohu.com%2f20101026%2fn276478103.shtml


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A large proportion of the worlds supply of aspirin,

acetaminophen, and the stabilizing compoundsused to formulate drugs into pills and capsules

come from Chinese factories, such as the onedepicted to the right. According to CFRs

Yanzhong Huang: In 2008, 40 percent of foreign

drug manufacturers registered with the FDA wereChinese and Indian, up from 30 percent in 2002.

According to a 2007 GAO report, China has thelargest number of registered drug manufacturers

exporting to the US (India is a distant second). Forexample, 83 percent of aspirin products are made

in China. In 2008, China also manufactured 14

percent of the $31 billion dollar market for active drug ingredients. Most suppliers of shikimic acid,

the base ingredient in the antiviral oseltamivir, are in China.

Whole generic drug formulations and the raw ingredients for medicines used by US patients now

come from overseas: 43 percent of them from China, and another 39 percent from India. Only 13

percent were produced in the United States, and a trivial amount in Europe. The challenge going

forward is to ensure the reliability and safety of medicinal compounds made in emerging market

countries, given their weak regulatory and inspection systems.

Monkeypox fills smallpox vacuum?

Arguably the greatest triumph of 20th Century global health was eradication of smallpox, achievedmore than 30 years ago. In the wake of that victory the World Health Organization team responsible

was nominated for the Nobel Peace Prize. But the Prize was never awarded, partly because French

scientists argued WHO failed to prove that smallpox viruses werent harbored by animals, probablymonkeys, in some extremely remote location.

Now a multinational team of scientists has published evidence of a dramatic increase in monkeypox

outbreaks in the Democratic Republic of Congo. Monkeypox is not the same virus as smallpox, but

the two microbes do share enough genetic coding to present similar epitopes for immune system

recognition. This should not be surprising, as Jenners original smallpox vaccine was made fromanother species, cowpox. The overlapping immunogenicity of the pox viruses has long been noted,

and then set aside as an interesting but not terribly relevant finding.

But now the multinational team, led by Bernard Moss of the U.S. National Institutes of Health, findsthat the surge in monkeypox outbreaks in Congo may represent an opportunistic virus filling a niche

vacated by eradication of smallpox. Moreover, the outbreaks are fueled by three generations of human

beings born since smallpox vaccination ceased in 1977. The team finds that the incidence of humancases of monkeypox has increased 20-fold since the 1980s, with never-vaccinated-against-smallpox

young people five times more likely to contract the disease.

Monkeypox infection crosses species between humans and monkeys


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(For details see: www.pnas.org/lookup/suppl/doi:10.1073/pnas.1005769107//DCSupplemental)

Zoonosis news: Inhaled and swine H5N1, gorilla malaria, pig

MRSA; horizontal gene transfer in the oceans

Zoonosis the movement of pathogenic microbes from one host species to another is not by any

means unique to monkeypox. Often sudden zooonotic events spark outbreaks or pandemics in the

newly-infected species, such as movement of SARS viruses from Chinese civets to humans, or theH1N1 influenza virus from North American swine to humans.

A team of Indonesian, Japanese and American scientists has now demonstrated that H5N1 aka bird

flu infects pigs. At least 700 swine in Indonesia havebeen shown to carry, or die from, H5N1. Most of thesepig cases have occurred in Java, where there have also

been numerous clusters of human cases with terrible

fatality rates (upwards of 75 percent of infected people).

Worse, the researchers demonstrate that the viruses

found in the pigs have evolved, so that they have genetic

adaptations to the mammalian pig host. This is worrying

because influenzas that circulate and adapt to pigs can

easily infect human beings. (See: DOI:10.3201/eid1610.100508.)

A separate research team working in Vietnam has shown that H5N1 can now spread via inhalation

between ferrets, another indication that the virus may be adapting to mammalian hosts. (See: VirologyJournal 2010, 7:231.)

Zoonotic events may lead to permanent disease threats for a population. Beatrice Hahn and colleagues

from the University of Alabama in Birmingham have recently shown that modern day falciparummalaria in human beings the form now circulating in Africa originated in gorillas. (See: Nature Vol.467:420-425.)
http://www.pnas.org/lookup/suppl/doi:10.1073/pnas.1005769107/DCSupplementalhttp://www.pnas.org/lookup/suppl/doi:10.1073/pnas.1005769107/DCSupplementalhttp://www.pnas.org/lookup/suppl/doi:10.1073/pnas.1005769107/DCSupplementalhttp://www.pnas.org/lookup/suppl/doi:10.1073/pnas.1005769107/DCSupplemental


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Multiple studies have recently shown cross-species spread of highly drug resistant (MRSA)

Staphylococcus aureus.

And now Florida researchers show cross-species transmission of antibiotic resistance genes betweenmicrobes in the oceans. Coastal areas with high human populations commonly witness dumping of

antibiotics into the seas, as part of overall waste disposal. Animal and human fecal matter may also

contain un-degraded antibiotics. Now it appears that bacteria in coastal and, remarkably, open ocean

ecologies are evolving antibiotic resistance, and sharing phages that carry the genetic trait acrossspecies. For those keeping count, the rate of this transmission, the authors say, is startling:

Environmental gene transfer frequenciesare 1900 to 459 million times thefrequency of transformation and 650,000 to 31 million times the frequency of

transduction previously measured in the marine environment. These results suggest a

genomic flexibility in marine microbial populations that facilitates their adaptation to

changing environmental conditions.(See: SCIENCE 330:50-51, 2010)

NDM-1

Arguably the most frightening new

microbial evolution is the NDM-1

mutation that has emerged in

Enterobacteriaceae bacteria that areamong the leading causes of hospital

infections and deaths. First noted inBritish travelers that had sought

medical treatment in India, themutation is named after New Delhi a

point not appreciated in India. But

NDM-1 mutations have now been

found in bacterial populations in

several countries, including throughout

the subcontinent, posing a very

worrying trend in evolving bacterialresistance to antibiotics. The NDM-1

microbes are highly drug resistant.(Pictured above are colonies of NDM-mutant bacteria thriving amid antibiotic-rich fluids.)

(See: Pitout, Johann DD. 2010. The latest threat in the war on antimicrobial resistance. The Lancet Infectious Diseases Vol. 10, Issue 9

(September). AND: Kumarasamy, Karthikeyan, et al. 2010. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the

UK: A Molecular, biological, and epidemiological study. The Lancet Infectious Diseases Vol. 10, Issue 9)

Researchers have now identified this mutation in E.coli, Klebsiella pneumonia, and otherenterobacterial strains, indicating the gene is shared across bacterial species. The gene, NDM-1,


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protects the bacteria by producing an enzyme that destroys antibiotics. The so-called New Delhi

metallo-beta-lactamase-1 (NDM-1) is an enzyme of significant power to destroy antibiotics. Even"last resort" antibiotics cannot overcome this genetic trait. NDM-carrying bacterial strains have been

identified in clinical settings in Canada, Germany, Belgium, Taiwan, Israel, Brazil, China, Australia,the Netherlands, Sweden and the United States, as well as throughout the Indian subcontinent.

(See: Hellerman, Caleb. 2010. Medical tourists bring home new superbug. The Chart: CNN Healthonline (11 August).

http://pagingdrgupta.blogs.cnn.com/2010/08/11/medical-tourists-bring-home-new-superbug/ .)

Surge in vaccine-preventable diseases

The State of California is in the grips of its worst outbreak of Whooping Cough (pertussis) since1955, meaning since mass vaccination was routine. During the first nine months of 2010 the State

experienced almost as many cases due to Whooping Cough (6,257) than were reported during the

entire year of 1950 (6,613). At that time California only had a population of 13 million (versus todays38 million) residents, so the absolute numbers might not seem so startling. But this note from the

National Network for Immunization Information puts matters in perspective:
http://pagingdrgupta.blogs.cnn.com/2010/08/11/medical-tourists-bring-home-new-superbug/http://pagingdrgupta.blogs.cnn.com/2010/08/11/medical-tourists-bring-home-new-superbug/http://pagingdrgupta.blogs.cnn.com/2010/08/11/medical-tourists-bring-home-new-superbug/


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Between 1940-1945, before widespread vaccination, as many as 147,000 cases of

pertussis were reported in the United States each year, with approximately 8,000deaths caused by the disease. In 1976, there were 1,010 case of pertussis in the US, the

lowest number of cases ever reported. Over the past few years the number of reportedcases of pertussis has increased, reaching 25, 827 in 2004. Worldwide, there are an

estimated 300,000 annual deaths due to pertussis.

In other words, the United States has gone from nearly pushing Whooping Cough into absolute

obscurity, to a 25-fold increase in cases since the implementation of nearly universal child vaccination.In California ten babies have died this year of the bacterial disease, and the actual incidence of

Whooping Cough this year will soon surpass that seen in 1959.

Welcome to the 21st Century.

California is not alone: Whooping Cough is at

record levels all over the country, and theCenters for Disease Control and Prevention

reports the incidence of pertussis has jumped

400 percent since 2009. It should come as nosurprise to public health leaders that California is

Ground Zero in this outbreak, as the State is alsohome to a powerful anti-vaccine movement, led

by celebrities and doctors that continue to claimthat vaccines contain chemicals that cause

autism. Though countless studies and judicial

rulings have concluded that vaccines are safe, and discounted any connection to autism, parental to

fully immunize children persists.

The choice to refuse vaccination is similar to refusal to buy into health insurance: Both stem from a

rejection of the notion of shared or pooled risk. By rejecting the needs of the herd, the individualeliminates herd immunity or shared burden of health insurance costs. Thirteen percent of Californias

parents have made that choice for their infants, refusing to immunize them prior to entry intokindergarten. And the highest rates of refusal are in the States wealthiest communities: Not

surprisingly, rich areas like Marin County north of San Francisco also this year have the largest

number of Whooping Cough cases.

Pertussis requires not only shots in infancy, but boosters later in childhood, which some parents

simply forget. Inadequately vaccinated children may act as pertussis carriers, serving as reservoirs for

the bacteria and passing them onto highly vulnerable people, such as infant siblings. CaliforniaGovernor Arnold Schwarzenegger signed a law in October that mandates booster shots as a

prerequisite for reentry into public schools. The law will go into effect in 2012.

Dutch researchers claim that pertussis Bordetella bacteria are evolving, as well, and gaining ways to

outwit immunization. (See: Allen A (2010), Whooping cough makes a comeback, Washington Post,September 27.) Details from Dr. Frits Mooi were posted on ProMED, as follows:

As pointed out in 2009 by Dr Frits Mooi (ProMED-mail Pertussis - Australia (02):

(SA) 20091108.3876): There are now many studies which show that outbreaks of


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pertussis are often associated with changes in the B. pertussis population. Most

recently, we have shown that more virulent (P3) strains have appeared which webelieve to be (partly) responsible for the outbreak in the Netherlands. The P3 strains

have emerged worldwide. Any discussion on the causes of sudden upsurges ininfectious diseases should include changes in the pathogen population.

---------

Mooi FR, van Loo IHM, van Gent M, et al: _Bordetella pertussis_ strains with increased toxin

production associated with pertussis resurgence. Emerg Infect Dis. 2009 Aug; 15(8): 1206-13.The full paper is available at

This year other states have seen a jump in Whooping Cough cases, including Ohio, Florida, Texas,Kansas and New Mexico. And a similar epidemic is unfolding in Australia.

Back in the 1920s public health researchers noted a distinct seasonality to whooping cough, with the

disease peaking in the colder northern states during winter, and in the warmer southern climespeaking in late spring. It was then speculated that pertussis competed with the infectious agents

responsible for diphtheria and scarlet fever, and the seasonality had more to do with bacterial

crowding-out than environmental temperatures.(See: Harmon GE

(1932), Seasonal Incidence of Whooping Cough in the United States,Am J Public Health Nations Health, August; 22(8): 831839.)

Measles is also making a comeback. In recent weeks outbreaks have

been reported in Northern Ireland(Date: Thu 14 Oct 2010; Source: The BelfastTelegraph ), England,Wales, Australia, Zimbabwe, and Zambia.

The Council on Foreign Relations Global Health Program iscurrently compiling a chart of vaccine-preventable outbreaks and

epidemics worldwide. We intend to post the chart, which will beregularly updated, and will inform you when it is ready for your

viewing and use. Your feedback, including additional outbreak

information, will be appreciated.

Food price inflation again

The Global Health Program has previously written about the inflation in world food prices, first in

2008, and again this year. Prices for basic grains have continued to inflate at an alarming pace. Thesurge in wheat costs was partly spurred by the massive fires that devoured thousands of hectares of

cropland this summer in Russia. But prices for everything from cornto rice have also been rising in atrend that bodes ill for the bottom 2 billion poorest people on earth.
http://www.cdc.gov/eid/content/15/8/1206.htmhttp://www.belfasttelegraph.co.uk/news/local-national/northern-ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.htmlhttp://www.belfasttelegraph.co.uk/news/local-national/northern-ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.htmlhttp://www.belfasttelegraph.co.uk/news/local-national/northern-ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.htmlhttp://www.belfasttelegraph.co.uk/news/local-national/northern-ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.htmlhttp://www.cfr.org/publication/16289/food_failures_and_futures.htmlhttp://www.cfr.org/publication/16289/food_failures_and_futures.htmlhttp://www.cfr.org/publication/22774/wheat_supplies_and_food_fears.htmlhttp://www.cfr.org/publication/22774/wheat_supplies_and_food_fears.htmlhttp://www.cfr.org/publication/22774/wheat_supplies_and_food_fears.htmlhttp://www.cfr.org/publication/22774/wheat_supplies_and_food_fears.htmlhttp://www.cfr.org/publication/16289/food_failures_and_futures.htmlhttp://www.belfasttelegraph.co.uk/news/local-national/northern-ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.htmlhttp://www.belfasttelegraph.co.uk/news/local-national/northern-ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.htmlhttp://www.cdc.gov/eid/content/15/8/1206.htm


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UNICEF estimates that a quarter of the under-five year old deaths in Central and Western Africa aredue to malnutrition. Similarly, the 2010 report of the International Food Policy Research Institute

says 21 percent of the Congolese population are undernourished, 11 percent of children are

underweight, and the infant mortality rate among under fives is 12.7 percent.

The UNs Food and Agriculture Organization (FAO) says in its annual report (State of FoodInsecurity in the World 2010 report) that the populations of 22 countries currently face acute food

crises and starvation. Nearly 1 billion people now, according to FAO, live in a state of chronichunger.

The FAO warns that even in the absence of food price volatility, many countries are now locked into

states of protracted crisis, defined as a state in which:Food insecurity for most of the population has persisted for more than 8 years;

At least 10 percent of foreign assistance funding is in the form of emergency humanitarian

relief;

The proportion of the population that is undernourished is at least three times the norm inother developing countries.

Sadly, 500 million of these people locked in protracted crisis are actually farmers, barely managing

to grow enough food to keep their families alive. Olivier De Schutter, the U.N. special rapporteur on

the right to food, argues that subsistence

farmers are now suffering from anothertype of agricultural price speculation

land grabs by large agricultural interests(Associated Press/Winnipeg Free Press.)Thirty million hectares of farmland per

year are lost land grabs and urbanization,De Schutter says.

Despite this grim litany, the food crisis of

2010 is not as bad as that experienced twoyears ago, when price volatility, market

speculation and poor harvests formed a

perfect storm that led to food riots all over
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the world. This year, aside from the burned crops of Russia and Central Asia, yields for corn, soy, rice,

and most basic grains are very good. Nevertheless, speculation on commodity futures has drivenprices higher, and sent shock waves through the World Bank. There is rising concern that the world

has, as a whole, entered a new stage in food access, in which inequities and starvation may be driven asmuch by speculation on the Chicago Commodities Exchange as drought, pestilence or war.

In mid-October the World Bank called for more support for its Global Food Crisis Response Program(GFRP) through June 2011, citing food price volatility as its reason for extending the program. The

emergency program is meant to assist farmers with subsidies for fertilizers, seed and basic farmingtools. Currently 5.9 million households receive direct support through GFRP. Bank President Robert

Zoellick said in an October 19 statement that there is, growing concern among countries aboutcontinuing volatility and uncertainty in food markets, which needed to be urgently addressed. These

concerns have been compounded by recent increases in grain prices. World food price volatility

remains significant and in some countries, the volatility is adding to already higher local food prices

due to other factors such as adverse weather. High volatility negatively impacts both consumers and

farmers.

How do we get out of this mess? In a recent paper (Revolt, Migrate, or Die Why food security

matters) for the German Marshall Fund, Mark Allegrini and Peter Sparding argue that the causes, and

solutions, are highly complex. One could easily conclude that the next decades will mark slowly rising

malnutrition all over the world, in that protracted crisis state described by FAO. But, they say, there

are concrete steps that could be taken today to save millions of lives:

Some of these factors are beyond the reach of immediate policy remedies. But others

are not. The international community reacted to the 2008 food crisis with a

proliferation of initiatives. The G8 LAquila Joint Statement on Global Food Security

in July 2009 elicited pledges of $22 billion over three years to agriculture

development. In response, a trust fund has been set up at the World Bank theGlobal Agriculture and Food Security Program to implement the pledges. In

addition to contributing to the trust fund, the United States launched its own GlobalHunger and Food Security Initiative, called Feed the Future. Other initiatives are

underway at the UN, within the European Union, and at other multilateralorganizations.

These efforts are a welcome start. However, the sheer multitude of initiatives runs the

risk of creating policy and implementation incoherence if coordination is not

improved. Even more importantly, donors are talking the talk while not always

walking the walk. Some pledges have yet to turn into real money. So far, only the

United States, Canada, South Korea, Spain, and the Bill and Melinda GatesFoundation have committed to the World Bank trust fund. This ambiguity has led

some African officials to question the Funds sustainability.
http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/http://blog.gmfus.org/2010/10/01/revolt-migrate-or-die-why-food-security-matters/


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Bulldozers in Haiti finally

First, the good news: Demolition of earthquake-ravaged Part-au-Prince has finally begun. After

agonizing months of haggling inside the Haitian government, but more importantly in Washington,

funds and approval for demolition have finally come through. Until structures that could crush peopleare removed, homes, schools, safe water and sewage systems and all the essential infrastructure of

urban life cannot be built.

The bulldozers began rolling through the streets during the second week of October, after delays that

seemed perplexing to many observers. After all, billions of dollars worth of relief money was

committed to Haiti after the January 12th earthquake, and so many aid organizations are swarmingover the country that they have become THE dominant industry and employer in the capital and much

of the region surrounding Port-au-Prince. With so much global concern and financing, how can it be,

11 months post-disaster, that demolition is yet to be vigorously executed?

The answer, of course, is money: Yes, billions have been committed, but where are the resources?

Even the early October release of funds to allow demolition operations to commence represents less

than $500 million, from the French and U.S. governments as well as private donors.

Where is the cash for such vital necessities to human health as safe drinking water and human wastetreatment facilities?

Ask Republican Senator Tom Coburn, an Oklahoma conservative who is, according to ObamaAdministration sources, using his authority to block distribution of more than $1.1 billion worth of

Haitian relief funds. Coburn explained (Washington Examiner opinion piece) last month why he is
http://www.washingtonexaminer.com/opinion/columns/OpEd-Contributor/Sen-Tom-Coburn-Facts-and-fiction-about-the-US-105372593.htmlhttp://www.washingtonexaminer.com/opinion/columns/OpEd-Contributor/Sen-Tom-Coburn-Facts-and-fiction-about-the-US-105372593.htmlhttp://www.washingtonexaminer.com/opinion/columns/OpEd-Contributor/Sen-Tom-Coburn-Facts-and-fiction-about-the-US-105372593.htmlhttp://www.washingtonexaminer.com/opinion/columns/OpEd-Contributor/Sen-Tom-Coburn-Facts-and-fiction-about-the-US-105372593.html


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doing so, noting that, "The situation in Haiti is confusing, but there are some things we know. First, we

know that immediately after the earthquake the United States responded quickly and compassionatelywith aid and relief. According to USAID, we have spent at least $1.1 billion in Haiti already. We also

know that in July of this year Congress passed and President Obama signed into law an emergencysupplemental bill that included $1 billion for Haiti."

But Coburn insisted, the State Department has "donenothing for 10 weeks," and "Contrary to various news

reports, the bill I expressed concerns about at the endof the session had nothing to do with our current

mission. The bill in question, sponsored by Sen. JohnKerry, D-Mass., would authorize $500 million for

next year," Coburn writes.

Why block any Haitian relief whether a billion or

half-billion dollars? "First, it is grossly irresponsiblefor Congress to authorize or appropriate any new

spending when we have a $13.6 trillion national debt that is strangling our economy, Coburn wrote

on October 20th. Second, it is irresponsible to wait until the last minute to try to fast -track costly andduplicative legislation no one has read," Coburn argues. He concludes: "When Congress reconvenes,

we can do the right thing and pass Haiti legislation in a responsible way. ... I would ask my colleagues:What would you sacrifice to help the people of Haiti? Surely Congress can agree that something in our

$3.7 trillion budget is less important than helping Haiti recover from this terrible tragedy. Leadershiprequires choices and sacrifices. The people of Haiti, and the world, are watching and waiting.

Tom Coburns objections can hardly be granted sole credit for the slow response in Haiti. A Haiti Real

Time Evaluation (RTE), released in late October, finds fault in the activities of just about every

external player on the Haitian field, from humanitarian relief and medical groups, to UN agencies anda multitude of NGOs. The report, led by Sir John Holmes, former under-secretary general for

humanitarian response at the UN, and currently director of the Ditchley Foundation, summarizes theactivities of all with this biting statement: There is still a tendency not only to reinvent the

wheel, but also to turn it the wrong way.

Though the RTE heaps praise on the emergency medical responders that toiled among the injured and

sick in February and March, most of the demolition and reconstruction activities hence come in for

sharp rebuke.

The report says that, at the operational level repeat problems emerged. Needs assessments wereincomplete and duplicative; transitional - as in medium-term - shelter was not provided at scale;

sanitation solutions were inadequate; and the overall protection response- particularly to sexual and

gender based violence - was weak.

Process-wise, few agencies informed local communities of what they were doing or why they were

there. And the UN showed poor leadership and proved highly indecisive.

On October 20th a group of human rights attorneys presented a petition to the Inter-AmericanCommission on Human Rights (IACHR) on behalf of rape victims women and girls living in the

Port-au-Prince squalor, victimized by bands of men and boys.


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The ultimate solution here is permanent, safe housing for Haitians. Unfortunately, the international

community has reneged on its commitment to provide essential funds for rebuilding and the U.S., inparticular, has not delivered even one cent of the reconstruction funding it pledged, Bill Quigley, one

of the petitioning attorneys, told reporters: Women are being forced to live in extremely unsafeconditions for the foreseeable future and it is a deplorable failure on the part of those who made such a

show about standing with the Haitian people in their greatest hour of need.

And then came cholera.

On Friday October 22nd, Haitian President Rene Preval announced that cholera had emerged in

northwestern Haiti, on the other side of a mountain ridge that forms the upper heights of Port-au-

Prince. At least 138 people were dead and upwards of 1,500 had developed the disease, Preval said, in

and around the town of Arbonite. Two days later a handful of cases turned up in Port-au-Prince and

fear spread rapidly. It is the first time cholera has struck Haiti in well over a century.

Arbonite, swollen with Port-au-Prince refugees, had inadequate safe water supplies before the

earthquake: The additional population put great stress on water supplies. By October 19 the citys St.

Nicholas Hospital was overwhelmed with cholera patients: Within two days 500 patients filled the

facility.

Patients fill the courtyards of Saint Nicholas Hospital. (Photo from Atlantic Monthly online)


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Five days after President Preval confirmed the outbreak nearly 5,000 cholera cases and 300

deaths were reported. As health leaders struggled to get oral rehydration kits to those in need

and trace the expanding paths of the vibrio, questions arose regarding the origin of the

outbreak. Because cholera had not claimed lives in Hispaniola since the 19th Century the

vibrio had to have been introduced from outside. With Haiti now home to thousands of

foreigners humanitarian relief workers, UN officials, development experts, health

investigators the cholera could conceivably have come from any place in the world thatcurrently is suffering from the disease.

The list of cholera outbreaks underway worldwide is a long one as Zambia, Chad, Nigeria,

Cameroon, Benin, India, and Pakistan all have active outbreaks at this time. The Nigerian

epidemic has led to some 39,000 hospitalizations and 1,500 deaths. In Cameroon 559 cholera

deaths have been reported. Terrible flooding has spread cholera in Benin and Pakistan.

Cholera is endemic in Bangladesh, southern India, Nepal and much of the Bay of Bengal

region.

Last week angers rose in Arbonite as the people became convinced that the UN Peacekeepersstationed in nearby Mirebalais, on the Arbonite River, were the source of the epidemic.

Local residents immerse themselves in the river believed to be the source of the cholera outbreak.(Photo from Atlantic Monthly online)


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United Nations officials were, predictably, reluctant to accept the Mirebalais UN outpost explanation.

Claire-Lise Chaignat, the head of the World Health Organizations cholera task force, told reportersany such speculation was "premature, adding, "The speculation about the UN troops from Nepal

having brought the disease to Haiti seems very unlikely. The way for the troops to be transported fromNepal to Haiti is long enough that the disease would have declared itself before they reached Haiti. We

also know that troops and armies normally live in good sanitary conditions and are not exposed to

conditions which are conducive to getting cholera."

Nepalese military officials have also denied any possible connection, telling their countrysSagarmatha TV that none of the UN-posted soldiers carried cholera. . Before they selected for

peacekeeping deployment, the peacekeepers have to go through strong health vetting. There is no

possibility of any infection in the new batch of soldiers as they have to undergo a 'through medicalcheckup' before participating in the peace keeping mission, Nepal Army Brigadier General Ramindra

Chhetri said, adding that the Mirebalais camp had been examined and found free of bacterial

contamination.

Tests of the waters outside the Nepalese encampment, conducted on October 22nd, did not turn up

cholera vibrio, according to UN officials.

The Haitian National Public Health Laboratory (NPHL) last week announced that Vibrio choleraeserogroup O1, serotype Ogawa was the strain responsible for the epidemic. That diagnosis was

confirmed by the U.S. CDC, using both genetic and immunological tests. Both laboratories testedsamples drawn from environmental sources in various parts of Haiti, yielding the same results in every

case.

There are two major subgroups of cholera in the world today: 01 and 0139. Within the 01 cholerae are

Classic and El Tor subtypes. The Ogawa strain is a form of the El Tor subtype, and it is

characteristically resistant to several antibiotics. In a 2007 outbreak in Mozambique researchers found

the bacteria had, High incidences of antimicrobial resistance were found for chloramphenicol (57.9

percent), co-trimoxazole(96.6 percent) and tetracycline (97.3 percent). Quinolone resistanceremained low (4.2 percent). (http://jac.oxfordjournals.org/content/60/3/662.full.pdf)

This year in India a strain of the Ogawa-type cholera emerged that was also resistant to tetracycline.

The researchers noted that, tetracycline-resistant V. cholerae O1 Ogawa isolates are being reported

from Madagascar,

Bangladesh, Tanzania,

Zaire, Latin America, and

Southern and Easternregions of India.(http://www.ijpmonline.org/text.asp?2

010/53/4/865/72014)

By analyzing the drug-

resistance patterns of the

Haitian strain researchersmay be able to narrow its

possible origins. But it will

probably not be possible to
http://jac.oxfordjournals.org/content/60/3/662.full.pdfhttp://jac.oxfordjournals.org/content/60/3/662.full.pdfhttp://jac.oxfordjournals.org/content/60/3/662.full.pdfhttp://www.ijpmonline.org/text.asp?2010/53/4/865/72014http://www.ijpmonline.org/text.asp?2010/53/4/865/72014http://www.ijpmonline.org/text.asp?2010/53/4/865/72014http://www.ijpmonline.org/text.asp?2010/53/4/865/72014http://www.ijpmonline.org/text.asp?2010/53/4/865/72014http://www.ijpmonline.org/text.asp?2010/53/4/865/72014http://jac.oxfordjournals.org/content/60/3/662.full.pdf


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irrefutably prove the strain came from Nepalese soldiers, or rule out that it was carried to Haiti byailing humanitarian relief workers or NGO employees. The life cycle of cholerae is complex, and theorganisms can make their way around the world by means other than human carriers. Outbreaks have

been spawned by bilge water from a ship that collected the contaminated liquid in Asia, and dumped itin Latin American shores.

There is little to be gained by naming or blaming the alleged source of the outbreak. Far moreimportant are the hygienic measures Haitians can take assuming they have access to safe water and

soap to protect themselves. The epidemic ought to bring new urgency to the need to get those

bulldozers moving, and water and sewer systems constructed, along with ample decent housing for

the people of Haiti.

For more information on the current cholera epidemic in Haiti please read my interviewFighting

Cholera amid Haiti's Debrison the CFR website.
http://www.cfr.org/publication/23288/fighting_cholera_amid_haitis_debris.htmlhttp://www.cfr.org/publication/23288/fighting_cholera_amid_haitis_debris.htmlhttp://www.cfr.org/publication/23288/fighting_cholera_amid_haitis_debris.htmlhttp://www.cfr.org/publication/23288/fighting_cholera_amid_haitis_debris.htmlhttp://www.cfr.org/publication/23288/fighting_cholera_amid_haitis_debris.htmlhttp://www.cfr.org/publication/23288/fighting_cholera_amid_haitis_debris.html


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MDG postscript

Lest we end on a sour note, there are reasons to believe that global health dreams can sometimes

come true. CFR Global Health Program colleague Yanzhong Huang points out:

1. The Global Fund replenishment conference took place on October 5, and all of the newpledges are on their website:

http://www.theglobalfund.org/en/pressreleases/?pr=pr_101005c . Note India did not pledge a

dime. China did increase its pledge for 2011-2013 to 14 million (compared to 16 million for

the entire 2003-2010 period). This seems to be in line with Premier Wen Jiabaos UN speech,in which he vowed to redouble [Chinas] efforts to advance the global campaign against

HIV/AIDS, and ensure that the related MDG be met on schedule. However, it still lags far

behind the US (4 billion), Japan (800 million), even Russia (60 million). Compared to Russia,

which is eager to be viewed as a donor state, China seems to be content to being a recipient

than a donor. Even Access Bank, a leading African financial institution, has announced adonation of the sum of $1 million to the Global Funds project.

2. On September 22, at the UN MDG summit, Japanese PM Naoto Kan, who was Japans

Minister of Health and Welfare, announced that Japan will provide assistance of five billiondollars over five years beginning in 2011 to contribute to the achievement of the health-

related MDGs, esp. maternal and child health.
http://www.theglobalfund.org/en/pressreleases/?pr=pr_101005chttp://www.theglobalfund.org/en/pressreleases/?pr=pr_101005chttp://www.theglobalfund.org/en/pressreleases/?pr=pr_101005c


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We choose to end on a note of celebration. On October 14 th the Food and Agriculture Organizationpronounced the Rinderpest virus eradicated. Once the leading cause of deadly epidemics in cattle and

some species of wild African animals, Rinderpest is now officially the second microbe vanquished forall time, the first having been smallpox. In colonial-era Africa Rinderpest obliterated entire herds, and

commonly swept across the continent claiming more than 90 percent of livestock populations. It was

for cattle far more deadly that any contagious human disease.

For those of you residing in the northern hemisphere, enjoy the autumn weeks, and in the South, thespring.

As always, the Global Health Program of the Council on Foreign Relations will strive to keep you

informed.

Sincerely,

Laurie Garrett

Senior Fellow for Global Health

council of foreign relations november 2010

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