Laurie Garrett Interview: U.S. Global Health Leader MIA on Swine Flu

This is a condensed transcript of the interview, edited for clarity.

Q: What’s your thinking about the Obama Administration’s H1N1 response so far?
L.G.: The biggest problem right now is who’s in charge. From the outside, it looks like the Centers for Disease Control and Prevention is in charge, and certainly CDC is in the driver’s seat for certain pieces of the pandemic response. But as we have known since at least 2005, when the Bush Administration started trying to figure what a pandemic preparedness plan should look like and what agencies should lead the response, CDC is not the only player, and there are some very significant pieces of the problem that needed to be taken care of at the Food and Drug Administration, the State Department, the National Security Council, and very importantly, the Office of Global Health Affairs (OGHA) in HHS.

Q: There’s no one running the Office of Global Health Affairs, is there?
L.G.: It’s an empty seat. There is no special advisor to HHS Secretary Kathleen Sebelius, no undersecretary in that role, no deputy secretary in that role, etc.

Q: So what’s the consequence? What isn’t happening with regards to this pandemic that would be happening if someone had this seat?
L.G.: We face a very deep and dangerous 5 or 6 weeks. A number of international issues are of urgent concern. And it’s not clear to me—or to anybody else that I talk to in the government—who on our side should be dealing with all this. In the Bush Administration, Bill Steiger in OGHA was coordinating, if not actually making key decisions, in response to these problems. In the absence of an OGHA director, what do we do?

There is a very acute rift growing between roughly 12 wealthy countries and the rest of the world regarding access to the flu drugs Tamiflu and Relenza and to a potential H1N1 vaccine. It’s very clear that two things are conspiring to exacerbate this problem. First of all, it’s hard to grow the seed stock for vaccine. All the pharmaceutical companies are reporting difficulties that will surely mean the date of availability will be pushed back, and there will be scarce supplies. Some of the companies said we’re not taking any more orders. Well guess what? The countries that got their orders in are the wealthy world. Where does that leave 4 to 5 billion human beings on the planet? This could  turn out to be the great challenge of our time in terms of global equity and globalization, and that could affect other global negotiations from the World Trade Organization to the next Doha Round discussions, and even I would argue the Copenhagen climate change talks. Each of these has ramifications to the scientific community, and they’re being affected by how the poor and middle-income countries perceive the wealthy world’s attitude about this pandemic.

Q: There’s no WHO mandate to say, "Here’s how much vaccine exists, here’s how it will be distributed." Could anybody run the show? Do we need that?
L.G.: The only way equity and distribution could possibly happen given the scarcity issues is if the United States led the effort. We’re the biggest consumer of vaccine. We are the only one in a position to walk in and say to all the key players, "Alright, we’ve got to come to some conclusion here that’s going to both increase supply but also increase equity around the world."That’s going to have to mean some system of understanding of who needs to get vaccine. Does the United States need 360 million doses? I don’t think so. How many do we actually need? And what does the United States do with vaccine we do not use?

Q: There’s obviously the question of adjuvants, the immune system boosters that currently are not used in FDA approved flu vaccines. We could stretch vaccines greatly if we saw adjuvants as a public health responsibility.
L.G.: We absolutely should be using adjuvant. No holds barred. The attitude of the global community that I’m hearing is this is unethical. In terms of globalization, in terms of the whole future of relations between the emerging market countries and the United States and the wealthy world generally, it is absolutely imperative that we use adjuvant.

Now that brings in two sets of issues that have historic precedence. One has to do with liability questions and the 1976 swine flu vaccination campaign. The other is a large constituency of individuals that strongly believe that adjuvants have been responsible for a host of health problems, including autism.

Q: There’s another issue: Individual risk/benefit versus public good. If you use adjuvant to benefit an individual—if the vaccine wouldn’t work well without it—that’s one risk/benefit equation. But if you’re using adjuvant to supply vaccine to the rest of the world, that’s a different risk/benefit equation altogether. You’re requiring people to take risks so that others will have the product, too.
L.G.: We have a long history of accepting as generous Americans, citizens of the world, that we take risks on behalf of needy people elsewhere. Who were the first and strongest responders to the [Banda] Aceh tsunamis? United States military forces. When we look at food crises around the world, the citizenry and the government of the United States feel that it’s in our interest to step up to the plate even if it ends up costing taxpayer money. Helping the rest of the world and seeing ourselves as citizens embedded in a planetary community is not a new phenomenon nor is it one that we should ignore. And President Obama has been very clear that he wants an acceleration of our commitment to global health.

I guarantee you, if America does not strongly exercise good citizenship in this global crisis, we will pay a price in a whole host of ways that many people do not even imagine right now.

Q: Do you think Obama should come out and publicly state that the United States has decided that we will use adjuvant in order to share as widely as possible the vaccine antigen that we have purchased?
L.G.: Before the president makes any public statement along those lines, we need to see movement to fill the OGHA leadership on an emergency basis. We need a much stronger decision tree regarding exactly who is in charge of this international response on behalf of the United States. We need some rapid studies on appropriate adjuvant applications with flu vaccines.

Q: Have you heard anything from WHO in terms of its dealings with the U.S. government on this issues? Have they said anything publicly that you know of or is it all backroom?
L.G.: There’s a very high level of anxiety inside WHO, in the office of secretary-general of the United Nations, and in multiple ministries of health around the world. There’s a collective sense that we’re reaching a kind of showdown moment.

Q: Over adjuvants?
L.G.: Over equity. Look at this way. It’s not just equity of access. It’s equity of survival. If you think a vaccine is going to make a difference, even in a relatively mild flu outbreak, and save lives, then somebody, somewhere has made a conscious or unconscious decision that the life of one American is worth a few hundred lives in a poor country.

Q: If we had leadership at OGHA, would that make a big difference on this issue?
L.G.: If we had OGHA leadership right now, with a person of real stature in that job, this would be that individual’s full time preoccupation. WHO, by its charter, is a membership organization of nations. But the voting body that is the World Health Assembly, effectively the legislative body of WHO, is the ministers of health. When Director-General Margaret Chan wants to talk to Nigeria, she is speaking to the minister of health or that person’s designated spokesperson. She doesn’t speak to the minister of foreign affairs or the minister of finance. For our country, that has traditionally meant the WHO was talking to OGHA.

At one point during the Bush Administration, OGHA reached a level of power and clout that was unprecedented in its history and that literally meant no other agency representative in the entire U.S. government could speak to global players in health without clearing that through OGHA. So we’ve gone from a year ago, having that level of authority given to this obscure office most Americans have never heard of, all the way to the office is empty.

Q: Do you think it became too heavy handed before, though?
L.G.: Certainly a lot of china was broken by a very aggressive bull.

Q: You’re not referring to the country of China.
L.G.: [Laughter.]

Q: What are other examples of problems where OGHA influence would make a difference?
L.G.: We have an ongoing dicey situation involving Indonesia. The Minister of Health of Indonesia, Dr. Siti Supari, has insisted for several years that it is not the duty of her country to share samples of H5N1 bird flu viruses that emerged there, and now she’s added a host of other viruses to the list of things she will not share. 

Supari’s position all along has been that the evil drug companies will turn these viruses into vaccines, and then charge so much for their products that the poor countries the viruses came from will never be able to afford the life-saving products. What we now see unfolding with the H1N1 vaccine scenario would seem to validate her argument.

Q: What could OGHA leadership do in terms of Indonesia?
L.G.: It is vital that we have the leadership right now to say, "Look, everybody, we’re all in one world. The virus doesn’t carry a passport. This virus will cross borders and we have to have global solidarity. If it breaks down, all bets are off."

If we had an unfolding pandemic that ratcheted up a couple of notches so that the virus went through a mutational cycle and became more virulent without sacrificing its apparently extraordinary ability to transmit between humans, then very quickly distributors in the United States would discover that our N-95 masks, syringes, latex gloves, and protective gear for first responders are all made overseas. Why should India or China let their manufacturers fill American orders for these products if their countries are being denied access and cannot afford vaccine and drugs for their own massive populations?

Q: There’s a flip side to it that a skeptic would raise. This pandemic isn’t that deadly. Isn’t the scenario you’re portraying in danger of exaggerating the threat to the point where it’s scaremongering?
L.G.: The rebuttal is a no brainer. We’ve never had a pandemic 6 threat declared before. And you can argue until you’re blue in the face as to whether that was a smart or justified decision, but it has happened. What that signals to countries all over the world is not only are we supposed to rev up our surveillance and think about our pandemic response capacity, we’re also supposed to have access to some tools for our public health tool kits. Where is this stuff?

Q: Do you have an inside perspective as to why the OGHA Director has not been filled yet and whether there are candidates in line?
L.G.: There are no candidates. There is no real priority set by anybody that I can discern to getting that position filled.

Q: You’ve spoken to people about this. What do they say?
L.G.: The disappointment of Tom Daschle [who in February withdrew his name to serve as HHS secretary under Obama] set back everything in terms of appointments at HHS. There are lot of empty seats still. We also don’t have a director of the U.S. Agency for International Development and that appears to be in large part because of the vetting process. People have walked away from the job once they saw what the vetting ordeal was going to look like. There is a leading candidate and the vetting is still not done.

Q: You said you were beyond ebullient when Obama came in. Are you still?
L.G.: I’ve had a couple of cold showers. It’s apparent to me that we have very different views inside the government about what our commitments to global health and foreign assistance should look like and how they should be structured and organized.

There’s not a place on the planet that’s not challenged by swine flu right now, scrambling to come up with resources and tools and plans. Yet every country is finding it tough, and the poor countries are suffering the most. We have to show that we have an idea how to be a partner player in this new global landscape of global health.

The whole world recognizes, fortunately, that H1N1 right now is a relatively mild virus and we all have our fingers crossed that it will remain so. But it is still the test case. Thank goodness that the test for the world is a relatively mild virus. God help us if right at this moment we were dealing with H5N1 in transmissible form. Right now what the world is seeing is that when a pandemic comes, the rich world takes everything and saves itself.