The pathogenic paradoxes of globalisation

© Shutterstock
© Shutterstock
Cercopithecus aethiops, a small primate living in sub-Saharan Africa and Latin America, is a natural purveyor of yellow fever. The amiril virus is continuously present among their populations due to the mosquitoes (such as Aedes africanus or haemagogus) that transmit the diseases. © Institut Pasteur
Cercopithecus aethiops, a small primate living in sub-Saharan Africa and Latin America, is a natural purveyor of yellow fever. The amiril virus is continuously present among their populations due to the mosquitoes (such as Aedes africanus or haemagogus) that transmit the diseases. © Institut Pasteur
Aedes albopictus, one of the vectors of the chikungunya and dengue viruses. © Shutterstock
Aedes albopictus, one of the vectors of the chikungunya and dengue viruses. © Shutterstock
According to the WHO, 70 % of smokingrelated deaths over the next 20 years will be among inhabitants of developing countries. © Shutterstock
According to the WHO, 70 % of smokingrelated deaths over the next 20 years will be among inhabitants of developing countries. © Shutterstock

AIDS, SARS and avian flu: the past 30 years have seen the recurrence of major epidemics and of threatsepidemiologists thought had been relegated to the past. But while globalisation is opening up a space for new pandemics, is it also providing a geopolitical framework capable of combatting them?

In the late 1970s, leading health officials announced "the end of major epidemics".

Today, after 30 years of demographic growth and global development, the situation has been reversed. Not only are old scourges such as tuberculosis and malaria reappearing, but new pathologies are emerging and threatening the world with global pandemics. Although the nature and causes of their development are varied, they have all appeared in the new context of globalisation.

Each year more than two billion people travel by plane and millions of tonnes of goods are transported across continents. Meanwhile 60% of the world's population live in urban areas, a third of them in deplorable conditions of hygiene.

Speed and proximity

The WHO (World Health Organisation) estimates that an avian flu pandemic would infect 1.5 billion people worldwide. With an estimated mortality rate of 58 %, the consequences would be devastating. Although the epizootic has to date resulted in no more than a few hundred victims, the WHO states that "the question is not if a flu pandemic due to this or another flu virus will occur but when it will occur". Transport, urban concentration, migratory flows and industrial farming open the door to the development and propagation of all kinds of pathogens. While some already familiar pathogens are becoming increasingly resistant to existing drugs, the new global reality is also conducive to the appearance of new pathogens. "The past 25 years have brought 38 new pathogens," declared Professor Mark Woolhouse, epidemiologist at Edinburgh University (UK), at a seminar of specialists held in Saint Louis (US) in 2006. Of these new diseases 70 % are zoonoses, i.e. pathogens transmitted from animals to man.

Man and animals

If BSE, or ‘mad cow disease', failed to produce a draconian surveillance of intensive farming, avian flu is now confirming the need for precisely that. Rudolf Klein, Professor Emeritus at Bath University (UK), believes that the authorities had been aware of the risk linked to BSE since at least 1988 but had failed to sound the alarm. The result is 27 billion euros in lost revenue and more than 130 cases of Creutzfeldt-Jakob disease. As to avian flu, the Director-General of the International Office of Epizootics condemned at the time the reluctance of the affected countries to signal the pathogen's appearance.

Doctor André-Laurent Parodi, former member of the European Commission's Scientific Committee on Animal Health and Animal Welfare, believes that "high bird concentrations and domestic birds living in close proximity to man probably facilitated the appearance of cases in humans."(1) Deforestation, the extension of agriculture, poverty, or on the contrary, increased standards of living, can cause man to come into contact with wild animals that carry pathogens. Civet, a delicacy in China, could be at the origin of the SARS epidemic following importation of the meat from Asia and increased rearing of the animal to meet growing demand. Ebola, Marburg and Aids are three epidemics that probably originated in Africa and more precisely in viral strains carried by monkeys. As we claim new uses for land, there are more interactions with wild species - which are sometimes eaten, as in the case of monkeys - thereby opening the door for the transmission of viruses between species... and mutations in these viruses.

Climate change, dam constructions and international transport have favoured the resurgence of local epidemics and the spread of pathogens, especially those carried by the mosquitoes that spread malaria, dengue fever, chikungunya or Rift Valley fever. First identified in the Philippines in the 1950s, dengue fever today threatens 40% of the world's population. There is currently real concern that these diseases will migrate northwards in the event of global warming.

The bad habits of the North

While epidemiologists agree that Southern countries are the favoured sites for the emergence of new diseases, the Northern countries risk transmitting their pathologies to populations of the South. The WHO believes that over the next 20 years 70 % of smoking-related deaths will be in developing countries. Western lifestyles are being exported worldwide with all their associated ills, such as diabetes, obesity and drink-related problems. Tikki Pang, Director of the Department of Research and Cooperation Policies at the WHO, believes that "a key factor in the increase in these ‘lifestyle diseases' is the unprecedented increase in world food trade and its domination by large companies with aggressive marketing strategies." (2)

Another scourge of globalisation is sex tourism, estimated at 60 million participants a year. This not only spreads sexually transmitted diseases but also generates serious psychological disorders, especially among the millions of children who are abused or exposed to prostitution.

Many different actors

Globalisation is not responsible for all these evils per se, but it is creating the framework in which they are appearing. Can we also hope that it will provide the means to combat them?

In an interconnected and better informed world with many networks of authority, globalisation permits the creation of operational structures such as the WHO's Global Outbreak Alert and Response Network (GOARN). Present in 120 countries, its role is to detect, alert and warn in the event of a health emergency. "Its structure in the form of a network of multiple independent actors who are continuously exchanging information ensures it remains independent of governments and the WHO management," says Olivier Vilaça, an expert in political geography and former director of co-investment partnerships with the private sector for the Global Fund to Fight AIDS, Tuberculosis and Malaria.

As a communication tool, it makes it difficult for certain states to conceal a risk. As an operational structure bringing together actors from many different sectors, it guarantees a rapid response in the case of an alert.

Should the WHO opening up to networks in this way be seen as symptomatic of its failure to establish itself as the legitimate coordinator of the fight against AIDS? Olivier Vilaça believes that its "inability to take the prevention and treatment dimensions into account" has opened the door to new actors with many different origins, resources and interests. With the Global Fund to fight AIDS, Tuberculosis and Malaria, UNAIDS, the Gavi Alliance, activist networks such as ActUp, private foundations, transnational companies and scientific communities all involved, combating epidemics is becoming everybody's fight. Globalisation marks the end of global health being governed by a few countries or a single international body.

Conflicting interests

Having many different actors engaged in combating multidimensional problems raises the issue of conflicting interests. Although such a polycephal functioning can at times be sluggish it does make it possible to break certain taboos when it comes to subjects as serious as major epidemics. What kind of globalisation is it that denies many Southern countries access to medicines produced in the North, namely the molecules continuing to be protected by patents? A WTO agreement (World Trade Organisation) signed in 1995 and amended in 2001 regulates this intellectual property right and authorises governments to issue a compulsory licence for the production of a patented substance. The general case regulation nevertheless limits this licence to use inside the country and mentions that unspecified financial compensation will be paid to the patent holder. This imprecise agreement is regularly the source of conflict between activists, pharmaceutical companies and countries facing health problems.

According to Olivier Vilaça: "The debate on patents shows the current tension between the former system of international trade and the emergence of health, as seen as a global public asset, provided principally by nongovernment actors." Just as fear of a third world war caused Western nations to move closer together during the latter half of the 20th century, will the threat of pandemics be strong enough to instigate a global governance able to confront global health challenges? "Globalisation enables diseases to spread at a speed and on a scale that are unprecedented, but also brings the obligation to build a global political platform that demonstrates there is more to globalisation than the economic dimension alone," says Olivier Vilaça. Let us hope that the assertion by Charles Nicolle, winner of the Nobel Prize for Medicine in 1928, who wrote, "knowledge of contagious diseases teaches men that they are brothers and must stand together," does not remain a dead letter.

François Rebufat

  1. www.asmp.fr/travaux/communications/2007/parodi.htm
  2. www.nature.com/embor/journal/v5/n1s/full/7400226.html


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The global village on alert

Described by WHO(3) as a genuine "revolution", the new International Health Regulations (IHR) entered into force in 2007. They replace the 1969 regulations, extending their scope from just a few specific diseases to all emergency situations with potentially international consequences. The key terms are "early detection" and "management at source", i.e. before outbreaks can pose an international threat. To ensure the regulations are a success, 193 states and many public and private partners are supporting them. The IHR apply beyond national borders, thereby limiting the risk of countries trying to conceal the facts and delay action in the event of a health crisis.

WHO is well aware that 115 of the signatory countries lack the means to apply the regulations in full. It is therefore committed to helping these countries acquire the necessary structures to do so. While Doctor Margaret Chan, Director-General of the WHO, believes that these "universal threats" require "global solidarity", the anthropologist Yannick Jaffre of the Centre National de la Recherche Scientifique - CNRS (FR) remains realistic in seeing this aid by rich countries as "an essential insurance policy". The WHO's implementation of the GOARN in 1996, the creation of a European Centre for Disease Prevention and Control in 2005(4) and the 2004 opening of the European Med-Vet-Net(5) research network for zoonoses are all initiatives that confirm the commitment of countries - or at least the richest countries - to acquiring a system able to match the challenges of a globalised health.


Bioterrorism, an essentially psychological weapon?

Viruses, bacteria, mushrooms... the apprentice bioterrorist is spoiled for choice when it comes to choosing from an estimated 180 pathogens. Despite this, bioterrorism seems to be more of a psychological weapon than a real threat to health. When implemented with scant resources its effects will remain limited, since producing a highly pathogenic agent requires complex handling and technical means available only to major organisations, if not governments. Yet even the inexpert use of a pathogen such as the carbon bacillus in a public place, would have a devastating effect at a local level.

As the main target of bioterrorism are civilian populations, protecting them is a genuine challenge for the authorities. Should populations be given preventive vaccines, ‘indicators' - such as genetically modified plants that change colour on contact with agents - placed at public places, or special air filters fitted to limit the spread of toxic fumes? Do core structures have the means to cope with a crisis and are individuals and communities prepared? There is a need to avoid fear and panic, to have rapid warning and action devices, and to maintain operational structures. Between 2003 and 2004 alone the United States spent an extra $1.7 billion to ‘secure' its postal services.