Who Pays to Stop a Pandemic?

By Ruth R. Faden, the executive director and Patrick S. Duggan is the research coordinator of the Johns Hopkins Berman Institute of Bioethics and Ruth Karron, the director of the Center for Immunization Research at the Johns Hopkins Bloomberg School of Public Health (THE NEW YORK TIMES, 09/02/07):

BIRD flu has not yet turned into a pandemic, but it is already killing the meager hopes of some of the world’s poorest people for a marginally better life.

When poultry become infected with the deadly strain of avian influenza (H5N1), it is essential that all birds nearby be culled to prevent further spread. We all stand to benefit from this important pandemic prevention strategy, recommended by the World Health Organization and the United Nations Food and Agriculture Organization. Unfortunately, however, the world’s poor are unfairly shouldering the burden of the intervention.

Last month officials in Jakarta, Indonesia, announced a ban on household farming of poultry there. The domestic bird population of Jakarta is estimated at 1.3 million. Thousands of families were given until Feb. 1 to consume, sell or kill their birds. Now inspectors are going door to door to destroy any remaining birds.

The Indonesian government pledged to pay about $1.50 for each bird infected with the H5N1 virus, a sum that may approximate the bird’s fair market value. But most birds that have been killed under this policy are healthy, so their owners, most reports suggest, will receive nothing.

Moreover, it is not clear how Jakarta’s poor will replace the income they once received from chickens and other birds. When officials impose widespread culling, industrial-scale poultry producers — like the company that owns the large British turkey farm where bird flu was found this month — usually have the resources to absorb the losses. But when the birds of small-scale poultry farmers are culled, entrepreneurs who were just beginning to move up the development ladder can be plunged right back into poverty. The most dependent and vulnerable members of the community become even more dependent and vulnerable. “Backyard birds” are the only source of income for many women and children.

Families whose birds are found to be infected with the virus may suffer even more. People in Cambodia, China and India whose poultry have been blamed for avian influenza outbreaks have often been subject to extreme stigma and isolation, and there have even been reports of suicides by desperate farmers.

It is inevitable that the world’s poor will suffer most from a pandemic. A recent article in The Lancet predicted that if the next pandemic were to mimic the huge 1918 flu outbreak, 96 percent of an estimated 62 million deaths would occur in developing countries. But specific steps can and should be taken now to prevent or mitigate the injustices that are already occurring.

We are part of a group of 24 government officials, public health experts and scientists from 11 countries who recently met in Bellagio, Italy, with the support of the Rockefeller Foundation to call attention to how pandemic planning affects the world’s disadvantaged. We created a checklist for avian influenza control that explicitly calls on the authorities to compensate people who suffer losses from bird-culling programs, regardless of whether the destroyed birds are infected with the avian influenza virus.

Such a program in Jakarta alone would be expensive. Just to compensate families for their culled birds would require nearly $2 million, not including the cost of administering the program. Indonesia’s domestic bird population countrywide is estimated at 300 million, so if the culling program were to be expanded beyond Jakarta, the total compensation cost could run as high as $450 million.

Indonesia’s avian influenza budget for the coming year is reported to be less than $50 million. Clearly, without donor assistance, the government cannot afford to compensate families and farmers fairly. So the burden of pandemic prevention must also fall on the world’s wealthy nations.

Last year, the United States, the European Union and other nations pledged more than $2 billion to the global war chest for avian influenza response. Developing a program to compensate poor families in countries with limited resources is an enormous challenge. But it is time that the money pledged by the donor countries reach the people who are already the first victims of the next pandemic.