News from the WHA

This is a long one - I promise the next several notes will be MUCH shorter reads!

So the World Health Assembly (WHA) has been going strong for about a week and is officially nearing an end. While just about every health topic under the sun was discussed, I'll highlight a few here - in particular, the international brain drain of health workers; Bird Flu in Indonesia; and Taiwan's attempted entrance into the WHO. This note builds on information from previous notes by Carolyn Bennett (Taiwan and the WHO; Gender, Docs and Canadians at the WHO) and myself (WHO must shift vaccine policy). I believe Carolyn (MP for Federal riding of St Paul's) attended the WHA in Geneva, so if you're reading her blog/notes I'm pretty sure it reflects views from somebody who was actually there shooting the sh^t with people and participating first hand. For additional information on all of the agenda items discussed, visit http://www.who.int . Ok here we go...

1. International brain drain of health workers

In one of her notes, Carolyn touched on a meeting she had with Dr Ndioro Ndiaye (Deputy Director, IOM) on how much the poor health status of so many developing nations is exacerbated by the exodus of their best health workers to the schools and salaries of wealthier countries. Some leave knowing they will not return, with the idea that their future holds more promise in Europe, USA or Canada. Many others leaving for educational reasons, for example, go away with the plan of a return to their native land, but often find incentive to stay and work in their new home. This type of international brain drain leaves behind in 'source countries,' a tremendous void in already-resource-limited sectors, with public health care leading the way. In Malawi alone, for example, the past five years have seen 85% of doctors/64% nurses/52% of health administrators leaving the local health care system for international NGOs or for work overseas (UK, followed by NAmerica). To say they are nowhere close to meeting their countries' needs would be an understatement of astronomical proportions - yet the case of Malawi is not dissimilar to what is happening elsewhere in sub-Saharan Africa and the poorer countries of Asia and Latin America. This cycle continues while countries such as the UK, USA and my home of Canada continue to have immigration policies that recruit highly skilled workers from developing nations, many of whom come to service health sectors which we are perfectly capable of producing homegrown talent for. So what can we do about it? In a globalized world, immigration provides so many economic and cultural benefits, not to mention a potential for increased tolerance across borders. For all the benefits I have to ponder the Q - can we do a better job of it? When managing our immigration trends can we consider the consequences to elsewhere in the world instead of only the benefits or potential for prosperity an applicant brings to our society? For the health professionals who have come to this country and found employment, can we develop a mechanism to work with them and provide incentives to return home for short/periodic professional rotations in their field? Finally, we must look at this not just from an immigration perspective but from a development one. In providing greater assistance to countries to develop their own industries, improve their schools and health systems, we can help reduce so many of the reasons that force people to leave their homes in the first place.

For further reading on this I recommend you to the following article: Coombes R. 2005. “Developed world is robbing African countries of health staff.” British Medical Journal. Volume 230, p.923.

2. Bird Flu & Indonesia
(For CBCs take on this, check out http://www.cbc.ca/health/story/2007/05/23/bird-flu.html)

Earlier this year I discussed Indonesia's role in spearheading the developing world's campaign for a fairer mechanism to distribute pharmaceutical products. For the past 50 years WHO has been collecting virus samples from all over the world, and sharing them with vaccine companies who generally charge prices for their products which are far too expensive for developing countries to afford. Fed up with the process, Indonesia (where majority of human bird flu cases exist) stopped sharing samples for a couple months earlier this year, putting global pandemic vaccine production on hold. They later resumed sharing once WHO acknowledged there must be a change in course from traditional policies and promised to negotiate a fairer deal with the developing world with all parties. This issue was once again debated at the WHA where all 193 members agreed that virus sharing will continue with it being conditional that a better mechanism be developed. While it is wonderful news that the sharing process has resumed, I am concerned at the prospects for success at reaching such a deal anytime soon. While this story has been developing, a handful of reports have brought to light the fact that most of the companies that are making PanFlu vaccines are based in Europe - and that these countries have national crises/public safety laws making it illegal for vaccine products to be exported during a pandemic before their own citizens have access to it, and that even if a guaranteed stockpile is allocated to the developing world free of charge (to them) - it may be too late in reaching them for their needs to be met. This means that solving this problem of fair access is not just about finances and the developed world putting up the funds for poorer countries to have a supply in a time of crises - the issue of timing and being able to get the vaccine to them at the time they need it is just as critical, making WHOs plate even fuller with these negotiations. A new imagination is needed about this - and if several countries lose patience in how long it will take to develop a new mechanism and consider another stop of sharing, then we've all got bigger problems.

3. Taiwan & International Health

Also in her blog, Carolyn informed us that it seemed as if several of WHO's members were prepared to vote to allow Taiwan meaningful participation in the WHA and in shaping the agenda for the coming year. When the motion was called, however, it asked the assembly of WHOs members to consider granting Taipei full membership (as opposed to a partial option) which was ultimately defeated after a long day of voting. For those who are out of the loop on this one, Taiwan has a tremendous interest in using its health workforce and technological brainpower in becoming more active in global health affairs, and as an important part of their strategy to do so they are seeking formal membership to the WHO. WHO, as an agency of the United Nations, has a membership consisting of independent countries. The big controversy in all of this is that China, being an important member of the WHO, considers Taiwan to be part of their country and does not recognize them as an independent sovereign nation. So when the annual vote comes to pass at the WHA, the majority of delegations have elected to vote with the Chinese and will likely continue to do so as long as the motion being voted on is asking for Taiwan to receive full membership. Now questions and proposals of various kinds debating the prospect of some special type of *partial membership* have been floated around, but (to my knowledge) have not been voted on. With several members in the position of wanting Taiwan to play a meaningful role in things, while not being comfortable voting for them to have full status - if a motion calling for some unique level of partial membership was ever put to a vote, it is certainly much more likely to pass than traditional motions on this have been and Taipei will be able to be much more involved than ever before - even if it's not to the level that they want.

PPAO, Elder Abuse ... & getting you a bloody Will already!!

Last month I finished my most recent tenure with the Patient Advocate Office of Ontario's Ministry of Health & Long Term Care. Among other things, the PPAO works to:

- provide advocacy & rights advice services to patients;
- address hospital/facility-based or provincial systemic issues impacting on patients' rights;
- public and health care professional education through speaking engagements, publishing reports and engaging with the media.

Since my first contract with them, a decent share of my job involved policy research into things like the rights of mental health consumers; the impact of patient advocacy services on health outcomes; as well as elder abuse issues in our province's Long Term Care facilities and policies that have been identified to counter these problems. As one might imagine they weren't the most uplifting of files - but I was glad to have had it as this experience taught me a great deal about some of the most vulnerable members of society, and the limits of our health & social services in being able to meet their needs.

If there is one lesson above all others that I can take with me and shout out to all uh yall - it is that everybody should consider making a living will or power of attorney, even if you're one who thinks you have nothing to lose. While planning how to and who can distribute one's finances are what most people think of (definitely important) - it is only one aspect of why such documents exist. What's also at stake is who can make your medical decisions should you ever be diagnosed with a condition or have suferred a trauma which has left you incapable of making your own treatment decisions. Do you want to be kept alive at all costs? Do you want to be given a controversial or unproven experimental new therapy that might make you worse off for that chance to be a little better? The truth of the matter is that many of us (esp us younger cats) haven't even considered these types of things well enough to know how we really feel - but if we don't make these decisions and leave it to chance - by default these decisions are going to our closest relatives or worse perhaps, a public appointed guardian whose never met you. The Toronto Start reports that a whopping 80% of North Americans have not signed any sort of living will.

Yet while family might seem the logical choice in such unfortunate scenarios - even in the case of relatives who we don't doubt love us unconditionally, we may still disagree on many many things, let alone something as personal as this. Heck - when it comes to treatment decisions love may even be a weakness, as some people have great difficulty letting go or making the difficult decisions the patient might have wanted in favour of their own self interests or ideologies. While health facilities have a great deal to work on themselves - the reality is that the lion's share of abusive decisions or one's against what a patient wants or would have wanted are taken by the relatives they know and love who have been empowered with the legal voice of consent. Once you know what you want it's not hard to control your fate here - it's about finding someone you trust to act out your wishes, putting it down on paper, and then putting copies of it in the rights hands or an easy to find place should it ever be needed.

Ok so I've rambled way beyond the realm of Elder Abuse here as the whole issue of consent is important for all situtations were one's ability to manage their financial or treatment decisions is in question. Nevertheless it was the issue of Elder Abuse (both financial and physical/mental) that started me down this path and which I continue to remain interested in. I'm working on a longer piece about the past and present situation in Long Term Care facilities. I know a number of you have a wealth of knowledge in this area from either work or personal experience with friends/family ... if you care to share your stories/ideas/anything with me I'd love to hear it - feel free to email me at bryan.heal@learnlink.mcmaster.ca

Recognizing a Stroke

As published by most of the heart & stroke associations, the 5 hallmark warning signs of a stroke are:

- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden, severe headache with no known cause

If you experience these symptoms, or know someone who is - Immediately call 9-11 or whatever the emergency services number is where you are. Chances of recovery with minimal disability is GREATLY enhanced if the victim reaches hospital within 3 hours of the onset of symptoms.

Spread the word to everyone you know - especially to all in regular contact with elderly individuals. Too many victims could have been better off if they or those around them were able to sooner recognize the combination of symptoms as what they were and called for medical help.

Heart & Stroke conditions are the leading causes of death and disability in Canada. For more information on risk factors, and what you can do help prevent your chances of developing complications - visit http://www.heartandstroke.ca

WHO must shift vaccine policy

Although it’s been overshadowed in the news by all kinds of events, there’s been a new global health dilemma brewing in recent months that’s worth talking about. Highlighted by the recent standoff between the Indonesian Government and the World Health Organisation (WHO) over highly coveted Avian Influenza samples, a long standing practice of pharmaceutical companies and the WHO has been called into question and looks like it could forever change – with many of us potentially footing the bill.

Health officials all over the world are scrambling over how best to prepare their country’s people in the event that the dreaded *Bird Flu* should mutate and unleash itself as the next killer global pandemic. With much scepticism as to the feasibility of existing response plans to something this massive, there is much hope being placed in the development of a vaccine which if engineered successfully and used appropriately would theoretically keep fatalities to a minimum. One of the challenges scientists face with this modern day hunt for the cure, however, is the nature of the virus itself … Influenza is known to be highly prone to mutation (even for a virus), and current strains are rapidly evolving into new ones – many of which are significantly different from their predecessors. What this means is that for a vaccine to be effective it is important that it is based on the most current strain(s) possible – and therein lies the opening of this can of worms.

Indonesia has thus far been the unfortunate home to most of the human cases of H5N1 Influenza, including the most recent ones. As the lead agency monitoring global progress of the bug, it has been customary practice for local health officials to send samples of newly identified strains to WHO. WHO, in turn, historically shares these samples with vaccine makers so they can get to work on the most effective concoctions for prevention and treatment. These vaccine makers, however, are for profit corporations, whose products have largely been far too expensive for most countries to afford for their people. Increasingly angry, the Indonesian Government in recent months has championed the call for the developing world and stopped sending WHO H5N1 samples until this policy changes. Donor governments (e.g. USA, Canada) have in response stated that developing an H5N1 Flu vaccine is a matter of theirs and everybody’s security, and vaccine makers have complimented such remarks by stating that without access to recent strains, it will be near impossible to develop an effective vaccine. While both of these facts are certainly true, Indonesia’s concerns are nevertheless compelling, and include:

- International vaccine makers use strains identified locally to develop and mass produce commercial vaccines at a price which Indonesia cannot afford

- Since developed nations can afford the vaccine, and developing nations cannot, the current system reinforces & propagates already large global health inequities

- Indonesia’s position is supported by many other developing nations who agree the sharing/cooperation system must change so that it becomes practical for all people to reap the benefits of medical discovery

In recognizing the potential impact of these events, WHO has moved quickly to broker a compromise, and as of Tuesday (27 March 2007) Indonesia has resumed sharing samples with WHO. WHO has promised that they will not misuse any vaccine shared with them; that while new strains will still be used for vaccine research, they will facilitate technology & assistance transfers to set up local vaccine production capabilities. It has also been rumoured that WHO is considering brokering a *guarantee* of sorts such that in the case of a worldwide Pandemic, as incentive for pharmaceutical companies to manufacture enough vaccines they will purchase a large stockpile strictly to meet developing country needs.

Though I applaud the effort to resolve this dispute and acknowledge efforts from all parties to get the pipeline moving again - it’s this guarantee that is most interesting to me and which merits further discussion. WHO and many of its donors have acknowledged the need for developing countries to be able to access vaccines, or have increased capacity to produce their own. With this new Pandemic ‘insurance’ strategy of sorts, it is appropriate to ask if this will serve as a precedent for how things are to be coordinated when another disease emerges and rings global alarm bells. Secondly, and perhaps most important is a debate around who will pay for this? If this guaranteed purchase is to go forward and be of a meaningful size, and if we are to assume the *discount* they get from vaccine makers will still be earning these companies huge profits, we are talking about a potentially multi billion dollar commitment here. As an agency of the United Nations, the WHO receives its primary funding from its membership – which generally means countries who buy into it, with the lion’s share of financial support coming from the industrialized world. What that means is that the taxpayers of the G8 and other donor countries might have just been asked indirectly to cough up billions in support of these efforts.

Now I am not saying the commitment isn’t worth it – it is – there is no doubt that isolating this virus locally and ensuring its containment everywhere including the developing world is in all of our best interests. It’s just sad that it has come to this. Like most major aspects of international development, it all boils down to the widening gap between the wealthy and the poor. Most people on Earth are living in countries which cannot afford to provide necessary health services or develop strong economies – and many of the reasons for this are a result of our own trade policies, loan conditions or other possibly-well intended development schemes. I’m no economist, but irrespective of the health and welfare of others argument – wouldn’t it also be cost effective for the developed world to assist more developing nations in becoming prosperous so they can produce more of their own solutions, instead of having to cough up billions every time an international threat could potentially reach our shores?

Flu vaccine photo taken by the US Center for Disease Control and Prevention (CDC)