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 Obama’s 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.org and 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 Garrett’s ―Castrocare
in Crisis‖ published this year in Foreign Affairs. Earlier in the summer we
got clues to radical changes underway in Cuba when the individual that
had served as our ―minder‖ during a November 2009 trek around the
country’s 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 the
government 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
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 has
to, 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 island’s
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 AIDS
Programme (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 extremely
time-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, CFR’s new senior fellow for global health, launched 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 Health
Policy 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 the
Yale School of Public Health. The series is closed to the public and over-subscribed, but earnest
queries may be directed to Daniel Barker (dbarker@cfr.org).

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 Development
Goals‖, and another on Food Security, ―Global Food Security: Prospects for Investment and
Development‖, which was off the record.

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 President Obama’s development strategy revealed

In a speech to the United Nations General Assembly on September 23rd President Barack Obama
detailed his administration’s new set of foreign assistance policies, including those directly involving
health. The landmark and novel development framework follows an often frustrating 18 month
internal debate in the administration that involved input from at least four branches of the Cabinet,
and a long list of federal agencies. The President’s words had barely been uttered before most of the
leading development and global health oriented groups in the U.S. were lining up to sing President
Obama’s praise (except those focused on money-raising, which will be discussed further below). The
largest umbrella of development-oriented organizations, think tanks, religious groups and advocates,
the Modernizing Foreign Assistance Network, declared the Obama administration’s discourse, ―a
major victory,‖ for poor people worldwide, signaling, ―America’s first development policy, which at
long last provides a roadmap for more strategic, effective, accountable U.S. foreign assistance.‖

Coinciding with the President’s speech, which

was delivered during the Summit focused on the
five-year countdown for the Millennium
Development Goals, a slew of documents were
released by key US agencies, detailing their roles
in fulfilling the Administration’s new mandates.

Perhaps the most critical theme of the President’s

speech was Obama’s belief that foreign
assistance cannot and should not be viewed as
charity. Rather, Obama insisted, it is a
fundamental 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 what’s needed most right now – is
creating the conditions where assistance is no longer needed. So we will seek partners who want to
build 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) tell
us 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 why
the 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 the
QDDR 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. Kennedy’s 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 be
asking 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 President’s Emergency Program for AIDS Relief (PEPFAR) and
President’s Malaria Initiative (PMI) will have to integrate their efforts more closely with those
executed 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 Disease
Control 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 President’s words, ―As the final pillar of our new approach, we’ll insist on more
responsibility – from ourselves and others. We’ll 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 recent
Center 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 CGD’s website, Christina Droggitis comments on the
overwhelmingly 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 Obama’s 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 the
new 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 with
HIV, 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 President’s UN speech the Department of Defense
announced that $1 billion worth of bio-weapons funding given to DOD by Congress this year will be
diverted 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 the
November 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 likely
to 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 spend
liberals‖ 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 the
spectacular 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 life
expectancy 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 Public
Health.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 is
now 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 America’s 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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A key cause of this widening wealth gap was a change in U.S. tax law that went into effect during the
first term of the Presidency of George W. Bush. The Denver Post recently explained that until the
1960s the highest income tax rate was 90 percent; during the 1980s under President Ronald Reagan
the top taxation rate fell to 28 percent, but the following George Bush Administration raised the tax
ceiling to 39 percent, and by the end of the Clinton Presidency the upper limit was 39.6 percent -- and
the U.S. government had a budget surplus. Days after taking office in 2001 George W. Bush
successfully pushed the tax ceiling down to 35 percent.

The great gap widened further as a result of the 2008 financial crisis and ongoing global recession.
Last year, according to the World Bank, wealth gaps increased in most countries in the emerging
market and traditionally wealthy world, with money concentrating not in the top 10 percent, but in the
top 1 percent of the richest citizens’ coffers. The most extreme gap among industrialized nations
emerged in the United States, which now ranks at about the same level as Zimbabwe. The algorithm
used to express wealth distribution, Gini Coefficient, hit 0.46 in the US in 2009, double that of
Sweden (0.23), far worse than the UK (0.34) and the rest of Western Europe, and just 3.2 points
better than Zimbabwe (0.50).

The U.S. 2009 census showed a striking increase in poverty, with 4.2 million Americans dropping
below the federal poverty line in a single year, for a total of 43.6 million. Even among employed
Americans the Census news was grim: The bottom 20 percent of U.S. wage-earners garnered a
combined mere 3.4 percent of the nation’s income in 2009. In contrast, the top 20 percent income-
earners grabbed a combined 41.5 percent of national income. Real value median income in the US has
plummeted from nearly $52,000 in 2001, to $49,777 in 2009.

David Rothkopf (no radical – former managing director of Kissinger and Assoc.) offered a striking
analysis of this trend in his 2008 book,
SUPERCLASS. Rothkopf points out that in 1900
the wealth gap between richest and poorest nations
was 9:1; by 2008 it was 100:1.

The World Bank Gini coefficient estimates have

worsened over the last 25 years in almost every
country in the world -- especially the big emerging
markets of China, India, Eastern Europe and
Russia. Robert Frank (author of ―Richistan: A
Journey Through the American Wealth Boom and
the Lives of the New Rich‖) argued before the 2008
financial crisis that the top 1 percent wealthiest
Americans (earning more than $350,000/year) felt
they were merely middle class, and expressed great
jealousy towards the truly rich – the 0.1 percent
wealthiest Americans, raking in more than $2.3
million annually.

Angela Ismailos, the wife of shipping magnate

George Economou, backed by a purple sail, on
her dream boat, Baracuda. Photograph by Todd
Eberle for Vanity Fair.

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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 tax
changes, 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; the
top 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 than
they 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, few
people 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 safe
drinking 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 on
their 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 to
the 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 Communiqué: http://www.g20.utoronto.ca/2010/g20finance101023.html.) The Ministers
shook 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 early
stages of a currency war, in which nations are
following China and Japan to deliberately
devalue 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 no
longer as apparent as it seemed when the MDG targets were set in the 1990s. "Even before the crisis
there 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 nation’s
banks and growing thanks to resource gains (e.g. petrochemicals and crude oil) or debt servicing (such
as China’s absorption of U.S. debt). According to the 2010 Preqin Sovereign Wealth Fund Review the
aggregate value of the world’s sovereign wealth funds (SWFs), ―now stand at $3.51 trillion, which
represents a 9 percent increase from last year’s figure, confirming that sovereign wealth funds have
retained their collective significance in the world of institutional investors. The largest sovereign
wealth 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 Norway’s Government Pension Fund – Global and China’s
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 or
invested 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 population’s
consumption, 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 2015
targets;
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 health initiative.
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 their
national 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, nobody
believes that to be true.

Economist Jeffrey Sachs, Director of the Earth Institute at Columbia University, decried the modest
funding 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 model
Millennium 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 and
Michael Clemens insist that the Millennium Villages programs haven’t done 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 world’s 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 approach
universal 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 Fund’s
main advocates and political groups worldwide. A stage was set for failure, frankly: President Obama’s
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 that
require Congressional approval. Advocates that have been denouncing President Obama, and
charging that George Bush was a better friend of people with AIDS, will soon discover how much of
the Obama Administration’s 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 soft
money, 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 $11
billion, more than $2 billion shy of what it claims is the minimum necessary to stay the course.

Médecins 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 will
result 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 crisis
plan 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 low
scenario ... 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 be
lowered.

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 currency
transactions, garnering a projected $33 billion annually, was rejected as a ―new tax measure‖ that
―won’t 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;1–11) offers
several thoughtful, well-researched case studies on the impact of the Global Fund’s targeted disease
programs on general healthcare delivery in Thailand, Papua New Guinea, Indonesia, and Laos, 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:

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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 when
the 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 in
galvanizing 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 the
governance of global health.‖

Water

It’s hard to imagine anything more basic to human health than oxygen and water. As mentioned
above, 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 reasons
shun 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 water
scarcity, shrinking global biodiversity and human health. The main message: ―80% of the world’s
population is exposed to high levels of threat to water security.‖

The researchers find that most of the world’s 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 and
North 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 a
very 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?

13
 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 amounts
of most of these elements can be found in soil samples all over the world, extraction of these exotic
chemicals 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 you’ve got plugged
into 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 21 st Century
green revolution. China invested heavily in development of novel methods of extracting REEs from
concentrated 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 considered
consequential. 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 part
of 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

14
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 a
Chinese 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 electric
car production to a halt. Though there is widespread skepticism about Japan’s claim of Chinese
government intervention in REE exports, the controversy spurred the rest of the world to wake up to
the 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 European
electric 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 Wen
Jiabao 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 least
environmentally 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 world’s supply of raw ingredients used for everything from aspirin
to heparin, vitamin C to advanced psychoactive pharmaceuticals.

15
A large proportion of the world’s supply of aspirin,
acetaminophen, and the stabilizing compounds
used to formulate drugs into pills and capsules
come from Chinese factories, such as the one
depicted to the right. According to CFR’s
Yanzhong Huang: ―In 2008, 40 percent of foreign
drug manufacturers registered with the FDA were
Chinese and Indian, up from 30 percent in 2002.
According to a 2007 GAO report, China has the
largest number of registered drug manufacturers
exporting to the US (India is a distant second). For
example, 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, achieved
more 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 weren’t harbored by animals, probably
monkeys, 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 Jenner’s original smallpox vaccine was made from
another 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, finds
that 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 human
cases 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

16
 (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 the
H1N1 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 have
been shown to carry, or die from, H5N1. Most of these
pig 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: Virology
Journal 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 falciparum
malaria in human beings – the form now circulating in Africa – originated in gorillas. (See: Nature Vol.
467:420-425.)

17
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 between
microbes 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 across
species. For those keeping count, the rate of this transmission, the authors say, is startling:

―Environmental gene transfer frequencies…are 1900 to 459 million times the

frequency 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 are
among the leading causes of hospital
infections and deaths. First noted in
British travelers that had sought
medical treatment in India, the
mutation 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 bacterial
resistance 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 other
enterobacterial strains, indicating the gene is shared across bacterial species. The gene, NDM-1,
18
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 Health online (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) since
1955, 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 today’s
38 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:

19
 Between 1940-1945, before widespread vaccination, as many as 147,000 cases of
pertussis were reported in the United States each year, with approximately 8,000
deaths 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 reported
cases 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 the
Centers for Disease Control and Prevention
reports the incidence of pertussis has jumped
400 percent since 2009. It should come as no
surprise to public health leaders that California is
Ground Zero in this outbreak, as the State is also
home to a powerful anti-vaccine movement, led
by celebrities and doctors that continue to claim
that 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 individual
eliminates herd immunity or shared burden of health insurance costs. Thirteen percent of California’s
parents have made that choice for their infants, refusing to immunize them prior to entry into
kindergarten. And the highest rates of refusal are in the State’s 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. California
Governor 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

20
 pertussis are often associated with changes in the B. pertussis population. Most
recently, we have shown that more virulent (P3) strains have appeared which we
believe to be (partly) responsible for the outbreak in the Netherlands. The P3 strains
have emerged worldwide. Any discussion on the causes of sudden upsurges in
infectious 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 <http://www.cdc.gov/eid/content/15/8/1206.htm>

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 climes
peaking 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): 831–839.)

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

been reported in Northern Ireland (Date: Thu 14 Oct 2010; Source: The Belfast
Telegraph <http://www.belfasttelegraph.co.uk/news/local-national/northern-
ireland/measles-outbreak-declared-after-eight-fall-ill-14976232.html>), England,
Wales, Australia, Zimbabwe, and Zambia.

The Council on Foreign Relations Global Health Program is

currently compiling a chart of vaccine-preventable outbreaks and
epidemics worldwide. We intend to post the chart, which will be
regularly 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. The
surge 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 corn to rice have also been rising in a
trend that bodes ill for the bottom 2 billion poorest people on earth.

21
UNICEF estimates that a quarter of the under-five year old deaths in Central and Western Africa are
due 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 UN’s Food and Agriculture Organization (FAO) says in its annual report (State of Food
Insecurity 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 chronic
hunger.‖

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 in
other 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 another
type 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 two
years ago, when price volatility, market
speculation and poor harvests formed a
perfect storm that led to food riots all over

22
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 driven
prices 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 as
much 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 farming
tools. 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 about
continuing 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 L’Aquila 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 — the
Global Agriculture and Food Security Program — to implement the pledges. In
addition to contributing to the trust fund, the United States launched its own Global
Hunger and Food Security Initiative, called ―Feed the Future.‖ Other initiatives are
underway at the UN, within the European Union, and at other multilateral
organizations.

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 Gates
Foundation have committed to the World Bank trust fund. This ambiguity has led
some African officials to question the Fund’s sustainability.

23
 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 people
are 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 swarming
over 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 waste
treatment facilities?

Ask Republican Senator Tom Coburn, an Oklahoma conservative who is, according to Obama
Administration 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

24
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 compassionately
with 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 emergency
supplemental bill that included $1 billion for Haiti."

But Coburn insisted, the State Department has "done

nothing for 10 weeks," and "Contrary to various news
reports, the bill I expressed concerns about at the end
of the session had nothing to do with our current
mission. The bill in question, sponsored by Sen. John
Kerry, 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 irresponsible
for 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 and
duplicative 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. Leadership
requires choices and sacrifices. The people of Haiti, and the world, are watching and waiting.‖

Tom Coburn’s 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 and
a 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 the
activities 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 were
incomplete 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-American
Commission 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.
25
―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., in
particular, 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 unsafe
conditions 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 city’s 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)

26
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 19 th 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 that
currently 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 Peacekeepers
stationed 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)

27
United Nations officials were, predictably, reluctant to accept the Mirebalais UN outpost explanation.
Claire-Lise Chaignat, the head of the World Health Organization’s cholera task force, told reporters
any 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 from
Nepal 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 country’s
Sagarmatha 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 medical
checkup' 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 22 nd, did not turn up
cholera vibrio, according to UN officials.

The Haitian National Public Health Laboratory (NPHL) last week announced that Vibrio cholerae
serogroup 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 tested
samples 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 resistance
remained 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 Eastern
regions of India.‖
(http://www.ijpmonline.org/text.asp?2
010/53/4/865/72014)

By analyzing the drug-

resistance patterns of the
Haitian strain researchers
may be able to narrow its
possible origins. But it will
probably not be possible to
28
irrefutably prove the strain came from Nepalese soldiers, or rule out that it was carried to Haiti by
ailing humanitarian relief workers or NGO employees. The life cycle of cholerae is complex, and the
organisms 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 it
in Latin American shores.

There is little to be gained by naming or blaming the alleged source of the outbreak. Far more
important 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 interview Fighting
Cholera amid Haiti's Debris on the CFR website.

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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 new
pledges 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 Jiabao’s UN speech,
in which he vowed to ―redouble [China’s] 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 a
donation of the sum of $1 million to the Global Fund’s project.

2. On September 22, at the UN MDG summit, Japanese PM Naoto Kan, who was Japan’s
Minister of Health and Welfare, announced that Japan will provide assistance of five billion
dollars over five years beginning in 2011 to contribute to the achievement of the health-
related MDGs, esp. maternal and child health.

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We choose to end on a note of celebration. On October 14th the Food and Agriculture Organization
pronounced 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 for
all 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, the
spring.

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

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