Some key developing and developed countries, along with officials of the World Health Organization, are meeting in Jakarta this week looking for ways to resolve a standoff over pandemic flu vaccine that is bedevilling even those with the best of intentions.
The world's capacity to make vaccine to respond to a severe flu pandemic is woefully inadequate. And, as it stands now, the distribution of that vaccine will be inequitable, with developing countries virtually deprived access.
Angered by that reality, Indonesia has upped the ante, refusing to share H5N1 avian flu viruses with the global community since the beginning of the year. Indonesia's Health Minister, Siti Fadilah Supari, insists her country will not provide virus samples to the WHO as long as pharmaceutical companies can use them to make vaccines her country cannot afford.
Those who want to right this looming wrong aren't clear how to inject equity into a production system based on free market principles and cold, hard math. They say there are no easy or short-term solutions to the vaccine distribution dilemma.
"There are not. I agree. There are not,'' says Dr. Arlene King, the Public Health Agency of Canada's director general of pandemic preparedness.
Another expert, an influenza community insider well versed in the limitations of the vaccine production system, concurs _ and warns that those who try to simplify the issue run the risk of exacerbating an already tense situation.
"I think people do a disservice to the field by pretending that there are (easy solutions) -- creating expectations that simply can't be fulfilled,'' said the expert, who asked not to be named.
The three-day meeting, hosted by Indonesia, will see the WHO advance some modest proposals for improving access to vaccine, including the notion manufacturers might be persuaded to create a small virtual stockpile by holding back a portion of their output for developing countries. The WHO is also trying to use some donated funding to encourage partnerships between developing countries and vaccine makers which could see production or packaging plants located outside the developed world.
The WHO will also gently try to explain the hard realities of the situation, presenting data on global production limitations. And it will make a presentation on the WHO's new International Health Regulations which come into effect later this year. Withholding information critical to global public health -- as Indonesia is doing -- is outlawed under those rules, which were adopted by the WHO's 193-member states.
WHO officials will also explain that there are public health measures, like school closures, which can slow spread of influenza and which may lessen the blow of a future pandemic.
"That's very important, because there are other things besides vaccine,'' says Dr. David Heymann, the WHO's special representative for pandemic influenza.
"Vaccine is not the panacea. It's not the one thing that will prevent this.''
Given that vaccine won't be available for four to six months after the start of a pandemic, it is not clear how big an impact it will have even in countries with access. But vaccine has become a symbol of the wide gap between what developed countries can afford to do to prepare for a future pandemic and what little exists for poorer countries battling H5N1 now.
The WHO, which needs regular access to H5N1 viruses to monitor its pandemic risk, is trying to play honest broker. But it is almost powerless to effect real change, the insider says.
'The problem for WHO is that it often recognizes that the world is unfair and it does everything in its power to make it fairer. (But) it is incapable of telling people the reality,'' he says.
"WHO can't force people to do it (share). WHO doesn't have the money to buy vaccine. It can't force (vaccine) technology transfer (to developing countries). It can do very little, in fact, to even facilitate technology transfer.''
"It has very limited degrees of freedom.''
Most vaccine production capacity is situated in developed countries -- Canada, Japan, Germany, France and the United States -- that use seasonal flu vaccine every winter. Manufacturers have no real surge capacity. Their plants are sized to make what they sell.
A number of these regular customers, including Canada, have signed contracts for first or early access to pandemic flu vaccine.
It's believed that those contracts have virtually locked up the global supply for the first year after pandemic vaccine starts to become available. That means countries that don't already have contracts have little hope of getting vaccine until at least 18 months into a pandemic -- by which point the worst of the damage may be done.
And the problems go beyond the limited vaccine production capacity.
Vaccine is only liquid in a vial, unless a country has the infrastructure to distribute it. Resource-poor countries may find it challenging to organize a mass emergency immunization program, involving mountains of syringes, armies of health-care workers and a way to ensure vaccine is refrigerated from airport hangar to remote clinic to people's arms.
"It's not just simply having the vaccine available. You've got to be able to get it in to people. So you've got to build immunization infrastructure,'' says King.
If the world has a number of years more to prepare for a pandemic, some of these problems will start to resolve themselves, experts say. Research currently underway will point to ways to make much more effective use of vaccine output. And vaccine production capacity is expanding.
"But in the foreseeable future, demand will greatly exceed supply,'' the flu community insider says.
"There will be rationing of material. ... The ability to distribute it will vary greatly from country to country.''
'And as we always do in times of major disasters, we'll do the best we can with the resources that we've got. And the results that we get will reflect the quality of the leadership and the quality of the resources that are available from place to place.''
