This report marks the culmination of nine months of deliberation by the Commission — a group formed to develop actionable recommendations for a long-term U.S. strategic approach to global health.

We have not answered all the questions that emerged, nor have we devised perfect solutions. But we believe we have put forward a compelling, concrete, and pragmatic plan of action.

Watch the video from this event

Download the Commission Report.

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The arrival of the new year has inspired a number of newspapers, magazines, and journals to look back at 2009’s experience with the ongoing swine flu pandemic. Their recent assessments and others can help answer four central questions about H1N1 and the U.S. response.

What is the current situation?

Flu pandemics come in waves. This outbreak’s first wave started in late April and peaked over the summer of 2009. The second wave, which began in August, may now be coming to a close. According to data from Quest Diagnostics, the world’s largest diagnostic testing company, requests for H1N1 tests have fallen 75% since they peaked the week ending October 28. Testing rates are now equivalent to those at the start of the second wave.

Although the CDC transitioned from tracking individual cases of H1N1 on July 24, it continues to estimate H1N1 hospitalizations and deaths. These approximate data indicate that 34 million to 67 million cases of H1N1 occurred between April and mid-November, with 154,000 to 303,000 influenza-related hospitalizations and 7,070 to 13,930 influenza-related deaths. Awful as they are, these numbers are thankfully far below the President’s Council of Advisors on Science and Technology’s August prediction of 30,000 to 90,000 deaths.

The 1918 to 1920 flu pandemic—the archetypal outbreak that killed 50 to 100 million people worldwide—was most dangerous in its later waves, which creates some worry about a third wave of 2009 H1N1. Luckily, however, former Centers for Disease Control and Prevention (CDC) Deputy Director Walter Dowdle and his colleagues, writing in the January 2010 issue of the Mayo Clinic Proceedings, report “no evidence of the evolution of the 2009 H1N1 virus toward a more transmissible or pathogenic phenotype.”

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We've received some very useful and insightful feedback to the essay, H1N1 Preparedness. If you'd like to add your own comments, please read the article and enter your thoughts in the sidebar.

Varnee Murugan - MPH student, Yale School of Public Health

I wholeheartedly agree with the recommendations in this paper. However, I think it is also important not to take too narrow a focus on this issue. Health systems strengthening will be extremely important here and primary health care should not be neglected. By bolstering primary health services, improving governance and mangement, and investing in basic infrastructure, surveillance and laboratory activities will run more effectively and efficiently. Please ensure that pandemic preparedness doesn't become yet another vertical program. If you truly want to think long term, everyone will benefit if there are investments made in health systems strengthening.

Dr. Nosayaba Osazuwa-Peters

The recent H1N1 influenza is a testament to the pestilence of the 21st century.

It also showed however that the earth is a global organism, and so no matter what advances the US or other rich nations make, outbreaks like the H1N1 will continue to affect negatively on earth; directly, through immigration, tourism and other factors, and indirectly through the health economics of the world.

The way forward is simple: Address the issue of health inequalities; devote more attention to preventive medicine research; synthesize a strategy for disaster and pandenmics preparedness.

Again, the Alma-Ata declaration holds the key. If all nations of the earth, spearheaded by the US, can champion the course of Alma-Ata, outbreaks will be better controlled if not totally prevented. So instead of spending all the millions in the world in fashioning new technologies and looking for modern breakthroughs, what will still benefits humanity as a single entity more is sometime truly global: the Alma-Ata way!

Lynn Etheredge - Rapid Learning Project, GW University

The major missing piece that i see in the analysis and recommendations is not in the traditional public health area (prevention, vaccines) but in the US (and world) capacity for "rapid learning" about best  clinical treatments, particularly for  higher risk patients, in a public health emergency.  The limited ability to do "comparative effectiveness research" is a serious problem even for normal medical care issues -- but an acute problem for public health emergencies, e.g. HiN1, where children and have suddenly been found to be much more vulnerable. Rx testing & clinical trials for pediatrics are a serious gap in clinical evidence,  even in the best of circumstances, For H1N1, it has taken HHS many months even to put together a network of ICUs, which needed a new contracting procurement & going through each institution's IRB approval process for participating in research. Even today, 22 million patients & 6 months into the pandemic, there is limited ability to provide guidance on such important issues as use of anti-virals, ventilator use, "double coverage" antibiotic therapy for children with H1N1, asthma & pneumonia, etc. A recent NYTimes op ed (enclosed) highlights the still-unresolved questions about how to assess genetic influence factors in risk (possibly more useful for H1N1  than traditional public health groupings) and treatment. With electronic health records, already for millions of patients in institutions with first-rate health programs (Kaiser-Permanente, Denver Health, Childrens Hospital of Philadelphia, etc.) it would be relatively easy for HHS to design, pre-contract & prepare for rapid-learning  networks about best clinical care in public health emergencies, The US needs to do this & the world also needs such capacities on the front line that can quickly offer better guidance to community physicians, hospitals, and clinics.

To read more comments, please visit this page.

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Stephen Morrison and Phillip Nieburg of CSIS recently co-authored a piece on uncertainties surrounding the H1N1 vaccine supply and President Obama’s decision to declare H1N1 a national emergency. The post produced many questions about vaccines and highlighted much of the confusion surrounding the flurry of information from health experts, government agencies and various news outlets.

Comment from the blog:

Schools are closing, parents are terrified, and much of this is being fueled by the fact the quality of reporting on 24 hour news stations is alarmist and detached from reality. Interviews are being given to random opinionated individuals with an "MD" by their name in favor of credited public health and influenza experts.

Should we be concerned that we aren't even trying to effectively track this disease? What you're saying is that numerical projections are completely bogus so any number spewed out to the population, in the thousands or millions, is a shot in the dark and heavily subject to political manipulation and sensational media. If hospitals aren't even testing for H1N1 on a large scale, how does Thomas Frieden presume to make any estimation at all?

Meanwhile, the Obama Administration will cover its tracks by declaring a national emergency because they are fearful of being viewed as unresponsive in an increasingly treacherous political climate of declining public support and accusations of ineffectiveness.

Americans are just looking for honesty. What are the actual projections for this disease? How bad is it really? Should parents be pulling their children out of school in droves? Should we be investing in protective masks for our families? Beyond washing our hands and avoiding public places while sick, are there any other preventative measures U.S. citizens can take?

Response from Phillip Nieburg:

The commenter is correct about the sometimes unhelpful quality of media reporting about H1N1, including the comments of people with limited understanding of disease surveillance and of public health in general.

Regarding the decision of the Centers for Disease Control and Prevention (CDC) to stop trying to count every person infected with H1N1, influenza is a disease with a wide spectrum of severity, from mild “cold” symptoms that do not include fever to overwhelming pneumonia and death. Once the existence of an influenza epidemic has been confirmed, as it has in this situation, the goal of influenza surveillance shifts from counting every infected person to gathering information on the severity and impact of disease. These latter data can better help guide decisions about the subsequent public health response. At this point, since infected people in the U.S. may ultimately number in the tens of millions, and since many mildly infected people with mild disease will not seek medical attention, and since confirming an H1N1 diagnosis requires an expensive laboratory test, it no longer makes sense to try to count every person infected with H1N1.

However, although the CDC has stopped counting every individual H1N1 infection, it is keeping close track of – and is making publicly available on a weekly basis - a number of other measures of epidemic influenza severity in the United States: (1) visits to doctors for influenza-like illness; (2) total influenza-related hospitalizations; (3) the proportions of weekly deaths recorded as being from pneumonia and influenza; (4) state health department estimates of the magnitude of influenza activity within each state; (5) the numbers and proportions of influenza viruses identified in laboratories as H1N1 viruses; (6) any resistance of circulating H1N1 viruses to oseltamivir, the principal anti-viral drug being recommended for high risk people infected with H1N1; and (7) influenza-associated pediatric mortality. Each of these disease indices is updated weekly and can be found online.

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With more than 4,500 deaths attributed to infection with the new H1N1 influenza virus, Latin America is among the world regions hardest hit by the 2009 influenza pandemic. Mexico reported the world’s first infections with H1N1 last April. While the United States, Canada, and Mexico all struggled to investigate and respond to the outbreak in the spring, Mexico faced particular challenges. A high number of confirmed infections and deaths early on, along with emergency measures that closed schools and businesses in an effort to contain the transmission of the virus, led tourists to cancel travel to Mexico and exacerbated economic difficulties in a country already struggling to cope with the effects of the global financial crisis.

The swine flu epidemic has not spared China. According to the latest available numbers, the country has registered 48,748 infections on the mainland and another 31,544 in Hong Kong. The Chinese government quickly implemented prevention and containment policies in response to early cases, even receiving some criticism for its extreme measures. In June, the People’s Republic commissioned 11 biotech companies to develop a swine flu vaccine. Sinovac succeeded, creating the world’s first approved vaccine with its Panflu 1. These efforts, described as the world’s most active response to the virus, earned substantial praise from the World Health Organization.

Co-authored by Stephen Morrison and Phillip Nieburg, CSIS

The unusual clinical characteristics of the H1N1 virus and the uncertainties about H1N1 vaccine production have brought home powerfully the unpredictability -- the “slippery” nature -- of influenza virus and of the vaccines designed to reduce its disease burden. And it has revealed the complexities and risks in making numerical projections, amid great uncertainty, and communicating them effectively to the American people.

As of October 17, the Centers for Disease Control and Prevention (CDC)  have reported that more than 1,000 people in the U.S., almost 100 of them children have died from H1N1 (swine) flu virus. The number may be higher, but not all flu-associated deaths were tested for specific influenza type. Hospitals do not test every flu case, so there isn't an accurate count of the total number of infections. CDC Director Thomas Frieden estimated that many millions have already had H1N1 and over 20,000 have been hospitalized. 

The President’s October 23rd Declaration of a National Emergency because of the H1N1 epidemic has raised both anxieties and additional questions about H1N1 influenza and about the H1N1 vaccine intended to protect us.

A formal declaration of a National Emergency provides Department of Health and Human Services Secretary Sebelius with the legal authority to relax federal administrative requirements so that hospitals facing large – and potentially overwhelming - numbers of swine flu patients may use alternative facilities for treating such patients or could more easily transfer them to other, less overburdened, hospitals.

This anticipatory step is reasonable, given the real possibility of an enlarged crisis, although it would be preferable to handle as a strictly administrative measure, free of the drama and anxiety created by the President directly engaging to declare an emergency. It is worth reexamining the legal requirements for a purely administrative declaration along with the strategy to communicate that decision.

The drama of that National Emergency announcement and of the growing H1N1 death and severe illness toll has been compounded by the inability of many people, including those in high-risk categories, to gain access to the H1N1 vaccine that they had been told would be available by now. The announcement earlier this month of significant delays in production – and resulting shortfalls, however temporary - of H1N1 (swine) influenza vaccine were frustrating and alarming to those who had been convinced by effective public health messages and by individual providers to believe that the disease risk was severe enough that they should be immunized soon. Communications, public expectations, and production shortfalls were in collision, generating considerable confusion and anxiety.

The current situation has arisen as a result of several technical glitches in vaccine production combined with over-optimism among those responsible for projecting vaccine production and availability.

The major technical glitch in recent months is that the virus being used to produce the H1N1 vaccine has not been multiplying as quickly as expected in the chicken eggs used to incubate it. Since far less H1N1 virus than expected was becoming available to put into the vaccines, fewer vaccine doses could be produced.

Because the test material used to measure the amount of virus production has itself to be manufactured from scratch, using the same H1N1 flu virus stocks, it was only after that test material became available last month that the true magnitude of the shortfall became evident.

The United States has not experienced this level of public concern and uncertainty about influenza since 1976, when swine flu was last considered to be a major threat. Although influenza disease surveillance, anti-viral drugs and clinical care of ill people have all improved over the intervening 33 years, we still rely on an antiquated system of egg-based influenza vaccine production, with all of its uncertainties. A future policy priority should be accelerating technological improvements in vaccine production.

To learn more about H1N1's classification as a 'slippery disease' and the government's management of the 1976 swine flu scare, see Harvey Fineberg and Richard Neustadt's 1976 book The Swine Flu Affair: Decision-Making on a Slippery Disease.

Image courtesy Samantha Celera

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What do sex and chickens have to do with global health?

While at first glance an amusing comparison, Sir Richard Feachem uses the two as an allegory for the threat of infectious disease pandemics in the 21st century.  These new pandemic strains will be transmitted through respiratory droplets or sexually, and be viral or multi-drug resistant bacteria in nature.  And the chickens?  Similar to diseases like H5N1 or the current H1N1 strain, Dr. Feachem predicts that the disease will be zoonotic, or transmitted from animals to humans.

During his speech at CSIS yesterday, Professor Feachem identified the following issues as being of highest priority:

1. the avoidable life and health expectancy gaps between developed and underdeveloped countries;
2. the potential danger of the human-to-human transmitability and mortality rates of emerging viral pandemics;
3. the dual pandemics of hunger and obesity; and the governance of health systems, including the vital role that the private sector can play in improving the healthcare of low- and middle-income countries.  

In “a global zip code lottery of health” he pushed the audience to close equity gaps both between and within countries.  His third theme, “the world’s biggest muddle” asked how we can improve healthcare, the world’s biggest industry comprising 12% of global GDP, and empower planners in low- and middle-income countries to improve health systems. Healthcare is a hot election issue in most countries, and a topic where there is a "striking lack of agreement" and a ground for an "array of strongly held opinions."  Without strong models in developed or developing countries, the current system is in a state of disarray that is too often large, unregulated and anarchic. He strongly advocated for harnessing the power of the private sector, which accounts for large portions of healthcare services in low-income countries, emphasizing the seriousness in "bringing private health care providers into the task of delivering public policy goals."

Sir Feachem concluded his talk by illustrating the 3 cross-cutting dimensions for global health: multisectoriality, integration of specific objectives and broader health care system strengthening, and global joint action to collectively achieve the goals that we want to achieve.

Although Sir Feachem underlines the importance of these 3 objectives, he urged us not to forget and to celebrate the monumental achievements have been made from the focus on specific conditions and diseases, such as AIDS, tuberculosis, and child mortality, adding that this remarkable progress needs to maintain its momentum in order to continue with its line of accomplishments.

Watch the entire speech below, and download the powerpoint presentation (PDF) here:

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Last week’s important decision by the Obama administration to take a global leadership position in sharing a significant proportion of the U.S. H1N1 (swine) influenza vaccine supply with the people of developing countries is likely to help save many lives. However, its longer term importance may well be the major shift in U.S. global health policy suggested by the decision.

In brief, the United States has agreed to donate 10% of its hundreds of millions of contracted doses of H1N1 flu vaccine to the World Health Organization (W.H.O.) for distribution to various developing countries. The U.S. vaccine donations will be made on a rolling basis so that resource poor-countries can begin receiving and administering vaccine relatively soon. A number of other industrialized countries (Australia, Brazil, France, Italy, New Zealand, Norway, United Kingdom) also announced similar vaccine donations nearly simultaneously. (The Swiss government had already committed in June 2009 to donate US$4.8 million directly to W.H.O. for the latter to purchase H1N1 vaccine at concessionary prices.) GlaxoSmithKline and Sanofi-Aventis, two large vaccine manufacturers, had also committed earlier to donations of more than 100 million H1N1 vaccine doses to W.H.O.

The ability of the United States and other countries to make these vaccine donations was helped by several factors. First, it has become clear within the last week that a single dose of the new H1N1 vaccine will provide satisfactory protection for adults and older children with normal immune systems, making a second (booster) dose unnecessary except for children under 10 years old. Since the U.S. H1N1 vaccine supply had been planned and requested to include the possible need for a two-dose series for most people, U.S. swine flu vaccine supplies will be more ample than it appeared earlier.

One of the greatest misconceptions about global health is that it only matters to developing nations. Global health deeply affects the economy and security of the United States, and that was the central message of Admiral Fallon's keynote address for a gathering of global health experts and North Carolina businesspeople and policymakers.

Watch the speech and then show your support for Smart Global Health