handle. Yet the funding was short-term, good only for about three or four years. Cambodian health officials and their WHO colleagues remained anxious. After the emergency funding for bird flu was exhausted, who would pay to keep the rapid-response teams trained and send them to the field? Who would pay to replenish the antiviral drugs as they expired and conduct lab tests on samples? Who would pay to print the flyers and brochures distributed to villagers warning of the virus? Who would pay for the cell-phone calls?
Nearly a year after I wrote about Ly Sovann for the
David Nabarro was an effusive speaker. Yet when it came to money for fighting flu, the world’s wealthiest countries got him to bite his tongue. Nabarro was an Oxford-trained physician, a veteran of development efforts in Asia and Africa, and, as a senior United Nations official, he had worked some of the world’s most horrifying disasters, including the Indian Ocean tsunami and the genocidal conflict in Sudan’s Darfur region. He had been in the UN’s Baghdad headquarters in 2003 when it was devastated by a car bombing that killed twenty-two of his colleagues. After all that, he had become the global flu czar. As United Nations System Senior Coordinator for Avian and Human Influenza, he was responsible for coordinating the alphabet soup of UN agencies involved with flu.
He was also the money guy. By 2007, donor countries and international institutions like the World Bank had pledged $2.3 billion toward fighting bird flu and preparing for pandemic. That was a significant sum, equivalent to what I later learned was being spent in the Washington area to replace an aging interstate highway bridge over the Potomac River. About $1 billion of the promised funding had already been delivered by the end of 2007, mostly to poorer countries. But as Nabarro reviewed the figures in advance of an avian-flu conference in New Delhi in December of that year, he realized that even if all the pledges were met, the needs would still far outstrip the available funds. He calculated the deficit would run into billions of dollars.
Some donor countries didn’t want to hear it. They had already ponied up at a pair of similar conferences the previous year. They didn’t want to want to get tapped for more. “The donors convinced me not to come out with a strong statement about funding gaps,” Nabarro told me soon after.
So in a briefing for reporters in New York before flying to New Delhi, he pulled his punches. He told the press that the world’s response to the pandemic threat was on the upswing but that “much more remains to be done.” He gave no dollar figure. That was the same equivocal message offered by a ninety-one-page progress report jointly released at the time by Nabarro’s office and the World Bank.
Less than two weeks after the conference was over, Nabarro sent out a new version of the report. It was practically identical except for two extra pages inserted toward the beginning. They said what Nabarro had not. “There are signs of declining donor interest,” the updated edition warned. It disclosed that pledges were tumbling while the shortfall in emergency funding was on the rise. (The number of donors and amount of new money pledged would decline even further in 2008 as a senior U.S. diplomat warned of growing “flu fatigue.”) The updated document warned that the immediate fight against bird flu was now short about $1.3 billion. Most of that was money required by countries on the front line. In late 2006, the World Bank had helped estimate the funding these countries would need through the end of 2008. The document reported that nearly half of this was still unmet. Most notably, countries in sub-Saharan Africa still needed $462 million and those in East Asia were short $341 million. Those figures did not even address the longer-term needs that Ly Sovann in Cambodia and his counterparts across the developing world would soon face.
To careful readers of the original ninety-one pages, this staggering deficit should have been no surprise. The report detailed sector after sector where frontline countries were outgunned by the virus. More than one-third of Asian and African countries surveyed said they had no lab capacity to confirm human flu infections. About half of these countries said they didn’t have enough antiviral drugs to cover even 1 percent of their population. The situation was equally grim on the livestock side, where many countries said they lacked basic veterinary services and lab facilities. On average, these countries required more than a week to identify poultry outbreaks and notify international authorities, a potentially catastrophic time lag. About a quarter of African and Asian countries reported they had no lab capacity to detect bird flu viruses in poultry. Only a small percentage paid farmers enough compensation to get them to report infected flocks rather than cover them up.
Looking five to ten years ahead, the report concluded, “Adequate financial support for long term technical assistance and for integrated country programs is essential.” How much would it all run? Nabarro declined to name a figure. He said an honest number would scare donor governments.
With outside assistance uncertain, some in the developing world have sought their own solutions, their initiatives driven by pride and pragmatism. Professor Nguyen Thu Van was one. Behind the high gray double doors of her Hanoi laboratory, Van was on a quest for the Holy Grail: a vaccine against the novel flu strain. Her team of young Vietnamese researchers scurried around the small, second-floor lab, some nights breaking only long enough to steal a few hours of a sleep in some corner of the elegant French colonial building that houses her institute. They were attempting a new, unorthodox approach to accelerate their effort. It involved developing a vaccine strain with fast-growing cancer cells despite the risk of deadly contamination. Two months before I met her in April 2005, the team had successfully tested the prototype on monkeys. The researchers were now preparing to try it on themselves.
At age fifty, Van was a veteran vaccine scientist with a proven record that had won her the top post at Vabiotech, a pharmaceutical company affiliated with Vietnam’s National Institute of Hygiene and Epidemiology. There was little about her appearance to suggest Van’s august place in her country’s emerging drug industry. She dressed simply in a plaid sweater over black slacks, with her plain, straight hair held back by a barrette. She had a quiet confidence to match. But her brown eyes gleamed when she predicted that Vietnam would soon outpace more advanced countries by developing the world’s first effective vaccine against the virus. She offered a warm smile that tempered the audacity of her boast.
Flu specialists outside Vietnam did not share her enthusiasm. To outsiders, her unconventional methods looked like reckless endanger ment. Yet to Vietnam, already facing recurring bird flu outbreaks, it was necessity, a clear case of national security. “We cannot wait,” Van told me.
Few pharmaceutical endeavors could save as many lives as the development of a pandemic flu vaccine. Yet the obstacles are many. For years, international research into any kind of flu vaccine languished, in large part because government investment was directed toward AIDS and other diseases considered more pressing. The drug industry had no incentive to put its own money into influenza at a time when anemic public demand even for seasonal flu shots often fell short of existing supply. As a result, the technique for making flu vaccines, an unwieldy process that uses fertilized chicken eggs, remained largely unchanged since the 1950s. Since bird flu began proliferating in Asia, researchers have been chipping away at the challenge. But without significant scientific advances, vaccines against a pandemic strain will only become available long after it has circled the globe because of delays inherent in the technology. An analysis in 2007 found it would take more than half a year after the pandemic strain emerged for the first doses to be delivered. This reflects a timeline that includes about a month for WHO to isolate and distribute the seed strain, a month and a half to ramp up manufacturing, and another four months to produce the vaccine and release it for use. And even after the initial doses debut, most people will still have a long wait because of the world’s modest production capacity.
The H5N1 strain has been particularly nettlesome. The virus has continued to rapidly evolve, spinning off various subtypes that confound efforts to develop a single vaccine in anticipation of an epidemic. The strain has also proven unusually resistant to experimental vaccines. This means higher doses are required to produce immunity, and the higher the dose, the less vaccine there is to go around.
Scientists have been experimenting with new ways to get over these hurdles. One has centered on using cells, rather than chicken eggs, to incubate vaccines. This could cut the production time for a pandemic vaccine in half while increasing available doses. Initial clinical trials of a bird flu vaccine made by Baxter Bioscience using this technology showed promising results, according to a 2008 report.
Another approach has centered on the use of chemicals called adjuvants, which enhance the effectiveness of a given dose by stimulating a person’s immune response. In 2007 the Belgian drug company GlaxoSmithKline reported the results of a study showing that an experimental vaccine against bird flu containing an adjuvant worked at lower doses than even seasonal flu shots. Later that year, WHO announced that these boosters could radically
