THE SPACE OF GLOBAL HEALTH The first big topic that the swine flu crisis has highlighted for work on global health more generally relates to the evolving conceptualization of global space itself. Swine flu's emergence in 2009 has been geographically represented in ways that tell us a lot about how the global in 'global health' is being routinely imagined today. The repeated mapping of the disease on definitively global maps that are in turn widely disseminated and read on the world-wide web helps represent and thereby reterritorialize analysis of the disease as a truly global (not just national, not just regional nor just continental) threat to global health (see From ghost maps to global maps). In short, the geographical representation of the disease in both formal and informal forms of surveillance has been planetary from the start. These global mappings clearly contrast with the blame geographies and origin stories that reterritorialize swine flu as the fault of Mexicans. Such geographically limited representations too quickly lead to the public health conclusion that controlling the virus should simply be about (as the Chinese government seemed to think) controlling borders and the movements of Mexicans. And such dangers are only further magnified, when, as Alan Ingram commented, such pathologization of people and place is tied to militaristic security discourses and geopolitical tropes that chart a so-called war against disease with territorial 'fronts' and 'battlegrounds'. By contrast global mappings of the disease instead depict the challenges presented by H1N1 as planetary problems for a global population that shares, albeit very unevenly, a basic biological vulnerability to a fast-moving, globe-trotting virus. More than this, the mapping of the disease as a global disease also makes it much easier to relate its molecular emergence to larger-scale border-crossing but political and economic processes that have made the viral breeding grounds and globe-trotting reassortment of swine flu a possibility in the first place.
ASYMMETRY AMIDST INTERDEPENDENCY The second global health lesson of the swine flu crisis moves in the opposite direction. At the same time as the maps of H1N1 have vividly illustrated an evermore global sense of the whole planet as a community vulnerable to shared contagion, the actual experience of the disease on the ground, its surveillance by public health officials, and the sorts of emergency preparedness it has prompted have all been marked by deep disparities and inequalities. In the same way, the much mentioned interdependency of global health itself should be understood to operate in ways that are twisted and turned by powerful asymmetries and uneven development patterns too (and, as the PBS global health atlas shows very clearly, global maps can obviously chart this inequality too). In the case of swine flu, the examples of such asymmetry amidst interdependency are many. They include the heightened vulnerabilities of poor communities and slum dwellers for whom routine public health advice about hygiene and washing hands sounds like wishful thinking. They extend to the massive inequalities in public health infrastructures themselves, along with all the problems of monitoring the spread of disease, doing clinical tests and getting out information about personal and institutional best practices. And perhaps most significantly in the case of swine flu preparedness, the inequalities in global health are made manifest at the level of access medicines. It fast became clear during the initial weeks of crisis that access to anti-virals such as Tamiflu (as well as any vaccines that might be developed) is directly structured by access to economic resources. Poor countries and communities are effectively locked out of what is a very limited global supply. Researchers at the Third World Network, point out thus that:
"The swine flu outbreak is a stark reminder that if a deadly pandemic were to develop, there will be a desperate fight over limited supplies of anti-viral treatments and vaccines, in which the developing countries will be at a vast disadvantage. Today more than 90% of the global capacity for vaccine manufacturing is located in Europe and in North America. Developed countries through 'advance purchase agreements' with manufacturers have already reserved a good portion of the limited current manufacturing capacity. Thus in the event of a pandemic, the world would be several billion doses short of the expected demand. If there is a worldwide pandemic of a new deadly influenza billions of doses of anti-viral treatments and vaccines will be required in the developing world and manufacturers will only be able to supply a small portion of what is needed. The anti-virals and vaccines sold to developing countries are also likely to be expensive, making them unaffordable for those in need. "
DEPENDENCE ON BIG-PHARMA The example of access to anti-viral medicine points in turn to the much wider problems for global health posed by reliance on for-profit drug development and delivery. Tamiflu is distributed and sold globally by the Swiss company Roche, and business newspapers such as the Financial Times have excitedly reported increased sales and profits for Roche alongside the increased global angst about swine flu. More than just revealing the money to be made in global health, though, the swine flu/Tamiflu ties also make manifest our global dependence on big pharma and the ways in which the trade rules protecting the private intellectual property rights of the big drug companies compromise the ability of governments, national public health agencies and the World Health Organization to work towards guaranteeing health for all (for more on IP controversies surrounding Tamiflu see theCPTech site). It's true that the Financial Times also reports Roche donating 5.7 million treatments to the WHO for distribution to low income countries, but that's barely enough for one medium sized city, and meanwhile the production of lower cost generics by an Indian company (itself threatened by big pharma's patent protections) hardly looks set to make up the global difference. These basic questions about drug access and global protection are important, but they barely begin to scratch the surface of the huge challenges to global healthposed by a dependence on big pharma. There are, for example, the problems of corporate profiteering surrounding the roll-out of vaccine and immunization campaigns in the global south; there are the problems of human subjects abuses in clinical trials off-shored to the global south; there are the related problems of corrupted bioethics review processes in wealthy countries and universities; and, at an altogether more global institutional level, there are all the problems surrounding the shrinkage of the policy space of the WHO and its member governments by the ways in which big pharma has locked in its monopolies in global trade regulations that are much more binding and effectively enforced than the international health regulations of the WHO itself.
GLOBAL HEALTH GOVERNANCE The concern over policy-space vis-a-vis big pharma relates in turn to many other questions that continue to be posed about global health governance more generally. The swine flu has highlighted some of these quite directly. There are the questions about the role and authority of the WHO, its chronic underfunding, and its tiny size in relation to planetary health crises, as well as the persistent problems surrounding the ways in which its regulations are undermined by both the corporate interests of powerful countries and poor country resentment and resistance it inspires (the so-called viral globalismof David Brooks being indicative in this respect of a more general pattern in which market fundamentalists point to the need for global health leadership but simultaneously undermine it). Then beyond the WHO itself there is the complex web of national agencies, philanthropies, NGOs, public-private partnerships that all interact to define the wider system of global health governance. As Swiss-based global health policy consultant Illona Kickbusch explained back in 2003: “We are in transition from what seemed a relatively stable, state defined and structured world of international health to a diffuse political space of global health. We need to analyse to what extent the political ecosystem that inhabits this space transfers power and to whom. We need to map the epistemic communities and the multitude of networks and their spheres of influence.” It is with a view to following this call to map the terrain of global health that the blog Geographies of Global Health has been started. Moving from the swine flu crisis to the much more general and all-encompassing crisis of global health itself, the ongoing goal will be to track the relations between the actual geographies of disease and the diverse ways in which such geographies both reflect and reinforce the processes through which the political space of global health is itself being constructed, contested and remade (for more on the theoretical resources I am drawing on to frame these questions see my paper - 'Unpacking Economism and Remapping the Terrain of Global Health' on the resources site of the People's Health Movement).
