The poor pay the bill for the big fear

Observations on bird flu

On 16 November 2002 the first fatal and readily contagious new disease to emerge in the 21st century, severe acute respiratory syndrome (Sars), began in China and spread with frightening speed. Just seven months later, the World Health Organisation (WHO) had collated reports from 33 countries of 8,456 cases and 809 deaths.

Press reporting of Sars's successor, Asian bird flu, has concentrated on our medical preparedness, yet what is most striking about this disease is that its rapid spread confirms something suggested by Sars: that the true driver of modern pandemics is globalisation.

More worrying still, experience shows that when it comes to fighting such epidemics, the costs and the benefits fall remarkably unequally across the international community. The costs are borne mainly by the affected countries, which are often poorer, while the benefits accrue to the world at large, but principally the wealthy west, so far spared a large-scale outbreak.

Tracing what happened in the Sars outbreak illuminates this issue - ignored by the media despite the obsession with bird flu - and may show us how the present precarious situation is likely to develop.

On 21 February 2003 a 64-year-old doctor, who had treated patients for what was thought to be an atypical pneumonia in China, checked in to a four-star hotel in Hong Kong and was given a room on the ninth floor. He then went sightseeing and shopping. The next day he was admitted to hospital with respiratory failure, but by then he had unwittingly transmitted the disease to at least 14 other guests and visitors to the ninth floor, and as this was an international hotel, the disease was soon travelling around the world.

One of the guests, a 48-year-old Chinese-American businessman, became ill days later in Hanoi. He was admitted to hospital and rapidly evacuated back to Hong Kong in an attempt to limit the spread of the disease. The patient died, and despite the precautions probable secondary Sars cases turned up among healthcare workers in Hanoi.

Other hotel guests staying on the same floor soon proved to be index cases of Sars in Singapore, Toronto and Taiwan. One guest, who had travelled back to Taiwan, infected passengers who shared a train carriage with him.

From the ninth floor of one hotel in one major city, in other words, the disease spread to four foreign countries in days, even hours, across distances of thousands of miles. In the world of easy air travel and mingling trade and tourist communities, disease too has globalised.

Who paid the bill? The closure of borders and of institutions such as hospitals and schools is estimated to have cost the affected Far Eastern economies alone $30bn - and that does not include the price of the social instability that occurred in the hardest-hit areas.

There lies the problem. The best way to stop such diseases spreading is to close borders and impose quarantine controls, and the world undoubtedly benefits as a result. For the communities most directly affected, however, such measures may end up producing more suffering than the disease itself. It is a classic "externality" scenario from the economics textbooks - one country suffers terribly behind closed borders while the rest of us benefit.

Yet the WHO retains the saintly image of medical saviour as it travels the world implementing quarantines, advising on the closing of borders, or highlighting to the international press where cases have developed, with disastrous consequences for local trade and tourism. It appears oblivious to the economic devastation it leaves in its wake, just as our press ignores the problem.

In the absence of compensation from any international fund, some countries may not have an adequate incentive to detect and announce possible infections, or to co-operate with isolation measures.

As long as the poorer countries incur most of the cost and gain relatively little of the benefit of containing an outbreak, there is a risk that they will hide epidemics happening on their soil.

There is something we can do. Just as we need to manage our fears at a time of crisis, so, given the increased risk of pandemics, we need to manage globalisation. We need to set up a global fund to compensate the poor for making sacrifices we all benefit from.

The problem with fear, however, is that it renders us even more self-centred than usual, at the very moment when our own interests require us to be more outward-looking.

Dr Raj Persaud is consultant psychiatrist at the Institute of Psychiatry, King's College London, and presents All in the Mind on BBC Radio 4

By Raj Persaud

Dr Raj Persaud is Gresham Professor for Public Understanding of Psychiatry and Consultant Psychiatrist at The Maudsley Hospital in South London he is Editor of The Mind: A Users Guide published in collaboration with The Royal College of Psychiatrists

This article first appeared in The debt pandemic

2005-10-24