What obligations, if any, do Canadians have to support poorer countries in response to a flu pandemic? Should countries have the right to close their borders to travelers coming from affected areas? How might a collaborative focus on minimizing harms, avoiding stigmatization, and preventing unnecessary constraints on international travel and trade be fostered and maintained?

According to the JCB authors, "in the face of an H1N1 pandemic influenza and other threats to global public health, anything less than the mobilization of substantial enduring financial and other support will amount to an abdication of the shared responsibility for global health and of the fundamental values of equality, reciprocity, and justice."

Canadians not only recognize the lack of equality, reciprocity and justice at the global level, but regard them as ethical imperatives and support policies that take aim at changing current realities. For example, a majority of survey respondents (54%) gave priority to saving lives globally over saving lives of Canadians (36%) in response to an influenza pandemic.

A strong majority (70%) of those surveyed agreed that Canada should provide international assistance to poorer countries facing a pandemic, even if this means fewer resources for Canadians as a result. When asked how much assistance should be provided, most Canadians (92%) responded that aid should amount to at least 7% of total resources committed to pandemic preparedness, and many (43%) felt that that amount should be 10% or more.

Participants thought that Canada ought to assume a more prominent leadership role internationally and that the traditional distinction between public and private sector responsibilities needed to change in order to mount an effective global response to the pandemic.

Support ran high for increasing regulatory control over drug manufacturing capacity and profit-seeking, and for prioritizing equity in global distribution of drugs. Town Hall participants were less united on the extent to which domestic obligations and the recent global economic downturn should modulate Canada's duty to reach out globally.

Among the authors' recommendations: Canada should share at least a 10% portion of its national stockpile of antiviral medications, H1N1 vaccine allocations, and outbreak management kits with poor countries, and encourage other wealthy countries to follow suit.

It should also seek global reassurances that vaccine priority will be given to health care workers, as well as the most vulnerable (children under five, pregnant women, people with weak immune systems and members of indigenous communities.

"Prioritizing the most vulnerable in other countries prior to the least vulnerable in this country would contribute immensely to allaying fears that the rich will live and the poor will die during a worsening global influenza pandemic."

As well, Canada's domestic vaccine producers should maintain full production capacity for as long as there is need in other countries and even after all Canadians have been offered vaccines. Consideration of the use of adjuvants in order to extend the overall vaccine supply should also be a priority, as should exploration of policy initiatives to create a global network of regionalized vaccine production sites insulated from market forces.

Risk communication

During the 2003 SARS crisis, poor communication between public health officials, health care workers and the public was cited as a major factor contributing to the confusion and even spread of the virus.

According to the JCB papers: "For people to accept public health measures that may limit their individual liberty and potentially cause them to be stigmatized, they must trust the information they receive as well as the authorities who provide the information."

Information must be available through a variety of sources for both professionals and the public, and recipients should know where information is coming from and from whom. Being transparent also means being open about what is known and what is not known about the situation, the authors add.

For citizens to be honest about their own health, the state need to acknowledge that transparency will not be penalized. For example, someone who accepts voluntarily quarantine needs assurance they will not lose their job.

Likewise, at the international level, "countries need to be able to trust each other to be transparent and honest about infectious disease outbreaks.

"Reciprocally, countries that do not trust the international community to be fair and to provide assistance may fear things such as economic loss as a consequence of having open and honest communications about outbreaks. The result may be that they chose not to be transparent with the global community."

"If countries have a moral duty to be transparent, then the global community has reciprocal moral obligations to compensate and support those countries that may suffer economic or health consequences as a result of transparent communication."

Vulnerability

Although the prevalence of chronic and acute diseases is higher among elderly and other certain groups, stakeholders felt that it was important to distinguish between age and disease and noted that age should not be a proxy for disease or provide the basis for allocation decisions.

In places, isolation due to geography may increase vulnerability.

"In Northeastern Ontario alone, the land mass is equivalent of Spain and Portugal combined, so 100,000 square miles, so logistical distribution of emergency supply and stockpile is a huge issue".

A particular challenge noted by many stakeholders: pandemic influenza planning occurs primarily at urban centres, for urban centres, thus not being sensitive to the difficulties that might arise in rural areas. Similarly disadvantaged: those who live in poverty or in crowded housing conditions such as shelters and prisons.

Source: University of Toronto Joint Center for Bioethics