The influenza pandemic of 1918 killed more than 50
million people. In the face of the possibility that another
virulent pandemic might occur, a group of international
experts convened by Johns Hopkins is urgently calling on
policy-makers and public health officials to disseminate a
new set of principles to better take into account the
interests of those who will be the worst affected: the
world's most poor and disadvantaged.
"There are both practical and ethical reasons why
policy-makers and public health officials should focus on
the most vulnerable populations," said Ruth Faden,
executive director of the
Bioethics Institute and the Philip Franklin Wagley
Professor of Biomedical Ethics at the Johns Hopkins
Bloomberg School of Public Health. "We have little hope of
averting a pandemic if poor villagers are afraid to report
sick birds or possible human cases to public health
authorities. At the same time, because it is inevitable
that the poor will suffer most during a pandemic, it is
especially unjust to also impose most of the burden of
prevention upon them," she said.
The recently drafted Bellagio Statement of Principles
represents a new framework for how to approach pandemic
prevention and response planning. It is named for the
Rockefeller Foundation's Study and Conference Center in
Bellagio, Italy, where international experts in economics,
epidemiology, ethics, human rights, poultry production,
public and animal health and public policy came together to
According to the group, current public health plans,
when examined through the lens of leading social justice
theory, too often fail to properly take into account the
world's most vulnerable populations.
The principles make reference to checklists developed
in Bellagio that urge policy-makers and health officials to
urgently take action. Specifically:
Make available accurate,
up-to-date and easily understood information about avian
and human pandemic influenza for disadvantaged groups.
Actively seek input from
traditionally disadvantaged groups, followed by deliberate
sharing with them of planned public policy responses.
Significantly increase the degree
of public involvement in the surveillance and reporting of
possible cases without fear of discrimination or
uncompensated loss of livelihood.
Identify and address any obstacles
that disadvantaged groups may face in benefiting from
Experts from American universities, Southeast Asian
nations and organizations such as CARE International, Human
Rights Watch, the World Bank, the World Health
Organization, the United Nations and others participated in
the Bellagio meeting. The group encourages policy-makers to
download the Bellagio Statement of Principles and the
checklists, which are available at
www.bioethicsinstitute.org in Arabic, Chinese, English,
French, Russian and Spanish.
Since the meeting of experts was held July 24 to 28,
additional cases of (H5N1) avian influenza have been
Ruth Karron, professor of international health and
pediatrics at the Bloomberg School, said, "While avian and
human pandemic influenza planning and response should be
based on sound science and public health principles,
attention should also be paid to the needs and rights of
the disadvantaged. That hasn't really happened on a
widespread scale yet," she said, "and is in part what
prompted the Bellagio meeting in the first place."
"There is much work to do, and it will not be easy,"
said Judith Rodin, president of the Rockefeller Foundation,
which sponsored the meeting. "With the Bellagio Statement
of Principles, we have a better sense of how we might move
forward to prevent or at least mitigate unjust outcomes for
the world's most vulnerable populations. It's not only
better public policy but the right thing to do."
David Nabarro, senior United Nations System influenza
coordinator and a meeting participant, said, "In the last
year I have met with many professionals who are hard at
work responding to avian influenza and preparing for a
possible influenza pandemic. They seek to ensure continuity
of basic needs, relief services, economic systems and
governance for populations facing adversity. "They
often ask whether there is an easily accessible source of
information on how to address the rights and interests of
disadvantaged people," he said. "The checklists are an
important and practical tool designed to help planners to
this end. I also anticipate that they will evolve as a
result of experience with their use in field settings."
Karron agrees, adding that "while we believe the new
framework has relevance beyond pandemics, we also want to
continue to learn more from people living and working in
the affected areas. We hope to hear about the utility of
the principles and checklists as they are employed in
real-world situations," she said. "This is part of why it's
important to disseminate the principles and checklists as
widely as possible."
Faden said she considers the Bellagio Statement of
Principles just a beginning. "It starts the debate on how
we should rethink our approach with ethical considerations
in mind," she said. "We want to hear from policy-makers and
public health practitioners. And we want to emphasize that
this work is a living document that will be modified over
time by multiple users in multiple contexts. We'll adjust
our strategies to encourage the adoption of the principles
and use of the checklists and make this less about a
top-down approach and more about one that — for the
benefit of those worst affected — simply works."
A list of participants, suggested next steps and more
information about the Bellagio Statement of Principles are