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The newspaper of The Johns Hopkins University October 2, 2006 | Vol. 36 No. 5
Experts: Protect Most Vulnerable From Flu Pandemic

Meeting yields checklists for action, including active involvement of the poor

By Ed Bodensiek
Berman Bioethics Institute

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 Berman 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 craft it.

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 preparedness plans.

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 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 reported.

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 available at


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