The Next Pandemic: Bird Flu, or Fear?

Dr. Marc Siegel contrasts bird flu with SARS, the Spanish flu and swine flu.

Dr. Marc Siegel contrasts bird flu with SARS, the Spanish flu and swine flu. hide caption

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Fear and paranoia often take hold when a disease threatens to become an epidemic. Dr. Marc K. Siegel is the author of the new book Bird Flu: Everything You Need to Know About the Next Pandemic.

Bird Flu takes on the issues that are injected with a sense of panic and dread, as many parts of the world have grown to fear the spread of a deadly influenza outbreak in recent years. That outbreak, says Siegel, is a distinct possibility. But he urges those who may be at risk to trust in reason — and ignore the hype — in judging the risks.

In making his case for an honest appraisal of the dangers, Siegel cites progress in vaccine work and improved living conditions world-wide as two improvements that should make an epidemic far less deadly than that of 1918.

Siegel's previous books include False Alarm: The Truth About the Epidemic of Fear, in which he argues against paranoia and reactionary strategies in health care and public safety. Siegel, who teaches at the New York University School of Medicine, is also a weekly columnist for The New York Daily News. He is a frequent contributor to The Los Angeles Times and The Washington Post.

Excerpt: 'Bird Flu'

Part I

FACTS AND FICTIONS

What is bird flu?

All bird flus are influenza A. Influenza A is primarily a respiratory virus, causing coughing, congestion, sore throat, muscle aches, fatigue, and fever in most species it infects.

This strain (also called the H5N1 virus) surfaced in Hong Kong eight years ago, although it may have been around for four decades previous to this. It has mostly been affecting Asian poultry. When tested in the laboratory, it has been found to be quite deadly, killing ten out of ten chick embryos against which it was tested. It is difficult to tell how many birds it has killed in Asia, though, because millions of birds have been killed by humans to prevent its spread. As soon as one chicken develops symptoms, it is killed along with all the chickens that may have come in contact with it.

BIRD FLU BASICS

It appears to be quite deadly to humans as well, although in Hong Kong in 1997 many humans reportedly developed antibodies to the virus and did not get sick. There is concern that if the virus mutated, it could cause a pandemic because we do not have built-up immunity to it. This mutation could occur either at random or if the virus mixes its DNA with a human flu virus inside a pig or a human. But it's also quite possible (in fact it's even more likely) that it may never mutate at all or that if it does mutate, the mutated virus would result in a much less severe illness in humans.

What is influenza?

Influenza is a virus. Unlike bacteria, which are single cells, a virus is not a full cell and cannot reproduce on its own. To reproduce, a virus infects a cell and uses the resources of that cell. Essentially, a virus is just a sack of genetic material enclosed by a protein envelope. Viruses don't even fit the definition of "alive," though most scientists agree that they are.

There are two types of viruses: DNA (deoxyribonucleic acid) and RNA (ribonucleic acid). Influenza is an RNA virus. Influenza comes in two main varieties: A and B. (It also comes in a C, which rarely causes illness.)

Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses, and seals. Influenza B viruses circulate widely only among humans and generally do not make us as sick as influenza A does. Influenza A viruses are divided into subtypes based on two bumpy proteins on the surface of the virus: the hemagglutinin (H) and the neuraminidase (N). These two identifying proteins are why the current bird flu is referred to as H5N1. There are 16 different hemagglutinin subtypes and 9 different neuraminidase subtypes, all of which have been found among influenza A viruses in wild birds. H5 and H7 subtypes include all the current pathogenic strains.

How does influenza spread and what complications does it cause?

Influenza is spread by airborne droplets and is inhaled into the respiratory tract. It incubates in the body from one to four days before a person feels ill. Complications tend to occur in the very young, in the elderly, and in patients with chronic cardiopulmonary diseases. The major complication of flu is pneumonia from influenza itself, or bacterial pneumonia from pneumococcus or haemophilus.

How is influenza diagnosed?

Influenza is most commonly diagnosed by recognizing symptoms or by direct examination of respiratory secretions. Blood examination (serology) can determine exposure.

What is a pandemic?

A pandemic occurs when many people in several different regions of the world are suffering from a specific illness at the same time. Human pandemics may occur when we are exposed to a virus strain for the first time and we lack immunity to it.

Is there a bird flu test?

The current bird flu is diagnosed by testing the blood for antibodies to the H5N1 strain. The test is 100 percent accurate, though it doesn't tell how sick a bird (or a person) is. Transmission from bird to human is possible but rare, and almost exclusively from close or frequent contact.

How does a bird get it?

It's endemic in birds, especially waterfowl like geese and ducks. It's usually a benign infection of the gastrointestinal or respiratory tracts of waterfowl, and it has existed in birds for many thousands of years. It can pass from wild birds to the poultry on farms when they come into contact, and certain strains, known as pathogenic avian influenza, make these domestic birds very sick. The flu virus mutates frequently, changing its genetics, but it rarely goes through the changes that allow it to routinely infect mammals.

How do birds transmit it to each other?

Birds transmit viruses the same way we do: by sneezing, coughing, and touching other birds.

Is there a cure once you have it?

There is no cure for any influenza for either birds or people. The body's own immune system fights it, and antiviral drugs such as amantadine, ramitidine, Relenza, and Tamiflu are probably all effective against H5N1 bird flu, though the degree of effectiveness hasn't been shown.

Although there have been over a hundred reported human cases in Asia, it's not clear if more people have it, but it just didn't make them sick. With most cases of the annual flu virus, the vast majority of people get better without serious treatment as their immune system fights off the virus. It's the cases where prolonged recuperation or hospitalization becomes necessary that worry doctors.

How fast would a human pandemic spread?

There is concern that air travel would accelerate transmission around the world, although scientific recognition of the mutation early on and the worldwide communication network could help to slow its spread by warning people.

What should I be doing to protect myself?

People are concerned about the possibility of a coming pandemic. The way this information has been communicated in the media and via several of our public health officials carries the message that something major is in the offing. This makes a worst case seem like the only case. In fact, the government has a reason to consider worst-case scenarios as it attempts to protect us, but we need to consider that a massive pandemic may well not be in the offing. As I suggest here specific measures of personal preparation, I, too, must be careful about hidden messages. When I advise a certain kind of preparation, I must consider if I am inadvertently suggesting that something must be about to happen.

I do not think a massive bird flu pandemic that kills many millions of people worldwide is about to happen, for reasons that I will go into throughout this book. The major reason is that, as with mad cow disease, which has killed hundreds of thousands of cows but only a little over a hundred people, we are currently protected by a species barrier.

For bird flu to pass human to human, further changes in its structure have to occur. Influenza viruses change frequently, but this form of H5N1 appears to have been around since the 1950s, and in the eight years that it has infected millions of birds (1997–2005), documented human cases have been rare (less than 150 clinical infections with 70 deaths at the time of this writing). We don't know how many thousands have developed antibodies to this virus and not gotten sick from it, so it may not be as deadly as it seems to be to humans. If it mutates sufficiently to infect us routinely, it may do so in a way that causes it to be far less lethal.

Should I prepare emergency supplies of food and water just in case?

Absolutely not. We've been asking one another this question ever since experts told us that the year 2000 bug in our computers would shut down communications and banking nationwide. Sinister things scare us out of proportion to their actual risk of affecting us, and we respond, quite naturally, by wanting to be afraid. But bird flu can be seen as one in a long line of things we've been warned about, and for which we supposedly need some kind of "safe room" with an ample supply of food and water just in case.

In one sense, there is little difference between a grizzled terrorist and a mysterious bird flu. Both scare us beyond their reach, beyond the likelihood that they will hurt us. In the wake of 9/11, our leaders have been playing Chicken Little. First it was anthrax, then West Nile virus,

then smallpox, then SARS. In each case we were warned that we had no immunity and could be at great risk. In each case there was no accountability going forward, no

"We're sorry, we got this one wrong, but we just wanted to prepare you just in case."

It is difficult to trust an official who scared us unnecessarily about smallpox to inform us contextually about bird flu, even if that person is a devoted scientist. The national psyche has been damaged by all these false alarms. We each make risk assessments, scanning our environment for potential threats, worrying more and more of the time. The emotional center of the brain, the amygdala, cannot process fear and courage at the exact same moment. If we could train ourselves to filter out dangers that don't threaten us by setting our default drives to courage or caring or laughter, we'd be a lot better off.

We don't need emergency supplies of food — we need leaders and information sources we can trust. In a true emergency, our satellite-driven communication system will be our ally, as long as the warnings we receive are accurate and not overblown. Fear is our ultimate warning system, designed to protect us against imminent danger. Our fear responses should not be overdetermined. By jumping from one fear to the next, we create a climate of distrust.

One of my patients told me that he is readying for the coming flu pandemic not only by stockpiling food but by keeping two rifles, ammunition, and a trained German Shepherd at the ready. He envisions a scenario where he may have to barricade himself into his house in order to protect his wife and his two young children. He expects people to be dropping dead in the streets of flu, and he anticipates strangers trying to get into his house to hide from the virus. This Hitchcockian image is not only extremely unlikely, it contributes to a pattern of thinking that pits us against one another. It is only a half stop from this kind of irrational fright to deep-rooted prejudices where everyone is "the other" and the only way to maintain safety is to cordon off your house.

Should I wash my hands more frequently?

Hand washing is always a good idea as a protection against all respiratory and gastrointestinal viruses, from the common cold to influenza to mononucleosis. Good sanitary practices are essential to not getting the flu if you are in very close contact with it, but more than that, good hygiene is important in not getting any kind of virus or bacteria.

In the fall of 2005, the purchase of hand sanitizers was up almost tenfold. I'm sure this is a response to the fear of getting bird flu. Bird flu is not here, and frequent hand washing or use of sanitizers is a way to reassure yourself in the short term that you are doing something to protect yourself. I would never discourage hand cleansing, but keep in mind that any quick remedy for bird flu fears also reinforces the notion that bird flu is almost here, when there is no evidence to support this. The same is true for avoiding poultry. It may make some people feel safer for a brief moment, but it also reinforces the misconception that our poultry supply is at risk, when it isn't.

Are there specific medical supplies I should stockpile against bird flu? What about Tamiflu?

There is currently no need to personally stockpile antivirals like Tamiflu (Roche pharmaceuticals) for protection against bird flu. Tamiflu has been tested against this bird flu in mice and is probably effective in humans as well at reducing symptoms, but the doses would probably have to be higher for bird flu than for the usual flu to be effective. It is generally effective when taken in the first forty-eight hours after symptoms begin. A recent study suggests that Tamiflu stockpiles for 25 percent of the population would be sufficient to protect us during a colossal pandemic.

Currently there is no indication for taking Tamiflu for anyone other than perhaps a bird handler or cockfighting organizer in areas of Asia where bird flu is endemic. As with Cipro for anthrax, there is the tendency for fear to create a dependency need for a pill that is not particularly necessary. Not only that, but personal stockpiles remove the physician as an essential filter to decide when a med should be taken. Tamiflu is a well-tolerated drug with nausea as its most common side effect, but taking it when there isn't a situation of true risk from exposure or an ongoing flu is a wasteful use of the drug. Amantadine, an older antiviral drug that is also effective against many strains of influenza A, has been shown in a recent study to have developed a 12 percent resistance to flu viruses because of overuse.

Tamiflu is an expensive drug that has approximately a three-year shelf life, and since bird flu most likely won't mutate to a form that can routinely infect humans over the next few years, the chances are that if you stockpile Tamiflu, you will either misuse it or be compelled to throw it away when it is out of date.

Plus, even if you stockpiled it, without a physician's instructions you'd never know when the appropriate time to take it would be. When there's a rumor of a sick parrot in a cage at LaGuardia? When a human gets it in Madagascar? The first time someone sneezes in your vicinity near the poultry counter of your local supermarket?

How can I protect myself in general against airborne viruses?

This is an important question, and the same basic precautions against all respiratory viruses are applicable to human flu as well as to bird flu if it were to mutate to a human-to-human form. First, frequent hand washing decreases the spread of flu viruses. Be conscious of how often you shake hands or casually kiss someone at a party. These friendly practices spread viruses such as the flu. A sneeze or a cough can propel a virus ten to twelve feet. Cigarette smoke also spreads respiratory viruses, so smokers (and smokers' friends) have to be very careful when they are sick to not blow smoke into a crowded room.

Isolating sick people is the best protection against the spread of flu. Unfortunately, a patient may be spreading the virus for several days before becoming clinically ill. Close contacts of people who are ill should anticipate the possibility of getting sick and in the "window period" should take extra precautions in terms of limiting personal contacts.

What about the yearly flu vaccine?

The yearly flu vaccine is helpful in terms of introducing a "herd immunity," which may protect high-risk groups (the elderly, asthmatics, those with emphysema and diabetes, infants, pregnant women, and the immunocompromised) by decreasing the amount of circulating flu virus. But a British study this year showed only a mild effect on saving elderly lives.

This result is consistent with a previous National Institutes of Health (NIH) review of the elderly's response to the flu vaccine over the past three decades. But the vaccine is still recommended for those over sixty-five, as it appears to decrease the risk of getting severe complications of the flu, such as pneumonia, which can lead to hospitalization. I recommend the yearly flu shot to anyone in a high-risk group, and I suggest it as an option for anyone who is over fifty or has any chronic illness. Unfortunately, because the flu vaccine is still made by cultivating the virus in chicken-egg culture (fifty-year-old technology), those with egg allergies often cannot tolerate it.

And as far as anyone knows, the yearly flu vaccine does not offer protection against bird flu. This is subject to some debate, because there is crossover protection from one strain of influenza to another, but significant protection against the H5N1 strain has not been shown.

As I will discuss later in this book, there is ongoing research into the development of a single flu vaccine that will cover all strains, including H5N1, and will offer protection for at least ten years. If such a vaccine were commercially available, it would certainly alter prevention strategies for pandemics.

In the meantime, the current flu vaccine is good for only one year. It is made this way in part because the predominant yearly flu strain changes from one year to the next. Epidemiologists track it in South America and Asia at least six months before it comes to the United States. Scientists try to make a vaccine that they feel will best match the predominant yearly strain.

Patients in any of the high-risk categories should also be considered for pneumovax. The pneumonia vaccine lasts for five to ten years and covers twenty-three different strains of pneumococcal pneumonia, a common and potentially life-threatening complication of the flu.

Approximately 50 percent of the deaths during a flu season are from pneumonia, the vast majority of which are from the bacteria pneumococcus, which is generally covered by the pneumonia vaccine. If there is a bird flu pandemic, the pneumonia vaccine will be a useful adjunct, in that it will protect people from a serious secondary complication that leads to about half of the deaths.

In the meantime, an op-ed in The New York Times on November 30, 2005, had my phone ringing with urgent calls for pneumovax. Though some of my patients were embarrassed to admit it, the article—though it had been attempting to show the value of protection against pneumonia as part of a prevention strategy against flu—had also inadvertently sent an implicit message that a pandemic was in the offing. This converted the pneumonia vaccine to yet another prop or treatment of the fear of bird flu, rather than of bird flu itself.

Should I take a bird flu vaccine?

Currently, there is no commercially available bird flu vaccine for human use. One has been developed for the H5N1 virus, and the NIH is currently testing it in an elderly population of volunteers with good results so far. But since the current H5N1 bird flu hasn't mutated to a form that can routinely affect people, there is currently no indication for this vaccine. If H5N1 does mutate, it may change to a form that is only partly affected by the current vaccine. In H5N1's current form, it appears that high doses (given in two separate shots) are necessary to achieve immunity. A similar vaccine has been developed that is quite effective in birds. Over 20 million birds have been vaccinated in China to date in an attempt to help control H5N1 while it is still primarily in the bird population.

What are the chances of bird flu getting me?

Right now, the chances are almost nonexistent for anyone who does not have intimate contact with birds in Asia. And even for Asian bird handlers, the chances are very slim. The concern about the disease itself is based on the fact that the H5N1 pathogenic avian influenza is a very aggressive killer of birds, and as it spreads in birds, it increases the worldwide viral load of this particular virus.

Because flus change rapidly, it is feared that the more virus there is, the greater the chance it will mutate spontaneously or acquire the necessary genetic material from exchange with another flu virus inside a pig or a human.

But the chances of this occurring are very small for any given period of time and are not directly proportional to the number of infected birds. In the meantime, it is important to realize that not a single bird in the United States has been found to have this pathogenic avian influenza. As of this writing, no migratory birds have yet brought it to Alaska, and even if that dreaded event were to happen, most of America's poultry is not killed in the open where H5N1 can easily spread. And even in Asia, where birds freely walk the streets of many villages and towns and outbreaks in birds continue to occur (twenty-four outbreaks in China this year alone, and in May H5N1 killed 10 percent of the world's bar-headed geese), eating cooked poultry is safe.

Casual contact with birds will not give you the flu. You are protected by a species barrier; it is very difficult for you to get this virus from birds, even in parts of Asia where the virus is endemic in birds.

Bird feeders are safe; pigeons are safe; and if you encounter a dead bird, do not assume that it died of bird flu. If you are worried to that extent, it is a sign that fear is becoming virulent, rather than that H5N1 is spreading.

I am so bombarded with bird flu warnings in the media that I feel I should do something. What should I do?

Eat right and get plenty of exercise—the same things your doctor always tells you. Right now, the best thing you can do is to not obsess about it and to continue with your regular routines. I hope that this book will provide a perspective on bird flu that will counter excess emotion with reason.

Avian influenza has been around for thousands of years, and thousands of varieties of the virus exist, a few of which mutate sufficiently to affect humans. Many pathogenic strains never make that jump. Rarely a pandemic strain develops, the last two of which (in 1957 and

1968) have only been slightly worse than the yearly flu season in the United States. It behooves the world's scientists, animal experts, and public health officials alike to do their best to try to control H5N1 in birds. That job hasn't worked nearly well enough to this point. Improved international cooperation is crucial. Better funding for bird culling and vaccination programs is crucial. But currently, the problem is far more a bird problem than it is a human problem.

If a fire occurred away from your house, your best protection would be to put out the fire rather than to immediately build a firewall around your house. Currently, fear of bird flu is much more a human problem than bird flu itself. Fear is intended to be a warning system to protect us against imminent dangers. It is good that we know about bird flu, that we are learning as a society that it has a potential to expand into a problem that can threaten us, but in the meantime, while it remains remote and theoretical, excess worry or turning on our fear radar unnecessarily can do us more harm than good.

It is wise for people to be interested in their health, not waiting until illness strikes to show concern. But personal attention is better paid to a healthy lifestyle and a display of positive emotions like courage and caring than to worry about health threats that may never materialize. Right now, there is no physical protection necessary for humans against bird flu, either here in the United States, where the H5N1 disease doesn't exist even in birds, or even in Asia, where cooking poultry kills flu viruses and casual contact with birds is safe.

Is travel to Asia safe?

If you're not planning on staying on a chicken farm and interacting intimately with the chickens, you're good to go. There have been twenty-four outbreaks of bird flu in China this year and several more in Indonesia. Twenty million birds have been vaccinated against bird flu, and many millions more have been culled. The UN Food and Agriculture Organization (FAO) is engaged in a multicountry program designed to increase awareness throughout Asia. To date, bird flu has claimed forty-two human lives in Vietnam, thirteen in Thailand, nine in Indonesia, four in Cambodia, and two in China. The virus remains extremely difficult for humans to catch.

"The FAO believes that eliminating avian influenza among poultry can delay H5N1 virus turning into a form that would create a human pandemic," Serge Verniau, an FAO representative in Afghanistan, said at a recent workshop there. The FAO has begun working closely with the World Health Organization and the World Bank to promote a regional network for improving surveillance and diagnosis of the disease in both birds and the rare human. It also hopes to encourage the exchange of information on the occurrence of the disease and on the lessons learned.

In the meantime, travel to Asia remains quite safe. The occasional human case has been the result of close contact between birds and people in primitive agrarian settings. But for tourists traveling to the major cities and towns, there is no risk of acquiring bird flu whatsoever. Even for people who live in the small villages where the outbreaks have occurred, the risks are remote beyond the food handlers and the bird handlers. As for the birds, even though much Asian poultry is free ranging and may come in contact with other birds, potentially spreading the infection prior to being killed for food (the incubation period in birds is seven to ten days), according to Dr. Ron De Haven of the U.S. Department of Agriculture (USDA), there is a growing surveillance network that is serologically testing thousands of birds in the area of an outbreak.

Cooking poultry kills the H5N1 virus 100 percent of the time, so eating cooked poultry in Asia is completely safe.

What are the chances of bird flu coming to the United States?

It is possible in birds, and very unlikely in humans. The USDA is working with the FAO and the Organization of International Epizootics to promote biosecurity throughout the world. It is very unlikely that a live bird will pass bird flu (H5N1) to North America, though bird smugglers do exist. According to Dr. De Haven, it is far more likely that some chilled or frozen poultry, mislabeled or smuggled from Asia, will be brought here containing H5N1.

This is very difficult to control and is also of minimal risk, beyond the panic it might cause. If a piece of dead infected poultry was brought here, the virus would be destroyed as soon as it was cooked and would not be transmitted to humans or other animals. The chances of an infected human bringing bird flu to the United States on a plane is practically nonexistent, simply because there are so few cases of human bird flu.

But there may be many more subclinical cases than are known, since routine serological testing of contacts of the few human cases has not been routinely done. But even if someone brought bird flu here on a plane, it would not spread, because there is no human-to-human

transmission with bird flu in its current state. A third possible way that bird flu could arrive here, perhaps the most likely, is through Alaska. Unlike the Middle East, there are no regular migratory bird pathways from Asia to the United States. But Pacific flyaway birds can occasionally make it across Siberia to Alaska. Since waterfowl (ducks and geese) are reservoirs for avian influenzas, and many species of ducks in particular can be asymptomatic carriers, it is conceivable that H5N1 could show up in Alaska and from there make its way down the West Coast or across Canada.

However, there is much less contact between migratory birds and poultry in the United States than in Asia. Most of our poultry here is commercially raised, kept and killed inside buildings, with little or no access to wild circulating flocks. The chance of bird flu circulating among our poultry is therefore much less than in Asia.

What if the worst-case scenario does occur and the H5N1 bird flu does mutate to a form that can infect me? What if it comes here to the United States in that altered form? What would I do then?

In the first place, as I hope to establish further in this book, worrying about the worst-case scenario all the time is bad for our health and takes our attention away from more pressing health concerns that we really can do something about. Secondly, there is little any of us can do right now to protect ourselves from an unmutated bird flu that doesn't directly threaten us.

But if this bird flu does mutate and explode into the next 1918-style pandemic, there will be plenty of worthwhile precautions we can take.

First, we can stay calm and listen to public health advisories over the airwaves. It will be important that a consistent, accurate, noninflammatory message be delivered by the CDC and by state and local health agencies. Today's worldwide communication network, including satellite and Internet, can be an enormous asset in keeping people informed and advised at the time of a great infectious-disease catastrophe.

Second, it would be important to reduce crowds as much as possible. One of the greatest reasons for the rapid spread of the Spanish flu was the public meetings and crowds and rallies throughout World War I that facilitated the spread of the H1N1 virus.

If a massive pandemic spread today, we would be advised to not meet in public, to isolate sick patients, to obey travel advisories, and above all, to not panic. Panic leads to the greatest amount of viral spread, because when people panic, they tend to take fewer precautions.

Washing hands frequently, not coughing or sneezing on people, and not shaking hands or sharing drinking cups or silverware are all crucial methods to control viral spread.

In 1918, people didn't understand what viruses were or how best to contain them. Many people—especially the poor—lived crowded, unsanitary lives. We also have medical treatments today that will be crucial in preventing deaths in a large pandemic. Patients with heart disease, asthma, diabetes, emphysema, and AIDS would all be much more at risk of dying if they lost access to their regular medical treatment.

Treatments for these underlying conditions that were lacking in 1918 and that led to the greatest loss of life will be lifesaving now. Pneumonia will need to be recognized right away and treated aggressively with antibiotics. Since pneumonia and other bacterial infections such as sinusitis were listed on the death certificates of over half of those who died of the Spanish flu, it is likely that early intervention with antibiotics (which hadn't been discovered in 1918) will reduce the death rates dramatically in any flu pandemic that happens now.

Maintaining national and regional supplies of medications will be paramount, especially as regular trade and business will likely be hampered by the pandemic and the need for strict travel guidelines.

Was the 1918 virus a bird flu?

Yes, it was, and research over the past decade has revealed that it made the jump directly from birds to humans via mutation. However, and this is something to always keep in mind, it was not a big killer of birds before this mutation occurred. There's not necessarily any connection between what's deadly in birds and what's deadly in humans.

Why are some projections for this bird flu worse than that of 1918?

As long as we're talking about worst-case scenarios, you should know that public health officials are concerned about the possibility of a worse pandemic at some point for the following reasons:

(1) The world is much more densely populated now than in 1918, with more of this population concentrated in the cities. Denser population is more conducive to the spread of a respiratory virus like influenza.

(2) There are more elderly, chronically ill, and immuno-compromised individuals now than in 1918. These groups are more at risk of dying of the flu, although, as I will discuss in a later chapter, it was the young who died in the highest numbers in 1918 of the Spanish flu.

(3) Plane travel increases the ease of viral spread from one corner of the globe to another, contributing to a pandemic.

(4) The virus itself is currently far more deadly than the 1918 strain, which killed about

2.5 percent of the people it infected. (Of course, the lethality of the virus should diminish significantly if the virus mutates. In order to mutate to a form that can infect us, it must sacrifice some of its ability to kill.) It's also important to understand that there are many people out there who mean well when they give these projections. A scientist looking for funding on how to significantly improve our vaccine capabilities may only be trying to scare people into understanding why longterm planning is important. Ironically, panicked politicians are likely to run right past him, funding short-term solutions that treat a created societal inflammation.

How should the government prepare to protect us against the worst case as well as against more likely scenarios?

The first thrust should be made toward trying to control bird flu in the bird population. Most people who hear about bird flu vastly overestimate how bad this is likely to be for humans, while underestimating how terrible it already is for birds. This particular pathogenic, H5N1, has been spreading and reappearing in birds in Southeast Asia since 1997, and it is quite deadly in birds. Recently it has spread to Turkey and China, and all attempts to stamp it out completely have failed.

No one knows what the risk is of it mutating to a form that can routinely be transmitted among humans, but Dr. De Haven, the USDA's chief administrator of the Animal and Plant Health Inspection Service, and many other animal and public health experts believe that the best strategy is to decrease the worldwide viral load by vaccinating large populations of birds in countries where the disease has appeared and culling birds in affected populations.

The USDA has allotted over $4 million for a bird biosecurity outreach program in Asia to keep infected birds from coming to the United States, but far more money is needed. Billions are proposed to be spent on human preparation, but if more were spent on controlling a bird disease in birds, humans might never need the protection.

Dr. De Haven has been meeting regularly with the FAO, the Organization of International Epizootics, and leaders from the World Bank, who are now to begin to provide funding.

On the human side of the equation, it is wise for our government and governments around the world to work together. Our CDC is combining with the WHO to build a worldwide network that tracks emerging diseases and recognizes and prepares for potential pandemics. If bird flu is the disease that fuels that response and improves that network, that is a good thing.

At the same time, resources should not be taken away from the current worldwide killers (malnutrition, AIDS, tuberculosis, malaria, heart disease, schistosomiasis, hepatitis) to provide excess resources only for bird flu worst-case scenarios.

The current H5N1 bird flu should be targeted mainly in birds, because the risk to humans is currently very slight. And nothing would reduce the risk of its killing people directly or mutating into a deadly human virus like cutting back on the pool of birds that have it.

Preparation for human pandemics can be of a more general nature, because we don't know what pathogen will cause the next major pandemic or even whether it will be a bird flu.

Here are some major priorities for governmental protection and preparation that I will describe throughout this book:

• Improve the hospital infrastructure and include emergency response plans for influenza as well as for other pathogens.

• Upgrade vaccine manufacture using twenty-firstcentury genetic technology, cell culture, and DNA splicing, with the goal to improve response time. If 100 million doses of a vaccine for a specific flu could be manufactured in a month or two, as is possible with the latest techniques, then the need for government stockpiling for a particular bird flu such as H5N1 would be much less.

• While developing these new vaccine strategies, put together emergency stockpiles against certain pathogens, such as H5N1, where the effects of a human pandemic would be greatest.

• Discourage personal stockpiles. Personal stockpiles will lead to improper use of a drug like Tamiflu, when no current need exists. Patients won't know when it is right to take this drug without a doctor's advice.

• Public health officials must learn a new language for communicating risk. It is crucial to learn how to correctly convey to the public that a threat over a given period of time is very small but worth taking seriously because the worst case is devastating.

Proper preparation can be accomplished without panicking the public. It should not be necessary to alarm the public as a ploy to get funding for disaster planning. This strategy frequently backfires, as money gets wasted on only the worst case and there is little left for the more likely threats. Since we can't worry or prepare for everything, we should expend our national resources rationally.

• Revamp the Federal Emergency Management Agency (FEMA). This agency has become so dysfunctional because its focus has become bioterror, which is far more likely to affect a smaller number of people than an influenza outbreak would. FEMA would function better if it were back on its own, separate from Homeland Security, preparing strategies for all major disasters, not just worst-case scenarios.

An example of how far FEMA has fallen is its own Web site, which uses a hermit crab as its educational mascot for children. It shows the shell being burned up or blown off and the crab crawling away to safety no matter what the disaster. But a hermit crab is hardly an inspiring creature for our children, even if it does survive. Whatever happened to our bald eagle? Is FEMA somehow afraid it will invoke images of bird flu?

• In the United States, we are dependent on other societies for many of our major products. In the event of a major pandemic, we might be cut off, so our government needs to work on improving its domestic supply of essential goods, from food to energy to medicines. Fear and panic are bound to accelerate this need of domestic production in a large pandemic, because in a climate of fear an afflicted country is likely to be shunned by the rest of the world. (SARS is an example of this, and its numbers were quite small compared to a major flu pandemic).

Dr. David Fedson, the former medical director of Aventis-Pasteur, said recently at a bird flu conference held by the Council on Foreign Relations in November 2005, "Do we realize that most of the diagnostic kits we have for flu in this country right now have component parts that come from outside the country or the entire kit is assembled outside the country? Supply chains are very thin. We'll lose our ability to diagnose this [flu] overnight when the pandemic begins because there is no surge capacity, no inventory capacity for making diagnostic kits."

What are the essentials of President Bush's plan for bird flu pandemic preparedness?

The plan calls for a $7.1 billion total expenditure. The president proposes that $2 billion of this would be devoted to stockpiling antiviral medications and 20 million doses of an experimental vaccine against the bird flu strain H5N1. $2.7 billion would go toward vaccine research and upgrading our methods of vaccine manufacture. Federal dollars would be invested in an international flu-surveillance network, and federal funding to state and local public health agencies would be boosted by $100 million.

Critics of the plan say that far too little is designated for the state and local agencies or for fighting bird flu in Asia, where it is currently (only $251 million would be spent overseas). Critics also have complained that the plan doesn't provide for improving the hospital infrastructure for disaster response. According to Dr. Irwin Redlener, associate dean and director of the National Center for Disaster Preparedness at the Mailman School of Public Health at Columbia University (speaking from the audience at the avian influenza conference held by the Council on Foreign Relations in November 2005):

"7.1 billion focused mostly on antivirals and vaccine development, which is fine, but less than seven percent of that budget could be construed as going towards anything that would help bolster a very ailing hospital system in the United States. Which in fact would be the only recourse that we would have if, in fact, we're dealing with a race against time, which we are. And if it becomes real that we get a pandemic prior to the development of sufficient capacity to contain, to vaccinate and to treat with specific antivirals, then all we have left is a health and hospital system . . . we'll find that we don't have sufficient isolation beds, intensive care beds, ventilators, et cetera, et cetera."

Watching cable news, I have the impression that something is about to happen. But many experts talk about long-term preparedness. How is that going to help me now?

Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, answered this question when speaking at the Council on Foreign Relations bird flu conference in November 2005:

"Much of the preparation that we need to do for pandemic influenza is long-term preparedness; it's not overnight, immediate-reaction preparedness. . . I think what's happened in the last six weeks has been a media on steroids, that basically went from no attention to this, or very limited attention. But then all of a sudden everybody discovered it after Katrina and the intersection between lack-of-preparedness and now-we-need-another-story created this. And what we need to do is even that out; we need to get perspective. . . . And hopefully we can get back to a point where we will see that this is really necessary preparedness."

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