Fill the Moat, Lower the Portcullis
The issues surrounding the possibility of a pandemic of the H5N1 strain of avian flu are extraordinarily complex, encompassing aspects of medicine, epidemiology, virology, and even politics and ethics. Moreover, there remains tremendous uncertainty about critical factors, such as exactly when H5N1, which now primarily affects birds, might mutate into a form that is transmissible from human to human, and how infectious and lethal it might be.
It is not surprising, therefore, that commentaries about avian flu often miss the mark. For example, a New York Times editorial, “The Flu Moat,” decried wealthy countries’ “me, first” attitude toward a possible pandemic of H5N1 avian flu, because “[t]he best hope of stopping a pandemic, or at least buying time to respond, is to improve surveillance and health practices in East Africa and Asia, where one would probably begin.” Well, not quite. We do need good surveillance, in order to obtain the earliest possible warning that a strain of H5N1 flu transmissible from human to human has been detected, so that nations around the world can rapidly initiate a variety of public health measures, not the least of which would be to begin a crash program to produce large amounts of vaccine against that strain. But the massive undertaking required to “improve health practices in the poorest countries of the world” plays better on the editorial page than on the ground. The “task facing poor nations where a pandemic might start” is not only “staggering” but virtually intractable, one of the curses of poverty. Intensive animal husbandry procedures that place billions of poultry and swine in close proximity to humans, combined with unsanitary conditions, poverty and grossly inadequate public health infrastructure of all kinds, make it highly unlikely that a pandemic can be prevented or contained at the source. It is noteworthy that China’s prodigious effort to vaccinate 14 billion chickens annually has been chaotic, compromised by the appearance of significant amounts of counterfeit vaccines and by the absence of protective gear for vaccination teams—who might actually spread disease by carrying fecal material on their shoes from one farm to another.In theory, it is possible to contain a flu pandemic in its early stages by performing “ring prophylaxis”—using anti-flu drugs and quarantine aggressively to circumscribe and isolate relatively small outbreaks of a human-to-human transmissible strain of H5N1. According to Johns Hopkins University virologist Donald S. Burke, “models show that it may be possible to identify a human outbreak at the earliest stage, while there are fewer than 100 cases, and deploy international resources—such as a WHO stockpile of antiviral drugs—to rapidly quench it. This ‘tipping point’ strategy is highly cost-effective.” However, a strategy can be “cost-effective” only if it’s actually feasible. Although ring prophylaxis might work in Minneapolis, Toronto or Zurich, in the parts of the world where flu pandemics begin, the probability of success approaches zero. In places like Vietnam, Indonesia, and China—where the pandemic strain will likely originate—expertise, coordination, discipline and infrastructure are lacking. The response in Turkey—where as many as 50 possible cases have appeared in the eastern part of the country within the past month—is illustrative. Officials in that region warned the government on December 16 of a surge in bird deaths but it took another 12 days for an investigation to begin. And when a fourteen year old boy became Turkey’s first avian flu mortality last week (followed soon by two siblings), a government spokesman criticized doctors for mentioning the disease because they were “damaging Turkey’s reputation.” This is ominously reminiscent of China’s initial response to SARS in 2003.It appears that up till now all of the human infections with the H5N1 strain of avian flu have been contracted from contact with infected poultry, but experts believe it is only a matter of time until the virus mutates to become capable of human to human transmission, an event which could give rise to a pandemic. The situation in Turkey is what the outbreak of a pandemic strain might look like at its earliest stages: the rapid spread of confirmed cases (and deaths) from an initial site to nearby villages and cities. We would expect to see a large number of illnesses among both employees and patients in hospitals where the victims are treated, and soon someone (perhaps even a carrier who isn’t ill) would spread it to Ankara, Tbilisi, Damascus or Baghdad, and then. . .If national governments are incapable of appropriate, timely actions to prevent or respond to a potential pandemic of avian flu, to whom could we delegate responsibility? The World Health Organization, perhaps—a component of the inept, self-serving, scientifically challenged, politically correct, unaccountable United Nations, which gave us the Iraq oil-for-food scandal and its continuing coverup, and a botched investigation into the assassination of Lebanese politician Rafik Hariri? Is there anyone so naive to believe that the UN can keep politics out of scientific and medical decisions?The anti-flu drugs Tamiflu and Relenza are extremely expensive and in short supply. If we were to drain the moat and make these available to poor countries for ring prophylaxis, history tells us that the drugs often would be administered improperly—such as in sub-optimal doses—in a way that would promote viral resistance and only intensify a pandemic. Or perhaps sold on the black market to enrich corrupt government officials.A politically incorrect but rational strategy would be for the richer countries to devote resources to developing countries primarily for surveillance in order to obtain timely warning of the existence of an H5N1 strain that is transmissible from human to human, but to focus the vast majority of their funding on a number of parallel, low- and high-tech approaches—vaccines, drugs, and other public health measures—that will primarily benefit themselves.If the pandemic were to begin relatively soon—say, within a year or two—there would be little that could be done to attenuate significantly the first wave of infections. (If we’re ready to rush the pandemic strain into a crash program to manufacture vaccine, we could possibly blunt the second wave, however.) A flu pandemic will require triage on many levels, including not only decisions about which patients are likely to benefit from scarce commodities such as drugs, vaccines and ventilators, but also broader public policy choices about how—among, literally, a world of possibilities—best to expend resources.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />