This month's outbreak of H5N1 avian flu in Turkey—as many as 50 human cases and several deaths—looks very like what we might see in the first weeks of a pandemic, if the virus mutated and became transmissible from person to person. <?xml:namespace prefix = o ns = “urn:schemas-microsoft-com:office:office” />
Officials in the stricken region warned the Turkish government Dec. 16 of a surge in bird deaths. But another 12 days passed before an investigation began. And when a 14-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.” These responses ominously resemble the passivity and denial by the Chinese government during the SARS outbreak of 2003.
How should industrialized countries combat H5N1? 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.
We do need good surveillance of H5N1 in Asia and Africa, to obtain the earliest possible warning that a strain of H5N1 flu transmissible from human to human has been detected, so nations around the world can rapidly initiate a variety of public health measures—not the least to begin crash production of large amounts of vaccine against that strain.
But the 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 infrastructures, make it very unlikely 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 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.
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 naive enough to believe the U.N. 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 the drugs often would be administered improperly—such as in suboptimal 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, to obtain timely warning an H5N1 strain 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 begins relatively soon—say, in a year or two—little 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 best—among, literally, a world of possibilities—to expend resources.