The first book of Kings relates that when Elijah's servant looked toward the sea he saw nothing. Seven times Elijah told him to look again, "and at the seventh time he said, 'Behold, a little cloud like a man's hand is rising from the sea.' . . . And in a little while the heavens grew black with clouds and wind, and there was a great rain."
For the past year health officials have been scanning small, isolated stories of bird flu transmission, hoping that the H5N1 strain was not mutating to a form that could spread easily by person-to-person rather than bird-to-person transmission. If that happened, a pandemic with millions of deaths would be likely.
Then last month World Health Organization officials discovered evidence that six of seven people in an Indonesian family died after being infected by one family member who coughed frequently within a small room. The officials found "no evidence of significant mutations," but the incident put bird flu in the headlines once again, and raised questions of how well the United States and other countries are prepared for what could become a great rain.
There's no question that the danger is enormous-and no U.S. official after Katrina wants to be caught underestimating catastrophe. Late last year the Department of Health and Human Services (HHS) offered a worst-case scenario: Two million Americans die, with panicky people overwhelming hospitals, fighting for food, and rioting at vaccination clinics. President Bush mused about the prospect at a press conference: "The policy decisions for a president in dealing with an avian flu outbreak are difficult. One example: If we had an outbreak somewhere in the United States, do we not then quarantine that part of the country, and how do you then enforce a quarantine?"
According to a 400-page Pandemic Influenza Plan put out by HHS, state, local, and tribal authorities "should be able to" isolate individuals and then set up voluntary quarantine measures-but that plan reads like some hurricane disaster plans, filled with generalities and good intentions but light on specifics.
How would a quarantine work? CBS medical reporter Sanjay Gupta forecast "recommended isolation. . . . You might be told on your local news or even [by] a phone call or something to stay home, don't be outside, stockpile some food and don't come in contact with people until we tell you." After the experience of Katrina in New Orleans, do we really think that all or even most people will stockpile food, and that they will obey instructions?
Not expecting much from a quarantine, the HHS projection has 93 million people becoming ill at some point during the 16 prime weeks of pandemic, with 8.5 million people hospitalized, and costs exceeding $450 billion. The Congressional Budget Office chimed in with its worst-case financial cost: $675 billion.
The number of people to die would depend on the virulence of the mutated flu. It clearly would produce economic disaster: perhaps no air travel not only for several days as after 9/11, but for several weeks or months. In the midst of a pandemic, interstate commerce might virtually end for a time. Many people would have to rely on their own supplies of food and water.
The worst-case scenarios suggest the possibility of a national New Orleans. With food distribution costs increasing and scarcities common, prices for food and other essential goods could soar. Some jobs would disappear, job absenteeism would grow, mortgage defaults would increase, and the threat of bank runs and closures would be great. Probably every company in the airline industry would go into bankruptcy. The Federal Reserve would need to be prepared to increase liquidity in financial markets and keep check-clearing systems from shutting down.
The Pandemic Influenza Plan also emphasized the need for "timely and transparent dissemination of clear, accurate, science-based, culturally competent information." Good intentions, but no specifics: Based on Katrina reporting, it's likely that many media would spread panic. So let's start here: What's a non-panicky way to appraise what could be catastrophe?
First, recognize danger. If bird flu mutated, worldwide air travel would quickly spread the disease. The two-day typical influenza incubation period-the time from infection to visible illness-would allow those infected to transmit the virus during the day before they become ill. It's likely that the typical person becoming ill would transmit the virus to two or three other persons. Pessimists argue that the medical system would be quickly overwhelmed.
Second, acknowledge that predictions of big numbers, based on the experience of the flu pandemic of 1918, may be over-the-top, since medical advances of the past century could make a huge difference: We now have antivirals, antibiotics, and vaccines against many types of pneumococcal bacteria. (Not the flu itself but secondary complications, particularly pneumonia, caused the huge death total then.)
The most important argument against prophets of doom is that, despite all the headlines over the past year, the worrisome strain (H5N1) is not new: Scottish chickens had it in 1959, English turkeys in 1991, and Hong Kong chickens in 1997. In all that time it has not mutated. Headlines in 1997 hyped the "Race to Prevent World Epidemic of Lethal 'Bird Flu,'" but that also was a false alarm.
Crucially, most avian viruses cannot be transmitted to humans because the receptor proteins in bird and human lungs are very different. The hemagglutinin protein of the H5N1 virus binds easily to bird cells, allowing the virus to replicate easily, but it struggles in human cells. Viruses constantly drift and shift, so H5N1 could swap chunks of genetic code with human influenza and become something that could pass from person to person like a common cold does-yet that's not probable.
Scientific materialists estimate odds, and others talk of luck, but all of these probabilities are in God's hands. And it looks as if we still have some time to plan for a potential calamity in the coming year, and more time to guard against further problems by revising national policies concerning three mundane matters: poultry inoculation, vaccine production and pricing, and litigation.
The traditional way of stopping the spread of H5N1 among birds has been to destroy poultry exposed to the virus: In Asia and Eastern Europe, over 150 million birds have died or been killed in recent years in an effort to stop the virus. But stopping the spread before it starts is also possible through bird inoculation: At the end of 2005 China announced a national plan to inoculate its poultry for H5N1.
In the United States, a crew of seven or eight workers wearing protective gear could inject vaccine into the necks of chickens, taking a week to treat a typical farm holding about 100,000 birds. Cost would be about $500 million for enough vaccine to inoculate all of America's 10 billion chickens, and another $500 million for labor.
Politically potent opposition to vaccination comes from the National Chicken Council, a trade association representing companies such as Tyson Food and Perdue Farms, which says vaccination would hurt the $2 billion chicken export business. The poultry industry says that major importers of U.S. chickens would not accept vaccinated poultry, since the basic screening tests they use for bird flu can't say for sure whether chickens have been infected or vaccinated.
The poultry industry says it has other ways to fight a chicken pandemic: Kill all the chickens in an area around an infected group, require workers and visitors to wear protective clothing, and so forth. Besides, all the chickens could be vaccinated and a mutated H5N1 could still come to the United States via airlines. But the major concern is dollars, and if a refusal to spend contributes to a pandemic among humans, the love of money will have contributed to a slaughter that would justifiably result in the most bitter of recriminations.
The human vaccine question sits amid a different economic and legal landscape. Since viruses frequently mutate, a vaccine often works for only one season, so a manufacturer must recover his entire cost of production in a few months. The movie business is somewhat analogous in its emphasis on fast recovery of investment-the first weekend of theater exhibition is key-except that movies have DVD sales, but no one wants a vaccine past its prime.
To continue the analogy, add one more disincentive: Imagine that if a movie became hugely popular, governments would suddenly declare that tickets must cost 50 cents rather than $8. (Popularity for politicians, yes, but what effect on future production?)
Now, let's turn this from entertainment to life-and-death matters. Doctors believe that the antiviral drug called Tamiflu, if taken within 48 hours of avian flu onset, will be able to relieve the worst symptoms and prevent many deaths. The Swiss company Roche should be receiving laud and money for bringing the drug to the world. Instead, Roche faces demands to sell Tamiflu or license government production of it in many countries at give-away prices.
The World Health Organization has tried to force Roche to give up its Tamiflu patent rights; officials in Indonesia, Taiwan, and other countries have forced Roche to license production. Sen. Charles Schumer (D-N.Y.) is among the U.S. politicians proposing that the United States break Roche's patent rights.
It's vital to produce more Tamiflu, but to do so in a way that does not send a negative message to researchers and companies deciding whether to invest heavily in the drug that could preserve life from the next threat. Politicians, though, know that the pandemic a decade or two down the road will not be on their watch and will not affect their immediate electoral chances. They can be vote-wise and life-foolish.
The better way is either to pay market prices for needed drugs or to offer big prizes for companies that come up with vital drugs. George Mason University economist Tyler Cowan suggests that the federal government offer Roche the option of licensing production in this country, at generous prices and with favorable regulatory treatment and easy facility construction.
We also need to deal with the litigation threat that has grown over the half-century from 1957 to 2005, during which time the number of vaccine makers in the United States shrank from 26 to four, with two of the four doing little in vaccine research. We have vaccine shortages in nine of the 12 vaccines commonly given to children. The problem is that when a large population is vaccinated, a small percentage (but a large number) will become ill, and almost all will be approached by lawyers who say big bucks are waiting.
The legal path could be cleared if courts did not impose strict liability for rare side effects but instead required proof of negligence. Alternatively, the federal government could indemnify vaccine manufacturers for damages attributed to the vaccine. The National Vaccine Injury Compensation Program has since its creation in 1986 done that for rare injuries sustained following the administering of vaccines used routinely for children, but it does not cover many vaccines, does not cover unborn children, and gives gambling lawyers the option of going before juries that sometimes run away from both law and science.
Legal change often depends on media perception. Many pundits pound pharmaceutical companies, but Paul Offit, chief of infectious diseases at the Children's Hospital of Philadelphia, argues that these companies should be honored: During the past century they have been the major contributor to increasing the American lifespan by 30 years.
The often-abused companies have created and mass-produced vaccines against pertussis (whooping cough) that dropped the number of children's deaths from 8,000 annually to fewer than 20; vaccines against polio that reduced the number of children it paralyzed annually from 15,000 to zero; vaccines against rubella (German measles) that reduced the number of children with severe birth defects from 20,000 to zero.
Today, removing litigation disincentives to mass production is particularly important because we may not be far off from some vital breakthroughs in vaccine production. Scientists are beginning to genetically engineer viruses that could be used in vaccines. One company plans to use canine cultures to produce avian flu vaccine. Overall, it looks like the time to produce vaccine can be cut from six months or more to three months or less. Companies are also working to use less of a vaccine by mixing in adjuvants, chemicals that magnify vaccine effects so that what was needed for one dose can now take care of 40 or 50.
Those advances could come soon, but they're not here yet. In the short run we have to prepare for pandemic possibility. For example, since schools would close down during a pandemic, teachers will need to be prepared to post work online and do virtual instruction. Some companies are planning to have employees work from home in case of a pandemic, which makes sense not only to avoid spreading the virus but because day-care centers would also be closed.
In the event of a pandemic, local health-care systems will be stretched and stressed as never before, so they would need to have and use databases of volunteers-doctors, nurses, other professionals-willing to help out in case a pandemic hits. With emergency rooms crowded by flu patients it would be important to turn church halls and school gyms into clinics for those with non-flu emergency medical needs.
Medical facilities would have to have stockpiled testing kits for avian flu and large supplies of antibiotics, respirators, IV fluids, and the other innovations that can make a new pandemic much less costly in lives than the 1918 disaster. Generic statin drugs used to fight cholesterol might also fight the secondary results of flu infection.
Companies such as Federal Express would be crucial in shipping as other patterns of commerce broke down. Faith-based organizations would be crucial both in direct relief work and in the preservation of community when everything seemed chaotic. Individual action, from stockpiling food before the crisis to frequent hand-washing and mask-wearing during it, would be essential.
And, as Elijah knew, one action is most crucial: prayer.