Cover Story

Be prepared

Health | With policies on poultry inoculation, vaccine production, and pricing in flux, fighting bird flu is a matter of planning, not panic

Issue: "Bird flu," June 10, 2006

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.

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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.)


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