When epidemiologists start using words like "inevitable," referring to an outbreak of pandemic illness, the time when a thinking person might remain in ignorance is past. And if, to this point, you haven't begun educating yourself about the life-and-death threat posed by the H5N1 flu now migrating through bird populations Asia, and soon to expand beyond—well, start.

The bottom line is that avian influenza is endemic and probably ineradicable among poultry in Southeast Asia, and now seems to be spreading at pandemic velocity amongst migratory birds, with the potential to reach most of the earth in the next year.

Each new outpost of H5N1 -- whether among ducks in Siberia, pigs in Indonesia, or humans in Vietnam -- is a further opportunity for the rapidly evolving virus to acquire the gene or even simply the protein mutation that it needs to become a mass-killer of humans.

This exponential multiplication of hot spots and silent reservoirs (as among infected but asymptomatic ducks) is why the chorus of warnings from scientists, public-health officials, and finally, governments has become so plangently insistent in recent months.

The new U.S. Health and Human Services Secretary Mike Leavitt told the Associated Press in early August that an influenza pandemic was now an "absolute certainty," echoing repeated warnings from the World Health Organization that it was "inevitable." Likewise Science magazine observed that expert opinion held the odds of a global outbreak as "100 percent."

Mike Davis, "The Coming Avian Flu Pandemic"

Reminders of the great flu pandemic of 1918-19 are circulating. Nearly a century on, we seem to have gained little advantage over our grandparents and great-grandparents, in the matter of planning: our vision of course is immeasurably sharpened, and when the storm breaks, it won't be a surprise this time, not to anybody that's paid attention at least. But all we'll have to show for it, apparently, may be the awful, slow-motion oncoming-crash sensation you get reading the news from Thailand or Indonesia or Siberia. Any preventive ability we've theoretically gained these last decades will almost certainly be overwhelmed by systematic failures in a public health policy massively distorted by the profit motive.

Please don't imagine that some miracle vaccine's going to allow us to cheat disaster. Based on the news from Asia, time seems to be getting short, and for an outbreak beginning any time in the next couple of years the logistical window is all but closed.

What if the next pandemic were to start tonight? If it were determined that several cities in Vietnam had major outbreaks of H5N1 infection associated with high mortality, there would be a scramble to stop the virus from entering other countries by greatly reducing or even prohibiting foreign travel and trade. The global economy would come to a halt, and since we could not expect appropriate vaccines to be available for many months and we have very limited stockpiles of antiviral drugs, we would be facing a 1918-like scenario.

Production of a vaccine would take a minimum of six months after isolation of the circulating strain, and given the capacity of all the current international vaccine manufacturers, supplies during those next six months would be limited to fewer than a billion monovalent doses. Since two doses may be required for protection, we could vaccinate fewer than 500 million people — approximately 14 percent of the world's population. And owing to our global "just-in-time delivery" economy, we would have no surge capacity for health care, food supplies, and many other products and services. ...

What if the pandemic were 10 years away and we embarked today on a worldwide influenza Manhattan Project aimed at producing and delivering a pandemic vaccine for everyone in the world soon after the onset of sustained human-to-human transmission? In this scenario, we just might make a real difference.

Michael T. Osterholm, New England Journal of Medicine

Lost in its foolish dreams of a global crusade against evil, and committed besides to a policy of allowing Big Pharma to cash in as and where it chooses, no planning or leadership has come from the Bush administration, nor will.

Two things: first, this is a political issue if ever there was one—an issue in which masses of people must work to change the priorities of their government (and of a class of elites who seem, still, all but heedless of the growing danger). Prospects look dim for the kind of movement necessary, but every voice raised (even on a small, haphazardly maintained blog like this one) adds a bit of weight. Which is one reason I say, educate yourself, and then do whatever's in your power to spread the word. Melanie, at Just a Bump in the Beltway, has been doing easily the most consistent and forward-looking blogging of anyone on the subject—grab her feed if you haven't already. The Flu Wiki she's set up is an invaluable resource, and probably the best place to start. You should certainly also bookmark the dedicated flu blog H5N1.

Which brings me to the second thing. "Inevitable" in the mouth of an epidemiologist doesn't mean, "H5N1 is the inevitable agent of pandemic," it doesn't mean, "Pandemic is inevitable in a month," or in six months, or eighteen. It doesn't even mean an H5N1 pandemic will inevitably be the once-in-a-century, maximally virulent infectious event we have most to fear. (Though that body of despairing opinion, as Melanie will attest, is out there and well represented in the scientific community.) Some combination of genetic luck and conscious political agency in the next several years may yet avert the worst. But don't count on it. It becomes a crucial exercise of imagination to picture a world in which significant numbers of people—not foreign people on the teevee, either, but us historically exempt Americans—are dying, in which the ordinary comforts of life are radically diminished or absent, in which simple prudence forces people to quarantine themselves, to avoid almost all unscreened human contact, for months at a time. That's going to be a hard world to live in, for whatever the duration of the pandemic. You need to think about protecting yourself: you need to consider things like stockpiling food and water, for instance. (If that sounds like an unduly alarmist thing to say, trust me, it won't when you've done your reading.) The personal and family preparedness section of the Flu Wiki makes a good jumping-off point.

posted by michael  3:11:47 PM  
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