Flu Pandemic Preparedness Snowballed

The Flu Pandemic Preparedness Snowball
by Peter M. Sandman
Posted: October 10, 2005
Trying to arouse concern about anything is pushing a rock uphill. But if you抮e lucky, the rock gets to the top of the hill and starts rolling down the other side. As it gains mass as well as momentum, it converts to a snowball. Of course there抯 more than one hill; your rock/snowball is likely to need more pushing before long. Still, the snowball phase is certainly worth noting, and celebrating.
That抯 where flu pandemic preparedness is right now. During the past two weeks, U.N. head Kofi Annan appointed a new pandemic 揷oordinator,?David Nabarro, whose maiden speech used a higher upper-end worldwide death prediction (150 million) than any of his World Health Organization colleagues had previously voiced. In the U.S., which has lagged behind many other developed countries by some measures of preparedness (antiviral stockpiles, domestic vaccine production capacity, and candid warnings to the public, for example), Democrats and Republicans vied with each other to see who could most aggressively insist that 搘e抮e not prepared,?and actually cooperated in several legislative efforts to get better prepared. Two research teams published studies showing marked similarities between the mother of all flu pandemics in 1918 and the H5N1 virus now looming over much of Asia. Whatever measure of buzz you want to use ?radio talk show topics, website hits, lists of most-emailed articles, street corner conversations, even naysayers?what抯-all-the-fuss-about columns ?the effort to try to get the world (at least the first world) ready for a bird flu pandemic had a good fortnight.
I have overused the phrase 搕eachable moment?in my writing about risk communication, and I promised myself to give it a rest. But the point has never been more relevant than right now. Forget the rock and the snowball and think cattle branding. In precaution advocacy ?trying to get people worried about a risk, and therefore disposed to take precautions ?it抯 best to strike while the iron is hot. The iron is pretty hot right now. Unless a pandemic begins soon, it may not be hot for long. Once again, this is a teachable moment.
Be nice to the newbies.Watch out for people抯 adjustment reaction ?and the authorities?adjustment reaction.Focus less on the pharmaceutical fix.Focus more on worst case scenarios.Focus more on non-medical preparedness.Focus more on non-governmental and local preparedness.Focus more on worldwide preparedness.Get clear on the 損an?in 損andemic.?/FONT>Get clear on the 損re??and the 搈aybe??in pandemic preparedness.
This column will be a potpourri of miscellaneous warnings and quibbles about pandemic risk communication as it seems to be evolving. For the basics, see last December抯 ?/FONT>Pandemic Influenza Risk Communication: The Teachable Moment.?For an annotated good example, see July抯 ?/FONT>Superb Flu Pandemic Risk Communication: A Role Model from Australia.?For the rest of my writing on pandemic communication (yes, I抦 a little obsessed), see my website抯Pandemic Flu and Other Infectious Diseases Index. 1. Be nice to the newbies.
Anyone who has ever been an activist knows how demoralizing it is to start winning. You had this solid 搃n?group of fellow fanatics. Everyone knew everyone else; everyone knew the facts and the issues; everyone knew how special you all were to care so deeply, to keep plugging away despite your neighbors?obliviousness. Then you made some progress, and suddenly there were strangers coming to your meetings, asking stupid questions, offering inappropriate suggestions, making everyone uncomfortable, sometimes even usurping leadership. In a1984 article for the nuclear freeze movement, I wrote:
We oldtimers inevitably gravitate to each other at gatherings, especially when we抳e been through tough times together, or when we have work to transact and gossip to transmit. This leaves newcomers sitting painfully alone, watching the inner circle and pondering the invisible 揔eep Out?signs we didn抰 mean to post. You can抰 stop the formation of cliques, and you can抰 stop wanting time with your friends. But you can consciously reach out to newcomers. In larger groups you can even institutionalize a buddy system. Pair each newcomer with another newcomer to compare notes with, and with an oldtimer to go to for basic information.
Until very recently, most of the bird flu blogs and wikis and interactive websites were doing a nice job of welcoming newcomers ?certainly a better job than the nuclear freeze movement did two decades ago. There were FAQs for newbies, and an overall tone of acceptance leavened the inevitable corrections of beginners?errors. ( 揧eah, I used to think that too,?is a lot easier to take than 揥hat a dumb thing to say!? The h2h [human-to-human] transmission of bird flu information was going fine. But the last two weeks have seen an explosive increase in newcomers to bird flu sites. These latest newbies are in the early stages of their adjustment reaction. Some are frightened and urgent; some are skeptical; nearly all are ignorant. Some of the oldtimers are feeling crowded and a little contemptuous, and it抯 showing.
The Flu Clinic is a 搑oom?on thecurevents.com (current events) bulletin board. On October 5, the curevents moderator posted a warning: I am very disappointed in the direction that this room has taken over the last couple of weeks. Yes, the board has grown a great deal in terms of the number of participants. But I am also seeing a much more negative development. People are becoming openly hostile and aggressive, personal attacks are increasing, and it is having repercussions.... The personal attacks are going to stop.... The discussions are going to stay focused on flu topics. I don抰 want to see any more political debates, economic discussions, prep threads, gun control arguments and so forth in here.... People are going to be respectful of other viewpoints. That means that one person might like alternative medicine, while another might not.... And most importantly, it means that some people think H5N1 is going to be a catastrophe and others will not....
I understand that most of the people here think it is 搘hen not if?and will be bad. Regardless, I WILL NOT allow this place to become a 搕rue believer cult?where opposing viewpoints are shouted down.
Another flu bulletin board, this one onagonist.org, is in danger of shutting down altogether, because the moderators 揾ave grown very weary of moderating the consistent food fight attitude here in this forum.... We don抰 want to shut down the Disease threads.... But, the tone, tenor and behavior are way out of line.?
Some of us bird flu fanatics are likeliest to lose our tolerance for newbies when the newbie is the newly interested President of the United States, a newly appointed official of the World Health Organization, or even a newspaper reporter covering the pandemic story for the first time. Commentaries on bird flu media coverage and the public utterances of public officials have sometimes evinced a carping tone. One of the best flu sites iseffectmeasure.blogspot.com, whose editors use the nom-de-web 揜evere.?On September 30 Revere posted a commentary under the title 揃raindead take notice,?noting what they called 揵elated signs of life among our braindead politicians who are dimly seeing that maybe bird flu is the next Katrina.?
This is a self-defeating tone for people whose goal is to spread the word. Worse, it抯 a self-defeating attitude. As a fellow fanatic put it to me a few days ago: 揟he mainstream is finally starting to pay attention, and some of the flu geeks are getting upset. They haven抰 quite figured out why. They just know they抮e in a bad mood.?(The 揻ellow fanatic?is my wife, colleague, and frequent coauthor Jody Lanard. She can抰 write any avian influenza columns with me right now, because she抯 working temporarily as WHO抯 Senior Advisor for Pandemic Communications in Geneva. I抦 on my own.)
There抯 no question that the flu pandemic preparedness snowball picks up a lot of misinformation as it rolls:
揟amiflu抯 like a vaccine except it抯 generic, not tailored to a specific strain of flu.?/FONT>
揟he experts are sure H5N1 will go pandemic; it抯 not if, it抯 when.?/FONT>
揥e抮e okay as long as we watch our birds carefully and don抰 let that Asian bird flu get a foothold in North American poultry flocks.?
I heard these three from one talk show host during one ten-minute period. Actually, Tamiflu can stave off the flu if you keep taking it, and can weaken the disease if you take it soon after getting sick, but it doesn抰 confer immunity the way a vaccine does. The experts are sure there will be some kind of flu pandemic sooner or later, but whether H5N1 will ever learn to spread efficiently from human to human is anyone抯 guess. And if H5N1 does eventually accomplish efficient h2h transmission, it won抰 matter where; from then on it抯 a human pandemic, and protecting local birds won抰 affect it a bit.
As pandemic concern keeps increasing ?if it does ?errors like these will be self-correcting. Last week抯 newbies will learn better, even as this week抯 newbies make similar mistakes. It will be useful to notice which facts beginners keep getting wrong, so we can correct the errors or even warn against them. ( 揥hen people first hear about bird flu, they often get the impression that.... But actually....? And it抯 important to figure out which errors really get in the way and which just irritate us oldtimers. (President Bush抯 opinion that quarantine is likely to stop a pandemic, emphasized at his news conference last week, is a good candidate for correction. By now someone has probably told him that his government抯 experts don抰 think so.) Of the three errors in the previous paragraph, by far the most damaging to the preparedness effort is the widespread belief that local birds are the key. If H5N1 progresses from 搊ccasional bird-to-human transmission?to 揺fficient human-to-human transmission,?it won抰 matter where it happens. If it happens anywhere, the odds are overwhelming that H5N1 will get here (wherever 揾ere?is) in a matter of weeks or months. Pandemic viruses are avatars of globalization.
As we correct the errors that most need correcting, we should try hard to be gentle. It can help to recognize that our desire to be harsh may emanate from injured ego. Nobody can control a snowball. We can try to guide it, but if it keeps rolling and growing (as we hope it will), inevitably it抯 going to pass us by and find its own course. As the snowball expands, we feel deflated. We need to be nice to the newbies anyway. 2. Watch out for people抯 adjustment reaction ?and the authorities?adjustment reaction.
I have written elsewhere aboutadjustment reactions. When people are first confronting a risk they haven抰 thought about before, it is normal ?and useful ?to 搊ver-react?for a while. Some people become hyper-vigilant; some take precautions prematurely; some obsess. Then a few people turn into fanatics, while most settle into the New Normal, more attentive than previously to the new risk, but not so obsessed anymore.
Officials are prone to misinterpret the public抯 adjustment reaction as panic or hysteria. Instead of helping people get through it, they tend to try to tamp it down.
The big achievement of the past two weeks is a quantum increase in the willingness of authorities to say scary things about bird flu. In the U.S., at least, this is in part a side effect of Hurricane Katrina; the U.S. government feels it dare not risk accusations of under-reacting to another potential crisis. I think it抯 also a result of U.S. government fears that just about everyone else was expressing more concern about bird flu than the U.S. government was:
Civil society was sounding the alarm ?from the Council on Foreign Relations to the New England Journal of Medicine to Trust for America抯 Health.
The private sector was getting interested ?hundreds turned out for a recent New York conference on how the financial industry can prepare for a pandemic.
Other countries?governments were moving further and further out in front.
Some state and local officials (most notably King County, Washington) were getting way ahead of Washington D.C. in talking up pandemic preparedness.
Democrats (and Republicans) in Congress were making noises and introducing bills.
It looks very much like President Bush authorized Health and Human Services (HHS) Secretary Michael Leavitt to sound scary too.
And Leavitt has delivered on the new policy. On October 6 he said: 揌ere抯 the dilemma: We抮e not prepared as a country. No one is prepared in the world.?On October 8 he said: 擳he world is woefully unprepared. You抎 think that it would be a matter of constant concern to us. It has not been, anywhere in the world and, consequently, the world is unprepared. And we抮e now as a civilization rallying to say, 慦hat can we do to better prepare?挃 You can quarrel with Leavitt抯 implication that preparedness is a dichotomy and that no countries are paying closer attention than the U.S. But you can抰 quarrel with his candor about the need to do more. 揥oefully unprepared?is the kind of phrase you抎 expect from the opposition ?and indeed several Democratic politicians had used the phrase as far back as March 6. But it抯 different when the party in power criticizes itself.
As momentum builds, what should come next is the public抯 adjustment reaction. I don抰 know what form it will take. A run on Tamiflu, maybe. Or private stockpiling of surgical masks. Or a growth spurt in hand-washing. Or increased pressure on local and national officials to publish their pandemic plans, and to make them more detailed and more practical. Or a decline in chicken sales, or in tourism to Southeast Asia. Some of these precautions make better sense than others ?but it抯 not rare for precautions in the adjustment reaction phase to be less than optimal. The proper risk communication response is to try to guide the adjustment reaction by first validating the impulse to act, and then suggesting wiser precautions people can take.
The least desirable risk communication response to the public抯 adjustment reaction to the pandemic flu threat is to insist that the public is over-reacting. This is, if you will, an adjustment reaction to the adjustment reaction, an official over-reaction to the public抯 over-reaction. (The technical term is 搑eactance.? It will be unfortunate if people cope with their new bird flu fears by buying less chicken for a while. It will be more unfortunate if officials respond to the decline in chicken sales, if that抯 what happens, by staging chicken-eating photo ops at which they ridicule the public for panicking. And it will be devastatingly harmful if the lesson officials draw from all this is that they should try to keep people from worrying about a flu pandemic.
People need to worry about a flu pandemic, so they can start getting their families and their communities ready. And eating less chicken isn抰 panicking.
(A personal comment: While I do not recommend photo-ops of cheerful officials eating chicken, I do recommend going out of your way to eat chicken. During the SARS outbreak, going to Chinese restaurants was a gesture of solidarity and empathy, supporting a group that was being stigmatized and damaged during the public抯 SARS adjustment reaction. Ridiculing the adjustment reaction may score political points, but it will not help frightened people get through it faster. Respectfully suggesting alternative precautions will.) 3. Focus less on the pharmaceutical fix.
Infectious disease experts have been insisting for years that the world抯 system for manufacturing vaccines is broken. Part of the problem is technical. We are still using a mid-twentieth century technology that is slow, precarious, and inefficient; in an era of bioengineering, vaccines are grown in chicken eggs. And part of the problem is social. Vaccine manufacturers incur high potential liability without much potential profit, so most pharmaceutical companies don抰 want to be in the business at all, much less modernize it.
It is definitely good news that the U.S. government now says it is determined to do something about the vaccine mess. We can argue about the right solution ?whether the government should take over vaccine manufacturing altogether, or make it more profitable by becoming a better customer, or make it less risky by protecting companies from lawsuits, or underwrite research into new technology, or subsidize a few new domestic factories, or just cajole companies into manufacturing improvements in hopes of an unspecified quid pro quo later. But almost any solution is bound to be an improvement. Though it抯 all too human for flu fanatics to find fault with the government抯 new focus on vaccines (see#1 above), the proper response is thank you and congratulations and keep up the good work, not 揥hat took you so long??
But it抯 not all about vaccines.
The problem with reforming the vaccine manufacturing system is that it will take time. Nobody knows how much time; technological breakthroughs don抰 keep to a schedule. And nobody knows how successful the reform effort will be ?that is, how short we can make the gap from when a new virus launches a pandemic (or seems poised to do so) to when there is an adequate supply of a vaccine tailored to that virus. And of course nobody knows how long we have before the next pandemic strikes.
So it certainly makes sense to rethink the vaccine manufacturing process, in hopes of a shorter gap and a larger supply when the time comes. And it probably makes sense to keep making and stockpiling vaccines tailored to the evolving H5N1 virus, in hopes that the latest stockpiled vaccine will match the eventual pandemic virus closely enough to be useful. But it does not make sense to be confident that either of these two measures, or both of them together, will save the day. If the next pandemic starts soon, we won抰 have a vaccine stockpile and we won抰 have a speedy process for producing enough of a new vaccine.
Nor are Tamiflu and Relenza (the two antiviral drugs that seems to work on H5N1 so far) guaranteed to save the day. Many other western countries have put more stress on antivirals than the U.S., which has put its money on vaccines instead. Now the U.S. wants to hedge its bets by greatly enlarging its antiviral stockpile. That, too, probably makes sense. But there抯 no way the U.S. can get enough antivirals for the entire population. For the foreseeable future, the U.S. will need to choose between protecting key personnel (health care workers, cops, firefighters) and treating people who are already infected. Even that抯 an ambitious goal. No corporate official will say how long the queue is for backordered antivirals. And nobody is saying what pressure (if any) the U.S. and other governments are exerting to cut ahead in the queue. If the next pandemic starts soon, antivirals won抰 be a major factor either, except in a few countries with sizable stockpiles in hand.
What does all this information on vaccines and antivirals have to do with risk communication? Five things:
The focus on the pharmaceutical fix is excessively optimistic. It is keeping people from focusing enough on worst case scenarios.
The focus on the pharmaceutical fix is excessively medical. It is keeping people from focusing enough on non-medical preparedness.
The focus on the pharmaceutical fix is excessively governmental. It is keeping people from focusing enough on what civil society, the private sector, and individuals can do
The focus on the pharmaceutical fix is excessively national. It is keeping people from focusing enough on local preparedness.
The focus on the pharmaceutical fix is excessively first-world. It is keeping people from focusing enough on ways to help Africa, Asia, Latin America, and the Middle East prepare for a pandemic.
4. Focus more on worst case scenarios.
Too much pandemic risk communication, especially from government, is structured like a television commercial: Introduce a horrible problem, then tell the viewer how your product is guaranteed to solve the problem. Michael Leavitt, David Nabarro, and other world leaders deserve credit for being more willing than previously to concede how horrible the problem may be. But they are sometimes a little too willing to stress how great their portfolio of solutions is.
Nabarro, for example, floated that scary 150 million number on September 29 as his upper-end estimate of how many a 1918-like H5N1 pandemic might kill, with 5 million as his lower-end estimate for a pandemic more like the mild ones of 1957 and 1968. That抯 good. He was saying it might be horrific or it might not. But then he added: 揑 believe the work we抮e doing over the next few months on prevention and preparedness will make the difference between, for example, whether the next pandemic leads us in the direction of 150 [million dead] or in the direction of 5 [million dead].?
If Nabarro actually believes that, he is nearly the only one who does. There won抰 be a lot more vaccine or antiviral doses stockpiled a few months from now than there are now. So how many people an early 2006 pandemic would kill depends mostly on how infectious and how virulent the mutated virus turns out to be, not on anything we do between now and then. Most experts think pandemic prevention is pretty much a lost cause (though bird culls can be useful, and some think a last-ditch effort to contain a newly hatched pandemic before it spreads far is worth trying). As for preparedness, if the pandemic comes soon and the virus turns out more like the ?8 strain than the ?7 or ?8 strain, for the most part preparedness won抰 be about reducing flu deaths; it will be about reducing collateral deaths from other causes (see#5 below).
Similarly, Leavitt said on October 8 that the world is 搘oefully unprepared?for a flu pandemic. He didn抰 quite acknowledge that the United States is less prepared than some other countries, or that it might have been expected to be better prepared than most ?but at least he didn抰 exempt the U.S. from his description. Leavitt was doing the media rounds, and the world抯 lack of preparedness was a consistent leitmotif. Just as consistent was Leavitt抯 prescription for getting prepared. Aside from vaccines and antivirals, he focused mostly on improved surveillance in Asia, in the hope that we can nip an incipient pandemic in the bud. (That 搘e?is a bit misleading. Lacking any commitment from first-world countries to donate from their own antiviral stockpiles to try to ring-fence an emerging outbreak in Southeast Asia, the World Health Organization has arranged for manufacturer Roche to donate three million treatment courses of Tamiflu for the purpose.)
What Leavitt hasn抰 come anywhere near saying, even in the last two weeks, is what most flu experts have been saying all along: There may be no way to prevent, halt, or even delay a severe pandemic. There may not even be a way to significantly alleviate the influenza death toll. Maybe the best we can do is take steps to avoid additional suffering and additional deaths from infrastructure collapse (see#5 below).
Still, Leavitt shows more sense of the tragic than most U.S. career politicians have shown. On October 4, thirty-two Democratic senators sent a letter to President Bush expressing 揼rave concern that the nation is dangerously unprepared for the serious threat of avian influenza.?The President responded by devoting much of a news conference to the issue. He focused especially on the quixotic notion of deploying the military to enforce a domestic quarantine of any infected region. 揟he people of the country,?he noted, 搊ught to rest assured that we抮e doing everything we can.?
To start with, the President抯 belief that the public ought to 搑est assured?is 180 degrees off. The public needs to progress 揻rom apathy to alarm and from alarm into action,?as the Trust for America抯 Health advocacy organization puts it, 搒cared into its wits?in Michael Osterholm抯 phrase. And of course we抮e not doing everything we can. Nor should we; the essence of risk management is always figuring out which precautions to take and which to forgo. (Large-scale involuntary quarantines are one we can probably forgo.) The President and his opponents seem to share two false assumptions: that it is possible and desirable to do everything you can to prepare for a risk, and that if you do everything you can you will no longer be dangerously unprepared.
It is true that our tolerance for alarming information depends on our sense of self-efficacy. Telling people the pandemic risk is huge and there is nothing to be done would be debilitating rather than inspiring. The trick is to inspire people the way Winston Churchill inspired people during World War II ?not with happy talk and false optimism, but with determination.
Winston Churchill notwithstanding, politicians are politicians. When they finally become aware of a threat, it is with little sense of the tragic and little willingness to acknowledge the limitations of preparedness. One side demands, and the other side promises, that the government will hold back the tides. 揥e抣l stop the virus in Asia. We抣l stop it at our borders. We抣l quarantine any region that gets a case. We抣l shoot a vaccine dose into every arm. The American People deserve no less!?
This insistent pharmaceutical optimism militates against preparedness for a severe pandemic. That抯 what worries me most about the focus on vaccines and antivirals.
We don抰 know when the next pandemic will come. More importantly, we don抰 know when the next severe pandemic will come. If it holds off long enough, and if the world gears up seriously enough, we may actually be able to develop an adequate medical response; we may be able to make sure 1918 never happens again. Or that may be beyond us. We don抰 know. What we do know is that the next severe pandemic may very well come when we are still, as we are now, woefully unprepared with an adequate medical response. That抯 the worst case scenario. People need to know about it.
For more on how to talk about bird flu worst case scenarios, see ?/FONT>Worst Case Scenarios.? 5. Focus more on non-medical preparedness.
Why do people need to know about the worst case scenario? So they can start getting ready for it ?not with vaccines and antivirals, but with inventory adjustments, with improved hygiene habits, with knowledge about social distancing, and with plans to recruit immune survivors as volunteers.
If the next pandemic is a mild one, the medical response will be almost the only response needed. But medical preparedness for a severe pandemic isn抰 feasible right now, though it might be some day. Non-medical preparedness, on the other hand, is feasible today. There抯 a significant chance it may turn out essential tomorrow.
So far the main official sources of pandemic information (such as the World Health Organization and the U.S. government) have had little to say about the possible impact of a pandemic on production and transport. That has been left to private commentators, such as Michael Osterholm of the University of Minnesota抯 Center for Infectious Disease Research and Policy and Laurie Garrett of the Council on Foreign Relations. In a severe pandemic, lots of people will be dead, sick, caring for loved ones, or afraid to go to work. And travel of all sorts will be is greatly reduced. With production and transport slowed to a trickle, shortages are inevitable ?especially in our era of just-in-time inventory. At a pandemic preparedness conference I attended a few weeks ago, Laurie Garrett sat quietly through several excellent presentations on various aspects of avian influenza. 揥ell, yes,?she asked from the floor when the question period arrived, 揵ut how will we eat??
What are we likely to run out of that we can抰 afford to run out of? Food is certainly high on the list. So is energy, more for heating than for transport. And medicines ?not flu medicines, particularly, but cancer medicines and the rest. And essential supplies and parts. What happens, for example, when the local water treatment plant runs out of chlorine or filters or whatever else a water treatment plant needs to keep running? If a disastrous 1918-like pandemic hits, the question is whether the health disaster we probably cannot do much to ameliorate will be accompanied and followed by additional disasters we really could have ameliorated, if only we had prepared better for them. We need to take steps so that people who are spared by the pandemic influenza virus aren抰 done in by starvation, cold, chronic diseases, or contaminated water.
Security is another non-medical issue official sources haven抰 had much to say about. We don抰 want people who are spared by the virus done in by riots either. But I抦 pretty sure they抮e thinking about security, even if they抮e not talking about it. I worry whether anybody is thinking enough about staffing and inventory.
Then there抯 hand hygiene ?which isn抰 really 搈edical?because you don抰 need a doctor to do it right. Infection control experts agree, with solid evidence to support them, that the single best available precaution against the spread of influenza is washing your hands as often as you can. They also have evidence to support their advice to avoid touching your eyes, nose, and mouth. Additionally, though without much evidence, they recommend covering your mouth when you cough. (They抳e got to know that it抯 hard to cover your mouth without using your hands unless you wear a surgical mask ?but for some reason most of the experts aren抰 enthusiastic about public use of masks. They say they抮e worried mask-wearers might become complacent, a worry they never seem to have about hand-washers.)
Hand hygiene is mostly individual and profoundly low-tech, so it has trouble getting as much attention as it deserves. The U.S. Senate has just proposed to spend $3.9 billion on pandemic preparedness improvements, most of it on vaccines and antivirals. I somehow doubt there抯 money in the budget to retrofit restroom sinks so you don抰 have to touch the faucet when you turn off the water, or restroom doors so you don抰 have to touch the doorknob as you leave. (Many restroom faucets and doors at HHS headquarters in Washington and WHO headquarters in Geneva don抰 meet this elementary hygiene standard.)
The distinction between medical and non-medical preparedness bears on the recent WHO spat over mortality figures. This Numbers Game has a long history; Jody and Iwrote about earlier installments at length. The most recent installment came when Nabarro blurted out his 150 million figure during a news conference at U.N. headquarters in New York, his first public appearance after being appointed to his new pandemic coordinator job. In Geneva the next day, WHO spokesman Dick Thompson did damage control. As Emma Ross抯 Associated Press story put it: WHO抯 flu spokesman at the agency抯 Geneva headquarters made a surprise appearance Friday at the UN regular media briefing in an effort to put Nabarro抯 comments in context. While he did not say the 150 million prediction was wrong, or even implausible, he reiterated that WHO considers a maximum death toll of 7.4 million a more reasoned forecast....
揥e抮e not going to know how lethal the next pandemic is going to be until the pandemic begins,?said WHO influenza spokesman Dick Thompson.
揧ou could pick almost any number?until then, he said, adding that WHO 揷an抰 be dragged into further scaremongering.?/FONT>
Thompson went on to explain that most WHO officials prefer the mortality estimate of 2?.4 million ?based on modeling the mild 1957 and 1968 pandemics ?because a mild pandemic is statistically likelier than a 1918-style pandemic, which was apparently a one-off event. Since most of the world抯 countries can barely afford to gear up for a mild pandemic, why dispirit them with worst case estimates based on the 1918 disaster? 揟here is a limited amount of public health money available to countries and we have to give them the best guidance on how to spend that money,?he said.
Thompson抯 point makes real sense for medical planning ?but not for non-medical planning. The right estimate for a poor country to use in medical planning is probably the 2-7.4 million estimate of how many a mild pandemic might kill. Only the wealthiest countries can afford to consider trying to have a medical response to a severe pandemic. But every country needs to consider its non-medical response to a severe pandemic. For non-medical preparedness, Nabarro抯 150 million ?or even Michael Osterholm抯360million ?is a better planning number. These are numbers that force us to think about how we will keep our societies functioning, so infrastructure failures do not kill people the influenza virus spared. 6. Focus more on non-governmental and local preparedness.
It takes a national government to reconfigure vaccine manufacturing or build a strategic national stockpile of antiviral medications. But most non-medical preparedness doesn抰 necessarily involve the national government at all, except perhaps for advice and information-sharing:
Manufacturers and service providers can rethink their inventory control procedures. What will they be able to provide for themselves if their usual supplier can no longer make it or ship it? What can they do without in a pinch? What do they need to stockpile?
Every organization can rethink its staffing needs. How can we get essential tasks done despite soaring absenteeism? What sorts of cross-training now might save the day later?
Every organization can rethink its social contact needs. Infectious disease transmission is a function of the number of social contacts ?keeping people home more means keeping more of them alive. What jobs can shift to telecommuting? How can we educate children without making them come to school? How can we distribute food without making people come to the supermarket or the soup kitchen? Should we redefine 揹elivery person?as an essential job that qualifies for prophylactic antivirals?
Nonprofits can start planning to coordinate volunteers. Like any emergency, a pandemic will yield huge numbers of people who want to do something to help ?including many who contracted pandemic influenza and survived, and are therefore immune. Who is going to sort them out and get them where they抮e needed most, doing high-risk jobs that don抰 require special skills (washing linens at the hospital, for example, or making deliveries to people sick at home)?
Local governments can ask themselves hard questions about leadership and survival. How will they keep essential services (police, fire, water and sewerage) operating? What inessential sources of infection (movie theaters and restaurants, for example) will they want to shut down? Where will they put the bodies when the morgues are full? How will they maintain order?
What抯 left for individuals to do? Inculcate hand hygiene habits now. Figure out how you抣l take care of a sick family member without getting everyone else sick. Stockpile what you抣l need so you don抰 need to go out so much. Ask your doctor for a prescription for Tamiflu or Relenza ... and fill it fast, before the drugstores run out. (Admittedly, this is a zero-sum game by now.) Above all, push every organization you抮e tied to ?your church, your employer, your club, your children抯 school ?to start its own pandemic planning process.
A revised U.S. pandemic preparedness plan is due to be released any day now. According to Michael Osterholm, who reviewed it in draft, one important way the new plan differs from its predecessor is its focus on non-governmental and local preparedness ?including non-medical preparedness. In an October 9 story entitled 揊lu Plan Leaves Many Decisions at Local Level,?the Washington Post reports: 揟here have been tremendous improvements in the plan even over the last week to 10 days,?Osterholm said. In particular, he said, the most recent version emphasizes the likely prolonged effects of a flu pandemic and the need for unprecedented cooperation between the government and the business sector for more than a year....
揃asically, cities and states are going to have to shoulder a lot of this burden of response on their own. There is no other choice. When you have all 50 states, every major city, every county and every hospital in crisis ?the federal government can抰 address all of that,?Osterholm said. 揈very place is going to need resources and expertise at the same time, and in fact every country in the world is going to need those things.?
In describing what Osterholm called 搕he upper bounds of what a pandemic could look like,?the plan describes potential shortages of medicines for non-influenza illnesses, disruptions in the delivery of food and conceivably a lack of caskets and crematorium space.
It抯 very good news that the U.S. government抯 plan is trending in these directions. The U.S. government抯 rhetoric is just beginning to do likewise. Too many government statements still imply that Washington will save us all. So why should the local hospital, supermarket, water treatment plant, or family think about ways to get ready?
But Leavitt seems to be consciously changing his department抯 tune. On October 7 he told The New York Times that flu planning 搘ill require school districts to have a plan on how they will deal with school opening and closing?and 搕he mayor to have a plan on whether or not they抮e going to ask the theaters not to have a movie.?Over the next couple of months, he said, 搚ou will see a great deal of activity asking metropolitan areas, 慉re you ready??If not, here is what must be done.?
It抯 not either/or. My snippy references to 搕he pharmaceutical fix?notwithstanding, the vaccine manufacturing system does need fixing, and fixing it is probably the best long-term influenza-fighting investment the national government can make. By all means let the feds work on the levees. But the flood may come before the levees are strengthened. The rest of us should be preparing for the flood. 7. Focus more on worldwide preparedness.
Vaccines and antiviral drugs are fairly slow and difficult to manufacture. Given the very limited manufacturing capacity, many experts doubt whether there will ever be enough of either to meet the pandemic needs of the United States and the other western countries. Nobody even pretends there will ever be enough to meet the needs of the rest of the world. For Africa, Latin America, and much of Asia, the pharmaceutical fix is a delusion. There抯 one possible exception: statins. Virologist Robert Webster has pointed out that statin drugs, widely used to fight cholesterol, are also anti-inflammatory. He says there is some evidence they might work against flu, possibly including H5N1. And lots of statins are off-patent and cheap. But when we think about pandemic preparedness in terms of vaccines and antivirals, we抮e thinking about the West.
Does the West care about the rest of the world?
Right now there is enormous worldwide interest in Southeast Asia. That抯 not because Southeast Asians will be any more vulnerable in a pandemic than the rest of the world抯 population. And it抯 not because the world cares more about the health of Southeast Asians. It抯 because so far that抯 where most of the sick birds and all of the sick people have been. That抯 where an H5N1 pandemic is likeliest to start. So that抯 where the West will have its only chance of nipping the pandemic in the bud. Sure we抎 like to help Southeast Asia if we can. But mostly we need Southeast Asia to help us.
And so the U.S. State Department hosted a bird flu meeting of 65 countries last week, mostly to talk about surveillance and transparency. And as I write this, U.S. Secretary of Health and Human Services Michael Leavitt is in Southeast Asia for a series of meetings with health ministers.
The key questions: Will the government of Vietnam, Thailand, Cambodia, or Indonesia know promptly if it encounters a cluster of bird flu victims, suggesting that the virus may be acquiring the knack for h2h transmission? Will it tell us what it knows? Will it tell us when it抯 not sure yet, just suspicious? Above all, will it let us take our own blood samples? (That抯 not just because we trust our labs more than their labs. It抯 mostly because we need a blood sample to start tailoring a vaccine to the newly mutated virus.) When you抮e done asking these questions about Vietnam, Thailand, Cambodia, and Indonesia, ask them about China. Ask them about Myanmar. And ask yourself how cooperative you think the United States government would be if the positions were reversed ?if some other country wanted access to a U.S. patient抯 blood in order to develop a vaccine that U.S. citizens were unlikely ever to be able to afford ... or even offered a chance to buy.
There should be room for a quid pro quo here. Some biotechnology companies pay royalties to indigenous peoples when the company develops a marketable medication or other product from a local organism抯 genome. An Asian commitment to report early and provide blood samples quickly deserves a reciprocal western commitment to provide vaccine doses. (Of course, then the Asian countries would be in the same predicament that some western countries may end up in: having some vaccine but not enough for everyone. A health ministry official from a country that is H5N1-free so far recently said it might be politically better to have no vaccine than to have just a small amount. She was optimizing for political stability, not for lives saved from flu.)
If international cooperation is possible on any issue, it ought to be possible on pandemic preparedness. When it comes to infectious diseases with pandemic potential, we truly are one world.
One possibility that both the U.S. and the World Health Organization are vigorously pursuing is ring-fencing ?surrounding an outbreak while it is small and 搒mothering?it with antiviral drugs before it has a chance to spread. (Ring-fencing has never been tried for influenza; there were no antiviral drugs in existence during the last flu pandemic.) As Health Secretary Leavitt put it on October 9, 搃f it happens in Thailand or Laos or Cambodia, the rest of the world can go there and help them contain it. Containment is our first strategy.?The quid pro quo here is fairly clear. Southeast Asia improves surveillance and transparency, so ring-fencing has a chance. The West contributes expertise and antivirals. It抯 a long shot, but if it works it could save millions of Asian lives as well as millions of western lives. Not to try would be crazy.
A number of western countries, including the U.S., are already sending other expertise to Southeast Asia, on topics ranging from epidemiology to veterinary medicine to risk communication. Every contact between a person and an H5N1-infected bird is another opportunity for the virus to mutate. Figuring out how to change animal handling practices to reduce the number of such contacts is common sense, good for everyone. Figuring out how to convince Asian poultry farmers and their neighbors to follow the recommended protocols is tougher, but obviously a key part of the job.
Ring-fencing and veterinary improvements are both about pandemic prevention. Where there has been almost no action so far, as far as I know, is international pandemic preparedness. Suppose prevention fails and we end up facing a severe pandemic, a rerun of 1918? What can we do together now to make that eventuality less horrific for us all? What are our chances, for example, of working out a way to keep travel and transport operating? (Our experts will tell us that quarantines are hopeless and pointless beyond the very earliest phases of pandemic spread; our intuitions and politics will tell us to try anyhow.) What are our chances of coming up with humane ways to address the inevitable border tensions when people start trying to flee from places where the virus is hot to places where, at the moment, it is not? What can the world抯 richest countries do to make it possible for the poorer countries to better survive the catastrophe? 8. Get clear on the 損an?in 損andemic.?/FONT>
Most emergencies are local. Tsunamis, earthquakes, hurricanes, wars, famines, and terrorist attacks all happen where they happen. The rest of us ignore them or look on in horror or try to help.
Pandemics are unique. They happen everywhere, more or less at once.
Wherever and whenever an influenza pandemic starts, it will spread pretty quickly. So far there is no pandemic virus. H5N1 is an avian influenza virus ?a flu virus in birds ?that is spreading very successfully within the bird population. It has managed to pass from a bird to a person fewer than 200 times we know about, and from a person to another person only two or three times we know about. That抯 why we don抰 have a human pandemic yet. If and when the virus changes so it can pass easily from person to person, it will qualify as an outbreak. If surveillance procedures catch a local outbreak with pandemic potential quickly enough, there is a slim chance it might be encircled and eradicated before it spreads. The chance is slim because surveillance and early reporting are imperfect, and because people are infectious before they feel sick; they get on buses and airplanes while they抮e unknowingly incubating the disease. So odds are it will spread. When it starts infecting people across a wide area, we抣l call it an epidemic. When it starts infecting people everywhere, it will be a pandemic. ( 揚an枖 is the Greek root meaning 揳ll.?
If the next pandemic follows the pattern of most past flu pandemics, it will last a year, maybe two. It will come in waves. An area will be 揾ot?for a few weeks or months, then there will be a period of relative calm, then another wave. The first wave has often been milder than the second or third.
Here抯 the paradox: Because a pandemic is worldwide, it is intensely local. There is nobody 搊utside?the pandemic to send help. Every community is pretty much on its own.
Many people don抰 understand that yet. You hear people talking about how they抳e got a pandemic over in Asia somewhere, but not here. You hear earnest discussions about why one part of the world is more vulnerable to pandemics than another. You 揾ear?the unspoken assumption that if the worst happens help will come pouring in, just as it poured into New Orleans after Hurricane Katrina.
Consider this October 6 Associated Press story out of Maryland, headlined 揊armers Call Avian Flu Safeguards Adequate? Eastern Shore poultry farmers pleaded for calm this week after President Bush said he抯 growing more concerned about avian flu possibly spreading to people. Farmers and state officials say current safeguards are adequate to prevent a pandemic of the disease in humans.
揟here抯 reason for concern, of course, and it抯 not something we should ignore, but I don抰 think it poses a great threat in this country. We抮e ahead of the curve,?said farmer Doug Green, who raises 100,000 broilers in Princess Anne.
Scientists say it抯 only a matter of time before a worldwide influenza outbreak. Concern is rising it could be triggered by the avian flu called H5N1....
But poultry farmers said the nation is safe, for now, from a deadly outbreak in people. The strain of bird flu that sickened humans in Asia has not been discovered in the U.S.
A spokeswoman for Salisbury-based Perdue Farms Inc. said American farmers are far better suited than Asian farmers to contain bird flu before it spreads to people....
In Delaware, where poultry is the top agricultural product, state officials say their safeguards are adequate.
揥e抮e ready. We抮e confident we can respond,?said Anne Fitzgerald, spokeswoman for the Delaware Department of Agriculture.
Psychology and risk communication teach that people resist taking on new worries by concocting rationales for believing they抮e less at risk than others. Neil Weinstein coined the label 搖nrealistic optimism?for this universal phenomenon. I remember working with Neil on radon warning messages back in the 1980s. We tried to tell New Jersey homeowners that they should test their homes for radon gas, a natural byproduct of uranium in the soil that could pose a serious risk of lung cancer. Person after person explained that they understood the risk was serious for other people. But 搈y house?is at the top of a hill, or at the bottom of a hill, or old, or new, or well-insulated, or well-ventilated ... so 揑抦 not at risk.?(My favorites were the people who had learned that radon tends to accumulate in the basement. Since they had no basement, they figured they were safe ?as if their radon weren抰 accumulating in the living room instead.)
Resistance to pandemic warning messages will take various forms. But one of them is sure to be this one: The bird flu pandemic won抰 get here because our birds are clean. 9. Get clear on the 損re??and the 搈aybe??in pandemic preparedness.
Right now, your risk of contracting bird flu is very close to zero. Unless you抮e in the poultry business in Asia, you simply have no contact with the H5N1 virus. And as far as we know, your current risk of contracting pandemic influenza is exactly zero; there is no pandemic today. To reiterate: Very few cases of avian influenza have occurred in people, ever. And the last influenza pandemic was in 1968.
Your risk of contracting pandemic influenza will stay at zero until some flu virus that our bodies haven抰 encountered before ?H5N1 or a different strain ?starts spreading efficiently from human to human. Then, quickly, your risk will become sizable.
What is the probability of that happening? Nobody knows. Some experts think it would have happened already if it were going to happen at all. Others ?among them David Nabarro and Michael Osterholm ?say they抮e almost certain it抯 coming soon. Most are in the middle somewhere. Flu pandemics occur roughly three times a century, so in a perfectly ordinary year there抯 about a three percent chance of a pandemic, mild or severe as the flu gods dictate. But the course of H5N1 since 1997 has presumably raised the odds of a pandemic, and many think it has raised the odds (to an unknown and unprovable extent) that if a pandemic does come it will be a severe one. Some officials in the U.S., Australia, and elsewhere are throwing around a pandemic probability estimate of ten percent. There抯 no science behind the number, and usually no time frame given when it抯 used. But it does capture most experts?sense that a pandemic is much likelier than in the average year, though far from a sure thing.
Does that ten percent guess make you want to take precautions, or does it make you think the whole issue is overblown? Consider the question this way. What probability of your house burning down would you accept before you decided it was worthwhile to buy fire insurance? What probability of heart disease would you accept before you decided it made sense to change your diet and get a periodic electrocardiogram? What probability of getting in an auto wreck would you accept before you decided to wear a seatbelt? Would ten percent do the trick in these other cases? And if another year goes by and your house, your heart, and your car are all intact, does that mean you should stop taking precautions?
Preparedness and precaution-taking are about hedging your bets. You always hope the bad thing won抰 happen; you usually think it probably won抰 happen. But just in case it does, you take steps to reduce your risk. This is a profoundly sensible but somewhat unnatural thing to do. The natural thing to do is to notice (rightly) that everything抯 fine so far, then to figure (again rightly) that everything will probably turn out okay anyway, then to deduce (wrongly) that there抯 no reason to worry, so chill out.
In a thoroughly typical example, Fox channel WAWS in Jacksonville, Florida reported on October 7 that 搘hile officials are concerned?about an influenza pandemic, 搈any area residents are not, saying it抯 just too early to panic.?The story explains: 擬ost aren抰 worried because the CDC says there抯 a low risk of catching Avian Influenza since it抯 difficult to pass to humans.?It quotes a local physician, Dr. Ken Hitz, on ways to protect against the flu, but notes that 搈any of Dr. Hitz抯 patients are not worried about a flu a world away, and say the whole thing抯 been blown out of proportion.?
Leave aside the implication that worrying and panicking are pretty much the same activity. What this passage most clearly demonstrates is the weird but widespread notion that there is no reason to protect against a risk until the risk is on your doorstep. Don抰 take precautions or get yourself prepared if nothing has gone wrong yet. Certainly don抰 take precautions or get yourself prepared if the odds are good nothing抯 going to go wrong. The story neglects the 損re?and the 搈aybe?in pandemic preparedness.
These errors are mainstays of human psychology, and of mainstream journalism as well. An October 6 Reuters story out of Washington was headlined 揢.S. Sends Mixed Message on Bird Flu Threat.?Here抯 how the story starts: WASHINGTON, Oct 6 (Reuters) ?The U.S. administration sent mixed signals on the threat from bird flu on Thursday, with President George W. Bush urging mass production of vaccines while his health secretary played down the risk of a pandemic.
All officials conceded the United States was unprepared for a possible pandemic, and pointed to a number of meetings being held this week to confront the problem....
The head of the U.S. Centers for Disease Control and Prevention has said an influenza pandemic that could kill millions is certain and may be imminent.
However U.S. Health and Human Services Secretary Michael Leavitt, while urging preparations for a possible outbreak, said the risk was relatively low and a pandemic probably would not happen.
擳he probability that we抣l have a pandemic flu is unknown,?Leavitt said at a Washington health technology conference. 揑 will tell you from all I hear from scientists and physicians it is relatively low, but it is not zero.?
The risk is high enough that the United States should be prepared, he added. And it is not.....
揌5N1 may happen, but it probably won抰. If it does we need to be better prepared.?/FONT>
There is no mixed message here. Some experts would dispute Leavitt抯 claim that the risk of a pandemic is 搑elatively low,?but none would disagree that even a relatively low risk of killing hundreds of millions of people in a next few years justifies precautions and preparedness.
Risk communicators should not have to claim a threat is guaranteed and imminent in order to urge people to take protective action. Greenpeace should not have had to claim that a global warming catastrophe was just around the corner to get us focused seriously on greenhouse gases. President Bush should not have had to claim that Saddam Hussein already had weapons of mass destruction to get us thinking seriously about Iraq. Meteorologists should not have had to promise a Category Five hurricane in New Orleans to get us moving on levee improvements.
Preparedness isn抰 about things that are already happening. And preparedness is only rarely about things that are sure to happen. Preparedness is mostly about things that might ?or might not ?happen.
A severe H5N1 influenza pandemic might ?or might not ?happen. We hope it won抰. We need to get better prepared, now, in case it does. That抯 not a mixed message. It抯 the right message.
?2005 By Peter M. Sandman

            
Peter M. Sandman
59 Ridgeview Rd.
Princeton NJ 08540-7601Phone: 1-609-683-4073
Fax: 1-609-683-0566
Email:peter@psandman.com
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