The Next Pandemic?

Laurie Garrett

From Foreign Affairs, July/August 2005

Summary:  Since it first emerged in 1997, avian influenza has become deadlier and more resilient. It has infected 109 people and killed 59 of them. If the virus becomes capable of human-to-human transmission and retains its extraordinary potency, humanity could face a pandemic unlike any ever witnessed.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and is the author of The Coming Plague and Betrayal of Trust.

At the time, it was widely believed that influenza appeared in cycles, with especially lethal forms surfacing at relatively predictable intervals. Since 1918-19, the United States had suffered through influenza pandemics in 1957-58 and 1968-69; the first caused 70,000 deaths and the second 34,000. In 1976, scientists believed the world was overdue for a more lethal cycle, and the apparent emergence of swine flu at Fort Dix seemed to signal that another wave had come. The leaders of the CDC and the Department of Health, Education, and Welfare (HEW) warned the White House that there was a reasonably high probability that a catastrophic flu pandemic was about to hit. But opinion was hardly unanimous, and many European and Australian health authorities scoffed at the Americans' concern. Unsure of how to gauge the threat, President Gerald Ford summoned the polio-fighting heroes Jonas Salk and Albert Sabin to Washington and found the long-time adversaries in remarkable accord: a flu pandemic might truly be on the way.

On March 24, 1976, Ford went on national television. "I have just concluded a meeting on a subject of vast importance to all Americans," he announced. "I have been advised that there is a very real possibility that unless we take effective counteractions, there could be an epidemic of this dangerous disease next fall and winter here in the United States. ... I am asking Congress to appropriate $135 million, prior to the April recess, for the production of sufficient vaccine to inoculate every man, woman, and child in the United States."

Vaccine producers immediately complained that they could not manufacture sufficient doses of vaccine in such haste without special liability protection. Congress responded, passing a law in April that made the government responsible for the companies' liability. When the campaign to vaccinate the U.S. population started four months later, there were almost immediate claims of side effects, including the neurologically debilitating Guillain Barré Syndrome. Most of the lawsuits -- with claims totaling $3.2 billion -- were settled or dismissed, but the U.S. government still ended up paying claimants around $90 million.

Swine flu, however, never appeared. The head of the CDC was asked to resign, and Congress never again considered assuming the liability of pharmaceutical companies during a potential epidemic. The experience weakened U.S. credibility in public health and helped undermine the stature of President Ford. Subsequently, an official assessment of what went wrong was performed for HEW by Dr. Harvey Fineberg, a Harvard professor who is currently president of the Institute of Medicine.

Fineberg concluded:"In this case the consequences of being wrong about an epidemic were so devastating in people's minds that it wasn't possible to focus properly on the issue of likelihood. Nobody could really estimate likelihood then, or now. The challenge in such circumstances is to be able to distinguish things so you can rationally talk about it. In 1976, some policymakers were simply overwhelmed by the consequences of being wrong. And at a higher level [in the White House] the two -- likelihood and consequence -- got meshed."

Fineberg's warnings are well worth remembering today, as scientists nervously consider H5N1 avian influenza in Asia. The consequences of a form of this virus that is transmittable from human to human, particularly if it retains its unprecedented virulence, would be disastrous. But what is the likelihood that such a virus will appear?

DEVOLUTION

Understanding the risks requires understanding the nature of H5N1 avian flu specifically and influenza in general. Influenza originates with aquatic birds and is normally carried by migratory ducks, geese, and herons, usually without harm to them. As the birds migrate, they can pass the viruses on to domesticated birds -- chickens, for example -- via feces or during competitions over food, territory, and water. Throughout history, this connection between birds and the flu has spawned epidemics in Asia, especially southern China. Aquatic flu viruses are more likely to pass into domestic animals -- and then into humans -- in China than anywhere else in the world. Dense concentrations of humans and livestock have left little of China's original migratory route for birds intact. Birds that annually travel from Indonesia to Siberia and back are forced to land and search for sustenance in farms, city parks, and industrial sites. For centuries, Chinese farmers have raised chickens, ducks, and pigs together, in miniscule pens surrounding their homes, greatly increasing the chance of contamination: influenza can spread from migrating to domestic birds and then to swine, mutating and eventually infecting human beings.

Ominously, as China's GDP grows, so do the expensive appetites of the country's 1.3 billion people, more of whom can afford to eat chicken regularly. Today, China annually raises about 13 billion chickens, 60 percent of them on small farms. Chicken farming is quickly morphing into a major industry, with some commercial poultry plants rivaling those in Arkansas and Georgia in scale -- but lagging behind in hygienic standards. These factors favor rapid influenza evolution. By the close of the twentieth century, at least two new types of human-to-human flu spread around the world every year.