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.

But the snafu raises serious questions: If billions have been spent to improve laboratory capabilities since 2001, why did nobody notice the H2N2 flu until about six months after the kits had been shipped? Why did a private company possess samples of the virulent flu? Why was the sample included in the kits? In the aftermath of the September 11, 2001, attacks and the anthrax scare, many countries reclassified 1957-58 and 1968-69 influenza strains as Level 3 pathogens, requiring extreme care in their handling, distribution, and storage -- why did the United States still consider H2N2 to be a mere Level 2 pathogen, a type frequently mailed and studied? Finally, around the world, what other labs -- public and private -- currently possess samples of such lethal influenza viruses? The official CDC answer to these questions is, "We don't know."

Even with all of these gaps, probably the greatest weakness that each nation must individually address is the inability of their hospitals to cope with a sudden surge of new patients. Medical cost cutting has resulted in a tremendous reduction in the numbers of staffed hospital beds in the wealthy world, especially in the United States. Even during a normal flu season, hospitals located in popular retirement areas have great difficulty meeting the demand. In a pandemic, it is doubtful that any nation would have adequate medical facilities and personnel to meet the extra need.

National policymakers would be wise to plan now for worst-case scenarios involving quarantines, weakened armed services, and dwindling hospital space and vaccine supplies. But at the end of the day, effectively combating influenza will require multilateral and global mechanisms. Chief among them, of course, is the WHO, which since 1947 has maintained a worldwide network that conducts influenza surveillance. The WHO system oversees laboratories all over the world, chases (and sometimes refutes) rumors of pandemics, pushes for government transparency regarding human and avian flu cases, and acts as an arbiter in negotiations over vaccine production, trade embargoes, and border disputes. Its companion UN agency, the Food and Agriculture Organization (FAO), working closely with the World Organization for Animal Health, monitors flu outbreaks in animal populations and advises governments on culling flocks and herds, cross-border animal trade, animal husbandry and slaughter, and livestock quarantine and vaccination. All of these organizations have published lengthy guidelines on how to respond to a pandemic flu, lists of answers to commonly asked questions, and descriptions of their research priorities -- most of which have been posted on their Web sites.

The efforts of these agencies should be bolstered, both with expertise and dollars. The WHO, for example, has an annual core budget of just $400 million, a tiny increment of which is spent on influenza- and epidemic-response programs. (In comparison, the annual budget of New York City's health department exceeds $1.2 billion.) An unpublished internal study estimates that the agency would require at least another $600 million for its flu program were a pandemic to erupt. It is in every government's interest to give the WHO and the FAO the authority to act as impartial voices during a pandemic, able (theoretically) to assess objectively the epidemic's progress and rapidly evaluate research claims. The WHO in particular must have adequate funding and personnel to serve as an accurate clearinghouse of information about the disease, thereby preventing the spread of false rumors and global panic. No nation can erect a fortress against influenza -- not even the world's wealthiest country.

Few members of the U.S. Congress or its legislative counterparts around the world were alive when the great Spanish flu swept the planet. There may be some who lost parents, aunts, or uncles to the 1918-19 pandemic, and perhaps even more have heard the horror stories that were passed down. But politics breeds shortsightedness, and for decades the threat of an influenza pandemic has been easily forgotten, and therefore ignored at budget time. Politicians and health leaders made many serious errors in 1918-19; some historians say that President Wilson sent 43,000 soldiers to their deaths by forcing them aboard crowded ships to join a war he had already won. But in those days, human beings had no understanding of their influenza foe.

In 1971, the great American public health leader Alexander Langmuir likened flu forecasting to trying to predict the weather, arguing that "as with hurricanes, pandemics can be identified and their probable course projected so that warnings can be issued. Epidemics, however, are more variable [than hurricanes], and the best that can be done is to estimate probabilities."

Since Langmuir's time a quarter of a century ago, weather forecasting has gained a stunning level of precision. And although scientists cannot tell political leaders when an influenza pandemic will occur, researchers today are able to guide policymakers with information and analysis exponentially richer than that which informed the decisions of President Ford and the 1976 Congress. Whether or not this particular H5N1 influenza mutates into a human-to-human pandemic form, the scientific evidence points to the potential that such an event will take place, perhaps soon. Those responsible for foreign policy and national security, the world over, cannot afford to ignore the warning.