The Coming Pandemic

Researchers have finally identified the cause of the 1918 flu pandemic that killed 50 million people. After years of study, researchers discovered that the virus is a form of avian flu that made the transition to humans.

"The work, being published in the journals Nature and Science, involved getting the complete genetic sequence of the 1918 virus, using techniques of molecular biology to synthesize it, and then using it to infect mice and human lung cells in a specially equipped, secure lab at the Centers for Disease Control and Prevention in Atlanta."

How they were able to synthesize it is a story in and of itself. Amazingly, the virus was recreated using the lung tissues of dead soldiers that had been stored in formalin for 80 years and a woman who died of the disease and was preserved in the Alaskan permafrost:

"Dr. Taubenberger and his colleagues spent nearly a decade carefully extracting and piecing together the viral genes, like putting together a jigsaw puzzle. Along the way, they published findings that they and others used to try to understand the 1918 flu, but until now they had only published the sequences of five of the eight genes. The last three, which make up half the virus's length, are published in their paper, in Nature."

This revelation is simply incredible. Though medical researchers have known for decades that the 1918 pandemic was a form of flu, they had little idea where it originated from, how it spread through people so quickly and thoroughly, and where it eventually went. Discovering that it was in fact a form of avian flu only lends credence to those who are arguing today that the single greatest disease threat that we face right now are avian flus coming out of Asia that appear to be gaining the ability to cross the species barrier into humans.

I have to confess to not knowing much about the issue before recently. But a recent edition of "Foreign Affairs" profiled the threat of avian flu, and the authors' conclusions were certainly...disquieting. Unfortunately the articles are not available online without subscription since it's a back issue, but they're certainly worth reading if you can find a hard copy somewhere, have access to an online database, or are a Foreign Affairs subscriber that neglected to read them.

The first article, titled "Preparing for the Next Pandemic" and authored by Laurie Garrett-Senior Fellow for Global Health on the Council of Foreign Relations-is sort of a primer on the issue, highlighting the possible threat of an outbreak of avian flu among people, and explaining in unpleasant detail the consequences such a pandemic would have on human society around the globe.

"The arrival of a pandemic influenza would trigger a reaction that would change the world overnight. A vaccine would not be available for a number of months after the pandemic started, and there are very limited stockpiles of antiviral drugs. Plus, only a few privileged areas of the world have access to vaccine-production facilities. Foreign trade and travel would be reduced or even ended in an attempt to stop the virus from entering new countries--even though such efforts would probably fail given the infectiousness of influenza and the volume of illegal crossings that occur at most borders. It is likely that transportation would also be significantly curtailed domestically, as smaller communities sought to keep the disease contained. The world relies on the speedy distribution of products such as food and replacement parts for equipment. Global, regional, and national economies would come to an abrupt halt--something that has never happened due to HIV, malaria, or TB despite their dramatic impact on the developing world."

"In short order, the global economy would shut down. The commodities and services countries would need to "survive" the next 12 to 36 months would have to be identified. Currently, most businesses' continuity plans account for only a localized disruption--a single plant closure, for instance--and have not planned for extensive, long-term outages. The private and public sectors would have to develop emergency plans to sustain critical domestic supply chains and manufacturing and agricultural production and distribution. The labor force would be severely affected when it was most needed. Over the course of the year, up to 50 percent of affected populations could become ill; as many as five percent could die. The disease would hit senior management as hard as the rest of the work force. There would be major shortages in all countries of a wide range of commodities, including food, soap, paper, light bulbs, gasoline, parts for repairing military equipment and municipal water pumps, and medicines, including vaccines unrelated to the pandemic. Many industries not critical to survival--electronics, automobile, and clothing, for example-would suffer or even close. Activities that require close human contact--school, seeing movies in theaters, or eating at restaurants-would be avoided, maybe even banned."

Lest you think she's playing the part of Chicken Little, she details very carefully exactly how these consequences could come about. Of course our fates would not be entirely in the hands of the disease. There are public measures we can take, including vaccinating populations against the particular strain of flu posing the threat. However:

"Vaccine would have no impact on the course of the virus in the first months and would likely play an extremely limited role worldwide during the following 12 to 18 months of the pandemic. Despite major innovations in the production of most other vaccines, international production of influenza vaccine is based on a fragile and limited system that utilizes technology from the 1950S. Currently, annual production of influenza vaccine is limited to about 300 million trivalent doses--which protect against three different influenza strains in one dose--or less than one billion monovalent doses. To counter a new strain of pandemic influenza that has never circulated throughout the population, each person would likely need two doses for adequate protection. With today's limited production capacity, that means that less than 500 million people--about 14 percent of the world's population-would be vaccinated within a year of the pandemic. In addition, because the structure of the virus changes so rapidly, vaccine development could only start once the pandemic began, as manufacturers would have to obtain the new pandemic strain. It would then be at least another six months before mass production of the vaccine."

Then of course there's the issue of distribution. Who gets these vaccines first? You can be assured that the countries which produce the vaccine will want to protect their populations first. She does say that anti-viruals, including one popular one known as Tamiflu, will be of great use in preventing the worst effects of the disease among those who contract it. And yet the same problem of supply and distribution presents itself: there is only enough for 40 million people around the world, and manufacture of significant quantities of the drug can take up to a year. And this only the beginning of the medical supply shortages we would face.

Her article does end on a positive note. She says that while a pandemic cannot be avoided entirely, it's impact can be greatly lessened. Beginning to prepare for it now by stockpiling anti-virals, building the capacity to produce vaccines much more quickly, and strenghtening our health system overall, will save us from a disaster the magnitude of which our ancestors suffered in 1918.

Another article, this one titled "The Human-Animal Link" and written by Willian Karesh and Robert Cook, both eminent veterinarians working for the Wildlife Conservation Society, discusses the link between this potential outbreak, recent outbreaks, and our worldwide animal consumption and products practices. In it they make what I find to be some startling revelations about the connection between mass outbreaks of disease and the modern means by which we consume animals for food.

"Meanwhile, humanity has become vulnerable to cross-species illnesses, thanks to modern advances such as the rapid transportation of both goods and people, increasing population density around the globe, and a growing dependence on intensified livestock production for food. The global transport of animals and animal products, which includes hundreds of species of wildlife, also provides safe passage for the harmful bacteria, viruses, and fungi they carry, not to mention the prion proteins that cause insidious illnesses such as mad cow disease and chronic wasting disease in deer and elk."

Among those cross-species illnesses they list SARS, avian flu, Ebola, mad cow, and HIV, among others.

It's well-known that spread of avian flue and SARS is due largely to the largely uncontrolled wildlife markets in China, but there are examples closer to home:

"The West is also in danger, as was discovered in late May 2003, when the first cases of a mysterious illness were reported in hospitals in Illinois, Indiana, and Wisconsin. Patients, many of whom had been in close contact with pet prairie dogs, started coming down with skin ulcers and fevers. It was soon discovered that a prairie-dog dealer in Wisconsin had let a number of his animals mix with rodents recently imported from Ghana that happened to be carrying the monkeypox virus. An animal distributor had then sold the infected prairie dogs to pet stores in Milwaukee and at an animal swap meet in northern Wisconsin. Within about a month, 71 human cases of monkeypox in six Midwestern states had been reported to the CDC; luckily, no one died."

And it's not only the uncontrolled wildlife trade that threatens us. Disease looms ever present in the market for meat products here at home in the U.S.

"The increasing movement of animals and humans around the world and their greater exposure to the many diseases that dance between them have also placed domesticated livestock at increasing risk. This is especially so since the ravenous international demand for animal meat has turned livestock production into an ultraintensive industry, with swine, poultry, and cattle operations now packing huge numbers of animals into limited spaces. Moreover, projections by the International Food Policy Research Institute indicate a doubling of animal production in developing countries over the next 20 years. Although modern factory-farm practices maximize food production, they also make livestock more susceptible to illness. Infection spreads quickly through crowded animal pens, and growing antibiotic resistance makes fighting disease more difficult. Many farms now routinely mix antibiotics with animal feed to avoid transmitting illnesses, and selective breeding for specific traits often predisposes animals to conditions requiring repeated antibiotic treatment. Such increased antibiotic use is helping to create dangerous drug-resistant superbugs that may endanger both animals and humans."

At the end of the article they make their recommendations for what can be done to stave off a flourishing of disease transmission from animals to humans. Controlling the trade of wild animals, putting an end to diease spawning practices in factory farms, and much more comprehensive monitoring of disease in wild animal populations are just a few of the solutions that they name.

Of course, all of these steps requiring greater awareness of the problem, and money. In a time of budget-tightening, where Congress can barely bring itself to take adequate steps to protect us from a known threat like terrorism, it's hard to imagine they'll open the pocket-book for unknown and unquantified threats like avian-flu, where researchers can't honestly say when a pandemic could strike (though they all seem to agree it's only a matter of time.) But this is an extremely important issue. As Americans we've become accustomed to thinking over the last several decades that natural and health disasters are somebody else's problem, that Ebola and tsunamis don't happen here. We've been lucky to be right, at least until Katrina struck and drowned an entire city. We can't afford to be complacent on this issue, which would make the casualties in that catastrophe pale in comparison.

Update: The State Department is hosting a meeting of 80 nations today on this very issue.