Barack Obama

The Big One?

Saturday, October 22, 2005

THE NATIONAL JOURNAL
By Marilyn Werber Serafini

How governments deal with the avian-flu threat could determine whether it's a containable event or a full-blown catastrophe.

In the United States alone, seasonal influenza each year kills up to 40,000 people, lands about 200,000 people in the hospital, and costs more than $10 billion in lost productivity and direct medical expenses. But that's nothing compared with the flu that may hit the United States as early as this winter. While each century brings several influenza pandemics, rarely is the disease as potent and deadly as avian flu is threatening to be.

Early symptoms in humans -- fever, coughing, sore throat, muscle aches -- match those of other strains of flu, but avian influenza can kill within days, by severely attacking the lungs.

Avian flu thus far has killed more than 60 people, all of them in Asia. But experts predict that it could be more deadly than the Spanish flu that killed more than 500,000 Americans -- and more than 20 million people worldwide -- in 1918. So far, about half of the people who have gotten avian flu have died. And, in an important difference from seasonal flu, this avian flu spreads faster, because its victims are contagious before they know they have it. While most victims have caught the avian virus from chickens, several have gotten it from other humans.
Moreover, the avian-flu virus is rapidly changing, and scientists say that it will inevitably become easily transmittable from human to human.

The economic impact of a flu pandemic could resemble that of the Great Depression, says Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota (Minneapolis). According to Trust for America's Health, a nonprofit organization that promotes public health as a national priority, the United States could lose
$166.5 billion because of deaths and lost productivity, and the potential massive disruptions to commerce and society could raise that number significantly. An April 2005 draft report of
National Planning Scenarios, produced by the President's Homeland Security Council and the Department of Homeland Security, puts the economic impact of a flu pandemic at $87 billion to $203 billion.

With these dire forecasts setting off worldwide alarms, U.S. policy makers are scrambling for preparedness strategies. President Bush is aggressively pursuing cooperation agreements with foreign leaders, and Health and Human Services Secretary Mike Leavitt is seeking alternatives to the very limited global supply of antiviral drugs and exploring ways to produce an effective vaccine as quickly as possible. Congress, meanwhile, is working on legislation to appropriate tens of billions of dollars to stock up on supplies such as antiviral drugs and masks, and to craft emergency plans at the federal and local levels.

The stakes could be huge. The steps the federal government takes now could mean the difference between a moderate, containable event and a full-blown medical and economic catastrophe. In the pages that follow, National Journal examines five sets of critical decisions facing the federal government.

* Vaccines and Antivirals. What should the federal role be in ensuring a swift and nimble vaccine industry, not only for avian flu but for any potential pandemic? Should government aggressively fund research? Guarantee the purchase of vaccines that might never be used? Promise private manufacturers liability protections against vaccine-related injuries and deaths? Flu vaccines are in short supply, as are antiviral drugs, which destroy or weaken the virus in an infected person.
Right now, manufacturing vaccines or antivirals pays poorly in this country, and the United States depends heavily on other countries for its supplies. Not a good position in a global pandemic.

* Quarantine, Police Powers, and Civil Rights. In a pandemic, should the feds establish a police state, complete with thermal screeners at building entrances to detect fever, surveillance cameras in homes, and police or military personnel surrounding the potentially sick? Quarantines -- not just of individuals but of entire villages -- helped to prevent the spread of severe acute respiratory syndrome, or SARS, in China two years ago. But researchers believe that Americans would reject such restrictions, and many public health officials prefer gentler approaches, such as the strategies Canada used to combat its SARS outbreak in 2003. Most people will voluntarily confine themselves if they think they're contagious. But what about the people who don't?

* Medical Capacity. Nurses are in short supply already, and one-quarter of them could fall victim to avian flu. Others might stay away from hospitals to avoid bringing the dangerous bug home to family members. As for treatment, given the limited reserve of antiviral medications in the U.S. stockpile, and the grim prospects for developing a vaccine any time soon, should the federal government use limited supplies to treat the sick, or to protect health care workers?

* Federal or Local Response? Local governments and public health offices feel certain that in a nationwide pandemic, they would mostly have to fend for themselves. How much help could the federal government provide in sending supplies, antivirals, and vaccines? Would the White House be willing to call in the military to build field hospitals and provide other support?

* International Cooperation. Could the United States guarantee international cooperation during a global pandemic, or would every nation have to fend for itself? Early in the SARS outbreak, China was thought to be hiding cases; several Asian countries were reluctant to share information and virus samples. How readily should the United States follow the lead of the World Health Organization? If an avian-flu outbreak begins in Asia, should the U.S. offer up its antiviral medications to try to contain the virus there?

Some experts remain optimistic that avian flu may never escalate to a pandemic, or may lose potency before it reaches U.S. soil. Nevertheless, even many of these experts agree that before long, some pandemic will plague the world. And the optimists are outnumbered by those who are bracing for the worst.

In recent weeks, Bush has repeatedly brought up the subject of avian flu in sessions with foreign leaders. "During my meetings at the United Nations, not only did I speak about [avian flu] publicly, I spoke about it privately to as many leaders as I could find -- about the need for there to be awareness, one, of the issue; and two, reporting, rapid reporting to [the World Health Organization], so that we can deal with a potential pandemic," Bush said at an October 4 White
House press conference.

As the Health and Human Services Department put the final touches on an emergency flu-pandemic plan, Secretary Leavitt left on October 8 for 10 days of meetings with heads of state and health officials in Thailand, Cambodia, Laos, and Vietnam. Accompanying Leavitt were Centers for Disease Control and Prevention Director Julie Gerberding, National Institute of Allergy and Infectious Diseases Director Tony Fauci, and representatives from the State Department and the WHO. "We need the world community to be transparent and cooperative," Leavitt told reporters before leaving. "We want to observe the conditions in which the virus can develop. We're going to the countryside as well as to markets." Fauci emphasized the need to
get virus samples "in real time."

The Senate, meanwhile, overwhelmingly approved a measure in late September to provide nearly $4 billion to the Centers for Disease Control and Prevention to combat avian flu -- mostly to build a stockpile of antiviral drugs. Sens. Barack Obama, D-Ill., and Tom Harkin, D-Iowa, included the spending as an amendment to the Defense Department appropriations bill. The appropriation is not in the House bill, so the outcome will be decided in conference committee.

Back in March, Obama inserted a provision in the Foreign Assistance Act to authorize $25 million to establish a high-level interagency task force to help contain possible outbreaks overseas. That legislation is still pending in the Senate, but $25 million was included in emergency spending legislation approved last month. Another $10 million for flu surveillance is in the Senate version of the Foreign Operations Appropriations bill now in conference.

Policy makers are also trying to get a handle on the broad economic consequences of a pandemic, which could reach far beyond health care costs. Worried consumers would likely avoid malls, bars, schools, theaters, and stadiums, for example, at great cost to many merchants, vendors, suppliers, and workers. Many consumers would likely shift their transactions from bricks-and-mortar stores to the Internet.

Public transportation would falter, and parents would likely stay home to guard their children rather than send them to school, said Constance Hanna, the director of health services for Honeywell International. Honeywell and other manufacturers "will have huge absenteeism issues," she said, "and productivity will suffer." High-tech factories would grind to a halt as international and domestic transport breakdowns interrupted their just-in-time supply of spare parts, she said, adding, "We do not have major stores of the parts that we need to make product."

Nations might seek to minimize links to other countries, thus complicating or halting much trade in livestock, foods, goods, and even services. The tourism business -- hotels, travel agents, restaurants, airports, airlines, and vacation spots -- would likely be an early victim of an outbreak. A fearful public mood could further dampen consumer spending.

Much of this impact was foreshadowed in 2003 by the comparatively small-scale outbreak of SARS in Canada. SARS appeared first in Asia in February 2003, but was carried by a Canadian resident back to Toronto in mid-March. Once in Canada, the disease spread to 252 people, killing 44.

Despite the relatively small number of cases in Toronto, SARS had a large impact on the city's economy, where 28,000 tourism jobs were lost, according to a report by BMO Nesbitt Burns Economics, an investment-analysis firm owned by the Bank of Montreal. Concerts, movie shoots, and at least four major conventions were canceled. Revenue at restaurants, theaters, and zoos dropped sharply, and one high school was shut down after a student was infected. Nationwide, Canada's economic growth of 3 percent in the first quarter of 2003 was followed by a 1.2 percent decline in economic activity in the second quarter, according to the BMO report. But compared with an avian flu, Hanna said, "SARS was a baby."

Flu Pandemics

Outbreaks in the past 100 years

* 1918: More than 20 million people worldwide, including 500,000 Americans, die as a result of the Spanish flu pandemic.
* 1957-58: About 1 1million people worldwide, including 70,000 Americans, die from a flu outbreak originating in China.
* 1968-69: About 750,000 people worldwide, including some 34,000 Americans, die from the Hong Kong flu.
* 1997-2005: Avian flu is identified, and to date has killed more than 60 people in Asia. But estimates are that it could be as deadly as the Spanish flu.

Sources: Trust for America's Health, Department of Homeland
Security, United Kingdom Department of Health

Avian Flu

Since its discovery in 1997, only two cases of avian flu are thought to have been transmitted human-to-human. Most avian flu has come from chickens.

Human     Cases Deaths

Vietnam   90    40

Hong Kong 18    6

Thailand  17    12

Cambodia  4     4

Indonesia 1     1

China     2     1

Total     132   64

Source: New England Journal of Medicine
Figures as of September 29, 2005