Thursday, May 05, 2005

Time's up

Today's New England Journal of Medicine carries an important, but ultimately dismaying, Perspective by Mike Osterholm, Director of the Center for Infectious Disease Research and Policy (CIDRAP). It is an easy, non-technical read, but here's the short version. If a major influenza pandemic were to happen today or in the next 6 months, were screwed. If it happens in a year, we're in poor but slightly better shape, but only if we started planning and implementing like mad right now. If we had ten years, we might actually be able to put in place a mechanism to dodge the periodic pandemic bullets that are a global scourge. But only with the kind of national leadership lacking in virtually all developed countries.

Here are some of Osterholm's most important points. The US has tolerated an influenza death toll of 30,000 to 50,000 persons in a (normal) year because of a lack of a national commitment to universal annual influenza vaccination. This is ten World-Trade-Centers-in-slow-motion worth of lives our government, both the executive and the congress, allows to happen because it doesn't have the will or the guts to oppose an entrenched health care industry (organized medicine, hospitals and drug companies). Alone among industrialized nations we have no national health system, the only plausible mechanism that could assure universal immunization in this country.

But as Osterholm notes, and as readers of this blog know well, the effects of a pandemic will go beyond the health impact:
If it were determined that several cities in Vietnam had major outbreaks of H5N1 infection associated with high mortality, there would be a scramble to stop the virus from entering other countries by greatly reducing or even prohibiting foreign travel and trade. The global economy would come to a halt, and since we could not expect appropriate vaccines to be available for many months and we have very limited stockpiles of antiviral drugs, we would be facing a 1918-like scenario.
Once the strain was isolated it would take a minimum of 6 months, using the current egg-based technology, to start to make a vaccine. With current manufacturing capacity working at maximum we might be able to produce enough vaccine to immunize perhaps one out of seven people on the globe, assuming we had a way to get the vaccine to them, which we don't. For those who fall ill, even in the US, the outlook is bleak. There are only about 100,000 mechanical ventilators in the country (and they are not evenly distributed nor do we know where they all are), and at any given time about 80% are in use, meaning we have a reserve of only about 20,000. Since H5N1 (and 1918 flu) was disease of the young and young adult, we would also need a large supply of pediatric ventilators, which we don't have. As Osterhold says, in a pandemic, "most patients with influenza who needed ventilation would not have access to it." And that's not all:
We have no detailed plans for staffing the temporary hospitals that would have to be set up in high-school gymnasiums and community centers — and that might need to remain in operation for one or two years. Health care workers would become ill and die at rates similar to, or even higher than, those in the general public. Judging by our experience with the severe acute respiratory syndrome (SARS), some health care workers would not show up for duty. How would communities train and use volunteers? If the pandemic wave were spreading slowly enough, could immune survivors of an early wave, particularly health care workers, become the primary response corps?
All good questions. We don't have any good answers, although we should have them. Our health care delivery "system" has done little planning and what the federal government has done is mostly generalities and only on paper. This is a scandalous lack of public health leadership at every level. The Bush administration, with its preoccupation with bioterrorism, has perpetuated and exacerbated the existing negligence, but it is also the fault of state and local health departments, university "leaders" and the private sector. The international agencies, like WHO are also to blame, with their wimpy, hesitant and timid approach. CDC needs to exert bold public and visible leadership and do it now, to kick start state and local health departments into action and get the private sector to take notice. Instead we have public silence or near silence.

What if we had a bit more time? Osterholm's boldest suggestion is for an all-out Manhattan-Project-like effort to devise a generic influenza vaccine and the global manufacturing capacity to go with it. This will require global "public" financing. If it relies on current market mechanisms it will never happen:

The current system of producing and distributing influenza vaccine is broken, both technically and financially. The belief that we can greatly advance manufacturing technology and expand capacity in the normal course of increasing our annual vaccination coverage is flawed. At our current pace, it will take generations for meaningful advances to be made. Our goal should be to develop a new cell-culture–based vaccine that includes antigens that are present in all subtypes of influenzavirus, that do not change from year to year, and that can be made available to the entire world population. We need an international approach to public funding that will pay for the excess production capacity required during a pandemic.

The prospects don't look good, with entrenched special interests advancing ideas like Senator Joseph Lieberman's "Bioshield II" Big Pharma giveaway legislation. The big drug companies would rather make their (obscenely more profitable) erectile dysfunction drugs than vaccines, but with Uncle Joes help wil be only too happy to do a bit of vaccine work in order to get their patents extended. Thus the most frightening aspect of Osterholm's piece is the last paragraph, the one he wrote to try to goad, cajole and convince the Bushs, Liebermans, Gerberdings, Stohrs of this world to do something:
Is there anything we can do to avoid this course? The answer is a qualified yes that depends on how everyone, from world leaders to local elected officials, decides to respond. We need bold and timely leadership at the highest levels of the governments in the developed world; these governments must recognize the economic, security, and health threats posed by the next influenza pandemic and invest accordingly. The resources needed must be considered in the light of the eventual costs of failing to invest in such an effort. The loss of human life even in a mild pandemic will be devastating, and the cost of a world economy in shambles for several years can only be imagined.
This just makes your heart sink, because you know it's not going to happen if it is up to our "leaders." We'll have to prepare on our own in our own localities. Time to get busy.