Monday, November 29, 2004

Influenza and leadership

This post is ostensibly about avian influenza A (H5N1). It's really about how we are going to cope without effective public health leadership. Avian flu is a freight train coming our way. Whether or not it hits us will just be a matter of dumb luck one way or another and is probably out of our control by now. How badly we are hurt if we are hit isn't. But it isn't just a matter of an effective plan or manufacturing a vaccine, although both are part of it. As much as anything it is about a public health system that is leaderless, uninspired and dispirited. I plan to devote several later posts to this issue, but first, bird flu.

Last week's dire predictions concerning a potential avian flu pandemic made the newswires but surprisingly little impact on the major blogs. There are some notable exceptions (DemFromCT on Daily Kos covered it nicely) and one of the major public health blogs as well (Public Health Press). The (excellent) blog Infected Hands calls attention to a report suggesting that intradermal injection of vaccine might require less inciting antigen and hence stretch supplies further as well as make administration easier and faster, although this remains to be seen.

But one post, by Melanie on American Street, deserves additional comment. In "Waiting for a Protein to shift" she takes issue with reporting that suggested the global death toll would be 7 million (a number also reported here). She notes,
This [referring to a Reuters news article] is very sloppy reporting. First, the Spanish Flu pandemic of 1918 killed 50 million people. The population of the planet was a fraction of what it is now, about 1.8 billion. The lethality (mortality) rate of the 1918 virus was between 2-5%. By contrast, 75% of the people who have contracted this year's Avian virus (that can be identified, always a sketchy business this early) have died. That's a stunning rate. The 1918 pandemic did its lethal business in a mere 8 weeks [not quite true; Ed.]. Given how much more mobile the world is now, it is chilling to contemplate how much damage this year's bug could do in next to no time.


The Reuters writer, then, took at face value the 7 million deaths from a possible Avian flu pandemic from the "expert" with which he spoke. In 1918, more than half of the world's population was infected by the flu. Actual numbers of deaths by this Avian flu would be catastrophic. So, the tone of this article, while a little hysterical, actually understates the amount of danger that this potential represents.

In earlier bulletins, WHO was already calling for public health authorities all over the world to begin to prepare for vaccinating their entire populations. If this bug is as bad as it looks, that's not an outrageous demand. Unfortunately, the earliest estimate for the vaccine to begin to be available is March, and I think that even if we put all of the vaccine makers in the world to the task of manufacturing it, we'll have a little difficulty cranking out 5 billion doses in time to do a lot of good.

Right now, our defensive strategy is to hope that the mutation doesn't occur before we are ready for it. I'm not liking those odds.
I think Melanie makes a good point about the low-ball estimate for mortality (which regrettably I repeated). There is still no agreement on how many people died in the 1918 pandemic (estimates range from 20 million to 100 million over three separate waves and 18 months). Just in the last few days WHO personnel have given numbers that range from very conservative (2 - 7 million) to 20 - 50 million to 100 million (quoted here and here). But even the largest of these numbers seems too low if one accepts WHO's global infection figure of 30% together with most estimates of case fatality (which for the handful of H5N1 cases so far is over 70%). If 30% of the world's population of 6.4 billion is infected and there is a 30% mortality that is almost 600 million deaths. A mortality of 10 million would only be a mortality of 0.5%. Note that a 30% global incidence is not impossible. These numbers are all over the place and obviously no one really knows. But there are sound reasons to fear the high end, although even the low end is catastrophic.

What to do? Success on a vaccine is one way to slow and ameliorate these huge numbers. But in another report from WHO (as reported in the British Medical Journal today ) it is recognized that the "market" doesn't work for vaccines, something we have clearly seen with this season's flu debacle in the US (full report, Priority Medicines for Europe and the World Project can be found here). As Melanie notes, it isn't feasible to produce and vaccinate the entire globe, but the production of some "herd immunity" in the population can slow and blunt the spread of the disease, buying precious time to make adjustments to cope with a pandemic. At the moment there is essentially no native immunity to H5N1. Even vaccinating 30% of the population would be a tremendous help, but would also be a tremendous task.

And such a successful vaccination program isn't likely to happen, but even if it did there would still be hell to pay. One response is essentially nihilist. In the nuclear freeze movement of blessed memory we used to have a poster giving the steps to take to protect yourself against a nuclear attack. It ended with sitting down, putting your head between your knees and kissing your ass good-bye. That kind of response won't happen because we are hardwired to try to survive. But it would be nice to have some vision other than as a bit part in a post-apocalypse reality show.

I don't see much that our public health officials are doing to plausibly prepare for this. We go through an endless cycle of "needs assessments," contingency plans and appropriations that never find their way to the street level. Most knowledgeable people don't believe we are in much better position to cope with an emergency than we were a few years ago. We have no more surge capacity in our hospitals than before. Even a slightly worse flu season than usual overwhelms them. And there will be a serious shortage of nurses and other care givers, not to mention undertakers. It isn't as if this hasn't happened before. It has. But we aren't really in better shape. There is neither the political will, the political vision, nor the political public health leadership. We are drawing up plans on paper on how to get to the life boats when the ship hits the iceberg. Even if that works in an orderly way (and there isn't enough room for everyone), there is precious little thought what to do when we are set adrift.

So what am I saying? In an earlier post (Vioxx: What would Gandhi do?) I suggested we adopt a "constructive program" and do our own planning, constructing and implementing on a small local scale. We don't need CDC or Tommy Thompson to think about how to use hotels or motels for surge capacity (each room has a bathroom), begin to organize volunteer retired nurses and doctors (our neighbors) in case of an emergency, start talking to the mortuaries about what they will do, inquire again and again at our community hospitals about adequate supplies of respirators (including pediatric sizes since this virus seems to have a predilection for children). I know some of these things are (allegedly) being done by state health departments. But my (up close) observation is that with staffing shortages, turf battles and a stunning narrowness of vision, most of it isn't happening and the plans on paper will be out the window in the first 24 hours after a true emergency is recognized.

I would love to be wrong about this. Convince me.