With recent reports of avian flu in Western Europe, the disease is clearly no longer East Asia's problem. It's a dilemma for the world. Last week I emailed Revere, the pseudonymous leader of Effect Measure, a public health group blog. Since its inception in late 2004, Effect Measure has been covering the global response to avian flu. My goal was to discuss the pandemic fears and what the world — and ordinary people — can do to prepare for it.
Revere, an environmental epidemiologist in a senior faculty position at a major research university, has 40 years of experience in medicine and public health. He is also one of the individuals behind the Flu Wiki, an Internet-based experiment in community mobilization and knowledge-pooling to face the feared epidemic. He paints an alarming picture. “If a pandemic is going to happen (and we don't know how to predict if it will or not with certainty), it will happen whatever we do,” he writes. “There will be no “outside” for help to come from, so each community needs to prepare to cope on its own.” In previous flu pandemics, hundreds of thousands of people went sick or died, leading to massive disruptions as workers failed to show up to work and instead surged into ill-equipped and ill-prepared hospitals.
Revere sees two big tasks ahead: managing the consequences of a potential pandemic, and building (or rebuilding) the world's rotting public health infrastructure.
GV: Why did you start blogging?
Revere: The blog originated as a forum to discuss the failed leadership in public health in the U.S. (also elsewhere). We have posted almost 700 items on a wide variety of public health topics. The most frequent, however, has been bird flu, which we began to talk about almost a year ago because it seemed the perfect metaphor for failed leadership in public health. At that time it was difficult to convince people of two points: that avian influenza was a serious potential threat; and that we weren't prepared to meet it. Hurricane Katrina solved the second problem and along with the inexorable spread of bird flu in poultry and wild birds contributed to solving the first. Bird flu is now on the public agenda worldwide.
GV: How well are current measures, like the destruction of infected flocks, working to contain the disease?
Revere: The idea that mass killing of infected birds could stop this disease from spreading had some intuitive appeal as long as it was localized. This tactic seemed to have success in Hong Kong in 1997. However the disease game back with a vengence in Southeast Asia in 2003 and has since become a panzootic (pandemic among animals, in this case birds) throughout Asia. It is too late to stop it in this way. The genie is out of the bottle. Mass culling will buy a short amount of time, perhaps, but isn't likely to be effective at this point.
GV: But do vaccines exist that will protect us?
Revere: One or more experimental vaccines do exist. There is no proven vaccine and none that is in production or whose production, even if begun immediately, would supply more than a fraction of the global need. Most places also have no effective public health infrastructure to deliver a vaccine, even if it existed. The known results for the [National Institutes of Health] vaccine trials suggest that we do not have a practical recipe yet, as the data suggested that the dose required was far in excess of production capacity. Many countries are working on producing a practical vaccine for humans at the moment (Hungary is the latest to claim success), but it isn't realistic to suppose we will have a vaccine solution for some years. We also don't know what genetic version of the virus will wind up being the pandemic strain, so it isn't possible at the moment to make a specific and effective preparation until that information is known, i.e., until after a pandemic starts. With current methods, a vaccine would take six to eight months to be produced. Many groups are working on techniques to speed this up (e.g., cell culture or DNA-based vaccines).
GV: Can the global public health infrastructure cope with this threat? Will developing countries bear the brunt of the possible pandemic?
Revere: Ad hoc workarounds will be the hallmark of both developed and developing countries. Many developed countries have seriously neglected or weakened their public health infrastructures (the U.S. is a prime example), and the main tasks of consequence management will fall to local communities anyway. Some developing countries may be better off in this regard as they will not have so many critical infrastructure interdependencies and will have social structures that better allow “neighbor helping neighbor,” which is what this will come down to. But the developing world will still bear the brunt, mainly because it has less material resources and poorer baseline health.
GV: What can individuals do to prepare?
Revere: We believe that the key need at the moment is for individuals to get together to anticipate and plan for a situation where there might be extensive absenteeism (say 30%). Once you begin to think the consequences of this through, you also begin to realize that there is much that can be done in advance to ameliorate the impact. The Flu Wiki is devoted to this kind of planning. Just to take one small example, many retail businesses like pharmacies (and food stores) operate on a “just in time” inventory system. If the supply chain is interrupted for a week or ten days, serious shortages result. Thus diabetics or heart disease patients might find that they can no longer find insulin or blood pressure medication at their local drug store. A state or community could make a very short list in advance of such medicines and plan for an alternate source and supply chain, perhaps using the National Guard or militia for transportation and logistics to a distributed series of wholesale supply points. Volunteers could be enlisted to distribute them. There are many examples like this. It doesn't take a lot of resources or outside help, but it does require some foresight. Now is the time to get ready.
Photo: ‘Vanishing’ by 3 steps ahead (Bartholomew Plucinski).