As apocalyptic horror fantasies go, the threat of an avian-flu pandemic remains blessedly hypothetical. Before it can wreak Hitchcockian havoc on a city like New York, it must jump through a tangle of if/then hoops, including (but hardly limited to) morphing into a virus that can hop from human to human and making landfall in the United States. But should if become then—should the H5N1 virus go pandemic—then New Yorkers had better hope it doesn’t happen within the next year or two. At least.
“If it comes, then it’s going to be incredibly difficult to deal with,” said Thomas Frieden, the city’s commissioner of health and mental hygiene and flu-fighter in chief. “If it were to happen in the next year or two, it’s not likely that we would have either effective vaccines or effective vaccinations that would be in use to be taken by the general public. So the most important messages may be very simple messages, such as cover your cough, wash your hands, and don’t go out if you’ve got a cough and fever.”
As the bird flu continues its pathogenic march around the globe, this is not exactly the kind of message that jumpy New Yorkers want to hear. On Monday, Secretary of the Interior Gail Norton announced that it is “increasingly likely” that the bird form of bird flu will arrive on U.S. shores within the year. And that same afternoon, scientists reported that the nasty H5N1 virus has evolved into two separate strains in humans, a development that could both complicate the quest for a vaccine and increase chances of human-to-human transmission.
For those who don’t have faith in the power of a covered cough to prevent a pandemic, this is not happy news. But should the fowl flu go human within the near future (a possibility, though by no means a certainty), traditional public-health measures may in fact be the Health Department’s best option for getting the city through its big Tippi Hedren moment.
“We take pandemic flu very seriously,” said Mr. Frieden, whose high-profile campaigns against everything from smoking to transfats have made him one of the most visible health commissioners in city history. “You have to take it very seriously because of its potential for doing great harm.”
The avian flu first reared its viral head in 1997, killing some two million birds and counting. There is no guarantee that it will mutate into a lethal human-to-human form (and there are valid arguments that it won’t), but scientists fear that some of its behavioral similarities to the deadly 1918 “Spanish flu,” as well as the fact that the world is overdue for a pandemic, make it a prime candidate for the Next Great Scourge. If it follows in the footsteps of its 1918 sister—rather than the milder 1957 and 1968 outbreaks—some scientists fear the death toll could reach as high as two million Americans.
This is a worst-case scenario, one that should have been made unthinkable by nearly 90 years of medical advances. But in the wake of the monumental federal flubbing of Hurricane Katrina, as well as several decades of health-system neglect, scientists warn that it would be foolish not to pay attention to the threat of a pandemic, whether it takes the shape of H5N1 or some other virus.
“The public-health system is in shambles, and we are not ready to deal with even a moderate type of pandemic,” said Dr. Irwin Redlener, the director of the National Center for Disaster Preparedness. “So we can’t just say we’re going to absorb it if it happens.”
Among the best ways to prepare for pandemic, many scientists and public-health experts agree, is by pouring resources back into the system, particularly research and development. By concocting and then creating a robust stockpile of vaccines and antivirals, scientists argue, the country could disarm the virus before it has a chance to go nuclear.
“What you really need is a Manhattan Project to devote a lot of resources to improving antiviral therapies and improving vaccinations,” said Dr. Martin Blaser, the president of the Infectious Diseases Society of America and chairman of the Department of Medicine at New York University. “Most people think that if we can put appropriate levels of funding behind it, we can make big improvements.”
Thus far, however, Congress has appropriated only half of the $7.1 billion the Bush administration requested for fighting avian flu, and the administration has, in turn, yet to spend all of the money that Congress allocated for antiviral drugs like Tamiflu and Relenza. As of March 1, it had ordered only 14 million of the 80 million antiviral courses it has said it hopes to acquire.
But even with generous funding increases, some public-health experts estimate that it would still take a solid six months to concoct a vaccine against a pandemic strain of the virus. Producing enough of that vaccine to inoculate the whole U.S. population would take several years longer. “We’re still using 50-year-old technology based on chicken eggs to manufacture flu vaccine,” said Kim Elliott of the Trust for America’s Health. “We have one flu-vaccine manufacturer, and we import the rest.”
This is where Mr. Frieden’s cover-your-cough-and-wash-your-hands strategy kicks in: in the time lag between the uncertain present and the development of a vaccine. Known as “social distancing” in public-health circles, this is a fundamentally defensive strategy, meant to mitigate rather than to eradicate.
In its most basic form, it can be as simple as encouraging city dwellers to don face masks or do away with air-kissing and shaking hands. But should things get ugly, it can easily be ratcheted up to include closing the public schools, shuttering the theaters, urging people to hole up in their homes and even instituting quarantines— though Mr. Frieden said this last tactic is unlikely.
“As someone once said, for every complicated problem, there is a solution that is quick, simple and wrong,” he noted, dismissing the idea of a quarantine. The reason, he and others explained, is that flu carriers (what one might call Avian Marys) tend to be contagious as much as 48 hours before showing symptoms, so any attempt to quarantine them would probably be moot.
Timing is everything when it comes to a pandemic, and Mr. Frieden’s plan focuses almost as much on early-detection strategies as on response. (Detection and response are the two prongs of his plan, which he will formally release in several months, he said.) Already, several of these strategies are up and running, including a Trekkie-sounding program called the syndromic surveillance system. According to Mr. Frieden, this system tracks as many as 60,000 “health events” a day, collecting data on everything from emergency-room visits and ambulance runs to pharmacy prescriptions and employee absences at certain large employers.
The good news, several public-health authorities said, is that New York has one of the most sophisticated public-health departments in the country, as well as one of the most experienced, thanks to SARS and anthrax. But there are still plenty of wrinkles to be ironed out. For Mr. Frieden, one of the biggest concerns is a shortage of intensive-care beds. And The New York Times recently reported that a November drill in which the Health Department tried to give 250 flu shots an hour at a Chelsea clinic fell far short of this goal.
But perhaps the biggest challenge for the city is money. Under the administration’s bird-flu plan, the federal government is responsible for procuring vaccines and antivirals, while the localities do much of the gritty, hand-to-hand flu-fighting. However, of the $3.8 billion allocated by Congress for avian-flu prep, only $350 million goes to this frontline work—a sum that disappears all too quickly when divided between some 5,000 health departments.
Mr. Frieden said he’s been lobbying Congress to try to fix this imbalance. “We’re disappointed by the lack of sufficient funding for state and local health departments,” he said.
But in the meantime, he is also taking his own public-health advice: He is not panicking, and he is not losing any sleep.