How to Prepare for a Pandemic

It’s fitting that in a booming metropolis of 20 million people, the first sign that Mexico City had been recalled to life wasn’t a public religious ceremony or a political rally but a traffic jam. After a weeklong shutdown in response to the H1N1 flu outbreak, on May 5–Cinco de Mayo–Mexico City began to stir again. The spread of the swine flu had slowed, leading Mexican officials to hope that the worst had passed. “Our strategy is working,” said Mexican President Felipe Calderón. “We are now in a position to gradually resume our everyday activities.”

International health officials who had been on high alert since reports of a new influenza virus first surfaced in late April had also begun to relax–just a bit. Scientists at the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) found few serious or deadly cases outside Mexico and little evidence of sustained spread of the disease in most countries. Though by May 6 the virus had infected 1,516 people in 22 countries–including 642 in the U.S., where two people have died from it–and the world was still officially on the brink of a pandemic, the mood had cooled considerably at CDC headquarters in Atlanta. “We’re not out of the woods,” said Dr. Richard Besser, the CDC’s acting director, but “we are seeing a lot of encouraging signs.”

So, were the hundreds of U.S. school closures and the presidential press conferences about hand-washing much ado about not that much? Unfortunately not. As health officials pointed out repeatedly, we’re still in the early days of the H1N1 outbreak, and influenza viruses are notoriously unpredictable. Right now the new disease seems to be no more dangerous than the seasonal flu (researchers who have examined the genetic code of the H1N1 virus say it appears to lack key mutations that made past pandemic-causing viruses so deadly), but H1N1 could return next winter in a more lethal form–just as the virus that caused the catastrophic 1918 pandemic did. “This is a situation that can evolve,” said Dr. Keiji Fukuda, the WHO’s interim assistant director-general for health, security and the environment. “If it does turn severe, this is something we have to jump on.”

The reality is that while health officials in the U.S. and the rest of the world deserve praise for their comprehensive response to the new flu virus, H1N1 wasn’t a true test of our mettle but a warning shot. “We should look at this as a wake-up call, not one more snooze alarm,” says Dr. Irwin Redlener, the director of the National Center for Disaster Preparedness at Columbia University.

H1N1 makes clear how vulnerable our interconnected globe is to emerging diseases. As a result of jet travel and international trade, a new pathogen managed to seed itself in more than 20 countries in less than two weeks. But while globalization has its liabilities, it is also a strength because it gives us the tools to create a truly international disease-surveillance system. And the threat of a pandemic should remind us that we must fill the gaps in the creaky U.S. health-care system; during an infectious-disease outbreak, everyone will be at risk. “We live in one world, with one health,” says Dr. Juan Lubroth, a senior officer at the U.N.’s Food and Agriculture Organization.

A Viral Early-Warning System

We missed H1N1 when it was still just swine flu because we weren’t looking for it. There’s only scattered surveillance for pig diseases in the U.S. and Canada; in Mexico, there’s even less. According to the American Association of Swine Veterinarians (AASV), there were few reports of unusual sickness in the months leading up to the H1N1 outbreaks–not that vets would have necessarily noticed, since flu in swine is common and rarely serious. “We haven’t seen anything that would have tipped us off,” says Dr. Tom Burkgren, AASV’s executive director.

Why should we spend scarce medical resources swabbing the inside of pigs’ nostrils, looking for viruses? Because new pathogens–including H5N1 bird flu, SARS, even HIV–incubated in animal populations before eventually crossing over to human beings. In the ecology of influenza, pigs are particularly key. They can be infected with avian, swine and human flu viruses, making them virological blenders. While it’s still not clear exactly where the H1N1 virus originated or when it first infected humans, if we had half as clear a picture of the flu viruses circulating in pigs and other animals as we do of human flu viruses, we might have seen H1N1 coming. (When it comes to sniffing out new pathogens, says one epidemiologist, “we’re like a drunk looking for his keys.”) Faster genetic sequencing and the Internet give us the technological means to create an early-warning system. But we need to spend more on animal health and get doctors talking to their veterinarian counterparts. “For too long, the animal side of public health has been neglected,” says Dr. William Karesh, vice president of the Wildlife Conservation Society’s global-health program.

H1N1 has already jumped out of animals and established itself in people, so it’s too late to contain it, but there are new viruses brewing all the time in the animal world. That includes H5N1 bird flu, which is simmering in Asia and Africa and could still mutate and trigger a pandemic. Globalization has made us especially vulnerable to new diseases–the right pathogen in the right place could spread around the world in 24 hours–but it also gives us the tools to form an effective defense. “The fact that the world is one continuous village now means viruses that would have gone extinct before have the potential to take hold much more rapidly,” says Nathan Wolfe, director of the Global Viral Forecasting Initiative (GVFI). “But it also means we can create a planetary immune system.”

Wolfe’s brainchild is a model of what that immune system might look like. With funding from the likes of Google, GVFI has teams on the ground in Africa and Asia surveilling wild animals and the people who live in proximity to them for new pathogens. These “sentinel populations” will provide early warning when a new virus emerges; if a dangerous disease is discovered as soon as it crosses from animals to people, quick action can contain it–but only if we’re looking. “Tens of millions for surveillance could save us the hundreds of billions it would cost to deal with a pandemic,” says Peter Daszak, president of the Wildlife Trust. “An ounce of prevention really is worth a pound of cure.”

When a Pandemic Comes

The occasional pathogen will get through even the most vigilant early-warning system. Viruses, after all, are pretty good at what they do. A new flu pandemic is all but inevitable, and while the response to H1N1–the rapid deployment of Tamiflu, the blizzard of advice from the Federal Government–shows we’re better prepared for a pandemic than ever before, it doesn’t mean we’re truly prepared. A virulent flu pandemic–one that spreads throughout the world and sickens 25% to 30% of Americans–would cause our health-care system to crash like an overloaded website. Partly because of recession-fueled budget cuts that have led to the loss of 10,000 jobs in state and local health agencies over the past year, our hospitals have little in the way of surge capacity–excess beds and ventilators–that would allow them to handle a sudden influx of sick patients. And there’s no guarantee that those hospitals could remain staffed during the peak of a pandemic. “We haven’t tested what would happen if one-third of the public-health workforce were not available because they were sick or taking care of family members,” says Robert Pestronk, executive director of the National Association of County and City Health Officials.

The disruption that a pandemic might cause outside the health sector–what Michael Osterholm, who heads the Center for Infectious Disease Research and Policy (CIDRAP), terms “collateral damage”–could be even worse. The “just in time” supply chain on which so many U.S. corporations rely leaves little slack and could buckle during a pandemic. In a report last year, CIDRAP noted that 40% of the U.S. coal supply, which generates half the nation’s electricity, is shuttled from mines in Wyoming to the rest of the country by train. If a pandemic simultaneously sickened enough coal workers–or the tiny number of engineers qualified to operate those trains–supplies of coal could dwindle fast, switching off the lights in much of the country. “We’d be dealing with two calamities if a pandemic hit,” says Osterholm. “The human morbidity from the flu and the collateral damage for the just-in-time economy.”

Research by the London School of Hygiene and Tropical Medicine indicates that countries in the developing world are totally unprepared for a pandemic. That’s especially true in Africa, where many nations lack pandemic plans altogether, even though high rates of HIV infection there would probably worsen the toll of flu. But there are international models the U.S. can follow. Hong Kong was ravaged by SARS in 2003, but today the city has 20 million courses of Tamiflu–three times its population. (The U.S. Federal Government has enough for just one-sixth of the population, with additional stockpiles held by states.) Holiday camps on the fringes of Hong Kong have been set up to serve as isolation wards, and the city has invested in epidemiology labs and more hospital beds. “Hong Kong really is the international gold standard when it comes to dealing with infectious disease,” says Peter Cordingley, spokesman for the WHO’s Western Pacific regional office.

Washington can and should continue to augment the country’s antiviral stockpile and publish revised pandemic plans like the 396-page doorstopper put out by the Department of Health and Human Services in 2005. Increasing our capacity to manufacture and distribute flu vaccines within our borders is also a must. But truly preparing the country for a pandemic means tackling the basic flaws at the heart of the health-care system–starting with the some 50 million Americans who lack any health insurance. They’re more likely to flood hospitals for care during a pandemic, further taxing what will be an overburdened system. “They’re akin to the Typhoid Marys of the last century,” says Columbia’s Redlener. “They’ll be spreading this disease in ways that are completely unpredictable.”

The danger posed by the uninsured is another reminder that when it comes to infectious disease, we’re all in this together. Sick pigs and sick people, a virus in Mexico and an infection in New Zealand–in a globalized world, microbial threats that seem far away can be on our doorstep in hours. “As a global community, we are only as strong as our weakest link,” says the CDC’s Besser. If we want to prevent the next pandemic–or at least survive it–we need to remember that.