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The lab tests confirmed the Vietnamese boy had died of H5N1, but his parents were sure the 13-year-old had never been in contact with sick poultry. For epidemiologist Tim Uyeki at the U.S. Centers for Disease Control (CDC) in Atlanta, part of a team responding to a bird-flu outbreak in Vietnam in January 2004, that was a red light, a possible sign of a human-to-human transmission. Uyeki traced the victim's contacts, investigating his family and friends, before neighbors finally provided the answer: the boy was an avid cockfighter, and held the roosters close when preparing them for a bout. "Influenza virus is excreted in the feces. Chickens and ducks have fecal matter all over them," Uyeki says in his office at cdc headquarters in Atlanta. "This boy was holding roosters with the rear end pointing toward his face, and that's direct contact." One more case closed, another lucky outcome on H5N1's genetic roulette wheel.
If the next spin comes bad, Uyeki will be among the first to know. His international colleagues at the WHO are devising a plan of last resort that they hope would smother a budding pandemic. Here's how it would work: sustained human-to-human transmission is confirmed and reconfirmed; the WHO tries to box in the emerging pandemic virus by treating all contacts of all known victims with the antiviral drug Tamiflu, which can prevent infection; and strict quarantines are imposed in the outbreak area, so unknown carriers are less likely to travel and spread disease. According to mathematical models, if the virus remains relatively hard to spread; if the affected country is willing to report itself as the potential source of a pandemic; and if officials are able to respond within about three weeks of the first cases—then the disease might be contained. "No one has tested this in the past, but we all know how devastating the consequences of a pandemic would be," says Margaret Chan, the WHO's director of communicable disease. "If this solution has even a small chance of success, we need to try it."
Another option for fighting a pandemic: develop a vaccine and inoculate as many people as possible so their immune systems recognize and attack the H5N1 virus. Such vaccines are in the final testing stages, but this approach is no panacea. Viruses can mutate unexpectedly, making it difficult for drug companies to keep up. Researchers can engineer a vaccine tailored to a new flu strain within weeks, but production in high volumes still depends on 1950s-era techniques. Months could go by before the first batch would be ready. As St Jude's Webster says: "How many people are going to die in the meantime?" Moreover, because only a few companies are capable of mass producing a vaccine, the world would be hard-pressed to boost output beyond the current 300 million annual doses. "Basically, we haven't prepared for a pandemic," says Hitoshi Oshitani, an avian-flu expert with the WHO's Western Pacific office. "You need huge resources to be able to respond, and I don't think any country in the world is well prepared." Osterholm is even more pessimistic: "We have as much chance of stopping a pandemic as we would of putting a curtain around Minnesota and keeping out winter."
Still, some scientists argue that the threat of a devastating global outbreak is overstated, and that the next pandemic is more likely to result in the lower death rates of the 1957 Asian flu pandemic or the 1968 Hong Kong flu outbreak, which killed about 2 million and 1 million people respectively. That would be a far cry from the 100 million death toll in 1918. But even if the mortality rate is relatively low, the economic impact could be severe. The cost of the SARS outbreak was estimated to be $40 billion in the Asia-Pacific region alone. "If we really had evidence that the genie was out of the bottle, the world would go into outright panic," says Osterholm, who believes that even a weak pandemic could trigger the kind of quarantines and travel restrictions that could bring the global economy to a standstill. "We're much more vulnerable now because in the past we were more self-sufficient."
For Guan, there is an awareness that a potential disaster is brewing and that an urgent opportunity to prepare is being squandered. "Our job is to make the world better," he says. "But like an ostrich, we hide our face in the sand." It might be tomorrow, it might be five years from now, or it might be longer, but a pandemic is coming. In the mutable, maddening world of influenza, that much is certain. The uncertainty is our response.