Lessons from avian flu

My book The Politics of Disaster came out in 2006 on the first anniversary of Hurricane Katrina. I had sections on what went wrong in New Orleans, what went right, how national disaster policy needed reform, how religious organizations could help, and how the United States could help with disaster abroad. The last section, titled “Disasters to come,” included chapters on earthquakes, nuclear terrorism, and pandemics.

In the pandemics chapter, I noted good news—improved communications since 1918—and bad news: “worldwide air travel would quickly spread the disease.” I took the experience of avian flu and wrote, “The two-day typical influenza incubation period—the time from infection to visible illness—would allow those infected to transmit the virus during the day before they become ill.” I showed my lack of prophetic ability by not expecting that people who appear or are healthy would be able to transmit a new virus—not an avian one—for a long time. But read on, please.

It’s likely that the typical person becoming ill would transmit the virus to two or three other persons. Pessimists argue that the medical system would be quickly overwhelmed, with the improvements of nearly nine decades not making a difference for most victims.

President George W. Bush, in April 2005, mused about the matter at a press conference: “The policy decisions for a president in dealing with an avian flu outbreak are difficult. One example: if we had an outbreak somewhere in the United States, do we not then quarantine that part of the country, and how do you then enforce a quarantine?” The question was a good one, since quarantines in a land of individualism are hard to maintain. The HHS Pandemic Influenza Plan informs us that state, local, and tribal authorities “should be able to” isolate individuals and then set up voluntary quarantine measures. But that plan reads like some hurricane disaster plans, filled with generalities and good intentions but light on specifics.

Likely results

Again, an avian flu pandemic is unlikely—but if it did arise and come to the United States, it would probably last for six to eight weeks, with two weaker waves following in subsequent months. Once underway, it would be like Heisman Trophy winner Reggie Bush during the 2005 football season: you can’t stop it, so your only hope is to contain it. The number of people to die would depend on the virulence of the mutated flu, but it clearly would produce economic disaster: perhaps no air travel for a much longer time than after 9/11. Interstate commerce could decline enormously for a time. Millions of people could be without outside supplies for not days but weeks.

The HHS Pandemic Influenza Plan notes the problems but, after four hundred pages of discussion, still leaves it unclear as to whether or how food and other supplies would be delivered, what would happen with jobs and schooling—many little details like that. The Pandemic Influenza Plan emphasizes the need for “timely and transparent dissemination of clear, accurate, science-based, culturally competent information about pandemic influenza, and the progress of the response can build public trust and confidence.” It offers good intentions but no specifics. Based on Katrina reporting, it’s likely that the media would spread panic.

Reporting of pandemic plans, so far, has also been short on detail, but that may be inevitable given our difficulty in coming to grips with such threats. In one broadcast CBS medical reporter Sanjay Gupta said, “There might be recommended isolation. … You might be told on your local news or even [by] a phone call or something to stay home, don’t be outside, stockpile some food and don’t come in contact with people until we tell you. And I think that’s going to be some of the most effective measures.” Really? After the experience of Katrina in New Orleans, do we really think that all or even most people will stockpile food, and that they will obey instructions? …

After the experience of Katrina in New Orleans, do we really think that all or even most people will stockpile food, and that they will obey instructions?

Creating a vaccine

The human vaccine question sits amid a different economic and legal landscape. Since viruses frequently mutate, a vaccine often works for only one season, so a manufacturer must recover its entire cost of production in a few months. The movie business is somewhat analogous in its emphasis on fast recovery of investment—the first weekend of theater exhibition is key—except that movies have DVD sales. But no one wants a vaccine past its prime.

Furthermore, even if a proven vaccine were available, production of it in massive quantities would take at least six months from the appearance of the particular pandemic-causing strain. That’s because we still depend on a sixty-year-old process for producing vaccines from fertilized eggs. Some politicians have been calling for the production of six hundred million vaccines within six months, which is more than ten times current capacity: those intentions are good, but six months would not be fast enough. We need a breakthrough—a genetically engineered universal flu vaccine would be ideal, and whoever comes up with it deserves both fame and fortune.

Progress has been slow, perhaps because of technical difficulties, but also due to forced low-cost licensing and the prospect of litigation. To understand the licensing problem, imagine that if a movie became hugely popular, governments would suddenly declare it illegal to charge eight dollars to see it; to ensure that poor people were not excluded, theaters would be allowed to charge only a dime. To understand the litigation threat, imagine that filmmakers could lose all their profits and possibly the entire company if a few viewers had negative reactions to the product on screen.

Now, let’s turn from entertainment to life-and-death matters. Doctors at the end of 2005 believed that the antiviral drug Tamiflu, if taken within forty-eight hours of avian flu onset, would be able to relieve the worst symptoms and prevent many deaths. (Tamiflu did not help two avian flu victims in Vietnam, but that appeared to have been an isolated occurrence.) The Swiss company Roche should have been receiving glory, laud, and money for bringing the drug to the world. Instead, Roche faced calls to sell Tamiflu or license government production of it in many countries at practically giveaway prices, and risked being labeled a mass murderer if it requested a return on its investment.

At the end of 2005, the World Health Organization was trying to force Roche to give up its Tamiflu patent rights; officials in Indonesia, Taiwan, and other countries had forced Roche to license production; and New York Senator Charles Schumer was among the American politicians proposing that the United States break Roche’s patent rights. Many agreed on the goal—the rapid production of Tamiflu—but few noted that mandating production at confiscatory prices would send a negative message to researchers and companies deciding whether to invest heavily in developing drugs that could preserve life from the next threats.

It was vital to produce more Tamiflu but to do so in a way that gave Roche a good return on its investment. Although it’s risky business to use an avian metaphor when discussing bird flu, politicians were lining up to strangle a goose that laid a golden egg. They could win immediate popularity by letting people get drugs more cheaply. Few had eyes to see what does not yet exist—and what will not unless inventors receive encouragement. Nor did many politicians care: the pandemic a decade or two down the road will not be on their watch and will not affect their immediate electoral chances. They could be vote-wise and life-foolish: their breaking of the seventh commandment (“Do not steal”) could lead regularly to their breaking of the sixth (“Do not murder”).

Strangling this goose is a bird-brained idea. Bill Gates, whose foundation is helping health programs around the world, noted that the key issue in increasing world health isn’t the cost of drugs but “the drugs that aren’t being invented, and part of the reason they aren’t being invented is that [if] the pharmaceutical companies work in these areas, then they’re expected to give the drugs away.” There are two better ways: either pay market prices for needed drugs or offer big prizes for companies that come up with vital drugs. George Mason University economist Tyler Cowan suggested that the federal government offer Roche the option of licensing production in this country at generous prices and with favorable regulatory treatment and easy facility construction.

There are two better ways: either pay market prices for needed drugs or offer big prizes for companies that come up with vital drugs.

Litigation, again

Licensing issues are one part of the problem; legal liability questions also need answers. The litigation threat is one that has grown over the past half-century, during which time the number of vaccine makers in the United States shrank from twenty-six in 1957 to four, with two of the four doing little in vaccine research. We have vaccine shortages in nine of the twelve vaccines commonly given to children. The problem is that when a large population is vaccinated, a small percentage (but a large number) will become ill, and almost all will be approached by lawyers who say big bucks are waiting.

The legal path could be cleared if courts did not impose strict liability for rare side effects but instead required proof of negligence. Alternatively, the federal government could indemnify vaccine manufacturers for damages attributed to the vaccine. The National Vaccine Injury Compensation Program, since its creation in 1986, has done that for rare injuries sustained following the administering of vaccines used routinely for children. However, it does not cover many vaccines, does not cover unborn children, and gives gambling lawyers the option of going before juries that sometimes run away from both law and science. These holes need to be plugged so that predatory lawsuits do not force companies to decide between their own survival and the public interest.

Overall, in our avoidance of risk, we’ve created or sustained FDA regulations tougher than those of western Europe and in the process provided a tad more safety at the cost of innovation: to use a football metaphor, our game plan has given us 6-3 rather than 42-7 wins, and allowed officials to boast that we allowed no touchdowns. This is an inadequate metaphor when the price of an innovation that saves thousands is the loss of an innocent life, but the fight against disease is a war. Officers who write letters to grieving mothers know how difficult it is to lose anyone, but in war some soldiers die that more may triumph.

On these life-or-death matters, the politics of disaster have pushed us to try to get by on the cheap. Federal procurers have been efficient in this one area: since the U.S. government is the largest purchaser of vaccines used for children, it has been able to pay low prices in a penny-wise but life­foolish way. The government should pay higher prices for vaccines or, if the government-pressured marketplace will not provide a high enough return to attract companies to jump in, it should offer substantial prizes for innovation.

Licensing and litigation questions are difficult not logically but politically; when some politicians tire of making threats about gasoline prices, they assault pharmaceutical companies. And yet Paul Offit, chief of infectious diseases at the Children’s Hospital of Philadelphia, pointed out that these companies should be honored: during the past century they have been the major contributor to increasing the American lifespan by thirty years. They created and mass-produced vaccines against pertussis (whooping cough) that dropped the number of children’s deaths from eight thousand annually to fewer than twenty, vaccines against polio that reduced the number of children it paralyzed annually from fifteen thousand to zero, and vaccines against rubella (German measles) that reduced the number of children with severe birth defects from twenty thousand to zero.

Removing litigation disincentives to mass production is particularly important because we may not be far off from some vital breakthroughs in vaccine production. Scientists are beginning to genetically engineer viruses that could be used in vaccines. One company plans to use canine cultures to produce avian flu vaccine. Overall, it looks like the time to produce a vaccine could be cut from six months or more to three months or less. Companies are also working to use less of a vaccine supply by mixing in adjuvants, chemicals that magnify vaccine effects so that what was needed for one dose can now cover forty or fifty.

Those advances could come soon, but now, as HHS secretary Mike Leavitt said near the end of 2005, “We are underprepared.” That is not surprising, because politicians who gain votes by concentrating on what produces immediate results tend to be “Chicken Bigs,” suggesting that since the sky did not fall during the swine flu pandemic or during other times of warning, it won’t fall this time either. Since we are always surrounded by risks of low probability, since it’s hard to know which carries the greatest emergency, and since the likelihood of any particular disaster hitting during the term of office is small, underpreparedness is standard.

Removing litigation disincentives to mass production is particularly important because we may not be far off from some vital breakthroughs in vaccine production.

New Orleans writ large?

And so we are left with the possibility of a national New Orleans. If food distribution were to falter while many people stayed sequestered, the chaos rumored in New Orleans would become reality in every major city. With distribution costs increasing and scarcities common, prices for food and other essential goods could soar. Some jobs would disappear, job absenteeism would grow, mortgage defaults would increase, and the threat of bank runs and closures would be great. Probably every company in the airline industry would go into bankruptcy. The Federal Reserve would need to be prepared to increase liquidity in financial markets and keep check-clearing systems from shutting down.

Here’s where sector-by-sector planning is crucial. Maintaining electric power would be important, so utilities should plan to have crews of technicians—especially those without families—living at power stations to improve the prospects of continuity of supply. It would be vital to keep open ports to receive shipments of oil and gas and transport them to refineries. Since schools would close during a pandemic, teachers would need to be prepared to post work online and do virtual instruction. Some companies plan to have employees work from home should disaster approach, which makes sense not only to avoid spreading the virus but also because day-care centers would be closed.

Local health care systems would be stretched and stressed as never before, so they would need to have and use databases of volunteers—doctors, nurses, other professionals—willing to help out in case a pandemic hits. With emergency rooms crowded by flu patients, it would be important to turn church halls and school gyms into clinics for those with nonflu emergency medical needs. Medical facilities would have to have stockpiled testing kits for avian flu and large supplies of antibiotics, respirators, IV fluids, and the other innovations that can make a new pandemic much less costly in lives than the 1918 disaster. Generic statin drugs used to fight cholesterol might also fight the secondary results of flu infection.

Let’s look at how each of the major players would function at the peak of a pandemic. The military would not be needed for riot control operations because most people would avoid crowds, unless utter desperation came. Companies such as FedEx would be crucial in shipping as other patterns of commerce broke down. Faith-based organizations would be crucial both in direct relief work and in the preservation of community when everything seemed chaotic. But individual action, from stockpiling food before the crisis to frequent hand washing and mask wearing during it, would be essential.

So preparation is important, but we should not obsess over avian flu at the expense of other medical issues. The next pandemic or public health crisis could come from any number of sources, so we should focus on local preparedness and flexibility in responding to surprises, whether they result from terrorism or natural catastrophes. With all the threats out there, we should remember that we are not living in exceptionally dangerous times. In premodern times most children died during their first five years of life. In modern times, every generation has faced massive hazards: for example, Americans, in December 1941, found themselves facing both Nazi Germany and militant Japan, and averted disaster by becoming “the greatest generation.”