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The Flu Pandemic Preparedness Snowball

Trying to arouse concern about anything is pushing a rock uphill. But if you’re lucky, the rock gets to the top of the hill and starts rolling down the other side. As it gains mass as well as momentum, it converts to a snowball. Of course there’s more than one hill; your rock/snowball is likely to need more pushing before long. Still, the snowball phase is certainly worth noting, and celebrating.

That’s where flu pandemic preparedness is right now. During the past two weeks, U.N. head Kofi Annan appointed a new pandemic “coordinator,” David Nabarro, whose maiden speech used a higher upper-end worldwide death prediction (150 million) than any of his World Health Organization colleagues had previously voiced. In the U.S., which has lagged behind many other developed countries by some measures of preparedness (antiviral stockpiles, domestic vaccine production capacity, and candid warnings to the public, for example), Democrats and Republicans vied with each other to see who could most aggressively insist that “we’re not prepared,” and actually cooperated in several legislative efforts to get better prepared. Two research teams published studies showing marked similarities between the mother of all flu pandemics in 1918 and the H5N1 virus now looming over much of Asia. Whatever measure of buzz you want to use – radio talk show topics, website hits, lists of most-emailed articles, street corner conversations, even naysayers’ what’s-all-the-fuss-about columns – the effort to try to get the world (at least the first world) ready for a bird flu pandemic had a good fortnight.

I have overused the phrase “teachable moment” in my writing about risk communication, and I promised myself to give it a rest. But the point has never been more relevant than right now. Forget the rock and the snowball and think cattle branding. In precaution advocacy – trying to get people worried about a risk, and therefore disposed to take precautions – it’s best to strike while the iron is hot. The iron is pretty hot right now. Unless a pandemic begins soon, it may not be hot for long. Once again, this is a teachable moment.

This column will be a potpourri of miscellaneous warnings and quibbles about pandemic risk communication as it seems to be evolving. For the basics, see last December’s “Pandemic Influenza Risk Communication: The Teachable Moment.” For an annotated good example, see July’s “Superb Flu Pandemic Risk Communication: A Role Model from Australia.” For the rest of my writing on pandemic communication (yes, I’m a little obsessed), see my website’s Pandemic Flu and Other Infectious Diseases Index.

1. Be nice to the newbies.

Anyone who has ever been an activist knows how demoralizing it is to start winning. You had this solid “in” group of fellow fanatics. Everyone knew everyone else; everyone knew the facts and the issues; everyone knew how special you all were to care so deeply, to keep plugging away despite your neighbors’ obliviousness. Then you made some progress, and suddenly there were strangers coming to your meetings, asking stupid questions, offering inappropriate suggestions, making everyone uncomfortable, sometimes even usurping leadership. In a 1984 article for the nuclear freeze movement, I wrote:

We oldtimers inevitably gravitate to each other at gatherings, especially when we’ve been through tough times together, or when we have work to transact and gossip to transmit. This leaves newcomers sitting painfully alone, watching the inner circle and pondering the invisible “Keep Out” signs we didn’t mean to post. You can’t stop the formation of cliques, and you can’t stop wanting time with your friends. But you can consciously reach out to newcomers. In larger groups you can even institutionalize a buddy system. Pair each newcomer with another newcomer to compare notes with, and with an oldtimer to go to for basic information.

Until very recently, most of the bird flu blogs and wikis and interactive websites were doing a nice job of welcoming newcomers – certainly a better job than the nuclear freeze movement did two decades ago. There were FAQs for newbies, and an overall tone of acceptance leavened the inevitable corrections of beginners’ errors. ( “Yeah, I used to think that too,” is a lot easier to take than “What a dumb thing to say!”) The h2h [human-to-human] transmission of bird flu information was going fine. But the last two weeks have seen an explosive increase in newcomers to bird flu sites. These latest newbies are in the early stages of their adjustment reaction. Some are frightened and urgent; some are skeptical; nearly all are ignorant. Some of the oldtimers are feeling crowded and a little contemptuous, and it’s showing.

The Flu Clinic is a “room” on the curevents.com (current events) bulletin board. On October 5, the curevents moderator posted a warning:

I am very disappointed in the direction that this room has taken over the last couple of weeks. Yes, the board has grown a great deal in terms of the number of participants. But I am also seeing a much more negative development. People are becoming openly hostile and aggressive, personal attacks are increasing, and it is having repercussions.…

• The personal attacks are going to stop….
• The discussions are going to stay focused on flu topics. I don’t want to see any more political debates, economic discussions, prep threads, gun control arguments and so forth in here….
• People are going to be respectful of other viewpoints. That means that one person might like alternative medicine, while another might not…. And most importantly, it means that some people think H5N1 is going to be a catastrophe and others will not….

I understand that most of the people here think it is “when not if” and will be bad. Regardless, I WILL NOT allow this place to become a “true believer cult” where opposing viewpoints are shouted down.

Another flu bulletin board, this one on agonist.org, is in danger of shutting down altogether, because the moderators “have grown very weary of moderating the consistent food fight attitude here in this forum…. We don’t want to shut down the Disease threads…. But, the tone, tenor and behavior are way out of line.”

Some of us bird flu fanatics are likeliest to lose our tolerance for newbies when the newbie is the newly interested President of the United States, a newly appointed official of the World Health Organization, or even a newspaper reporter covering the pandemic story for the first time. Commentaries on bird flu media coverage and the public utterances of public officials have sometimes evinced a carping tone. One of the best flu sites is effectmeasure.blogspot.com, whose editors use the nom-de-web “Revere.” On September 30 Revere posted a commentary under the title “Braindead take notice,” noting what they called “belated signs of life among our braindead politicians who are dimly seeing that maybe bird flu is the next Katrina.”

This is a self-defeating tone for people whose goal is to spread the word. Worse, it’s a self-defeating attitude. As a fellow fanatic put it to me a few days ago: “The mainstream is finally starting to pay attention, and some of the flu geeks are getting upset. They haven’t quite figured out why. They just know they’re in a bad mood.” (The “fellow fanatic” is my wife, colleague, and frequent coauthor Jody Lanard. She can’t write any avian influenza columns with me right now, because she’s working temporarily as WHO’s Senior Advisor for Pandemic Communications in Geneva. I’m on my own.)

There’s no question that the flu pandemic preparedness snowball picks up a lot of misinformation as it rolls:

• “Tamiflu’s like a vaccine except it’s generic, not tailored to a specific strain of flu.”
• “The experts are sure H5N1 will go pandemic; it’s not if, it’s when.”
• “We’re okay as long as we watch our birds carefully and don’t let that Asian bird flu get a foothold in North American poultry flocks.”

I heard these three from one talk show host during one ten-minute period. Actually, Tamiflu can stave off the flu if you keep taking it, and can weaken the disease if you take it soon after getting sick, but it doesn’t confer immunity the way a vaccine does. The experts are sure there will be some kind of flu pandemic sooner or later, but whether H5N1 will ever learn to spread efficiently from human to human is anyone’s guess. And if H5N1 does eventually accomplish efficient h2h transmission, it won’t matter where; from then on it’s a human pandemic, and protecting local birds won’t affect it a bit.

As pandemic concern keeps increasing – if it does – errors like these will be self-correcting. Last week’s newbies will learn better, even as this week’s newbies make similar mistakes. It will be useful to notice which facts beginners keep getting wrong, so we can correct the errors or even warn against them. ( “When people first hear about bird flu, they often get the impression that…. But actually….”) And it’s important to figure out which errors really get in the way and which just irritate us oldtimers. (President Bush’s opinion that quarantine is likely to stop a pandemic, emphasized at his news conference last week, is a good candidate for correction. By now someone has probably told him that his government’s experts don’t think so.) Of the three errors in the previous paragraph, by far the most damaging to the preparedness effort is the widespread belief that local birds are the key. If H5N1 progresses from “occasional bird-to-human transmission” to “efficient human-to-human transmission,” it won’t matter where it happens. If it happens anywhere, the odds are overwhelming that H5N1 will get here (wherever “here” is) in a matter of weeks or months. Pandemic viruses are avatars of globalization.

As we correct the errors that most need correcting, we should try hard to be gentle. It can help to recognize that our desire to be harsh may emanate from injured ego. Nobody can control a snowball. We can try to guide it, but if it keeps rolling and growing (as we hope it will), inevitably it’s going to pass us by and find its own course. As the snowball expands, we feel deflated. We need to be nice to the newbies anyway.

2. Watch out for people’s adjustment reaction – and the authorities’ adjustment reaction.

I have written elsewhere about adjustment reactions. When people are first confronting a risk they haven’t thought about before, it is normal – and useful – to “over-react” for a while. Some people become hyper-vigilant; some take precautions prematurely; some obsess. Then a few people turn into fanatics, while most settle into the New Normal, more attentive than previously to the new risk, but not so obsessed anymore.

Officials are prone to misinterpret the public’s adjustment reaction as panic or hysteria. Instead of helping people get through it, they tend to try to tamp it down.

The big achievement of the past two weeks is a quantum increase in the willingness of authorities to say scary things about bird flu. In the U.S., at least, this is in part a side effect of Hurricane Katrina; the U.S. government feels it dare not risk accusations of under-reacting to another potential crisis. I think it’s also a result of U.S. government fears that just about everyone else was expressing more concern about bird flu than the U.S. government was:

• Civil society was sounding the alarm – from the Council on Foreign Relations to the New England Journal of Medicine to Trust for America’s Health.
• The private sector was getting interested – hundreds turned out for a recent New York conference on how the financial industry can prepare for a pandemic.
• Other countries’ governments were moving further and further out in front.
• Some state and local officials (most notably King County, Washington) were getting way ahead of Washington D.C. in talking up pandemic preparedness.
• Democrats (and Republicans) in Congress were making noises and introducing bills.

It looks very much like President Bush authorized Health and Human Services (HHS) Secretary Michael Leavitt to sound scary too.

And Leavitt has delivered on the new policy. On October 6 he said: “Here’s the dilemma: We’re not prepared as a country. No one is prepared in the world.” On October 8 he said: ”The world is woefully unprepared. You’d think that it would be a matter of constant concern to us. It has not been, anywhere in the world and, consequently, the world is unprepared. And we’re now as a civilization rallying to say, ‘What can we do to better prepare?’” You can quarrel with Leavitt’s implication that preparedness is a dichotomy and that no countries are paying closer attention than the U.S. But you can’t quarrel with his candor about the need to do more. “Woefully unprepared” is the kind of phrase you’d expect from the opposition – and indeed several Democratic politicians had used the phrase as far back as March 6. But it’s different when the party in power criticizes itself.

As momentum builds, what should come next is the public’s adjustment reaction. I don’t know what form it will take. A run on Tamiflu, maybe. Or private stockpiling of surgical masks. Or a growth spurt in hand-washing. Or increased pressure on local and national officials to publish their pandemic plans, and to make them more detailed and more practical. Or a decline in chicken sales, or in tourism to Southeast Asia. Some of these precautions make better sense than others – but it’s not rare for precautions in the adjustment reaction phase to be less than optimal. The proper risk communication response is to try to guide the adjustment reaction by first validating the impulse to act, and then suggesting wiser precautions people can take.

The least desirable risk communication response to the public’s adjustment reaction to the pandemic flu threat is to insist that the public is over-reacting. This is, if you will, an adjustment reaction to the adjustment reaction, an official over-reaction to the public’s over-reaction. (The technical term is “reactance.”) It will be unfortunate if people cope with their new bird flu fears by buying less chicken for a while. It will be more unfortunate if officials respond to the decline in chicken sales, if that’s what happens, by staging chicken-eating photo ops at which they ridicule the public for panicking. And it will be devastatingly harmful if the lesson officials draw from all this is that they should try to keep people from worrying about a flu pandemic.

People need to worry about a flu pandemic, so they can start getting their families and their communities ready. And eating less chicken isn’t panicking.

(A personal comment: While I do not recommend photo-ops of cheerful officials eating chicken, I do recommend going out of your way to eat chicken. During the SARS outbreak, going to Chinese restaurants was a gesture of solidarity and empathy, supporting a group that was being stigmatized and damaged during the public’s SARS adjustment reaction. Ridiculing the adjustment reaction may score political points, but it will not help frightened people get through it faster. Respectfully suggesting alternative precautions will.)

3. Focus less on the pharmaceutical fix.

Infectious disease experts have been insisting for years that the world’s system for manufacturing vaccines is broken. Part of the problem is technical. We are still using a mid-twentieth century technology that is slow, precarious, and inefficient; in an era of bioengineering, vaccines are grown in chicken eggs. And part of the problem is social. Vaccine manufacturers incur high potential liability without much potential profit, so most pharmaceutical companies don’t want to be in the business at all, much less modernize it.

It is definitely good news that the U.S. government now says it is determined to do something about the vaccine mess. We can argue about the right solution – whether the government should take over vaccine manufacturing altogether, or make it more profitable by becoming a better customer, or make it less risky by protecting companies from lawsuits, or underwrite research into new technology, or subsidize a few new domestic factories, or just cajole companies into manufacturing improvements in hopes of an unspecified quid pro quo later. But almost any solution is bound to be an improvement. Though it’s all too human for flu fanatics to find fault with the government’s new focus on vaccines (see #1 above), the proper response is thank you and congratulations and keep up the good work, not “What took you so long?”

But it’s not all about vaccines.

The problem with reforming the vaccine manufacturing system is that it will take time. Nobody knows how much time; technological breakthroughs don’t keep to a schedule. And nobody knows how successful the reform effort will be – that is, how short we can make the gap from when a new virus launches a pandemic (or seems poised to do so) to when there is an adequate supply of a vaccine tailored to that virus. And of course nobody knows how long we have before the next pandemic strikes.

So it certainly makes sense to rethink the vaccine manufacturing process, in hopes of a shorter gap and a larger supply when the time comes. And it probably makes sense to keep making and stockpiling vaccines tailored to the evolving H5N1 virus, in hopes that the latest stockpiled vaccine will match the eventual pandemic virus closely enough to be useful. But it does not make sense to be confident that either of these two measures, or both of them together, will save the day. If the next pandemic starts soon, we won’t have a vaccine stockpile and we won’t have a speedy process for producing enough of a new vaccine.

Nor are Tamiflu and Relenza (the two antiviral drugs that seems to work on H5N1 so far) guaranteed to save the day. Many other western countries have put more stress on antivirals than the U.S., which has put its money on vaccines instead. Now the U.S. wants to hedge its bets by greatly enlarging its antiviral stockpile. That, too, probably makes sense. But there’s no way the U.S. can get enough antivirals for the entire population. For the foreseeable future, the U.S. will need to choose between protecting key personnel (health care workers, cops, firefighters) and treating people who are already infected. Even that’s an ambitious goal. No corporate official will say how long the queue is for backordered antivirals. And nobody is saying what pressure (if any) the U.S. and other governments are exerting to cut ahead in the queue. If the next pandemic starts soon, antivirals won’t be a major factor either, except in a few countries with sizable stockpiles in hand.

What does all this information on vaccines and antivirals have to do with risk communication? Five things:

• The focus on the pharmaceutical fix is excessively optimistic. It is keeping people from focusing enough on worst case scenarios.
• The focus on the pharmaceutical fix is excessively medical. It is keeping people from focusing enough on non-medical preparedness.
• The focus on the pharmaceutical fix is excessively governmental. It is keeping people from focusing enough on what civil society, the private sector, and individuals can do
• The focus on the pharmaceutical fix is excessively national. It is keeping people from focusing enough on local preparedness.
• The focus on the pharmaceutical fix is excessively first-world. It is keeping people from focusing enough on ways to help Africa, Asia, Latin America, and the Middle East prepare for a pandemic.

4. Focus more on worst case scenarios.

Too much pandemic risk communication, especially from government, is structured like a television commercial: Introduce a horrible problem, then tell the viewer how your product is guaranteed to solve the problem. Michael Leavitt, David Nabarro, and other world leaders deserve credit for being more willing than previously to concede how horrible the problem may be. But they are sometimes a little too willing to stress how great their portfolio of solutions is.

Nabarro, for example, floated that scary 150 million number on September 29 as his upper-end estimate of how many a 1918-like H5N1 pandemic might kill, with 5 million as his lower-end estimate for a pandemic more like the mild ones of 1957 and 1968. That’s good. He was saying it might be horrific or it might not. But then he added: “I believe the work we’re doing over the next few months on prevention and preparedness will make the difference between, for example, whether the next pandemic leads us in the direction of 150 [million dead] or in the direction of 5 [million dead].”

If Nabarro actually believes that, he is nearly the only one who does. There won’t be a lot more vaccine or antiviral doses stockpiled a few months from now than there are now. So how many people an early 2006 pandemic would kill depends mostly on how infectious and how virulent the mutated virus turns out to be, not on anything we do between now and then. Most experts think pandemic prevention is pretty much a lost cause (though bird culls can be useful, and some think a last-ditch effort to contain a newly hatched pandemic before it spreads far is worth trying). As for preparedness, if the pandemic comes soon and the virus turns out more like the ’18 strain than the ’57 or ’68 strain, for the most part preparedness won’t be about reducing flu deaths; it will be about reducing collateral deaths from other causes (see #5 below).

Similarly, Leavitt said on October 8 that the world is “woefully unprepared” for a flu pandemic. He didn’t quite acknowledge that the United States is less prepared than some other countries, or that it might have been expected to be better prepared than most – but at least he didn’t exempt the U.S. from his description. Leavitt was doing the media rounds, and the world’s lack of preparedness was a consistent leitmotif. Just as consistent was Leavitt’s prescription for getting prepared. Aside from vaccines and antivirals, he focused mostly on improved surveillance in Asia, in the hope that we can nip an incipient pandemic in the bud. (That “we” is a bit misleading. Lacking any commitment from first-world countries to donate from their own antiviral stockpiles to try to ring-fence an emerging outbreak in Southeast Asia, the World Health Organization has arranged for manufacturer Roche to donate three million treatment courses of Tamiflu for the purpose.)

What Leavitt hasn’t come anywhere near saying, even in the last two weeks, is what most flu experts have been saying all along: There may be no way to prevent, halt, or even delay a severe pandemic. There may not even be a way to significantly alleviate the influenza death toll. Maybe the best we can do is take steps to avoid additional suffering and additional deaths from infrastructure collapse (see #5 below).

Still, Leavitt shows more sense of the tragic than most U.S. career politicians have shown. On October 4, thirty-two Democratic senators sent a letter to President Bush expressing “grave concern that the nation is dangerously unprepared for the serious threat of avian influenza.” The President responded by devoting much of a news conference to the issue. He focused especially on the quixotic notion of deploying the military to enforce a domestic quarantine of any infected region. “The people of the country,” he noted, “ought to rest assured that we’re doing everything we can.”

To start with, the President’s belief that the public ought to “rest assured” is 180 degrees off. The public needs to progress “from apathy to alarm and from alarm into action,” as the Trust for America’s Health advocacy organization puts it, “scared into its wits” in Michael Osterholm’s phrase. And of course we’re not doing everything we can. Nor should we; the essence of risk management is always figuring out which precautions to take and which to forgo. (Large-scale involuntary quarantines are one we can probably forgo.) The President and his opponents seem to share two false assumptions: that it is possible and desirable to do everything you can to prepare for a risk, and that if you do everything you can you will no longer be dangerously unprepared.

It is true that our tolerance for alarming information depends on our sense of self-efficacy. Telling people the pandemic risk is huge and there is nothing to be done would be debilitating rather than inspiring. The trick is to inspire people the way Winston Churchill inspired people during World War II – not with happy talk and false optimism, but with determination.

Winston Churchill notwithstanding, politicians are politicians. When they finally become aware of a threat, it is with little sense of the tragic and little willingness to acknowledge the limitations of preparedness. One side demands, and the other side promises, that the government will hold back the tides. “We’ll stop the virus in Asia. We’ll stop it at our borders. We’ll quarantine any region that gets a case. We’ll shoot a vaccine dose into every arm. The American People deserve no less!”

This insistent pharmaceutical optimism militates against preparedness for a severe pandemic. That’s what worries me most about the focus on vaccines and antivirals.

We don’t know when the next pandemic will come. More importantly, we don’t know when the next severe pandemic will come. If it holds off long enough, and if the world gears up seriously enough, we may actually be able to develop an adequate medical response; we may be able to make sure 1918 never happens again. Or that may be beyond us. We don’t know. What we do know is that the next severe pandemic may very well come when we are still, as we are now, woefully unprepared with an adequate medical response. That’s the worst case scenario. People need to know about it.

For more on how to talk about bird flu worst case scenarios, see “Worst Case Scenarios.”

5. Focus more on non-medical preparedness.

Why do people need to know about the worst case scenario? So they can start getting ready for it – not with vaccines and antivirals, but with inventory adjustments, with improved hygiene habits, with knowledge about social distancing, and with plans to recruit immune survivors as volunteers.

If the next pandemic is a mild one, the medical response will be almost the only response needed. But medical preparedness for a severe pandemic isn’t feasible right now, though it might be some day. Non-medical preparedness, on the other hand, is feasible today. There’s a significant chance it may turn out essential tomorrow.

So far the main official sources of pandemic information (such as the World Health Organization and the U.S. government) have had little to say about the possible impact of a pandemic on production and transport. That has been left to private commentators, such as Michael Osterholm of the University of Minnesota’s Center for Infectious Disease Research and Policy and Laurie Garrett of the Council on Foreign Relations. In a severe pandemic, lots of people will be dead, sick, caring for loved ones, or afraid to go to work. And travel of all sorts will be is greatly reduced. With production and transport slowed to a trickle, shortages are inevitable – especially in our era of just-in-time inventory. At a pandemic preparedness conference I attended a few weeks ago, Laurie Garrett sat quietly through several excellent presentations on various aspects of avian influenza. “Well, yes,” she asked from the floor when the question period arrived, “but how will we eat?”

What are we likely to run out of that we can’t afford to run out of? Food is certainly high on the list. So is energy, more for heating than for transport. And medicines – not flu medicines, particularly, but cancer medicines and the rest. And essential supplies and parts. What happens, for example, when the local water treatment plant runs out of chlorine or filters or whatever else a water treatment plant needs to keep running? If a disastrous 1918-like pandemic hits, the question is whether the health disaster we probably cannot do much to ameliorate will be accompanied and followed by additional disasters we really could have ameliorated, if only we had prepared better for them. We need to take steps so that people who are spared by the pandemic influenza virus aren’t done in by starvation, cold, chronic diseases, or contaminated water.

Security is another non-medical issue official sources haven’t had much to say about. We don’t want people who are spared by the virus done in by riots either. But I’m pretty sure they’re thinking about security, even if they’re not talking about it. I worry whether anybody is thinking enough about staffing and inventory.

Then there’s hand hygiene – which isn’t really “medical” because you don’t need a doctor to do it right. Infection control experts agree, with solid evidence to support them, that the single best available precaution against the spread of influenza is washing your hands as often as you can. They also have evidence to support their advice to avoid touching your eyes, nose, and mouth. Additionally, though without much evidence, they recommend covering your mouth when you cough. (They’ve got to know that it’s hard to cover your mouth without using your hands unless you wear a surgical mask – but for some reason most of the experts aren’t enthusiastic about public use of masks. They say they’re worried mask-wearers might become complacent, a worry they never seem to have about hand-washers.)

Hand hygiene is mostly individual and profoundly low-tech, so it has trouble getting as much attention as it deserves. The U.S. Senate has just proposed to spend $3.9 billion on pandemic preparedness improvements, most of it on vaccines and antivirals. I somehow doubt there’s money in the budget to retrofit restroom sinks so you don’t have to touch the faucet when you turn off the water, or restroom doors so you don’t have to touch the doorknob as you leave. (Many restroom faucets and doors at HHS headquarters in Washington and WHO headquarters in Geneva don’t meet this elementary hygiene standard.)

The distinction between medical and non-medical preparedness bears on the recent WHO spat over mortality figures. This Numbers Game has a long history; Jody and I wrote about earlier installments at length. The most recent installment came when Nabarro blurted out his 150 million figure during a news conference at U.N. headquarters in New York, his first public appearance after being appointed to his new pandemic coordinator job. In Geneva the next day, WHO spokesman Dick Thompson did damage control. As Emma Ross’s Associated Press story put it:

WHO’s flu spokesman at the agency’s Geneva headquarters made a surprise appearance Friday at the UN regular media briefing in an effort to put Nabarro’s comments in context. While he did not say the 150 million prediction was wrong, or even implausible, he reiterated that WHO considers a maximum death toll of 7.4 million a more reasoned forecast….

“We’re not going to know how lethal the next pandemic is going to be until the pandemic begins,” said WHO influenza spokesman Dick Thompson.

“You could pick almost any number” until then, he said, adding that WHO “can’t be dragged into further scaremongering.”

Thompson went on to explain that most WHO officials prefer the mortality estimate of 2–7.4 million – based on modeling the mild 1957 and 1968 pandemics – because a mild pandemic is statistically likelier than a 1918-style pandemic, which was apparently a one-off event. Since most of the world’s countries can barely afford to gear up for a mild pandemic, why dispirit them with worst case estimates based on the 1918 disaster? “There is a limited amount of public health money available to countries and we have to give them the best guidance on how to spend that money,” he said.

Thompson’s point makes real sense for medical planning – but not for non-medical planning. The right estimate for a poor country to use in medical planning is probably the 2-7.4 million estimate of how many a mild pandemic might kill. Only the wealthiest countries can afford to consider trying to have a medical response to a severe pandemic. But every country needs to consider its non-medical response to a severe pandemic. For non-medical preparedness, Nabarro’s 150 million – or even Michael Osterholm’s 360 million – is a better planning number. These are numbers that force us to think about how we will keep our societies functioning, so infrastructure failures do not kill people the influenza virus spared.

6. Focus more on non-governmental and local preparedness.

It takes a national government to reconfigure vaccine manufacturing or build a strategic national stockpile of antiviral medications. But most non-medical preparedness doesn’t necessarily involve the national government at all, except perhaps for advice and information-sharing:

• Manufacturers and service providers can rethink their inventory control procedures. What will they be able to provide for themselves if their usual supplier can no longer make it or ship it? What can they do without in a pinch? What do they need to stockpile?
• Every organization can rethink its staffing needs. How can we get essential tasks done despite soaring absenteeism? What sorts of cross-training now might save the day later?
• Every organization can rethink its social contact needs. Infectious disease transmission is a function of the number of social contacts – keeping people home more means keeping more of them alive. What jobs can shift to telecommuting? How can we educate children without making them come to school? How can we distribute food without making people come to the supermarket or the soup kitchen? Should we redefine “delivery person” as an essential job that qualifies for prophylactic antivirals?
• Nonprofits can start planning to coordinate volunteers. Like any emergency, a pandemic will yield huge numbers of people who want to do something to help – including many who contracted pandemic influenza and survived, and are therefore immune. Who is going to sort them out and get them where they’re needed most, doing high-risk jobs that don’t require special skills (washing linens at the hospital, for example, or making deliveries to people sick at home)?
• Local governments can ask themselves hard questions about leadership and survival. How will they keep essential services (police, fire, water and sewerage) operating? What inessential sources of infection (movie theaters and restaurants, for example) will they want to shut down? Where will they put the bodies when the morgues are full? How will they maintain order?
• What’s left for individuals to do? Inculcate hand hygiene habits now. Figure out how you’ll take care of a sick family member without getting everyone else sick. Stockpile what you’ll need so you don’t need to go out so much. Ask your doctor for a prescription for Tamiflu or Relenza … and fill it fast, before the drugstores run out. (Admittedly, this is a zero-sum game by now.) Above all, push every organization you’re tied to – your church, your employer, your club, your children’s school – to start its own pandemic planning process.

A revised U.S. pandemic preparedness plan is due to be released any day now. According to Michael Osterholm, who reviewed it in draft, one important way the new plan differs from its predecessor is its focus on non-governmental and local preparedness – including non-medical preparedness. In an October 9 story entitled “Flu Plan Leaves Many Decisions at Local Level,” the Washington Post reports:

“There have been tremendous improvements in the plan even over the last week to 10 days,” Osterholm said. In particular, he said, the most recent version emphasizes the likely prolonged effects of a flu pandemic and the need for unprecedented cooperation between the government and the business sector for more than a year….

“Basically, cities and states are going to have to shoulder a lot of this burden of response on their own. There is no other choice. When you have all 50 states, every major city, every county and every hospital in crisis – the federal government can’t address all of that,” Osterholm said. “Every place is going to need resources and expertise at the same time, and in fact every country in the world is going to need those things.”

In describing what Osterholm called “the upper bounds of what a pandemic could look like,” the plan describes potential shortages of medicines for non-influenza illnesses, disruptions in the delivery of food and conceivably a lack of caskets and crematorium space.

It’s very good news that the U.S. government’s plan is trending in these directions. The U.S. government’s rhetoric is just beginning to do likewise. Too many government statements still imply that Washington will save us all. So why should the local hospital, supermarket, water treatment plant, or family think about ways to get ready?

But Leavitt seems to be consciously changing his department’s tune. On October 7 he told The New York Times that flu planning “will require school districts to have a plan on how they will deal with school opening and closing” and “the mayor to have a plan on whether or not they’re going to ask the theaters not to have a movie.” Over the next couple of months, he said, “you will see a great deal of activity asking metropolitan areas, ‘Are you ready?’ If not, here is what must be done.”

It’s not either/or. My snippy references to “the pharmaceutical fix” notwithstanding, the vaccine manufacturing system does need fixing, and fixing it is probably the best long-term influenza-fighting investment the national government can make. By all means let the feds work on the levees. But the flood may come before the levees are strengthened. The rest of us should be preparing for the flood.

7. Focus more on worldwide preparedness.

Vaccines and antiviral drugs are fairly slow and difficult to manufacture. Given the very limited manufacturing capacity, many experts doubt whether there will ever be enough of either to meet the pandemic needs of the United States and the other western countries. Nobody even pretends there will ever be enough to meet the needs of the rest of the world. For Africa, Latin America, and much of Asia, the pharmaceutical fix is a delusion. There’s one possible exception: statins. Virologist Robert Webster has pointed out that statin drugs, widely used to fight cholesterol, are also anti-inflammatory. He says there is some evidence they might work against flu, possibly including H5N1. And lots of statins are off-patent and cheap. But when we think about pandemic preparedness in terms of vaccines and antivirals, we’re thinking about the West.

Does the West care about the rest of the world?

Right now there is enormous worldwide interest in Southeast Asia. That’s not because Southeast Asians will be any more vulnerable in a pandemic than the rest of the world’s population. And it’s not because the world cares more about the health of Southeast Asians. It’s because so far that’s where most of the sick birds and all of the sick people have been. That’s where an H5N1 pandemic is likeliest to start. So that’s where the West will have its only chance of nipping the pandemic in the bud. Sure we’d like to help Southeast Asia if we can. But mostly we need Southeast Asia to help us.

And so the U.S. State Department hosted a bird flu meeting of 65 countries last week, mostly to talk about surveillance and transparency. And as I write this, U.S. Secretary of Health and Human Services Michael Leavitt is in Southeast Asia for a series of meetings with health ministers.

The key questions: Will the government of Vietnam, Thailand, Cambodia, or Indonesia know promptly if it encounters a cluster of bird flu victims, suggesting that the virus may be acquiring the knack for h2h transmission? Will it tell us what it knows? Will it tell us when it’s not sure yet, just suspicious? Above all, will it let us take our own blood samples? (That’s not just because we trust our labs more than their labs. It’s mostly because we need a blood sample to start tailoring a vaccine to the newly mutated virus.) When you’re done asking these questions about Vietnam, Thailand, Cambodia, and Indonesia, ask them about China. Ask them about Myanmar. And ask yourself how cooperative you think the United States government would be if the positions were reversed – if some other country wanted access to a U.S. patient’s blood in order to develop a vaccine that U.S. citizens were unlikely ever to be able to afford … or even offered a chance to buy.

There should be room for a quid pro quo here. Some biotechnology companies pay royalties to indigenous peoples when the company develops a marketable medication or other product from a local organism’s genome. An Asian commitment to report early and provide blood samples quickly deserves a reciprocal western commitment to provide vaccine doses. (Of course, then the Asian countries would be in the same predicament that some western countries may end up in: having some vaccine but not enough for everyone. A health ministry official from a country that is H5N1-free so far recently said it might be politically better to have no vaccine than to have just a small amount. She was optimizing for political stability, not for lives saved from flu.)

If international cooperation is possible on any issue, it ought to be possible on pandemic preparedness. When it comes to infectious diseases with pandemic potential, we truly are one world.

One possibility that both the U.S. and the World Health Organization are vigorously pursuing is ring-fencing – surrounding an outbreak while it is small and “smothering” it with antiviral drugs before it has a chance to spread. (Ring-fencing has never been tried for influenza; there were no antiviral drugs in existence during the last flu pandemic.) As Health Secretary Leavitt put it on October 9, “if it happens in Thailand or Laos or Cambodia, the rest of the world can go there and help them contain it. Containment is our first strategy.” The quid pro quo here is fairly clear. Southeast Asia improves surveillance and transparency, so ring-fencing has a chance. The West contributes expertise and antivirals. It’s a long shot, but if it works it could save millions of Asian lives as well as millions of western lives. Not to try would be crazy.

A number of western countries, including the U.S., are already sending other expertise to Southeast Asia, on topics ranging from epidemiology to veterinary medicine to risk communication. Every contact between a person and an H5N1-infected bird is another opportunity for the virus to mutate. Figuring out how to change animal handling practices to reduce the number of such contacts is common sense, good for everyone. Figuring out how to convince Asian poultry farmers and their neighbors to follow the recommended protocols is tougher, but obviously a key part of the job.

Ring-fencing and veterinary improvements are both about pandemic prevention. Where there has been almost no action so far, as far as I know, is international pandemic preparedness. Suppose prevention fails and we end up facing a severe pandemic, a rerun of 1918? What can we do together now to make that eventuality less horrific for us all? What are our chances, for example, of working out a way to keep travel and transport operating? (Our experts will tell us that quarantines are hopeless and pointless beyond the very earliest phases of pandemic spread; our intuitions and politics will tell us to try anyhow.) What are our chances of coming up with humane ways to address the inevitable border tensions when people start trying to flee from places where the virus is hot to places where, at the moment, it is not? What can the world’s richest countries do to make it possible for the poorer countries to better survive the catastrophe?

8. Get clear on the “pan” in “pandemic.”

Most emergencies are local. Tsunamis, earthquakes, hurricanes, wars, famines, and terrorist attacks all happen where they happen. The rest of us ignore them or look on in horror or try to help.

Pandemics are unique. They happen everywhere, more or less at once.

Wherever and whenever an influenza pandemic starts, it will spread pretty quickly. So far there is no pandemic virus. H5N1 is an avian influenza virus – a flu virus in birds – that is spreading very successfully within the bird population. It has managed to pass from a bird to a person fewer than 200 times we know about, and from a person to another person only two or three times we know about. That’s why we don’t have a human pandemic yet. If and when the virus changes so it can pass easily from person to person, it will qualify as an outbreak. If surveillance procedures catch a local outbreak with pandemic potential quickly enough, there is a slim chance it might be encircled and eradicated before it spreads. The chance is slim because surveillance and early reporting are imperfect, and because people are infectious before they feel sick; they get on buses and airplanes while they’re unknowingly incubating the disease. So odds are it will spread. When it starts infecting people across a wide area, we’ll call it an epidemic. When it starts infecting people everywhere, it will be a pandemic. ( “Pan–” is the Greek root meaning “all.”)

If the next pandemic follows the pattern of most past flu pandemics, it will last a year, maybe two. It will come in waves. An area will be “hot” for a few weeks or months, then there will be a period of relative calm, then another wave. The first wave has often been milder than the second or third.

Here’s the paradox: Because a pandemic is worldwide, it is intensely local. There is nobody “outside” the pandemic to send help. Every community is pretty much on its own.

Many people don’t understand that yet. You hear people talking about how they’ve got a pandemic over in Asia somewhere, but not here. You hear earnest discussions about why one part of the world is more vulnerable to pandemics than another. You “hear” the unspoken assumption that if the worst happens help will come pouring in, just as it poured into New Orleans after Hurricane Katrina.

Consider this October 6 Associated Press story out of Maryland, headlined “Farmers Call Avian Flu Safeguards Adequate”:

Eastern Shore poultry farmers pleaded for calm this week after President Bush said he’s growing more concerned about avian flu possibly spreading to people. Farmers and state officials say current safeguards are adequate to prevent a pandemic of the disease in humans.

“There’s reason for concern, of course, and it’s not something we should ignore, but I don’t think it poses a great threat in this country. We’re ahead of the curve,” said farmer Doug Green, who raises 100,000 broilers in Princess Anne.

Scientists say it’s only a matter of time before a worldwide influenza outbreak. Concern is rising it could be triggered by the avian flu called H5N1….

But poultry farmers said the nation is safe, for now, from a deadly outbreak in people. The strain of bird flu that sickened humans in Asia has not been discovered in the U.S.

A spokeswoman for Salisbury-based Perdue Farms Inc. said American farmers are far better suited than Asian farmers to contain bird flu before it spreads to people….

In Delaware, where poultry is the top agricultural product, state officials say their safeguards are adequate.

“We’re ready. We’re confident we can respond,” said Anne Fitzgerald, spokeswoman for the Delaware Department of Agriculture.

Psychology and risk communication teach that people resist taking on new worries by concocting rationales for believing they’re less at risk than others. Neil Weinstein coined the label “unrealistic optimism” for this universal phenomenon. I remember working with Neil on radon warning messages back in the 1980s. We tried to tell New Jersey homeowners that they should test their homes for radon gas, a natural byproduct of uranium in the soil that could pose a serious risk of lung cancer. Person after person explained that they understood the risk was serious for other people. But “my house” is at the top of a hill, or at the bottom of a hill, or old, or new, or well-insulated, or well-ventilated … so “I’m not at risk.” (My favorites were the people who had learned that radon tends to accumulate in the basement. Since they had no basement, they figured they were safe – as if their radon weren’t accumulating in the living room instead.)

Resistance to pandemic warning messages will take various forms. But one of them is sure to be this one: The bird flu pandemic won’t get here because our birds are clean.

9. Get clear on the “pre” – and the “maybe” – in pandemic preparedness.

Right now, your risk of contracting bird flu is very close to zero. Unless you’re in the poultry business in Asia, you simply have no contact with the H5N1 virus. And as far as we know, your current risk of contracting pandemic influenza is exactly zero; there is no pandemic today. To reiterate: Very few cases of avian influenza have occurred in people, ever. And the last influenza pandemic was in 1968.

Your risk of contracting pandemic influenza will stay at zero until some flu virus that our bodies haven’t encountered before – H5N1 or a different strain – starts spreading efficiently from human to human. Then, quickly, your risk will become sizable.

What is the probability of that happening? Nobody knows. Some experts think it would have happened already if it were going to happen at all. Others – among them David Nabarro and Michael Osterholm – say they’re almost certain it’s coming soon. Most are in the middle somewhere. Flu pandemics occur roughly three times a century, so in a perfectly ordinary year there’s about a three percent chance of a pandemic, mild or severe as the flu gods dictate. But the course of H5N1 since 1997 has presumably raised the odds of a pandemic, and many think it has raised the odds (to an unknown and unprovable extent) that if a pandemic does come it will be a severe one. Some officials in the U.S., Australia, and elsewhere are throwing around a pandemic probability estimate of ten percent. There’s no science behind the number, and usually no time frame given when it’s used. But it does capture most experts’ sense that a pandemic is much likelier than in the average year, though far from a sure thing.

Does that ten percent guess make you want to take precautions, or does it make you think the whole issue is overblown? Consider the question this way. What probability of your house burning down would you accept before you decided it was worthwhile to buy fire insurance? What probability of heart disease would you accept before you decided it made sense to change your diet and get a periodic electrocardiogram? What probability of getting in an auto wreck would you accept before you decided to wear a seatbelt? Would ten percent do the trick in these other cases? And if another year goes by and your house, your heart, and your car are all intact, does that mean you should stop taking precautions?

Preparedness and precaution-taking are about hedging your bets. You always hope the bad thing won’t happen; you usually think it probably won’t happen. But just in case it does, you take steps to reduce your risk. This is a profoundly sensible but somewhat unnatural thing to do. The natural thing to do is to notice (rightly) that everything’s fine so far, then to figure (again rightly) that everything will probably turn out okay anyway, then to deduce (wrongly) that there’s no reason to worry, so chill out.

In a thoroughly typical example, Fox channel WAWS in Jacksonville, Florida reported on October 7 that “while officials are concerned” about an influenza pandemic, “many area residents are not, saying it’s just too early to panic.” The story explains: ”Most aren’t worried because the CDC says there’s a low risk of catching Avian Influenza since it’s difficult to pass to humans.” It quotes a local physician, Dr. Ken Hitz, on ways to protect against the flu, but notes that “many of Dr. Hitz’s patients are not worried about a flu a world away, and say the whole thing’s been blown out of proportion.”

Leave aside the implication that worrying and panicking are pretty much the same activity. What this passage most clearly demonstrates is the weird but widespread notion that there is no reason to protect against a risk until the risk is on your doorstep. Don’t take precautions or get yourself prepared if nothing has gone wrong yet. Certainly don’t take precautions or get yourself prepared if the odds are good nothing’s going to go wrong. The story neglects the “pre” and the “maybe” in pandemic preparedness.

These errors are mainstays of human psychology, and of mainstream journalism as well. An October 6 Reuters story out of Washington was headlined “U.S. Sends Mixed Message on Bird Flu Threat.” Here’s how the story starts:

WASHINGTON, Oct 6 (Reuters) – The U.S. administration sent mixed signals on the threat from bird flu on Thursday, with President George W. Bush urging mass production of vaccines while his health secretary played down the risk of a pandemic.

All officials conceded the United States was unprepared for a possible pandemic, and pointed to a number of meetings being held this week to confront the problem….

The head of the U.S. Centers for Disease Control and Prevention has said an influenza pandemic that could kill millions is certain and may be imminent.

However U.S. Health and Human Services Secretary Michael Leavitt, while urging preparations for a possible outbreak, said the risk was relatively low and a pandemic probably would not happen.

”The probability that we’ll have a pandemic flu is unknown,” Leavitt said at a Washington health technology conference. “I will tell you from all I hear from scientists and physicians it is relatively low, but it is not zero.”

The risk is high enough that the United States should be prepared, he added. And it is not…..

“H5N1 may happen, but it probably won’t. If it does we need to be better prepared.”

There is no mixed message here. Some experts would dispute Leavitt’s claim that the risk of a pandemic is “relatively low,” but none would disagree that even a relatively low risk of killing hundreds of millions of people in a next few years justifies precautions and preparedness.

Risk communicators should not have to claim a threat is guaranteed and imminent in order to urge people to take protective action. Greenpeace should not have had to claim that a global warming catastrophe was just around the corner to get us focused seriously on greenhouse gases. President Bush should not have had to claim that Saddam Hussein already had weapons of mass destruction to get us thinking seriously about Iraq. Meteorologists should not have had to promise a Category Five hurricane in New Orleans to get us moving on levee improvements.

Preparedness isn’t about things that are already happening. And preparedness is only rarely about things that are sure to happen. Preparedness is mostly about things that might – or might not – happen.

A severe H5N1 influenza pandemic might – or might not – happen. We hope it won’t. We need to get better prepared, now, in case it does. That’s not a mixed message. It’s the right message.

Copyright © 2005 by Peter M. Sandman

Contact information page:    Peter M. Sandman