Avian influenza is a viral asteroid on a collision course with humanity. Since the horrific autumn of 1918, when a novel influenza killed more than 2 percent of humanity in a few months, scientists have dreaded the reappearance of a wild flu strain totally new to the human immune system.
The flu subtype known as H5N1, which claimed its first victims in Hong Kong in 1997, is that nightmare come true. Now endemic in waterfowl and poultry throughout East Asia, it is the most lethal strain of influenza ever seen, killing chickens, people and even tigers with terrifying ease.
Although avian flu officially has taken fewer than 100 human lives so far (mainly farmers and their children in daily contact with poultry), most experts believe that H5N1 is on the verge of acquiring the new genes or amino acids that would enable it to travel at pandemic velocity across a densely urbanized world, with the potential, warns the World Health Organization, to cause 20 million deaths.
Since early spring, moreover, all the biological weather vanes have been pointing in the direction of imminent pandemic. In Vietnam the virus has suddenly increased its transmissibility, with several likely human-to-human cases. In China, where officials now admit that more than 1,000 migratory birds have died, there are unofficial Internet reports–strongly denied by Beijing–of 120 related human fatalities. In an unprecedented collaboration to sound the tocsin, Nature and Foreign Affairs have recently devoted special issues to the “plausible scenario” of a pandemic that kills millions and wrecks the global economy.
Governments have had ample warning, unlike the surprise of HIV/AIDS, that a new plague is coming. Indeed, Washington has had almost nine years to heed the advice of top influenza experts and mobilize the nation’s resources to battle H5N1 in Asia and at home. The Bush Administration’s failure to do so makes “homeland security” into a sick joke whose punch line may be a repetition of the 1918 catastrophe.
This past December 3, Secretary of Health and Human Services (HHS) Tommy Thompson held a press conference to announce his resignation. His tenure ended with a note of frankness rare in the Bush era. Unlike the previous seven Cabinet members purged in the President’s postelection housecleaning, Thompson, according to the New York Times, “gave candid, unexpected answers to questions posed to him.” Asked what worried him most, Thompson cited the threat of a human flu pandemic. “This is a really huge bomb that could adversely impact on the healthcare of the world,” killing 30 million to 70 million people, he said.
The Secretary, of course, spoke with the authority of someone with access to the best medical intelligence in the world, but reporters were undoubtedly surprised that Thompson was so alarmed about a peril that his department, with its $543 billion annual budget–a quarter of the federal total–had done so little to address. In the 2005 fiscal year, for example, Thompson had allocated more funds to “abstinence education” than to the development of an avian influenza vaccine that might save millions of lives. This is but one example of the way that all Americans, but especially children, the elderly and the uninsured, have been placed in harm’s way by the Bush regime’s bizarre skewing of public-health priorities. On Thompson’s watch, HHS and the Pentagon spent more than $12 billion to safeguard national security against largely hypothetical threats like smallpox and anthrax, even as they pursued a penny-pinching strategy to deal with the most dangerous and likely “bioterrorist”: avian influenza. The Administration’s lackadaisical response to the pandemic threat (despite Secretary Thompson’s personal anxiety) is only the tip of the iceberg. Over the past generation, writes Lancet editor Richard Horton, “the U.S. public-health system has been slowly and quietly falling apart.”
Under Democrats as well as Republicans, Washington has looked the other way as local health departments have lost funding and crucial hospital “surge capacity” has been eroded in the wake of the HMO revolution. The government has also refused to address the growing lack of new vaccines and antibiotics caused by the pharmaceutical industry’s withdrawal from sectors it considers to be insufficiently profitable; moreover, revolutionary breakthroughs in vaccine design and manufacturing technology have languished because of lack of sponsorship by either the government or the drug industry.
In October 2000 the GAO scolded HHS for making so little progress in the development of an avian flu vaccine. It warned that the United States might have only a month (or less) of warning before a pandemic became widespread, and it accused HHS of failing to develop contingency plans to insure expanded vaccine-manufacturing capacity. It also pointed to a major contradiction in business-as-usual reliance on the private sector: “Because no market exists for vaccine after [flu season], manufacturers switch their capacity to other uses between about mid-August and December.” At minimum, HHS needed to find some way to keep production lines running full time, all year long, as well as diversify the number of companies committed to vaccine production. In addition, the GAO chided HHS for dithering over whether to stockpile antivirals, even as top influenza experts were begging the government to procure as much oseltamivir (Tamiflu)–the most potent antiviral medicine for avian flu now available–as possible. Finally, the audit faulted HHS for poor coordination of the respective roles of the federal government, state agencies and private manufacturers. Almost eight years of “process,” the GAO report implied, had failed to achieve a “plan” in any substantive or meaningful sense.
All the flaws in HHS’s influenza program (particularly the lack of an antiviral stockpile and adequate vaccine-manufacturing capacity), were inherited by Thompson, the former governor of Wisconsin, described as a “a straight shooter” by Edward Kennedy. The Clinton Administration’s handling of public-health issues had certainly been disappointing, but the incoming Bush Administration was frightening to everyone who had been fighting to prevent the total meltdown of urban public health. Then, in September 2001, a new dispensation suddenly arrived in the form of poisoned letters contaminated with “weaponized” anthrax. DNA sequencing would later reveal that the anthrax strain used in the attacks probably originated from the Army’s own laboratory at Fort Detrick, Maryland, yet this probable “inside job” became the principal justification for national hysteria about the threat of “bioterrorism” supposedly posed by Iraq, Al Qaeda and other alien enemies of the United States.
With shockingly little debate and without any real evidence that such a threat even existed, most public-health advocacy groups, as well as such leading Democrats as John Edwards and Ted Kennedy, became ardent shareholders in the bioterrorism myth. Even the liberal Trust for America’s Health glibly talked of an “Age of Bioterrorism,” as if malevolent hands were already opening little vials of botulism and ebola on Main Street. In fact, the irresistible attraction of the so-called health/security nexus was the billions that the White House was proposing to spend on Project Bioshield, Bush’s “major research and production effort to guard our people against bioterrorism.” Many well-meaning people undoubtedly reasoned that, however farfetched the excuse, the Republicans were finally throwing money in a worthwhile direction and that some of the windfall would surely find its way to real needs after decades of neglect. Because the defensive preparations against bioterrorism borrowed heavily from pandemic planning, there was hope that influenza (previously shortchanged in the design of the National Pharmaceutical Stockpile in 1999) would be accorded its proper rank as a “most wanted” bioterrorist weapon.
Certainly the leading influenza researchers, from the first H5N1 outbreak in 1997, have been doing their utmost to alert medical colleagues worldwide to the urgent threat of avian flu, as well as outlining the immediate steps the Bush Administration and other governments needed to take. As befitted his position as “pope” of influenza researchers, Robert Webster of Saint Jude Hospital in Memphis tirelessly preached the same sermon: “If a pandemic happened today, hospital facilities would be overwhelmed and understaffed because many medical personnel would be afflicted with the disease. Vaccine production would be slow because many drug-company employees would also be victims. Critical community services would be immobilized. Reserves of existing vaccines, M2 inhibitors and NA inhibitors would be quickly depleted, leaving most people vulnerable to infection.”
Webster stressed the particular urgency of increasing the production and stockpiling of the NA inhibitor Tamiflu. Because this strategic antiviral was “in woefully short supply”–it is made by Roche at a single factory in Switzerland–Webster and his colleagues underlined the need for resolute government action: “The cost of making the drugs, as opposed to the price the pharmaceutical companies charge consumers, would not be exorbitant. Such expenditure by governments would be a very worthwhile investment in the defense against this debilitating and often deadly virus.” Failure to act would mean intense competition over the small inventory of life-saving Tamiflu. “Who should get these drugs?” Webster asked. “Healthcare workers and those in essential services, obviously, but who would identify those? There would not be nearly enough for those who needed them in the developed world, let alone the rest of the world’s population.”
Webster wasn’t calling for miracles, just prudent action to insure an adequate antiviral stockpile. But for almost three years he and other influenza experts were ignored, as were those who argued more generally that “the best way to manage bioterrorism is to improve the management of existing public-health threats.” The Bush Administration instead fast-tracked vaccination programs for smallpox and anthrax, based on fanciful scenarios that might have embarrassed Tom Clancy. In reality, the biodefense boom was designed to build support for the invasion of Iraq by sowing the fear that Saddam Hussein might use germ warfare against the United States. In any event, Washington spent $1 billion expanding a smallpox vaccine stockpile that some experts claim was already quite sufficient. Hundreds of thousands of GIs were forced to undergo the vaccinations, but front-line health workers–the second tier of the smallpox campaign–largely boycotted the Administration’s attempts to cajole “voluntary” participation.
In spite of this fiasco and millions of doses of unused vaccine, the Administration pressed ahead with the development of second-generation smallpox and anthrax vaccines, as well as vaccines for such exotic plagues as ebola fever; it continued to reject the “all hazards” strategy recommended by most public-health experts in favor of a so-called “siloed approach” that focused on a short list of possible bioweapons. In testimony before the House of Representatives, Tommy Thompson explained that while “private investment should drive the development of most medical products,” only the government was in a position to develop those products that “everyone hopes…will never be needed” as a protection against “rare yet deadly threats.” The government, in other words, was willing to spend lots of money on biological threats that were unlikely or farfetched but not on antivirals or new antibiotics for the diseases that were actually most menacing, like avian flu.
As biodefense morphed into the biggest show in town (growing from $1 billion in fiscal 2002 to more than $5 billion in fiscal 2004), Thompson’s perverse logic soon had perverse impacts that confounded the hopes of the biodefense boom’s early enthusiasts. For example, instead of spurring a welcome trickle-down of money for research on big killers like influenza, malaria and tuberculosis, biodefense projects stole top laboratory talent away from major disease research. With the National Institutes of Health’s research budget barely keeping pace with inflation (after its banquet days under Clinton), there was an irresistible tropism of researchers and research projects toward biodefense windfalls. Reporting on this new “brain drain,” writer Merrill Goozner cited the case of a leading UCLA lab that phased out its “basic science research on TB in favor of studying tularemia [rabbit fever]”–a disease that has zero public-health importance–because the latter infection was “on the government’s A-list of potential bioterrorism agents” and tuberculosis wasn’t. (After workers at a different lab accidentally infected themselves with tularemia, some scientists expressed concern to the New York Times that “leaky” biodefense research may pose a menace to public health comparable to the still uncertain threat from bioterrorism.)
To many infectious-disease experts, Project Bioshield was Bush and Thompson’s version of Alice’s Adventures in Wonderland: with priorities established in inverse relation to actual probabilities of attack or outbreak. “It’s too bad that Saddam Hussein’s not behind influenza,” complained Dr. Paul Offit, a dissident member of the government’s advisory panel on vaccination. “We’d be doing a better job.” Indeed, HHS’s zeal to combat hypothetical bioterrorism contrasts with its incredible negligence in exercising oversight of the nation’s “fragile” influenza vaccine supply. As the GAO had warned Clinton’s HHS Secretary Donna Shalala, vaccine availability in a pandemic would depend on the stability and surge capacity of existing production lines. But as shocked Americans discovered in the winter of 2003-04 and again in early fall 2004, the entire vaccine manufacturing system had decayed almost to the point of collapse. While Bush and Thompson were trying to bribe the pharmaceutical industry to join Project Bioshield, the same industry was abdicating its elementary responsibility to maintain a lifeline of new vaccines and antibiotics. Products that actually cure or prevent disease, like vaccines and antibiotics, are less profitable, so infectious disease has largely become an orphan market. As industry analysts point out, worldwide sales for all vaccines produce less revenue than Pfizer’s income from a single anticholesterol medication.
Thompson’s successor, Mike Leavitt, has repeatedly reassured Congress and the public that the pandemic danger has the Administration’s full attention and that he is receiving daily briefings on the worrisome situation in Asia. But in an extraordinary lecture at Harvard on June 1, Senate majority leader Bill Frist painted an apocalyptic picture of the chaos, even societal breakdown, that would ensue from our current lack of resources to deal with an avian flu or smallpox outbreak: “Hospitals and our long neglected public-health infrastructure would be quickly overwhelmed. In such a circumstance, panic, suffering and the spread of the disease would intensify…. Millions might perish, with whole families dying and no one to memorialize them.” The Tennessee Republican, who long boasted of being the only doctor in the Senate, also blasted the government’s failure to purchase an adequate stockpile of Tamiflu. “To acquire more antiviral agent, we would need to get in line behind Britain and France and Canada and others who have tens of millions of doses on order.”
Without reference to billions already wasted, Frist proposed an urgent new Manhattan Project to protect the nation against avian flu and other infectious diseases and bioterrorist agents. From the heights of the Republican leadership it is hard to imagine a more devastating admission of the Administration’s dereliction of duty to the health of the nation and the world.