Given the administration's record, it is no surprise that cries of alarm are met with skepticism. Thus, when President Bush finally acknowledged the risk of an avian flu pandemic and proposed strategies to deal with it, a certain amount of skepticism is appropriate. However, misjudging the extent and nature of the threat can lead to bad policies and these poor judgments can be a serious menace. Progressives must be careful not to let their skepticism about this administration and its actions obscure their ability to perceive real risks.
Unfortunately, a recent article by ZNet commentary by Lucinda Marshall [The Ultimate Chicken Joke] illustrates the danger. Marshall makes four points: 1) the occurrence of a pandemic is uncertain; 2) the main treatment option, Tamiflu, has unknown efficacy; 3) vaccines under development are just that, under development, and thus of unknown efficacy; and 4) pharmaceutical companies stand to gain a lot of money from stockpiling Tamiflu and Vaccines. She therefore concludes that the threat of avian flu is largely bogus and is being hyped by the administration to channel money to these companies. Let's examine these claims.
Assessing the Danger
Marshall is, of course, correct that the occurrence of a pandemic is far from certain. But she incorrectly minimizes the risk. She cites a Congressional Budget Office report as stating that the probability is only "one third of one percent." She neglects to tell the reader that this estimate is just the historical rate of a severe influenza pandemic [the report uses the phrase "based only on historical frequencies" to describe the basis for this estimate], and is not based on any estimate of the likelihood that H5N1, the current avian flu virus, will spawn a human pandemic. Marshall neglects to mention that the report also states that, based on history, "there is a roughly 3 percent to 4 percent probability of a pandemic occurring in any given year" (p. 5). The difference is between a mild pandemic (causing perhaps a hundred thousand American deaths) and a severe pandemic, with many more victims. The report also states, immediately after the 0.3 percent estimate, that "given the evidence of an existing epidemic of H5N1 in fowl, and the possibility that it might mutate to circulate efficiently in humans, the probability may exceed the historical frequency" (p. 6). If a severe avian flu pandemic occurs, the report estimates that 2 million Americans will die, whereas a mild pandemic (a much more likely event) will cause 100,000 deaths. Of course, many times that would die worldwide under either scenario.
Others, including the World Health Organization and many other scientists and public health organizations are also warning of an avian flu pandemic. Thus the WHO states on the avian flu FAQ "the risk of pandemic influenza is serious". As another of myriad examples, the mainstream Australian Lowy Institute estimates that, under a worst case avian flu pandemic scenario, 143 million people would die worldwide while a mild pandemic would result in 1.4 million deaths.
Additionally, many progressives who have examined the issue also warn of the threat from avian flu. Thus, Laurie Garrett, author of the award-winning Betrayal of Trust: The Collapse of Global Public Health, expressed her concern in the title of a recent article: Unless We Act Now, Bird Flu May Win [for a critique of Garrett's strategy to prevent this occurring, see Wherein I disagree with Laurie Garrett]. And Mike Davis, surely no friend of big pharma, expresses his view in the title to his 2005 book: The Monster at Our Door: The Global Threat of Avian Flu; Davis, in fact, believes that a pandemic is largely inevitable and will occur soon. As he states in a recent article: "'Several years' is a luxury that Washington has already squandered. The best guess, as the geese head west and south, is that we have almost run out of time" 6. Further, the authors of the progressive public health blog Effect Measure [http://effectmeasure.blogspot.com/] are quite concerned about the threat facing the human race from avian flu in the next several months or years. While these progressive authors disagree among themselves as to the degree of risk and what approaches should best be used to respond to the risk, they agree that there is considerable danger, danger that warrants major efforts now to avoid the worst.
It is important to realize that deaths (mortality in epidemiological lingo) is not the only major risk from avian flu. Even a mild pandemic could cause massive economic costs and dislocation, and a major pandemic could be economically catastrophic. Imagine what would happen if significant numbers of truck drivers or those who stock grocery stores were to become ill, or if panic, or just sensible public health policy, leads huge numbers of economically important personnel to stay away from work.
The Lowy Institute, in their report Global Macroeconomic Consequences of Pandemic Influenza, examine the economic impacts of an influenza pandemic under different scenarios. They estimate that a mild pandemic [similar to that which occurred in 1968-69, the mildest influenza pandemic of the 20th century] would cost the world $330 billion. In contrast, the worst-case scenario they investigate would result in a net loss of $4.4 trillion to the global GDP, a whopping decline of 12.6% in world GDP (this in addition to the 143 million deaths they estimate would result).
Also important to note is that the Lowy Institute analysis shows that the economic losses would be disproportionately borne by the developing countries. They predict that a pandemic would result in "a major shift of global capital from the affected economies to the less affected safe haven economies of North America and Europe" (p. 26).
It should also be noted that avian flu will have major economic impacts even if it never becomes a human pandemic. Just coping with the now inevitable world-wide spread in birds of avian flu will not be cheap. The World Health Organization estimates that, already, the infection has cost the world's farmers $10 billion and that 300 million farmers have been affected. As the disease spreads among birds, these costs will inevitably rise significantly.
Marshall is correct that there are serious reservations about the efficacy of Tamiflu for avian flu. In the last couple of months, a few avian flu patients have unsuccessfully been treated with the drug, leading to belief that Tamiflu-resistant strains of the H5N1 virus are developing, potentially reducing the effectiveness of the drug should a pandemic occur. It should also be pointed out that these reports appeared after the President's plan to stockpile Tamiflu was prepared. There does appear to be another drug, Relenza, which (according to the December 22, 2005 New England Journal of Medicine) is less likely to facilitate the development of resistant influenza strains. Relenza, however, is currently only available in an inhaled form which can make administration more difficult.
I am not an expert on drug treatment of influenza. However, given the potential devastation that a pandemic would cause, stockpiling a drug that might have some effectiveness is not irrational. If a pandemic breaks out, there is a danger that many vital systems, such as out health and food distribution systems could experience severe strain as workers get sick or stay home to care for sick family members. A drug of only limited effectiveness might make the difference between strain and collapse of those systems.
Marshall's conspiracy view of Tamiflu stockpiling does not explain why many other countries are taking similar steps, or why the World Health Organization is recommending the development of Tamiflu stockpiles 3. In fact, the world capacity to produce Tamiflu is severely limited, so that the US, having started planning late, will probably not be able to get much of its desired stock of the drug. Roche, the manufacturer of Tamiflu, will not need President Bush's help to sell all the Tamiflu they can manufacture in the foreseeable future. The manufacturer of Relenza, GlaxoSmithKline, has recently announced plans to increase production of the drug. No doubt, they also will not need the Bush administration's help in selling all they can manufacture in the foreseeable future.