We’re living on borrowed time.
The Year of the Rooster, 2005, began with several more flu deaths in Vietnam. In two cases, the virus was contracted from eating raw duck blood pudding, a local delicacy savoured on ceremonial occasions. Tests showed that GenZ was now endemic amongst the hundreds of thousands of ducks and geese that roam Vietnamese farmyards that are in constant contact with chickens, pigs, and children. Because duck influenza is generally asymptomatic, there was no obvious way—apart from time-consuming and expensive blood testing—to distinguish infected from non-infected birds. Vietnam’s desperate efforts at containment through the selective slaughter of poultry were undermined by the emergence of this “silent reservoir.” Disoriented local authorities, as a result, grasped at questionable expedients. As the Vietnamese New Year approached, riot police set up checkpoints around Ho Chi Minh City to interdict the expected influx of infected poultry during Tet celebrations.314 Municipal officials on 1 February also ordered the slaughter of all ducks in the city: a move that Dutch influenza expert Jan de Jong denounced as “really nonsense.” He told an American reporter that the only way to stop the outbreak in Vietnam was “a near-total culling of the region’s poultry and curtailment of poultry farming for several years.”315
Hanoi retorted with justice that it needed more international aid to bolster its surveillance network and to compensate peasants whose flocks were being culled. The country was too poor to afford the destruction of a vital part of its subsistence economy without compensation from the richer nations for whom it was expected to provide an epidemic firewall. Foreign influenza experts working in Vietnam echoed Agriculture Minister Cao Duc Phat’s appeal on 2 February for truly serious international assistance. Writing in the New York Times, Anton Rychener (the outspoken FAO representative in Vietnam), and Hans Troedsson (his WHO counterpart), pointed out that if the H5N1 outbreak had occurred in a poorer European country, there would have been a vast outpouring of money and medicine. “In the case of Asia, the international community has failed to come forward with enough money to finance desperately needed public health and veterinary measures and research on vaccines.”316 In an earlier interview with Nature, Dr. Jeremy Farar of Oxford University’s clinical research unit in Ho Chi Minh City had lashed out at the dilettantish behavior of Western scientists: “When there’s a problem, everyone flies in, creates a certain amount of havoc, flies out, and leaves nothing behind to change the situation.” (He specifically exempted St. Jude’s researchers and the crack Hong Kong team from his criticism.)317 Incredibly, part of the shortfall of aid was most likely due to lobbying by Western poultry interests. With the Bush administration obviously in mind, Nature had editorialized in mid-January against the “mindset of protectionism” that obstructed veterinary aid to Vietnam. “Rich governments are disinclined to build up poor countries’ ability to keep track of animal viruses, seeing this as economic assistance rather than humanitarian aid.”318
Although the tsunami catastrophe in the Indian Ocean was the principal agenda item at the WHO executive board meeting on 25 January, the deteriorating flu situation in Vietnam was also on many minds. The Secretariat had circulated a briefing on pandemic preparedness that warned that the “present situation may resemble that leading to the 1918 pandemic.” The report emphasized that “changes in the ecology of the disease and behavior of the virus have created multiple opportunities for a pandemic virus to emerge,” and that gradual genetic drift, rather than reassortment, might be sufficient to unleash H5N1 on humanity. The Secretariat, underlining the “unprecedented opportunity to enhance preparedness,” worried that vaccine development had not advanced “with a speed appropriate to the urgency of the situation.”319
Some of the rich countries represented on the thirty-two-member executive board, however, were seemingly more concerned to protect pharmaceutical industry profits than to increase the availability of vaccines and antivirals. When Thai delegate Dr. Viroj Tangcharoensathien proposed (with the precedent of AIDS medications in mind) that the poor countries on the frontline of the avian flu battle be allowed to override drug patents in order to produce affordable quantities of Tamiflu, the American and French delegates vehemently objected and ultimately forced the meeting to adjourn without a vote. Dr. Anarfi Asamoa-Baah, the head of the WHO’s communicable disease division, gloomily noted that “as a global community we are still ill prepared—and as long as one of us is not prepared, none of us is prepared.”320
At a conference in Ho Chi Minh City a month later, this “alarming lack of commitment” from Japan, Europe, and the United States was again a top agenda item as Asian health officials responded to a warning by the WHO’s Omi that the region was facing “the gravest possible danger of a flu pandemic.” Shocked conferees heard one researcher after another outline fatal flaws in the underfunded avian flu surveillance system. The Japanese National Institute of Infectious Disease, which had retested blood samples from the Pasteur Institute in Ho Chi Minh City, reported that some of the negative results were in fact positive: suggesting that avian influenza, although perhaps not as lethal as suggested by confirmed cases, was actually more widespread and thus statistically closer to reassortment with human influenza. For its part, the Oxford University team in Ho Chi Minh City added fuel to the fire with a case-study of a four-year-old whose GenZ infection imitated acute encephalitis without respiratory symptoms. (Decades earlier, some scientists had associated a strange epidemic of sleeping sickness, encephalitis lethargica, with the 1918 H1N1 virus.) How many other similar cases had been misdiagnosed? Disturbingly, the child’s stools were also full of H5N1—a warning that avian flu, like SARS two years before, might spread via poor sanitation. There was also nervous discussion of “insect vectors” after a startling announcement by Japanese researchers that they had found H5N1 in flies following the 2004 poultry outbreak.321
The gravest concern, however, was focused on the first flu deaths in Cambodia, a country with a corrupt government, primitive health services ($3 per capita annually), and no facility for the sophisticated serological analysis required to identify GenZ. Indeed, the outbreak only came to light when twenty-four-year-old Tit Sokan from Kampot province sought treatment in Vietnam. Earlier, her fourteen-year-old brother had died after Cambodian doctors threw up their hands at his condition. “He had a fever and couldn’t breathe normally so we took him to the hospital. The doctors gave him two bags of saline solution, then they told us to take him home. They said maybe we’d done something to offend our ancestors, and we should make an offering to them.” Tit Sokan herself was too ill to be saved by antivirals, and after her death WHO investigators learned of border villages full of sick pigs and infected chickens. (In mid-April, another young woman from the same province died of suspected bird flu.)322
At the beginning of March, evidence was emerging of a second human-to-human transmission: this time in a Hanoi hospital where two nurses attending a critically ill avian flu patient, and both nurses developed the infection. Warning of the “perfect storm now gathering,” The Lancet urged the European members of WHO to help Vietnam shut down small-scale free-range poultry production. “If the greatest pandemic in history is indeed on the horizon, that threat must be met by the most comprehensive public-health plan ever devised. That plan presently does not exist.”323 Meanwhile influenza authorities like Albert Osterhaus (University of Rotterdam) and Nancy Cox (CDC) were pleading in the pages of Science for the big Western labs to help Vietnam organize a broader, more accurate testing program in response to the troubling “information gap” about the evolution of GenZ.324
Researchers were appalled that the bird flu containment campaign in Vietnam was collapsing for lack of relatively trivial financial aid. Yet even on the U.S. home front, where “biosecurity” was supposedly a top priority, the CDC’s budget for emergency public-health assistance was slashed by an eighth in fiscal 2005. Although plenty of money was found to increase funding for “abstinence education” (now $193 million per year), child immunization was reduced and preventive-health block grants to the states were eliminated. (A $20 million increase for pandemic vaccine hardly offset the loss of the block grants.) At a time of maximum menace, the CDC altogether lost $500 million in critical funding: a recession that only deepened gloom in an agency suffering, according to top official Robert Keegan, from a “crisis of confidence” that had led to the resignation of a score of top scientists and administrators. In an internal memo revealed by the Washington Post in March, Keegan spoke darkly of an “atmosphere of fear” and staff “cowed into silence” in the face of Director Julie Gerberding’s autocratic style and her subservience to the administration’s ideological agenda. Another CDC official described life in the agency as an “Alice in Wonderland environment where the CDC director is like the Queen of Hearts. You know, ‘Off with their heads,’”325 Meanwhile, an open revolt had broken out against the War on Terrorism’s deleterious impact on university-based communicable disease research. Led by two Nobel prize-winners, 758 researchers signed a petition claiming that Washington’s obsession with exotic but potentially weaponizable viruses and bacteria had resulted in a 27 percent decline in federal grants for research on tuberculosis and other major non-terror diseases.326
With this dissension in the background, Mike Leavitt, the new secretary of HHS, spoke to the National Academy of Sciences on 7 April about his department’s strategy for dealing with H5N1. Following on the heels of an unexpected admission by Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, that a flu pandemic was a greater immediate threat than a bioterrorist attack, Leavitt emphasized that avian influenza had the administration’s full attention and that he was receiving daily briefings on the worrisome situation in Asia. He told his scientific audience that an H5N1 vaccine was in the human test stage, and that he had signed a $97 million contract with Sanofi Pasteur to develop new cell-based vaccine production lines.327
But the former governor of Utah did not address the problems inherent in vaccine production—the minuscule scale of the start-up, the long lead times, and the uncertainty whether current templates would match the evolved genome of a pandemic—that CDC Director Julie Gerberding had acknowledged in February at the annual meeting of the American Association for the Advancement of Science. Gerberding—according to a University of Minnesota news source—had warned that it was “nearly impossible to stop an outbreak by quarantining sick people” and “that flu vaccine production remains focused on ordinary seasonal flu, and it would be impossible to switch gears quickly to make a pandemic vaccine.”328 Leavitt also sidestepped widespread complaints about Washington’s failure to stockpile Tamiflu in quantities comparable to recent purchases by Great Britain (14.6 million courses) and France (13 million).329 Nor did he explain why the Bush administration was refusing to provide the aid that Vietnam so desperately needed to keep H5N1 in check.
Moreover, Leavitt’s sunny assurances that Washington had public biosafety well in hand were immediately undercut by the startling revelation that a Cincinnati bioscience firm had sent out more than 5,000 samples of a deadly pandemic strain of influenza. H2N2, the “Asian flu” virus that killed 1 to 4 million people during the 1957 pandemic, had not circulated amongst humans since 1968 and was a grave threat to anyone born afterward. Influenza researchers, chastened by the escape of an earlier “lab fossil” (a strain of H1N1—the 1918 virus) in 1977, had long fretted about the security of H2N2 specimens in lab archives. They were incredulous that Meridian Bioscience—a contractor to the College of American Pathologists (CAP)—had knowingly included H2N2 in the viral test kits routinely used to assess quality control in laboratories across the world. CAP had not been informed of the strain’s identity (which was, in any event, mislabeled on customs forms as “H3N2”), and most of the kits had been shipped through the U.S. mail. Although CDC experts had earlier urged the reclassification of H2N2 as a biosecurity level 3 agent, requiring the most stringent lab precautions, the recommendation was never implemented. As a result, “the CDC [did] not have regulatory authority over the distribution of the A (H2N2) influenza virus because it is not classified as a dangerous agent relevant to bioterrorism.”330
Indeed, it was only thanks to Canadian vigilance that the pandemic threat was discovered at all. At the end of March, the National Microbiology Laboratory in Winnipeg identified H2N2—a strain the Canadians consider too dangerous to use in lab certification tests—in a patient sample sent from British Columbia. Although the Vancouver woman didn’t actually have the flu, the contaminated sample was sufficient grounds for worldwide alarm. While Director Gerberding misleadingly reassured the public that “this strain of virus poses a very very low risk of transmission,” the CDC mounted a frantic campaign to track down and destroy the thousands of samples.331 A few missing test kits in Lebanon, near the epicenter of the Bush administration’s fears about bioterrorism, caused considerable anxiety until they were finally accounted for by local labs. Like the Chiron scandal the year before, the H2N2 fiasco demonstrated the public peril of lax federal regulation of production protocols and biosafety standards. How could Washington pretend to defend the nation against the avian flu threat or bioterrorism, when it had allowed a private company to put a potential pandemic in the mail?
While the CDC was chasing the missing H2N2 samples, a joint summit in Paris of experts from the FAO and the OIE was reviewing the campaign against H5N1. Their sobering conclusion was that the virus had become too ecologically entrenched, particularly amongst asymptomatic ducks, to justify the continued economic and ethical costs of culling yet millions more domestic birds. Avian flu, in short, was endemic and inextinguishable. It was also utterly unpredictable: the discovery of a highly pathogenic H7 strain in North Korea in March raised fears of a doomsday recombination with “H5 lethality and H7 transmissibility.” Meanwhile, the normally hermetic North Koreans clamored for international assistance to save their fledgling poultry export industry.332
As an alternative to the failed culls, the FAO and OIE proposed an ambitious poultry vaccination campaign in affected countries. The plan was a disappointment to experts who advocated the radical elimination of free-range poultry and wet markets. It also faced the formidable technical challenge of how to distinguish between vaccinated and infected birds, since their antibodies would otherwise be identical. More dauntingly, vaccination would require major financial aid to poor countries like Vietnam, Cambodia and North Korea: “economic subsidies” likely to be opposed by corporate poultry producers and U.S. conservatives. Not surprisingly only a few countries (Japan, Germany, and the Netherlands) were immediately prepared to support the Paris plan with modest contributions.333
By late spring 2005, therefore, every biological weathervane was pointing in the direction of an imminent pandemic. The basic WHO assessment of the threat—an inevitable outbreak that could kill millions, even tens of millions—had been accepted by all leading players, including the Bush administration. The rest of the print media had finally caught up with the New York Times, and avian influenza was almost daily in the news. Yet a certain quotient of disaster fatigue was also apparent: influenza experts, after all, had been warning of a viral apocalypse since the original Hong Kong outbreak in 1997. Almost nine years later, less than one hundred people had died and the pandemic was still just a prediction. In the meantime, tens of millions had died from AIDS, malaria, and diarrhoeal diseases. Is it possible that the WHO had exaggerated the threat of H5N1?
Alas, a flu pandemic is not a fate we can avoid. To recapitulate an earlier argument: Third World urbanization and the Livestock Revolution have fundamentally transformed influenza ecology and accelerated the evolution of novel recombinants. Moreover, there are multiple pathways to a new catastrophe on the scale of 1918. As we have seen, several subtypes of H7 and H9, in addition to H5N1, are slouching toward Bethlehem with bright prospects of producing pandemic offspring. All the major candidates, in addition, appear to be increasing their evolutionary fitness to spread rapidly through new avian and mammal species. The fifteen HPAI outbreaks since 2000, for example, have killed or led to the culling of ten times as many birds as all earlier known outbreaks combined. (“We’ve gone from a few snowflakes to an avalanche,” an Italian researcher told Science.)334 Even if humanity miraculously dodged H5N1, we would soon be under threat from other virulent avian subtypes.
The rich countries have had nearly a decade—a unique advance warning in the history of disease—to build a network of global defenses against the impending pandemic. But the crash program of vaccine development and antiviral stockpiling, advocated by Robert Webster and others since 1997, has yet to really commence. In Washington, London, and Tokyo, health ministers pay religious deference to pharmaceutical industry patents and profits while failing to assure the elementary provision of lifeline medicines. In Asia, as well as California and British Columbia, governments have covered up outbreaks, lied to international agencies, threatened whistleblowers, and possibly concealed illnesses and deaths. The huge livestock multinationals, with their crony ties to government in Thailand and China, have exploited the crisis to restructure poultry production to their selfish advantage. Although individual foreign researchers and institutions have provided heroic assistance to local authorities, the overall global aid effort has been a disgrace. Most egregiously, the United States—the country with the greatest historical moral obligation to Vietnam—has failed to provide that poor nation with the resources to monitor or contain the outbreak.
Over the last year, to be sure, some progress has finally been made on the vaccine and antiviral fronts. But the chief beneficiaries are a handful of wealthy countries—especially Canada, Australia, New Zealand, Singapore, and Japan—who have been provident enough to order early and in quantity from Roche. Britain, France, and Sweden have also taken serious steps, but the United States, which has recently spent billions on “biosecurity,” lags shockingly far behind its peers. We are better equipped to deal with imaginary anthrax and Ebola attacks than with an avian influenza pandemic. Meanwhile not the slightest effort has been made to protect the truly poor countries of Asia and Africa from the return of history’s greatest killer. A “global vaccine” is still a pipedream, and the Tamiflu buying spree by the rich countries has locked up the potential supply.
As with HIV/AIDS and the easily preventable infant diarrhoeal diseases, avian influenza is a fundamental test of human solidarity. Access to lifeline medicines, including vaccines, antibiotics, and antivirals, should be a human right, universally available at no cost. If markets can’t provide incentives to cheaply produce such drugs, then governments and non-profits should take responsibility for their manufacture and distribution. The survival of the poor must at all times be accounted a higher priority than the profits of Big Pharma. Likewise, the creation of a truly global public-health infrastructure has become a project of literally life-and-death urgency for the rich countries as well as the poor. The first step—as the editors of Nature, The Lancet, and other eminent journals have repeatedly emphasized—is a serious aid program to rescue the anti-pandemic campaign in Vietnam and Southeast Asia. On the thirtieth anniversary of the end of its genocidal intervention in Indochina, the United States needs to help the small farmers of Vietnam save the lives of their children.
As the hour hand on the pandemic clock ominously approaches midnight, I recall those 1950s sci-fi thrillers of my childhood in which an alien menace or atomic monster threatened humanity. Scientists try to sound the alarm, but politicians ignore the danger. Ultimately, however, the world wakes up to the peril and unites to defeat the invader. Human species survival overrides the antagonisms of the Cold War and competitive nationalism. Now, with a real Monster at our door—as terrible as any in science fiction—will we wake up in time?