Dr. Juan Lubroth is a hard man to meet. Head of the Food and Agriculture Organization of the United Nations (FAO) Infectious Disease Group, he is often on the road, traveling the world to organize the fight against highly pathogenic avian influenza (HPAI). It takes more than a month from when we first make contact for us to actually sit down together. So I’ve decided that if I get to ask him only one question, it will be the one that has been uppermost in my mind for weeks: Can we actually contain the H5N1 virus in the animal kingdom through a vigorous international campaign, and thereby avert a human pandemic in the first place? “Pandemic preparedness” has, after all, been headline news, but fighting HPAI in animals is barely a footnote.
Lubroth’s office has a large wooden sliding door, the only one I have seen in the building. It strikes me as appropriately barn-like. Inside he is at his desk, and luckily the phone isn’t ringing—yet. I’m sure he has more pressing things to do than talk to me, but when we sit down at a small conference table he is extremely attentive. Soft-spoken and circumspect, he combines scientific reserve (heading me off when I jump to conclusions) and a passionate interest in his subject, which is the wellbeing of animals.
Only it’s not just animals. Lubroth has a vision of “one world, one health,” in which the health of humans, domestic animals, and wildlife are all connected. There couldn’t be a better example of this than HPAI, and his answer to my first question is an emphatic yes, we can contain the virus. FAO’s strategy is based on the idea of stopping a pandemic by fighting the disease now in the animal kingdom and keeping it there—and hopefully stamping it out.
But that’s hardly the whole story. Lubroth stresses how much we don’t know about H5N1, the virus that causes HPAI. “We’ve had little opportunity to study this virus in the last two years. It’s hard to conduct research when you’re fighting a disease.” He lacks staff and he lacks money; “our appeal is not being heard by the donor community.” Still, he’s working with what he has and is “trying to be proactive.” He has recently been in South America, where FAO is devoting $2 million to setting up a network of labs and staff before the virus gets there. (I think but don’t say that the U.S. Congress, in its most recent pork-filled emergency spending bill, was ready to spend $15 million on a “seafood initiative.”)
To me, it seems that Lubroth’s global view has not so much been opposed as ignored. Discussion in the U.S. has focused almost entirely on pandemic preparedness, not fighting HPAI. But Lubroth gives credit where it’s due: In the recent outbreak in Egypt, there was not one but two labs doing H5N1 testing—the government lab, and an American one. “The U.S. military lab has been a very gracious partner,” he notes.
Living for weeks or months sequestered in an apartment, while the tumbrels go by with cries of “Bring out your dead,” strikes me as a great premise for a surrealist novel, but not a national avian flu strategy. One of Lubroth’s most interesting ideas is to do a study of human H5N1 resistance. Nightmare scenarios picture a human pandemic cutting a swathe like the Black Death. But it’s now been almost 10 years since the first human cases of HPAI emerged in Hong Kong: How many people came in contact with H5N1 and didn’t get sick? How many got sick and recovered, but never sought medical attention or never were recorded? Nobody knows. The terrifying human mortality rate of 50 percent is based only on those we know came in contact with the virus. Lubroth outlines a possible study that would test, say, 1,000 people in each of several heavily populated areas that have been hard-hit by H5N1 over a long period—Vietnam and Thailand, for example. We might get an idea of how many people in the population show antibodies to H5N1. But is any such study under way? No.
While we are talking, Lubroth is interrupted by a call from one of his veterinarians in Cote d’Ivoire. HPAI has cropped up there, too. After a brief conversation he ends by telling the vet, “Do good work and be safe.” It reminds me that the work of fighting HPAI is dangerous. But there are people out there doing it; wherever the disease is, there they go. One world, one health.
The view of H5N1 from Juan Lubroth’s office is very different from that from the Oval Office. Across the Atlantic, the new debate is over who will get the precious flu vaccine (if it exists) first. While “federal officials have said they intend to give vaccine first to health-care workers, followed by the oldest, sickest patients, a policy aimed at saving the most lives,” a federal panel of ethicists is considering the concept of saving not lives, but life years: “If you save a child who is 2, you’ve potentially saved 80 quality years… If you save a 65-year-old, you may have only saved 15 years of quality life.”
Another scheme, published in Science, proposes an “alternative ranking, with medical workers first and young adults next, followed by people ages 41 to 50 and finally those 51 and older.” In the great vaccine sweepstakes, you would think infants—with the most potential years ahead of them—would win a berth right away. But in fact they may not place or even show: “Within this framework, 20-year-olds are valued more than 1-year-olds because the older individuals have more developed interests, hopes and plans but have not had an opportunity to realize them.”
In the midst of this a friend of mine in New York City writes that she is storing up water and cans of tuna because authorities have said to do so. Living off tuna for weeks or months sequestered in an East Side apartment, while the tumbrels go by with cries of “Bring out your dead,” à la Defoe, strikes me as a great premise for a surrealist novel, but not a national avian flu strategy.
But we Americans will all be vaccinated and have our Tamiflu on the bedside table, right? To understand what has gone wrong with the U.S. response to avian influenza, one has to go back to the national strategy. Issued by the Homeland Security Council [PDF], it was inevitable that it would reflect the Bush administration’s usual obsessions. It’s clearly an Americans-only plan; although claiming to address “the full spectrum of events that link a farmyard overseas to a living room in America,” the farmyard got lost in the shuffle, along with the farmers. The plan also makes fighting the virus sound like another war in Iraq: We have to “develop a coalition of strong partners to coordinate actions to limit the spread of a virus with pandemic potential beyond the location where it is first recognized in order to protect U.S. interests abroad.” This literally says the coalition’s purpose shall be to protect U.S. interests. It would have been more gracious to admit that coalition partners might also have a stake in saving the lives of their own people. (All that was required was to insert the word “and” after “recognized.”)
We should especially note the phrase “a virus with pandemic potential.” The money to detect and contain outbreaks is to combat a future human pandemic form, not HPAI as it exists today. “Slowing or limiting the spread of the outbreak” doesn’t refer to the work of FAO, the World Organisation for Animal Health (OIE), the World Health Organization (WHO), or other agencies currently on the front lines of the animal epidemic. It means creating a cordon sanitaire around a human-to-human pandemic strain should one pop up in, say, Vietnam or Indonesia. That will give America enough time to create a vaccine and put up the “Keep Out” signs. This, it is hoped, will “prevent a pandemic from reaching our shores.”
Nationalism goes with clueless isolationism just as easily as it does with bumptious jingoism. Republicans may swallow Bush’s flu siege plan as easily as they did pre-emptive war, but no one else should be fooled. The idea that the “most effective way to protect the American population is to contain an outbreak beyond the borders of the U.S.” ignores the ancient truth that you can run but you can’t hide. During the 1918-19 flu, in a world vastly less connected and far more rural, there was nowhere to go: “The 1918 flu reached Alaskan villages where the only way visitors could arrive was by dogsled.”
But we Americans will all be vaccinated and have our Tamiflu on the bedside table, right? Unfortunately, the picture is not quite so rosy. Experimental vaccine results are thus far not encouraging. That’s why it’s crucial to decrease the amount of time it takes to make the correct vaccine once a human flu strain emerges. The government is shooting for being able to produce 600 million doses in six months. Given that the current capacity is zero, that’s a tall order; the target date for achieving it is 2013. And anyway, a lot of people can die in six months, as the history of epidemics from the Black Death to the 1918-19 flu attests.
“No man is an island,” John Donne said; and even if you were an island, a migrating bird could land on you and give you avian flu. As for Tamiflu, useful as it is, questions about resistant H5N1 strains are one of those little worries that have been submerged by issues like whether the National Guard will be called out to cordon off your town. Yet less than a week after George W. Bush unveiled his national strategy back in November 2005, an FAO update reported, “Japanese and Vietnamese researchers analyzed the genes of the virulent H5N1 avian influenza virus taken from a 14-year-old Vietnamese girl, who became infected in February, but recovered. Their laboratory examination [PDF]showed that the virus had a genetic mutation that makes it resistant to Tamiflu.”
Antiviral drugs and vaccines are essential. But the Bush plan encourages the fantasy of the U.S. as an oasis of health amid global devastation and death. “No man is an island,” John Donne said; and even if you were an island, a migrating bird could land on you and give you avian flu. As for Bush’s claim that “we’re doing everything we can,” that’s empirically false. We could do much more to combat the current animal form of HPAI.
Asian farmers have been bearing the brunt of that battle for 10 years. The disease has already cost the Asian poultry sector $10 billion, not to mention scores of human lives. Dr. Peter Horby of the WHO has said, “The threat to human health will persist as long as the problem persists in animals.” This is a very different outlook from the Bush plan’s. Animal diseases persist for generations—though how quickly we forget: in 1983-84, H5N2 swept through domestic fowl in the United States, and 17 million birds either died or had to be killed. H5N2 struck Mexican fowl in a long outbreak lasting from 1992 to 1995. And in 2003, an outbreak of H7N7 in the Netherlands made 83 people sick and killed one veterinarian. H5N1 is not the only bad guy out there, it’s just the worst. As with most animal diseases, it will require a sustained control and eradication effort over many years to contain and hopefully stamp out H5N1. So how about throwing a billion or two into the fight against current HPAI?
I make the assumption, following the Republican Congress, that a billion dollars is not a lot of money. It’s only 1/251st of what the Iraq war cost through the end of 2005 [PDF], though it’s 10 times what a recent multinational meeting asked for to fight avian flu in Asia. And it’s only 1/675th of what a bird flu epidemic could cost the U.S. economically, according to Bill Frist, M.D.
A long-term disease-fighting strategy is perforce a poverty-fighting strategy. An outbreak in a developed country is a different story from an outbreak in a poor one. If bird flu annihilates one of Purdue’s farms, that’s sad, but they write off the loss and I buy someone else’s chicken at the supermarket (as long as the outbreak is contained). But if bird flu kills the chicken that lays the eggs I feed my kids (and which represent, say, half their protein intake), and I have no money to buy a new chicken, that’s catastrophe. It’s also a strong incentive to hide my chicken from inspectors, or take it to market and sell it as soon as it starts to look droopy. The Bush plan talks (of course) about “novel investment strategies.” Here’s one: Pay the man for his chicken so he can buy a new one and keep his family economy and the kids healthy.
Countries like Vietnam and Thailand are already doing this—they’re called compensation strategies—but in Vietnam alone, 8 million rural households keep chickens. They eat some chickens and their eggs, while raising some chicks to be the next generation of egg layers and pot-fillers. It’s an endemic system because it works: the family’s return on investment is a whopping 700 percent. Kill all the chickens and you wipe out their capital and their protein. (Invent an investment product for Wall Streeters that pays 700 percent and then let’s see you take it away from them in the interests of public health.) Hence the need for compensation strategies.
The Bush plan did promise to “work through multilateral health organizations” like the WHO, FAO, and OIE. And in fact, at the Beijing pledging conference in January of this year, the U.S. was the number-one donor at $334 million. That’s a measly $334 million for the entire earth, excluding the United States. The U.S. State Department’s press release on the subject makes it sound like the money is mostly earmarked for pandemic detection, right out of the national strategy. Nothing about compensation programs or other “pro-poor” strategies.
It would be wrong-headed to say that the U.S. government should simply foot the bill for the avian flu fight. And I can understand not wanting to leave it all in the hands of the crisis-ridden and often dysfunctional U.N. system. So innovate—and that doesn’t mean outsource the job to Halliburton. Speaking of novel strategies, the one thing the Bush administration never asks of the private sector is to pay for anything or contribute to the common good. Exxon-Mobil’s profits for 2005 were $36 billion. Maybe Bush should talk to his base about avian flu—or maybe they should talk to him. The practical argument that his flu plan won’t work is unlikely to move the administration, any more than the obvious failure of its “plan” in Iraq.
There’s also a moral argument. In the same meditation, Donne says, “Any man’s death diminishes me, because I am involved in mankind.” Maybe Bush should revisit the doomed national strategy and transform it into an international strategy that tries to stop H5N1 now, rather than plan how to save selected Americans (excuse me, American life-years) in the future. Fighting the virus in the animal kingdom and helping poor countries to do it may not only be a better strategy; it might even be right.
One world, one health.
