Nearly four decades have passed since the world last saw an influenza pandemic. Many believe we are long overdue for another. On September 19, the same day that officials in Jakarta issued a high alert for avian flu, the Woodrow Wilson International Center for Scholars hosted an event to discuss the threat of an influenza pandemic. Marking the inauguration of the Global Health Initiative, the event featured Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP) and associate director of the Department of Homeland Security-funded National Center for Food Protection and Defense (NCFPD), and Helen Branswell, a medical writer for the Canadian Press, who has extensively reported on the avian flu and the SARS virus.

In their stark and eye-opening presentations, Osterholm and Branswell addressed the likelihood of an outbreak and the staggering social, political, and economic devastation that would result from a pandemic. "Welcome to my nightmare," Branswell said before describing how the world could be brought to its knees by a flu strain known as H5N1.

A Deadly Strain

In 1997, H5N1 emerged among the domesticated bird population in Southeast Asia. Since then, over 100 million chickens, ducks, and other fowl have been slaughtered in an effort to curb the virus' spread. The overall human toll remains low, but researchers note that this strain results in a 55 percent death rate in known human cases. If H5N1 mutates from its current form into a virus easily transmitted between people, a pandemic will be the likely outcome.

With 30 years of public health experience, Osterholm is familiar with frightening diseases and public health issues like toxic shock, HIV/AIDS, and bioterrorism. Yet, he warned at the outset of his presentation, "Without a doubt, if you were to add up my entire public health career's concerns, worries, and—in some cases—nightmares, they collectively do not meet the concern, worry, and nightmares that I have about the issue of an impending pandemic of influenza."

While H5N1 is one of the most watched flu strains, no one can say when—or even if—the right mutation will occur to make the virus readily transmitted between humans. Despite these uncertainties, Osterholm said, "The risk of another pandemic of influenza is one. It is not if it's going to happen; it's when, and where, and how bad."

Spanish Flu: Part II?

In the past 300 years, there have been 10 documented influenza pandemics—most notably the 1918 Spanish Flu, during which an estimated 25-50 million people perished. Each winter, Osterholm noted, the United States experiences its own pandemic in the form of seasonal flu, killing between 35,000 and 55,000 people. But an H5N1 pandemic would be nothing like the standard winter flu. Rather, scientists predict that widespread H5N1 in humans would be strikingly similar to the Spanish flu. Research and lab results from Southeast Asia indicate that H5N1, like the Spanish flu, is the most deadly for the healthiest segments of the population--those 18 to 40--instead of the traditional young and old victims. "It is 1918 all over again," Osterholm said. By comparing population data from 1918 to that of today, he estimated fatalities would range between 180 million and 360 million people worldwide.

Is the world prepared for a catastrophe of this magnitude? Both Osterholm and Branswell cited the United States' management of the Hurricane Katrina crisis, in which the might of an entire nation was required to aid three states. With an outbreak of H5N1, however, Branswell said, "Every jurisdiction is going to need every single doctor, nurse, lab technician, orderly, and paramedic they can muster. No one is going to be able to rely on the cavalry arriving."

SARS Gone Global

Having covered the 2003 SARS outbreak in Toronto, Branswell witnessed a public health crisis similar to an influenza pandemic—but on a much, much smaller scale. "I watched what a simple, not very highly transmissible virus did to a modern city with some of the finest health care facilities available," she said. "Tourism plummeted, hotels were empty, major conventions had cancelled, movie shoots moved away, concerts wouldn't come to Toronto, theater shows went dark, restaurants…fell on very hard times. People just hunkered down and stayed home."

Yet there were only six true outbreaks of SARS in the world: in China, Vietnam, Taiwan, Singapore, Hong Kong, and Toronto. "All that disruption and fear," Branswell asked, "for only six outbreaks?" If these isolated cases managed to rock the Canadian and Asian economies and also stop tourism in its tracks, what would happen if a worldwide outbreak of flu caused governments to close borders, halting transport and trade? "How do businesses continue to function when a third to a half of their work force calls in sick? How do crops get harvested?...How do [governments] prepare for an event that may or may not happen in their mandates? That may or may not claim millions of lives?" Branswell asked.

Planning for the Inevitable

If SARS can have such a global impact, how does a nation—and the world—prepare for what Osterholm and Branswell consider a truly imminent health crisis? In planning and, eventually, managing an influenza outbreak, vaccination plays a crucial role. But with only nine countries producing the world's supply of influenza vaccine, Osterholm noted that in the event of an outbreak, countries will likely nationalize vaccine supplies.

Nationalization will certainly lead to global inequities among the haves and have-nots. But inequality will result within borders as well. Recent National Institutes of Health (NIH) trials have shown positive vaccine responses to H5N1, but at levels 12 times the normal dosage. The United States produces all of its vaccine at one plant in Pennsylvania and makes 180 million doses of flu vaccine every year. According to Branswell, "If no way is found to improve dosing needs, the United States can produce enough vaccine in the first year of a pandemic to protect 15 million people—or 5 percent—of its population."

In the event of an outbreak, planning will play a key role in effective crisis management. Branswell spoke to one official who likened the situation "to peeling an onion: every time you take off a layer, you discover something else that needs to be planned for." For example, managing one vaccination clinic will require health care workers and security forces, both of which will need food and laundry services, and—most importantly—their health.

Crucial goods—food and drugs—may become difficult to produce or deliver. Without enough vaccine, "We have to wonder who will show up for work?" Osterholm said. The current just-in-time delivery system, in which foodstuffs are produced on demand rather than warehoused, will create immediate shortages if employees stay home, governments close borders, or planes are grounded — "Grounded planes mean grounded goods," Branswell said.

With fatality estimates in the high millions, Osterholm cautioned about bodies: "We need corpse management. We will not be able to handle the number of bodies. We will run out of caskets overnight."

Where Do We Go From Here?

"What do we do?" Osterholm asked. "From my perspective, we pray, plan, and practice…We have to plan as if this will happen tonight." Branswell's suggestions included making known the threat of avian flu. "For reasons I can't fathom, many news outlets in North America aren't paying attention to this story as a human health issue, global security threat, and potential economic disaster." She also urged governments to share their disaster plans with the public so that people can prepare themselves and their families for an outbreak. Branswell, like Osterholm, called for immediate action: "We don't know how much time we have to do the types of things that could turn a pandemic from a gigantic catastrophe to an ordinary disaster."

Drafted by Alison Williams.