Scott McPherson's Web Presence

One of the things not generally talked about during pandemic discussions is the impact a severe flu pandemic will have on financial markets such as life insurance.  I mentioned this lack of discussion when I recently lectured to senior employees of the Florida Department of Financial Services, or DFS.  DFS is run by a very impressive woman, Alex Sink.  Ms. Sink has run a banking empire (Bank of America) and has also served on numerous private sector boards and commissions.  She is also the only elected statewide Democrat on Florida's elected Cabinet, so she is unique in her ability to get her message of fiscal discipline to voters of all persuasions.

Anyway, CFO Sink required all her senior staff to listen as I gave my then-new "First pandemic of the information age" presentation, giving new meaning to the axiom "Death by Powerpoint."   Her senior managers and policy experts came to terms with the sheer volume of human suffering and the resultant stress that a sudden spike in death claims would have upon the life insurance industry, not to mention a downturn in tax receipts.  The actuarials in the audience quickly performed their unique calculus and their faces went pale with concern about the solvency of some life insurance companies who would hypothetically be paying death claims on young lives whose premiums had not been given time to prosper within the Law of Large Numbers that is the industry's hallmark.

Add to that growing list of concerned organizations the venerable Lloyd's of London.  Lloyd's, whose very name is synonomous with global best practices in the insurance and reinsurance fields, recently conducted a seminar on pandemic planning. It is one thing to read bloggers' diatribes about pandemic preparedness, including my own.  It is another thing to hear our government's top leaders -- including the President himself -- speaking on the need for preparedness.  But for some, confirmation only comes whan a prestiege firm such as Lloyd's comes out and says, "Do this."

For those people, consider yourself warned.  Lloyd's is taking the approach that a pandemic is an event with a very close beginning date. An extract taken from the Lloyd's press release:

Prepared for a pandemic?

2 May 2008

A pandemic ‘flu that causes massive disruption to economies around the world is inevitable and all businesses must prepare for it now. That was the stark message to emerge from a recent high level seminar co-organised by Lloyd’s and XL.

In a series of sobering presentations, business continuity and risk management experts explained how insurers and their customers could be affected by a pandemic and what they can do to mitigate the fall-out from a nightmare scenario.

In risk management terms, a pandemic is unlike any other natural or manmade disaster that businesses routinely prepare for. A ‘flu pandemic is not a sudden, short lived event like a terrorist attack or industrial explosion that destroys infrastructure in a localised area. It could last for months.

“Nobody knows when this will happen, so it is a challenge to make it real to people,” Professor Lindsey Davies, national director of pandemic influenza preparedness at the Department of Health admitted. “But it will happen.”
When the UK’s Financial Services Authority simulated the effect of a pandemic ‘flu on the City it assumed an absence rate of 49%. Richard Maddison, deputy head of business continuity risks at the FSA, said that the exercise revealed that from the outset participants’ were not fully aware of the impact a pandemic would have on their suppliers and that there was uncertainty about how a pandemic will spread. “Plans and HR policies need amending,” he warned.

All the evidence points to a lack of preparedness among business. A YouGov survey last year found that over three quarters of companies have inadequate plans; around a third have no strategy at all.

Drawing a pandemic timeline, the FSA’s exercise showed how institutions will be challenged as a pandemic quickly develops momentum. Chillingly, by week five of the simulation, companies were extending HR policies to include emergency financial support, accommodation and death in service benefits to employees.

The insurance industry will potentially have to cope with an variety of claims , while it is still reeling from its own business continuity problems, Trevor Maynard, emerging risk manager at Lloyd’s, said. Life and health programmes will be directly impacted but less immediately obvious losses could pile up as businesses grind to a halt, from credit insurance to event cancellation.

When the UK’s Financial Services Authority simulated the effect of a pandemic ‘flu on the City it assumed an absence rate of 49%. Richard Maddison, deputy head of business continuity risks at the FSA, said that the exercise revealed that from the outset participants’ were not fully aware of the impact a pandemic would have on their suppliers and that there was uncertainty about how a pandemic will spread. “Plans and HR policies need amending,” he warned. All the evidence points to a lack of preparedness among business. A YouGov survey last year found that over three quarters of companies have inadequate plans; around a third have no strategy at all. Drawing a pandemic timeline, the FSA’s exercise showed how institutions will be challenged as a pandemic quickly develops momentum. Chillingly, by week five of the simulation, companies were extending HR policies to include emergency financial support, accommodation and death in service benefits to employees. The insurance industry will potentially have to cope with an variety of claims , while it is still reeling from its own business continuity problems, Trevor Maynard, emerging risk manager at Lloyd’s, said. Life and health programmes will be directly impacted but less immediately obvious losses could pile up as businesses grind to a halt, from credit insurance to event cancellation.

http://www.lloyds.com/News_Centre/Features_from_Lloyds/Prepared_for_a_pandemic_02052008.htm

There is more, but I will let you read the release.  I do want to post Lloyd's Top Ten things to remember in a pandemic:

Top 10 tips for businesses to cope with a pandemic

• Although the emergency services are taking pandemic preparedness very seriously continuity plans should consider the impact of a reduced level of service.

• Educate your staff in advance on the hygiene and quarantine procedures they may need to take.

• Identify who your key personnel are and explore cross training to help cope with absent staff.

• Check that your suppliers are as well prepared as you are for a pandemic.

• Decide on corporate priorities and the key services that must be maintained.

• Exercise contingency plans against the timeline of a pandemic.

• Fully understand how telecommuting can serve the business and where the weak points are.

• Evaluate your requirements for bandwidth at your gateway and consider buying extra now.

• Be prepared for subsequent waves and plan for the recovery phase.

• Expect a more fluid job market as employees react to how they were treated by employers during the pandemic.

This is among the best advice I have ever seen for pandemic preparedness.  Of course the Devil is always in the details, but these tips are simple, straightforward and can apply equally to the public and private sectors.  And note that final bullet:  If your business fails to properly consider the role that pandemic planning and response took in their own lives, do not expect to retain them.  If you care not a fig for your employees enough to prepare them for pandemic flu, they will repay your lack of care by leaving you.  Hey, that rhymes!

Hat-tip to Flutrackers poster Shiloh. 

Over the weekend, a news story broke that a federal task force had released recommendations for triage of victims of a future flu pandemic.  The task force comprised doctors and researchers from well-known universities, medical organizations, and government agencies including the Department of Homeland Security, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.

The story was picked up by the Associated Press and other news organizations.  Here's the story:

Triage plan details whom to let die during a pandemic

Treatment blueprint gives severely hurt, elderly lower priority

Lindsey Tanner, Associated Press

Monday, May 5, 2008

Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding whom to let die.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux, a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

Their recommendations appear in a report published today in the May edition of Chest, the medical journal of the American College of Chest Physicians.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report states.

To prepare, hospitals should designate a triage team with the Godlike duty of deciding who will and who won't get lifesaving care, the task force wrote. Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific and include:

-- People older than 85.

-- Those with severe trauma, which could include critical injuries from car crashes and shootings.

-- Severely burned patients older than 60.

-- Those with severe mental impairment, which could include advanced Alzheimer's disease.

-- Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force. He said the report will be among many the agency reviews as part of preparedness efforts.

Public health law expert Lawrence Gostin of Georgetown University called the report an important initiative but also "a political minefield and a legal minefield." The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.

If followed, such rules could exclude care for the poorest, most disadvantaged citizens who suffer disproportionately from chronic disease and disability, he said. While health care rationing will be necessary in a mass disaster, "there are some real ethical concerns here."

James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans, even if they don't follow all the suggestions. He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.

While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.

Devereaux said compiling the list "was emotionally difficult for everyone." That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.

"You never know," Devereaux said. "SARS took a lot of folks by surprise. We didn't even know it existed."

http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2008/05/05/MNM210GNVM.DTL

I have told the story before.  Back in late 2006, HHS floated a trial balloon:  Let the governors of the states decide how best to distribute vaccine and antivirals during a flu pandemic, once the first responders were taken care of.  I sent my friend, then-governor Jeb Bush, an email that included the balloon from HHS.  I concluded in the missive,

"Jeb, Who do you vaccinate in a pandemic?  Your future or your past?"  I also told Jeb that, blessedly, he would not have to make that decision -- but his successor very well might.

The answer to my rhetorical question is very, very clear to me:  It is whoever is at highest risk.  If it's 1918 all over again, I would not hesitate to treat and vaccinate the most vulnerable first, based on mortality:  Young adults 18 to 40.  That might rankle the ire of AARP, but that is just too bad.

Allow me to explain why.

Look at the results of the Spanish Flu pandemic of 1918-19.  Depending on whose book you read, the life expectancy of an American dropped by anywhere from ten to twelve years in the wake of that pandemic.  That is how many youthful Americans died, both from World War I and the Spanish Flu.  We know today that more American soldiers died from flu than from contact with the enemy. 

We know that the most likely person to die in 1918 in the United States was a pregnant woman aged 27.  Her chances of dying if she acquired the Spanish flu were 55 in 100. 

America was able to weather that pandemic storm and prosper because making babies and building families were still the preferred projects in the eyes of American youth.  Now let us look at the realities of today.  We cannot say that with any confidence whatsoever. Political leaders must look at a pandemic within that context, and not just within the context of administering care for people. 

Were it not for immigration (legal and otherwise), the United States would have lost population from 1990 to 2000.  That is because people are not having babies in sufficient quantities to replace the people who are dying.  This fact is borne out in every single projection regarding future imbalances in Social Security, Medicaid, Medicare and federal entitlements in general.  Medicare is already out of balance, according to a good friend of mine, a Federal economist with the Department of Labor.  That means recipients of Medicare are pulling money out of the system faster than wage-earners  are paying into it.  Soon, Social Security will be the same way.  And by 2042, according to the Comptroller of the Currency, 100% of the Federal budget will be taken up by these entitlements.  No defense.  No transportation.  All entitlements.  What a mess.

Again, this is because there are fewer people being born than there are people dying.  And if you think this is bad, you should look at the looming danger about to befall Europe.  At least we grew:  Europe did not, and as a result has to import its labor now, with consequences we can see on televisions nightly.  Of all the nations of the earth, only Australia grew the "old fashioned" way.

From the Website of the Population Reference Bureau:

The more developed countries in Europe and North America, as well as Japan, Australia, and New Zealand, are growing by less than 1 percent annually. Population growth rates are negative in many European countries, including Russia (-0.6%), Estonia (-0.5%), Hungary (-0.4%), and Ukraine (-0.4%). If the growth rates in these countries continue to fall below zero, population size would slowly decline. As the chart "World population growth, 1750–2150" shows, population increase in more developed countries is already low and is expected to stabilize.

http://www.prb.org/Educators/TeachersGuides/HumanPopulation/PopulationGrowth.aspx

Imagine a scenario that takes the 1918 pandemic and extrapolates that pandemic's societal impact across today's population and across today's social and economic realities.  Take the 675,000 who died in the US and assume half were 18 to 40, as we always say in our presentations.  Now imagine if we took the 2.5 million Americans who would die if 1918 broke out all over again.  Imagine if we took more than one million Americans between 18 and 40 and just erased them from the map.  We also erase their earnings potential across their lifetimes.  We erase their incomes, their contributions to society, their ability to buy homes, their ability to build businesses, their ability to help mold a new America.  And we erase their ability to pay the taxes that will be needed to keep the nation afloat. 

That is where pandemic flu also crosses the line into the illegal immigration debate.  It is simple economics.  If a million younger wage earners die, a million more must take their place.  The United States will have no choice.  It will have to import its labor from wherever it can take it, and it will reshape the nation's future permanently. 

Forget the IMF, World Bank, CBO and British government projections of a drop of nearly 6% in global GDP.  Imagine if that drop maintained itself for years, maybe even decades..

In short, were a flu pandemic to erupt today, and if we do not try to save our future wage earners, leaders and mothers and fathers, we will surely bankrupt the nation and plunge the world into economic depression.  Without a national pandemic triage strategy to debate in the sunshine, and without the proper national resolve, we may wind up dooming the United States to its darkest period since the Civil War.  And this is assuming only a 2.5% Case Fatality Rate.  What if it is worse?  Heck, the CFR from SARS was nearly 10%! 

If H5N1 "goes pandemic," we know the CFR -- and the death curve -- are potentially even more depressing.  Sure, elderly people die.  But 90% of the deaths due to H5N1 infection are people under 40, and younger children suffer disproportionately.  Elderly people do not die in the same percentages when infected by H5N1.

The United States, therefore, simply cannot afford to treat all its people equally in a pandemic.  It must have a national triage strategy, saying that based on the mortality of the disease, certain age groups must come first for Tamiflu, for ventilators, for vaccine.  It means others will have to take a back seat or, regrettably, not get a seat at all.  And I doubt if there will be any real legal consequences for these decisions, since any flu pandemic invoking this level of triage will certainly also invoke a national state of emergency, maybe even martial law.  Those declarations pretty much wipe out any legal standing for dying plaintiffs.

So in the next pandemic, who gets the ventilator?  The 29-year old woman, or the 69-year old man?  Who do you save, your future or your past?

Is it really that hard to decide? 

One would be hard-pressed to find anyone as tuned in to the avian influenza situation as Florida's Commissioner of Agriculture, Charles Bronson.  A former state senator from the Vero Beach area, Commissioner Bronson was appointed Commissioner of Agriculture and Consumer Services in 2001 after the departure of his immediate predecessor, Bob Crawford, to the Citrus Commission.  He has been re-elected twice by massive margins.

It is easy to understand why.  He absorbs information like a sponge, he makes excellent decisions, and he has not allowed the trappings of his office to change him as a person.  In fact, the last substantive conversation I had with him was in the ice cream aisle of an Albertson's grocery store close to our homes.

It was the next-to-last substantive conversation I had with him -- on the floor of the Florida House -- that really floored me.  It was late April, 2007, and I sat down next to him to talk him up on the topic of bird flu.

It was he who talked me up!  Among the things I learned:

• Bronson hired the top avian influenza vet in the FDA away from them, following that person's work on the Delmarva Peninsula AI outbreak of a few years ago. 
• Bronson told me he wanted the nation's best bird flu vet working for him, because Florida has a significant poultry industry and he did not want to see that industry wiped out by bird flu. 
• That showed great wisdom and a desire to obtain the best minds, regardless of cost.
• Likewise, he began explaining past AI and equine influenza and equine encephalitis problems.  He also spoke about detection efforts and problems with same.  He knows his stuff, this Commissioner.

I was comforted by Bronson's knowledge of the threat and impressed with his methods to move forward to combat it, if and when it comes.  I am truly proud of my friend.

At the left are two charts.  One is the HHS "Wildfowl Flyways of North America" that we are all familiar with. 

Now look at the second chart, "Commercial Poultry in Florida' and see the areas of commonality.  No wonder Bronson wanted the best person he could lure away from the FDA to help with current and future AI efforts in Florida.

Commissioner Bronson takes a down-to-earth approach to things, so it is no surprise his agency's Pandemic Influenza Agriculture Planning Toolkit reflects his approach.  Written in plain, everyday English, this 28-page guide is an easy read.  It also seeks to both educate and urge preparedness without sugar-coating the situation.  This is both welcome and refreshing.  It tells things like they are, or will be.  For example, in the subheading "Vaccines," it mentions flatly that there will either be no vaccine, or vaccine will be in exceedingly short supply.  Likewise, it makes short shrift of antivirals, barely mentioning them other than to say there will be a "limited amount".  Under "Risk Communications," the Toolkit says that "sustaining public confidence over many months will be based on consistency" of the message during a pandemic.  Finally, under "Federal Assistance," the toolkit says there won't be any. 

The guide mentions that essential goods such as food and water, and services such as electricity could be compromised for several days or weeks. It then inserts the HHS panflu checklist for individuals and families, which we all are familiar with.  The guide next gives the HHS business panflu planning checklist.  Note the order of the inserts.  Placing families first, ahead of business concerns, is key to successful management of a pandemic.  I cannot tell you how many panflu plans I have seen (or COOP/DR plans, regardless of event) that fail because they fail to take reality into account.  that reality is that people's concern moves away from the business or corporation or government, and moves correctly into concern for family and the safety of the family.  Once the family is secure and safe, then the consciousness moves back to the workplace. 

Any pandemic plan that fails to take this concern into account will fail miserably.  ExxonMobil knows this, for example.  the ExxonMobil plan is to move entire families to its refineries and give them food, shelter and health care.  This, they recognize, is the only way they can ensure the continued refining of gasoline and other products during a pandemic.  

So the Florida agriculture plan rightly presents the order of concern during a pandemic; families, then the business.

After a page of links to Florida and Federal resources for pandemic information (regrettably, they forgot the Florida CIO Council's superb panflu Website, at bpr.state.fl.us/pandemic), the Toolkit moves into the Things Momma Taught Us:  Proper personal hygiene, covering your cough or sneeze, and keeping a respectable distance from strangers.  The Toolkit uses Red Cross and Florida Department of Health information to offer much more detailed family healthcare tips. These tips include making an electrolyte drink to hydrate victims, and how to reduce fever.  While good for the workplace, they are especially important for caregivers at home.  So the message to take care of family is doubly reinforced.  Seasonal vaccine steps are also encouraged, always important for poultry workers.

Closing out the Toolkit are two poster templates, provided by the Florida Department of Health.  They are good for seasonal flu and should be up in bathrooms and near time clocks all year round.

Things not in the Toolkit, but are covered by other Department of Agriculture and Consumer Services programs, include surveillance and management of poultry.  Bronson is a huge proponent of surveillance and, being a hunter himself, he works with other State agencies to make sure hunters report any suspicious behavior or activity by wildfowl.

This simple, easy-to-understand Toolkit should be printed and kept in a three-ring binder in everyone's home -- in a prominent place, close to medicines and food.  Perhaps Florida will use this guide as its default personal and business guide to send to every family in the state, as other states have done.

You can't get much better than this Toolkit as a starting point for family and business preparedness.

About two weeks ago, I wrote an open letter to Indonesian President Susilo Bambang Yudhoyono (or "SBY," as I understand he is called.  That reference comes from the always-welcome Blogsite of HHS Secretary Mike Leavitt).

The topic of my open letter was, of course, Indonesia's reluctance to participate in the community of nations.  The responses I received (not from SBY, but from faithful readers of this Blogsite)  were both welcome and interesting.  But they all had a common thread, which was:  Why spend good money after bad?  Why continue to accept Indonesia's pussy-footing on this important issue?  Haven't we done enough already?

Allow me to bring in a parallel:  Our Global War on Terrorism.  We have made it the stated policy of this nation that we will not wait for a terrorist attack to take place on American soil.  We will go after the terrorists wherever they are, whoever they are, and we will drive them into the ground.  We will gladly introduce them to whatever vestal virgins they may wish to visit  --  but on our terms, not theirs.

Let me say again: The global war on terrorism.  Now I want you to do a mental exercise:  Every time you read or hear the words "global war on terrorism," insert "fight against pandemic influenza." Or when you hear "the terrorists," think "pandemic flu."  Since homeland security experts (and the British government) have declared a pandemic to be as much of a risk as terrorism, we can substitute these expressions freely. 

Here we go:

We will take our Global War on Terrorism to all corners of the globe.  Anyone who is not helping us in this fight against The Terrorists is with the enemy.  We will defeat the terrorists because our fight is righteous and correct.  And woe betide anyone, or any nation, suspected of harboring the terrorists as a matter of national policy, or obstructing the Global War on Terrorism.  They will be dealt with.

We see the war in Afghanistan, the attempts to win the peace and build a new nation after winning the war in Iraq, and the efforts to wipe out individual al Qaida operatives via Predators, snipers, smart bombs (and occasionally some regrettably ill-placed bombs), and domestic arrests as evidence of the ongoing war against terrorism.

What we don't see are the deals, the secret agreements with nations such as Pakistan, and the flow of billions of dollars in aid (and other things) that allows us to continue to try and eliminate Islamic fascism's capacity to harm us.  That is both understandable and necessary; I am not sure I want to know how sausage and diplomacy are made, to paraphrase Mark Twain. 

You get the point.  If we are to remain consistent, we must engage bird flu as we also engage terrorism.  That means taking the fight to the enemy, no matter where it is.  It also confers a responsibility to other governments to be with us or against us.  "Us," in this case, is the WHO.  It is the UN.  It is 192 WHO member nation signees.  It is, quite simply, the rest of the planet.  In an ironic twist, it even includes some nations suspected of harboring terrorists!

We are dealing with an enemy -- the rise of pandemic influenza -- that is potentially a more indiscriminate killer of people than all the terrorist acts on the wish list of al Qaida combined.  It is amazing to me that various nations around the world are able to work cooperatively to ensure that the flow of information takes place to eliminate the spread of avian flu, despite their long-standing political and cultural differences.

As I mentioned in the open letter, we have nations such as Israel and the Palestinian Authority speaking regularly -- sometimes daily -- to corral H5N1.  India and Bangladesh are also working to try and contain bird flu, although things get mighty testy sometimes.

We even see transparency in the most unexpected of places.  Myanmar (Burma), arguably one of the most repressive regimes on Earth, is reporting its H5N1 problems.  China, which still "runs home to Momma" and reverts to secrecy at the worst times when it really needs openness and transparency, has improved its reporting of H5N1.  And Pakistan, which has almost as many geopolitical and geological problems as Indonesia, has the ability to welcome the WHO with open arms and securely move WHO lab workers into areas that are still crawling with al Qaida fighters.  We welcome these examples of transparency, even if we are not completely happy with the speed with which they occur.

In contrast, the nation of Indonesia has consciously decided to move into the opposite direction.  In fact, Indonesia has decided to become the bird flu equivalent of North Korea, becoming less and less transparent and trying to close off any attempt to determine its current status (NAMRU-2, WHO).

My goal -- and I am certain, the goal of HHS Secretary Mike Leavitt and his recent, unplanned and urgent trip to Jakarta -- was to try and get Indonesia to understand it has a global obligation in the fight against H5N1.  My open letter was certainly not intended to usurp or undermine Secretary Leavitt's diplomatic efforts, and I don't think anything I write could ever pack that much weight.  It was intended to show Indonesia that Americans care about what is going on in that nation, and that we all realize that this impasse could kill Indonesian and American children alike.  It was intended to show that Indonesia does not have to go it alone.  I also wanted to give some flexibility and options to both parties, and to show that some creative way might be found to end this impasse.

Part of the agreement signed between 192 nations and the WHO, as I understand it, makes viral strains the intellectual property of each nation.  That means Chinese H5N1 is the intellectual property of China.  But it also means that each signee nation must provide those samples in a timely manner to the WHO.  The WHO may or may not be allowed to release public sequences (which arouses the continual ire of Dr. Henry Niman and others), but at least someone gets to sequence those samples and look for mutations. 

Indonesia is a signee to that agreement.  Regrettably, Indonesia seems to have decided not to honor that treaty, and instead to continue to bicker and trivialize the situation.  By demanding some sort of vaccine guarantee in exchange for viral samples is the equivalent of cutting off one's nose to spite one's face.  No one knows if a Clade 2.1 mutation will spark the Next Pandemic.  No one knows if any currently-existing clade will trigger H5N1 H2H in humans.  And it is arrogant beyond words for Indonesia to think it should be guaranteed some sort of vaccine even when no one knows if it is their strain that will "go pandemic."

We already are shipping Tamiflu in prodigious quantities to Indonesia.  We are spending millions of American taxpayer dollars on preparedness in Tangerang province.  And only God and the OMB know how much in American taxpayer aid has already gone toward stomping out an Indonesian flu pandemic before it starts there.  In short, we are doing enough to help Indonesia.

By resolving to keep its H5N1 samples internal to Indonesia, and no matter how well-qualified its scientists are, it is playing Russian Roulette with the world's health.  This fact was underscored by the excellent recent editorial in the Wall Street Journal.  The Journal editorial also presented a political factoid; namely, that Health Minister Siti Fadilah Supari is courting Islamic factions in some bid for political office, and it always plays well in Jakarta and elsewhere to give the U.S. a hotfoot whenever possible.  this is confirmed by Secretary Leavitt's blog entry:

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

Except that this hotfoot will potentially burn everyone -- especially Indonesians.  Medical realities disclose that vaccine is an endgame strategy.  Vaccine will not be available until the second wave of a flu pandemic at best.  Maybe we won't see vaccine until the third wave.  No one knows.  But basing a global strategy on the basis of vaccine guarantees ignores the reality that most of Indonesia's population will be impacted well before a vaccine becomes available. 

The problem is, like the war on terrorism, we still have to work with recalcitrant nations.  We just cannot "write off" Indonesia.  We must convince this nation to cooperate with the United States.  This, too, was at the top of my list and the forefront of my consciousness when I wrote the open letter.

However, patience is a virtue that is not inexhaustible.  Secretary Leavitt underscored that thought when it gave Indonesia a time certain for a return to its treaty obligations.  Secretary Leavitt said in his blog:

I  have instructed my representative on this matter, Bill Steiger, to work with Ambassador John Lange, Secretary Rice's Special Representative for Avian and Pandemic Influenza, to continue our discussions with the Indonesians and others for the next two months. However, we cannot be party to an arrangement that will un-do 60 years of one of the world’s great public-health successes.

There are some situations that, despite our best efforts, we cannot resolve. In those cases, we just live with the added risk. The cost of Indonesia's refusal to share influenza samples is incrementally small. However, the damage done by accepting Indonesia’s view is profound, and simply unacceptable. 

Well said, Mr. Secretary.  We need to accept this worldview.  Indonesia needs to live up to its obligations. If not, move NAMRU-2 to a nation that would welcome it.  We'll get the Indonesian flu samples some other way.

And may God help us all if Supari wins any election for anything important. 

H5N1 avian influenza, which has run rampant in domestic poultry across the nation of South Korea in just a matter of weeks, has apparently just infected its first person.  That person is a South Korean soldier who was directly involved in the culling effort.

Some 14 other people (as of this Blog) were in hospital for symptoms of avian flu. 

The soldier was issued Personal Protective Equipment (PPEs) and was also given the antiviral Tamiflu as a preventive measure. 

For more on this development, check out these links:

http://www.flutrackers.com/forum/showthread.php?t=65451&page=2

http://www.recombinomics.com/News/04220805/H5N1_Korea_Transparency.html

http://www.recombinomics.com/News/04220804/H5N1_Korea_Mild.html