An influential voice weighs in on pandemic preparedness
Scott McPherson
in Information technology, Politics and government, Popular Culture, influenza and infectious diseases
|
8 Comments
Thomas P.M. Barnett has written an excellent opinion piece for the Scripps-Howard News Service. Titled "In the future: health screening at airports," the piece clearly and plainly lays out the enormous difficulties nations and the aviation industry in general will face when the next pandemic arrives (via a scheduled passenger airline flight). The link is at: http://www.scrippsnews.com/node/27573
Barnett is no stranger to planning. In fact, if you have not heard of him, let me condense his story. Barnett was in the Pentagon in the late 1980s and started giving Powerpoint presentations regarding what he believed was the inevitable implosion of the Soviet Union. He even went so far as to predict the American Navy, for example, would be called upon to help its Soviet counterparts.
The assembled admirals and generals scoffed at this heresy. More than once he was laughed out of the room. But the ensigns, commanders and captains in the back rows -- the inheritors of the military after the current silver-hairs retired -- they listened with intense interest.
And they believed.
When the Soviet Union did collapse, just as Barnett predicted and within the timeframes predicted, and the U.S. was asked to help its former enemies, those same youthful military leaders sought out the visionary Barnett. "Where's that guy with the Powerpoint!" they would yell at their adjutants. In response, Barnett's first book -- The Pentagon's New Map -- was a New York Times bestseller and the second-most popular book in the entire Pentagon, behind the Bible. Barnett's follow-up work, A Blueprint for Action, also sold well and both books are in trade paperback today and available at fine bookstores across the United States.
He is also a buddy of mine, so I am happy to shill for him! Barnett gives the most lucid explanation for the violence directed against the civilized world today via his "Core and Gap" message. It is simple yet not simplistic. It is simple genius and one only wishes someone at 1600 Pennsylvania Avenue would stand up and articulate it to the world. He is frequently bookended in peoples' minds with fellow globalization maven Thomas Friedman. To contrast: Friedman is the diplomat and Barnett is the enforcer (again, a reference to his desire to revamp the military into "The Leviathan" and "System Administrators" -- oh, just go buy the damn books!). He is sometimes described as "Jack Ryan with a Powerpoint." He is brilliant.
Barnett was heavily involved in the Pentagon's Y2K planning effort in the late 1990s, which is where I first heard of him. As I was running Florida's statewide Y2K preparedness effort, I naturally took a deep interest in those in Washington who were also thinking way outside the box.
Anyway, I have taken some excerpts from his latest column, which I referenced way back in the beginning of this blog. Here they are:
The White House recently released its new homeland security strategy and, unlike the initial 2002 version, this one focuses far more on natural disasters as opposed to terrorist strikes. That's a welcome change not simply because Hurricane Katrina was a humbling experience, but because globalization's growing connectivity means a naturally occurring pandemic is the most likely mega-disaster we'll face in the near term.
A bird flu-triggered pandemic could easily become the most deadly global outbreak since the 1918 Spanish Flu, which killed at least 20 million people worldwide. In the United States alone, over one-quarter of the population became sick, with approximately 600,000 people succumbing to the virus. Extrapolated to today's American population of 300 million, that yields a potential death count of 1.5 million to 2 million.
Flu strains enter the United States in the bodies of sick travelers, so the key here will be our efficient and effective screening of in-bound passengers at international airports. According to Oak Ridge National Laboratory scientists currently investigating pandemic response procedures for the Department of Homeland Security, for every flu carrier who --unwittingly or not-- eludes that envisioned net, as many as 10,000 Americans could suffer exposure within three weeks time.
Consider the sheer volume: over 25,000 passengers arrive through Los Angeles' international terminals on a daily basis. In August, when a software glitch struck U.S. Customs' computers there, 20,000 passengers were stranded for up to 18 hours.
Ideally, any systemic approach would include initial diagnostic screens conducted overseas at originating airports. Since virtually all international flights are lengthy, passive diagnostic screening at points of embarkation and debarkation would offer authorities the opportunity to compare and contrast readings over time. For example, additional measures would be warranted if a passenger's symptoms worsened during the flight or if those symptoms spread to other passengers.
In the summer of 2004 my wife and I got a preview of this sort of screening at Honk Kong's international airport during a localized outbreak of avian flu cases. As we walked through the terminal with our youngest child, just then adopted from China, I noticed a large computer screen along the wall where our ghostly images were being displayed in real time. It turned out that airport authorities were scanning our body temperatures passively as we passed through a chokepoint.
I walked over to the technicians and asked about the procedure, only to be told that if any of us had registered an above normal temperature, our entire family would have been required to spend at least 48 hours in Hong Kong -- at our own cost! -- before we could again attempt departure on an outbound flight. Fortunately for us, what turned out to be our infant daughter's impending ear infection didn't kick in fully until we were several hours into our cross-Pacific flight. Had we been again screened at our American port of entry, we would have been nabbed, preventing -- for all we knew at the time -- something far worse from unfolding. (bold mine)
Where do you draw the lines in all of this? I can't begin to say.
I just know it's important that our Department of Homeland Security think through all realistic scenarios and gear up for the real-world tests that inevitably lie ahead.
Thomas P.M. Barnett is a distinguished strategist at the Oak Ridge Center for Advanced Studies and senior managing director of Enterra Solutions LLC.
As fellow bloggers Crawford Kilian and Mike Coston have pointed out, it is refreshing to have someone actually use the correct numbers when predicting an influenza pandemic. It is no surprise that Barnett would use the appropriate numbers when predicting the potential pandemic's impact on the U.S. population.
What is most important to all of us is this: Because of Barnett's extreme gravitas inside and outside of the Pentagon and the Washington media, government think tanks and policy wonks everywhere, his voice becomes a powerful force for pandemic preparedness. I am hopeful that this is the first of many, many written and vocal forays into the world of pandemic preparedness. His Website/blogsite, by the way, is www.thomaspmbarnett.com .
Reader Comments (8)
I'm not good at math, so check my numbers here.
300,000,000 people in the U.S.
x .25 get sick = 75,000,000 (75 million sick)
of those, 10% succumb
x .10 = 7,500,000 (7.5 million die)
Now, 10% is the % of people in the U.S. that died from the 1918 Influenza, right?
But the Avian Flu in Indonesia is killing anywhere from 60% to 80% of the people that get it.
So, let's give the U.S. a break and suggest that the percentage that would succumb is 40%. That would mean 30,000,000 (30 million) would die. Yes?
Ah, sorry. Forgot the postscript.
If the above is not true, how did Barnett come up with only 1.5 to 2 million deaths?
Barnett is using the Federal government's own projections of the Worst Case Scenario, which is 1918 all over again. In 1918, the population was 112 million. The Case Fatality Rate was 2.5% of the infected (not of the general population). So if you take 1918's figures and transpose them to 2007, you get 90 million infected, 45 million with severe illness, and a Case Fatality Rate (CFR) of 2.5% of the infected, or about 2 million deaths. No one dwells on the question starting us in the face: Why only 90 million infected? This leads us down the Hope-Simpson road of asymptomatic carriers transferring virus that attains its lethal critical mass via some sort of galactic/atmospheric event.
At this point, to consider an influenza more severe than 1918's would be unthinkable to most policymakers. In their minds, it is the stuff of science fiction and Stephen King-esque horror.
Of course, we know that H5N1 could defy all experts' predictions (so far, it already has). But if the leaders prepare for 1918, that would be good enough for me! Hell, if they prepared for 1957 I would feel better about things than I do now. I just don't see the urgency in peoples' minds on this issue. Nonetheless, we must keep plugging away.
Now if you were 25 to 35 years of age in 1918, your CFR was 10%. This introduces tremendous bioethical considerations into the mix, such as: If young people are dying in disproportionatly higher numbers, yet the elderly are also dying, do you vaccinate your future or your past?
In my mind, that is a no-brainer. You vaccinate your future. You vaccinate your emerging workforce; emerging leaders; and emerging moms and dads. Yet these decisions will be made by elected leaders. Will they make the correct decisions? Literally, the future of the Union will rest on the ability of these elected leaders to make the correct decisions for the health of the Republic.
Get real. No one that is ill will be allowed to board an aircraft. No one from an outbreak area will be allowed to board an aircraft. People will be heavily screened for exposure to the illness. There is not going to anything passive going on. It will not be business as usual at the airports when you arrive in the country. Be ready for some additional waits at the airport. You may even get some pills shoved at you if they think you got exposed and sent home with instructions to not go outside for several weeks so you had better stock up on canned food now.
Current mortality rate for H5N1 is over 60%, in Indonesia it is over 80% for the strain they have there. This disease causes a cytokine storm and destroys your cells. It gets into tissues all over your body. It is the stuff of science fiction. If it goes human to human, forget 2 million dead in the United States, try more like 15 to 30 million dead, with worldwide deaths close to 500 million.
Bigdude,
I do not disagree with any of what you say. But we have seen case after case where one passenger -- who looked fine at the beginning of a flight -- infects almost an entire planeload of passengers (usually, thankfully, with a simple norovirus). But if we look back at 1918 -- and the famous "Buenos Aries streetcar" stories of people who got on at the beginning of a route and were dead at the end of the route -- we can see where these mass-infection events can and decidedly will happen during the next pandemic. In Miami alone, there have been several quarantined flights just in the past year, as passengers suddenly fall ill. Then there was the Johannesburg-to-London Virgin flight of last year, where a female passenger who had spent time in the Ivory Coast was stricken and died from suspected Ebola. She was fine when the plane took off!
I don't think anyone believes the 61% CFR on H5N1 is set in stone (as you point out, much higher in Indonesia). There may be a far greater number of people who have gotten sick with H5N1 who did not die. That would lower the CFR significantly, but we are still looking at double-digit CFR territory. The WHO report of last September agrees with your point when it said a non-reassortant H5N1 pandemic strain could maintain its high CFR.
However, there is also a prevailing opinion in influenza research circles that is looking at the PB2 E627K mutation/evolution and speculates there is a sort of trade-off or (as I call it) a counterbalance between ease of human transmission and reduced virulence. This goes back to influenza A's very nature. It is the Rodney King of viruses, saying "Can't we all just get along?" Its goal is peaceful coexistence, not anniliation of its host organism. The feeling in those research circles is that it has to give something up to get something else.
I personally pray they are right.
Hey Scott,
I hope your right. I spoke with my dughter who is a molecular biologist and she is convinced that when it mutates to human to human it will lose some of it's virility and the CFR will drop, however it will still be double digit. Remember that the 1918 Spanish Flu was a CFR of 2% and an estimated 40 million plus died, with 600,000 dead in the U.S., now put that into perspective with H5N1 at a higher double digit CFR and it could be real bad for us.
H5N1 is also a bad way to die. This is not like the regular influenza, where you have too much fluid in your lungs or maybe develop pneumonia. This flu causes a cytokine storm and destroys your lungs and other organs from within. All affected cells are destroyed and you hemorage. You die from loss of tissue, loss of blood, and choking on the blood in your lungs. Very, very ugly way to die.
My hope lies with the private drug companies that want to make money by selling lots of the right vaccine. They are racing to find DNA based vaccines and and Protein based vaccines. They could find a all purpose flu vaccine that would give us resitance to any influenza before this mutates into the human to human pandemic. Or not, and I am just placing my hope in greedy people that are hyping their stocks with supposedly promising stories of their pipeline drugs.
Bigdude,
Ditto that! Check my earlier blog on the disappointing results from Biocryst.
CFRs equalling or exceeding 10% are not that rare anymore, either. Recall that SARS had a CFR of 10%, and almost went pandemic, had it not been for the lack of an incubation period sufficient to start one.
And the 1918 virus had a CFR of 10% for ages 25 to 35 -- and even higher for pregnant women in that age group. The CFR was so high in 1918 among young people that the life expectancy took a huge nose dive.
I will be blogging on bioethics and panflu soon -- and the need to debate policy NOW, rather than later,especially regarding when to cut off vaccine for the elderly.
Hey Scott,
I look forward to that blog on bioethics. Not that I have lost all trust, but this new generation has no ethics and in the last 20 years most of the emigrants we let move here have no ethics it seems like. I just grew up in a time when there was trust and moral integrity and ethics, so it is now a bad world and I am not surprised when bad things happen.
Back to the point of my reply: I read Tara C. Smith blog today "A perfect Winter Storm", great article on not being prepared for the children where she quotes Dr. John Bradley of the American Academy of Pediatrics and what he says that there is no preparation for response to PanFlu for the children, including vaccines or antivirals. Also, she says alot of children are opting out of regular vaccininations on the lie of it being on religious beliefs (because of some belief it causes autism-based on faulty research).
I recommend that article to all parents.