Michael Fumento's "Fuss and Feathers" (Nov. 21), regarding the risk of an H5N1 pandemic, was at times misleading. For example, he labeled the SARS and Hong Kong bird flu outbreaks false alarms, when in fact authorities effectively intervened to prevent pandemics. He missed the point of us "Chicken Littles" – to encourage awareness and preparation, not hysteria.
Here's the "Chicken Little" agenda: First, approach the prospect of pandemic the way you do a house fire. House fires are very rare, but so catastrophic when they occur that we need to be prepared, with insurance, alarms, and so forth. In the short term, pandemic is also very rare, but so catastrophic when it occurs that we need to be prepared with knowledge and a few supplies.
Second, we saw with Katrina that "authority" cannot save us unless we meet it halfway. During a pandemic, we know health care systems will be swamped and unavailable to all but the sickest people. Most people will convalesce at home. Bearing in mind that people likely will be sick for a week and weakened for three more, citizens consequently should ensure they have symptomatic treatments on hand to get their families through a bad bout of flu.
Third, because of a just-in-time economy, if a pandemic hits, there may be short-term outages of some staple goods (if, say, truck-drivers are out sick) and longer-term outages of imported goods, including most medicines for chronic illness (blood pressure, asthma, etc.). It would be wise to have a month, preferably three, of supplies in case trade is shut down. Businesses should have a plan to deal with 30 percent worker absence for a month or two.
Workers should stay home while sick, and employers should send the sick home, while parents should keep sick kids out of school. And, of course, wash your hands, or use alcohol wipes or waterless cleaning gels. The longer you can delay catching the flu during a pandemic, the greater the chance that new medications or a vaccine will become available.
A serious flu pandemic might happen tomorrow, or it might happen in 50 years. Hedge your bets with a little preparation, and then don't worry. Getting through any pandemic will require teamwork. Public health and big pharmas will work on treatments, but individuals and businesses can reduce collateral damage by being aware and prepared.
Lisa Thornquist, MD
Michael Fumento unfortunately gets a little carried away in "Fuss and Feathers," even as he criticizes those who are hyping pandemic fears. Moreover, though I appreciate his calling my book The Great Influenza a "landmark" study, he also misuses some of the information in it.
The most important error he makes is understating the danger of the virus. It is true that even in 1918 most deaths probably came from bacterial pneumonia, and today antibiotics can treat that complication. But this must be understood in context, and with several caveats.
First, the virus itself would indeed kill people directly. In any pandemic, intensive care units will be overwhelmed, and without them a viral pneumonia would almost always be fatal. Even in the "mild" pandemic of 1957, 25 percent of the deaths came directly from the virus. In 1918 the chief target of the virus was the young adult population, which accounted for more than half the total dead. And in this demographic, most deaths did come directly from the virus. (Fumento accurately quotes me as attributing the actual mechanism of death to an overreaction by the immune system, but apparently fails to realize the virus itself triggered this overreaction, and therefore such deaths are the direct result of the virus.)
Second, even today bacterial pneumonia following influenza is a very dangerous complication; even with antibiotics, it has an 8 percent mortality rate. When the invading bacteria is antibiotic-resistant staphylococcus, the mortality rate jumps to 40 percent. And although under normal conditions staphylococci rarely cause pneumonia, in 1918 they often invaded the lungs.
Fumento makes another serious error when he suggests that conditions at the front during World War I influenced the evolution of the virus into lethal form. Since these conditions are unlikely to be replicated, that in turn suggests we have little to fear. There is a very nice theory to this effect, but it is unfortunately contradicted by all the data and supported by none. That makes it simply another instance of what Thomas Huxley called "the great tragedy of Science – the slaying of a beautiful hypothesis by an ugly fact."
Fumento is correct that we have no way of knowing whether the next pandemic will come tomorrow or in 20 years or in 50 years. But the threat of a pandemic is real and serious. Indeed, we are actually more vulnerable to influenza today than we used to be. CDC estimates that even a mild virus such as the one that killed 34,000 Americans in 1968 would today kill between 89,000 and 207,000. (The increase is because of a dramatically increased population with impaired immune systems, including the elderly, cancer survivors who had radiation or chemotherapy, and so on.) Our economy's vulnerability to a pandemic has also increased. We need not panic, but we should be prepared.
New Orleans, La.
Michael Fumento responds: Lisa Thornquist's implication that disease outbreaks only fail to occur because we insisted they would is always the last refuge of epidemic and pandemic panic-mongers. Yet when I wrote my Hong Kong bird flu article and my initial SARS article there was nothing but talk of doom in the air. It was simply given that no matter what was done something horrible would happen. Additionally, it has always been assumed that preventive actions will be taken; Dr. Michael Osterholm assumes it when he tosses around his estimate of 360 million dead from avian flu, and I assumed it for my article.
Other than that I have little problem with Thornquist's suggestions. But stocking up on three months' worth of supplies for something that may happen during the next 50 years is hardly feasible for those of us without the salaries of medical doctors--much less their refrigerator and pantry space!
Regarding John Barry's letter: Unfortunately, if you read his original book, and then the afterword in the subsequent paperback edition, you might think there are two different authors. The apparent explanation is that the afterword was a sales tool meant to capitalize upon the avian flu hysteria. All of the references to Barry were from his pre-hysteria book. Yet even the afterword concedes that "the only good news seems to be that an increasing number of virologists now doubt that H5N1 [avian flu] will be the next pandemic virus."
Again we see two John Barrys when he writes above, "It is true that even in 1918 most deaths probably came from bacterial pneumonia," though his book says that though there were other causes of death, "by far the most common was from pneumonia caused by secondary bacterial infections." So which is it: "most probably" or "by far"? In any case, other sources I cited indicate the pre-hysteria Barry again is the correct one.
He also ignores my reference to the pneumococcal polysaccharide vaccine to which I devoted two paragraphs, in part noting that "bacteria never develop resistance against it." It protects against almost 90 percent of all bacterial cases of pneumonia, including staphylococcus.
Barry's reference to direct viral deaths omits the availability of the antiviral drugs that I discussed at length. We do not have enough yet; but if Barry is convinced H5N1 is not bearing down on us, he has no case that a pandemic is imminent. The shortage decreases by the month and can be eliminated within a couple of years.
My discussion of the importance of the conditions of World War I was based not on Barry's book but, as noted, on Paul Ewald's Evolution of Infectious Disease (as well as historian Carol Byerly's recent book, Fever of War). Barry unfortunately provides us with no "ugly facts" that would slay these "beautiful hypotheses." Further, regarding the spread of the disease, nobody questions the importance of packed camps, trains, trucks, boats, and trenches. For this reason, among many, it is foolish to pretend our calendars read "1918."
Insofar as much of my article was devoted to preparing for the next pandemic on both a national and personal basis, I can hardly argue with Barry's conclusion. But CDC predictions, as we saw with AIDS and SARS, are often divorced from reality. It may not be as foolish to use 1968 for a reference point as 1918, but it remains that there were no antivirals in 1968, no PPV vaccine, and the use of new technologies to quickly and reliably produce flu vaccines was several decades away. Medicine has marched on, and there is no valid purpose in pretending otherwise.