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Unless we act now, bird flu may win

Author: Laurie Garrett, Senior Fellow for Global Health
February 26, 2006
International Herald Tribune

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Despite the commitment of billions of dollars to the fight against pandemic influenza, the world may lose the battle against avian flu, for lack of an effective strategy. Much of the money—nearly $4 billion from U.S. taxpayers, alone—is being spent inappropriately. For far less money, strategically deployed in a global campaign, the world could be a safer place for the coexistence of man and microbe.

H5N1 avian flu has reached Nigeria, Iran, Iraq, all the Black Sea nations and now Austria, Denmark, Bulgaria, Italy, Slovenia, Hungary, Switzerland, India, Egypt, France and Germany. There is a sense of panic in the air, as Asians, Europeans and Africans alike imagine a catastrophic human pandemic.

It could happen, but humanity ought not simply consider the event inevitable and frantically stockpile Tamiflu and other drugs of dubious efficacy. A definitive report in the Jan. 28 issue of the medical journal The Lancet concludes, “We could find no credible data on the effects of [Tamiflu] on avian influenza.” The Italian and Australian authors of the report warn that, “Over-reliance on a pharmacological solution to the ravages of influenza may impede the development and implementation of broader intervention strategies based on public-health measures.”

It is urgent that public health leaders and policy makers step back from the breech and consider how this bird pandemic is spreading, and what can be done about it. We know enough about influenza to develop and execute a rational strategy. It will require some significant feats of diplomacy and foreign policy, but it is achievable.

First, let’s stop pretending nature is mysterious, and concentrate on what we know. H5N1, though deadlier and potentially far more devastating than any other influenza seen in nearly a century, has followed a fairly clear set of biological, predictable principles since it first surfaced in Hong Kong in 1997.

Thanks to the brilliant work of scientists like Robert Webster, Malik Peiris, Kennedy Shortridge and K.Y. Yuen, we now understand that influenza is naturally an aquatic migratory bird virus that is carried by ducks, geese and a small list of other waterfowl. Influenza infection is usually harmless to these world travelers, but can kill other types of birds, such as chickens, domestic ducks and swans.

The vulnerable birds contract their infections when the migrating species land on farms or ponds, and pass influenza fecally. We now know that the H5N1 virus is particularly robust, and can survive suspended in fecal material for more than a month, making it possible that a flock of dead chickens spotted today may actually have become infected as a result of pecking its way through feces deposited weeks ago by a passing goose.

So far the only tactics being deployed once H5N1 turns up in domestic animals are slaughter, culling millions of animals that are suspected of being infected, or mass vaccination. If peasant farmers cannot afford to keep domestic animals indoors, away from wild birds’ contaminating viruses, an alternative is to keep the migrating birds away from the farms.

For at least a decade H5N1 has circulated among a small pool of migrating birds, mostly inside China, and occasionally broken out in other animals and people. Last May, however, more than 6,000 avian carcasses piled up along the shores of Lake Qinghai, in central China, one of the world’s most important bird breeding sites. Most of the dead included species that hadn’t previously evidenced influenza infection.

The Lake Qinghai moment was the tipping point in the bird flu pandemic. The virus mutated, evidently becoming more contagious and deadly to a broader range of bird species, some of which continued their northern migration to central Siberia. By June, Russia’s tundra was, for the first time, teeming with H5N1-infected birds, intermingling with southern European species that became infected before flying home, via the Black Sea.

Not surprisingly, by October countries from Ukraine to Greece were rumored to have H5N1, but only the Romanian government responded with swift transparency, culling tens of thousands of chickens and ducks. Most of the governments in the region did not confirm their H5N1 contaminations until Turkey, after at least three months of denial, was forced on Jan. 6 to admit that the virus had infected birds in a third of the country’s provinces, and had caused several human infections and deaths.

Since then, we have learned of confirmed bird and/or human H5N1 cases in Iraq, Azerbaijan, Iran, Greece, Spain, Italy, Croatia, Austria, Hungary, Slovenia, France, Germany, Denmark, Bulgaria and, most disturbingly, Nigeria, Egypt and India.

Not a single one of these countries’ outbreaks ought to have been surprises. Each of them is located along either the Black Sea/Mediterranean migratory bird flyway, which starts in Siberia and, at its southernmost point, ends in Nigeria and Cameroon, or the European flyway, which overlaps the former, and stretches from northernmost Siberia to Nigeria.

Anybody tracking the birds could have seen it coming. Several countries along the flyway between Saudi Arabia (which has confirmed H5N1 infections in falcons) and Nigeria have not reported H5N1 cases, but much of the region is North Africa’s sparsely populated Sahara Desert. Egypt reported widespread bird infection last week, and it is likely that infected birds have landed along the few waterways in the area, such as the Nile, Lake Chad and the Red Sea.

We should not be astonished to learn of H5N1 outbreaks in birds or people in the next few weeks in nations located along the East Africa flyway, which overlaps with the already contaminated Black Sea/Mediterranean one: Cameroon, Chad, Ethiopia, Sudan, Uganda, Rwanda, Burundi, Tanzania, Gabon, Angola, Namibia, South Africa, Madagascar, Mozambique, Malawi and the rest of the eastern African countries.

Because H5N1 has been confirmed in Nigeria, Egypt, Germany and Spain, which straddle the intersections of the Black Sea/Mediterranean and the East Atlantic flyways, over the next six weeks we should not be surprised to hear of H5N1 bird and even human cases in several northern European nations, including Britain and Iceland.

By June or July, if the biological imperatives continue to follow their course, H5N1 should turn up in eastern Siberia, and then Alaska, via the East Asia flyway. It might also at that time jump from Iceland, via Greenland, to northern Canada. Once in the Arctic zones of the Americas, H5N1 will be able to follow any, or all, of the four primary north/south flyways that span the Americas, from the Arctic to Tierra del Fuego. It is in the realm of reasonable probability that H5N1 will reach the United States this summer or early autumn.

Instead of simply sitting back and watching nature take its course, the global community should be proactive. Being ahead of the virus is akin to being ahead of the migrating birds. Instead of waiting for dead birds, and even dying people, to turn up in new areas, political leaders should heed the warnings from science and act accordingly—as, apparently, Sweden and the Netherlands are doing. The Swedes and Dutch looked at their maps, plotted the movements of infected birds, and last week ordered farmers to bring their flocks indoors, out of harm’s way. In poorer regions of the world, where indoor facilities for animals may be unaffordable, simple nets and fences can radically decrease contact between wild and domestic birds, and mass public education campaigns warning people to avoid contact with sick birds or carcasses may decrease the likelihood of avian-to-human transmission of H5N1.

One of the best untapped resources in this epic battle against influenza is bird-watchers, who are among the most fanatic hobbyists in the world. The major bird-watching organizations and safari clubs ought to work with the World Health Organization and OIE, the World Organization for Animal Health, to set up Web-based notification sites, where birders could report sightings of groups of dead birds, and the movements of key migrating species.

Ornithologists and climate experts should immediately sit down with pandemic planners and virologists, creating lists of known H5N1 carriers and plotting their most likely global movements. As the birds appear in new regions of the world, birders and professional wildlife surveillance personnel should issue alerts, which should be swiftly confirmed and form the basis of government response.

When carrier species are sighted in a region, swift action should be taken to minimize contact between the wild birds and their domestic kin. In such a way, it might be possible to limit avian deaths to susceptible wild birds, such as the dying swans of Europe.

While the H5N1 virus remains an avian killer, wealthy nations and biomedical companies should work hard on developing a rapid, simple method of diagnosing flu infections in people. Currently, many of the delays in reporting human cases around the world are due to the tedious laboratory procedures necessary to diagnose H5N1 infection. We urgently need a quick infection test that can be performed by nonprofessionals.

Rather than waiting for a tide of H5N1 to wash over the world’s birds, mutate, and then move in a tidal wave over humanity, we should create lines of defense that start with the wild animals, move next to protect poultry, and then rely on rapid screening of human beings to determine who is, and is not, infected with the virus.

In the absence of these sound footings, everything else is just wasted billions of dollars.

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