Council Fellow Laurie Garrett’s rebuttal to Siegel interview

Laurie Garrett, senior fellow for global health at the Council on Foreign Relations, writes a rebuttal to Marc Siegel’s views on epidemics.

[Dr. Siegel] demands absolute certainty before he will accept risk; well, that was Condoleezza Rice’s excuse for rejecting Richard Clarke’s memorandum warning of an Al Qaeda attack in August 2001. He rejects preparatory action in advance of a proven threat, arguing most of it is too expensive. In truth, the pandemic flu preparedness budget is miniscule—the last White House request was for less than $180 million. In contrast, [Siegel] could have raised these arguments to address the well over $3 billion spent to date to prepare America for a smallpox terrorist attack, an eventuality most experts in the field consider so remote as to be virtually impossible.

In the case of smallpox, the government argued that it’s true the germ had been eradicated and the only living samples of the virus were in high-security labs in Russia and the United States. However, the Soviets violated the agreement and moved their samples to a notorious bio-weapons lab in Siberia where mutant strains of the virus were developed. That lab’s weapons work has been shut down—but the samples could have been stolen or sold to evildoers.

I don’t see Dr. Siegel attacking the US bioterrorism/smallpox program in his email. In contrast to the risk of smallpox, pandemic flu caused by H5N1 offers this calculus:

1. The virus is genuinely in circulation in a geographic area that now spans from southern Indonesia to central Siberia, a distance of thousands of miles. This week we have word of discovery of H5N1-infected birds on the European side of the Urals and in the Caspian Sea, making it virtually certain the virus will now spread across Europe.
2. Unlike smallpox, which infects only one species on Earth (humans), H5N1 has been found in dozens of species ranging from migratory birds to pigs to humans.
3. The virus is actively mutating, taking on new and unpredictable characteristics.
4. Smallpox has at worst a 30 percent mortality rate in unvaccinated human beings, but the H5N1 kill rate in humans so far is 55 percent.
5. Smallpox vaccine is 100 percent effective, and a single stockpile, if properly stored, lasts for decades and would be effective against any smallpox strain. The virus does not readily mutate in nature.
6. In contrast, we have never in history managed to manufacture more than 250 million doses of flu vaccine in a timely manner. It is extremely difficult to make, requires some six to nine months to manufacture even meager supplies, and most of the world’s more than six billion humans have no prayer of accessing it. Further, the virus continuously mutates, so a vaccine effective in one season may be useless in the following one.

The government’s current efforts to make a mock-up H5N1 human vaccine represent a proof-of-principle, showing that such a product can be made. That was not a certainty. Unlike past flu strains, this one is 100 percent lethal to chickens, and we make vaccine by growing it on chicken eggs. So in order to make this vaccine, significant biological tinkering had to be done.

I assume Dr. Siegel would want absolute certainty that a pandemic strain was, indeed, transmitting from human-to-human before he would like alarms raised, money spent, and government mobilization underway. That would certainly mean letting millions of people die. A recent study published in Nature demonstrates that it is possible to stop a virulent pandemic, but only if it is identified and contained at the level of just thirty human cases. That is hardly reassuring, given the state of public health systems in the key Asian nations where H5N1 is now circulating. The lag time from identification of a case to global notification from Vietnam, for example, is averaging eight weeks. If H5N1 makes the necessary mutational change to become a rapid human-to-human transmitter, it is a virtual certainty that it will spread far beyond thirty people in eight weeks. The horse will be out of the barn before the systems Dr. Siegel might consider justified would kick in.

Dr. Siegel appears not to realize just how difficult it is to both manufacture appropriate vaccines and to distribute and use antiviral drugs. He also appears not to appreciate the difference between preparing middle class Americans for a threat, versus the citizens of the entire world. Resource scarcities in developing countries are so acute at this time that nothing would stop the movement of pandemic flu through their populations.