Table of Contents:

Foreword

Introduction

I. Storm Gathering

1. 1918

2. Master of Metamorphosis

3. H5N1

4. Playing Chicken

5. Worse Than 1918?

6. When, Not If

II. When Animal Viruses Attack

1. The Third Age

2. Man Made

3. Livestock Revolution

4. Tracing the Flight Path

5. One Flu Over the Chicken's Nest

6. Coming Home to Roost

7. Guarding the Henhouse

III. Pandemic Preparedness

1. Cooping Up Bird Flu

2. Race Against Time

3. Tamiflu

IV. Surviving the Pandemic

1. Don't Wing It

2. Our Health in Our Hands

3. Be Prepared

V. Preventing Future Pandemics

1. Tinderbox

2. Reining in the Pale Horse

Topics

References 1-3,199

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U.S. Army field hospital

What about advances in medical technology? The immune system’s attack on the lungs causes a condition called acute respiratory distress syndrome, a devastating, often lethal, inflammatory form of severe lung failure seen in other conditions such as extensive chemically seared lung burns.536 Treatment involves paralyzing the patients, producing a drug-induced coma, and mechanically ventilating them with a tube down the windpipe connected to a breathing machine (ventilator). This allows doctors to increase the flow of oxygen while suctioning fluid from the lungs, a treatment unavailable in 1918.

The mortality rates coming out of Asia, though, are not a function of outmoded medical facilities. Osterholm toured the facilities and was amazed at the care patients received. “Many of those patients get as good care as you are going to get at most medical centers in this country,” he said. “But they still crash and burn—the point being, the cytokine storm, even under the best of conditions, is extremely difficult. I don’t care if you’re in the intensive care unit at Johns Hopkins or the Mayo Clinic or in Hanoi. It’s a very difficult clinical condition to manage.”537 “In general terms,” Osterholm continued, “we are not much better able to handle acute respiratory distress syndrome, in any number of cases today, than we were in 1918.” “So,” he told a reporter, “do not go back and say, well, it is different today, it is not 1918. Unfortunately, folks, it is 1918 all over again, even from a clinical response standpoint.”538 If it happens again, Osterholm concludes, “modern medicine has little in its arsenal to fight it.”539

A former director of the National Institutes of Health describes how the scene is likely to look: “Hospital wards will be choked with thousands of victims young and old. They will be hooked up to respirators, lying in comas, and dying as their heart and blood vessels fail massively. Others will be waiting in the corridors.”540

Fifty percent of those falling sick are dying despite our best treatments, and in the event of a pandemic, even those therapies won’t be sufficiently available. There are only about 100,000 ventilators in all of America’s hospitals, and 75,000 or so are in use at any given time for everyday medical care year round.541 There are only nine major manufacturers of ventilators worldwide, each of which, according to a national marketing director, can only produce about a dozen a day. “They are usually built to order,” he says, “and it takes a couple of weeks to manufacture one.”542 Experts like Irwin Redlener, the director of Columbia University’s National Center for Disaster Preparedness, see the ventilator shortage as being emblematic of the country’s overall lack of preparedness. “This is a life-or-death issue, and it reflects everything else that’s wrong about our pandemic planning,” Redlener said.543

Within days of a pandemic, ventilators will be just one of many pieces of medical equipment that would be in short supply with the collapse of global supply chains. “Throughout the crisis,” Osterholm wrote in the public policy journal Foreign Affairs, “many of these necessities would simply be unavailable for most health-care institutions.”544 As things currently stand, says the American Hospital Association’s senior vice president for strategic policy planning, we will have no choice but to “learn to cope with 1950s medicine for a time.”545

Forget ventilators—there aren’t enough hospital beds. Redlener describes insufficient hospital capacity as our “biggest weak link.”546 Unlike most other health care systems in the world, health care in the United States is largely profit driven. The reconstruction of the U.S. medical system around managed care led to the closure of hundreds of hospitals across the United States,547 leaving many cities with little surge capacity to deal with an abnormal influx of patients.548 HMO corporate stock profiles can ill afford to provide extra beds and ventilators for some indeterminate future surge of patients.549

A 2003 survey by the American College of Emergency Physicians (ACEP), for example, found that 90% of the country’s 4,000 emergency departments were already seriously understaffed and overcrowded.550 The founder of the ACEP disaster medicine section described emergency care in the United States as being “like a house of cards waiting for a big wind to collapse it.”551 Just as visits to the nation’s emergency rooms are reaching an all-time high, according to the CDC, the number of emergency departments in the nation has actually decreased by 14% over the last decade or so.552 In the winter of 2004, emergency rooms in 17 of the 20 major U.S. metropolitan areas had to go “on diversion,” meaning they literally had to close their doors and turn people away because they were so full.553 “We [would] be caring for people in gymnasiums and community centers,” said Osterholm, “just like in 1918.”554

The CDC’s top flu expert, Keiji Fukuda, elaborates in a New York Times interview: “The United States medical system has been moving toward fewer hospital beds, less unused capacity. This makes sense from a business standpoint.” His voice then reportedly dropped to a softer, sadder register. “I come from a generation of doctors who didn’t think of what we do as first and foremost a business. But I suppose we’re dinosaurs. We have to operate in the real world where medicine is run on a cost-benefit basis.”555

According to a recent survey in the Economist, the United States was ranked 55th in the world in terms of acute care beds per capita,556 comparable more to the third world than to Europe, which has about twice the number of population-adjusted beds.557 Over the past generation, wrote the editor of Lancet, “the U.S. public health system has been slowly and quietly falling apart.”558

There is also concern about severe staff shortages.559 Clarified one system director of emergency and continuity management for a large hospital chain, “The question becomes not how many beds you have but how many beds you can staff.”560 During the SARS crisis in Toronto, many health care workers didn’t turn up for work for fear of taking the infection home to their families. Indeed, almost half of the cases in the outbreak were health care workers, and two nurses and one doctor died.561 A Johns Hopkins survey of public health employees in Maryland found that “nearly half of the local health department workers are likely not to report to duty during a pandemic.”562

For more than a century, the American Medical Association code of ethics included a noble obligation that mirrored the Canadian Medical Association’s: “When pestilence prevails, it is their [physicians’] duty to face the danger, and to continue their labours for the alleviation of suffering, even at the jeopardy of their own lives.” The AMA duty-to-care clause has since been removed.563 According to the journal of the American Bar Association, though, 32 state governments are currently considering legislation that would effectively force health care workers to show up for work in a medical crisis by threatening to yank their licensure.564