Pandemic Flu and Global Health Security II - Session Summary

The findings from the World Bank report

are highly relevant to where we need to go next, in the evolution of pandemic preparedness policy.  

First, the impact due directly to disease, whether deaths, sickness, or absenteeism, can be reduced by strategies that reduce the overall disease burden or infection rate.  

For example, as we know from this famous chart from 1918, cities that implemented multiple social distancing measures EARLY had a significant reduction not just of peak deaths, but also of overall deaths (area under the curve).  This happens because slowing down transmission reduces epidemic overshoot, as explained here.  

Secondly, 60% of the economic impact results from avoidance behaviors, reduction in travel, reduction in spending on consumer items, and yet, so far, few pandemic plans have sought to mitigate the impact of avoidance and panic, by educating the public well in advance.  

The paper does not give great details about how the models were run.  For example, it isn't clear (at least to me) whether they modeled the impact of supply chain failures.  In addition, they assumed a 20% reduction in travel and spending spread over a year, but in reality, these effects are not evenly spread out but will rise and peak in parallel to or even in anticipation of the worsening outbreak.  Certainly during SARS (below) the impact on air travel was sharp and uneven.

Such sharp knocks to the system may have impacts beyond the immediate measurable economic losses.  Pandemic flu creates a complex set of circumstances such that there is a heightened risk of tipping points being reached, where business and/or infrastructure failures can cascade into much greater systemic breakdowns.  Such shocks are highly unpredictable, as illustrated in this chart that I made a while back

How does one mitigate such consequences?  We can't, not with traditional top-down policies.  We are living in a highly networked and efficient world, such that there is very little slack in the system.  To reduce the risk of systemic failures, the only rational approach is to build redundancies into as many parts of the system as possible.

Which means, in essence, promoting preparedness and resilience at the level of the smallest economic unit, the individual and families.  

So far, too little attention has been paid to boosting bottom-up resilience, but that to me is the most rational piece of conclusion one can draw, from the World Bank report.  The problem is governments are more used to solving 'problems' than boosting resilience, ie focusing on the figure of the figure-and-ground conundrum, as discussed in this paper written for the UK government but entirely applicable to every country, Figure and Ground - A Strategic Approach to Pandemic Risk

It's late in the day, but as always it's better late than never.  If we want the world to have half a chance of surviving a pandemic with society relatively intact, the next iteration of country pandemic plans should include as a matter of priority strategies to empower communities, families, and individuals, helping them to understand and prepare.  Those who work on pandemic planning know full well how big a learning curve it is.  How can we expect the people to NOT panic, and NOT over-react, if we don't educate them well ahead of time?  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Tue Mar 17, 2009 at 21:47:24 PM UTC

A second comment, to echo David Nabarro

on our collective experience (or failures) in the HIV/AIDS pandemic.  Hindsight, of course, is always 20/20, but is no less valuable for it.

Right now, we don't know whether H5N1 will acquire the ability to cause a global pandemic.  There are some who point to the fact that H5N1 has been around for a whole decade and espouse the theory that "since it hasn't, therefore it won't", like this recent Op Ed in Washington Post.  (Revere has written some robust responses on Effect Measure, so I won't belabor the points.)  

If we look back at HIV/AIDS, similar arguments were made, depending on who you read, that the virus was supposed to have been around for decades, and therefore fears of a global pandemic was overblown.  Those who called for more action were accused of scaremongering, with motives ascribed to desire for research funding or worse.  Now, > 25 million deaths and many times more infections later, we know the early warnings were, if anything, too mild!!!

There is another parallel, where we tended to think of HIV/AIDS as something that happened to 'those other people' eg homosexuals, IV drug users.  It didn't seem to threaten us, normal, 'clean-living' people, and so we were complacent and turned a blind eye.  Now, the disease devastates men, women and children in many countries, including right in the heart of Washington DC.

Similarly, it's easy to dismiss H5N1 because it seems to only affect those who live in close proximity to backyard poultry, possibly with lack of access to modern sanitation.  

What we cannot ignore is the fact that viruses evolve.  They are constantly mutating.  What is true today will not be true tomorrow.  Viruses, whether HIV or H5N1, do not respect the limits of our imagination.

Today, as we think of the devastation of the HIV/AIDS pandemic, shouldn't we ask ourselves, what would we give, as a world, to turn the clock back?  If we could go back to the beginning, what would we be doing differently?

Unfortunately, we cannot turn the clock back, on HIV/AIDS.  those who died, we cannot revive.  Those communities that are laid waste, we struggle to support cos the problem is so enormous.  Think how much less effort it would have taken, for us to PREVENT this catastrophe??

It's too late, to talk about prevention, preparedness, and response, for the vast majority of those who suffer and have suffered from HIV/AIDS.  It is not too late, to tackle this other pandemic threat, the H5N1 influenza virus, giving it the respect and awe that it deserves.

We missed it once.  Do we want to miss it again?  That is my question.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Tue Mar 17, 2009 at 22:32:18 PM UTC

here's a seminal lesson

from the history of HIV/AIDS.  Back in 1984, the then Secretary of HHS Margaret Heckler, on the same day as she announced the 'discovery' of the HIV virus, also said, ahem, "We hope to have a vaccine [against AIDS] ready for testing in about two years." (source)

Excuse me, say what?  

That was 24 years ago.  2 decades and billions of dollars later, one of the most 'promising' of the HIV vaccine trials met a rather disturbing end.  

Warning Is Sent to AIDS Vaccine Volunteers
S. Africans Among Recipients Who May Be at Higher Risk of Contracting Virus
By Craig Timberg
Washington Post Foreign Service
Thursday, October 25, 2007

JOHANNESBURG, Oct. 24 -- South African AIDS researchers have begun warning hundreds of volunteers that a highly touted experimental vaccine they received in recent months might make them more, not less, likely to contract HIV in the midst of one of the world's most rampant epidemics.

The move stems from the discovery last month that an AIDS vaccine developed by Merck & Co. might have led to more infections than it averted among study subjects in the United States and other countries.

more at link

The point is, if we look at our track record, with a very long incubation period, 25 years after scientists first recognized the disease, we are STILL behind the curve as far as the HIV/AIDS pandemic is concerned.  What makes us think we'll do better with a much more swiftly transmitted, universally susceptible virus like flu?

Also, remember these words from Margaret Chan,

"Experts have told us. They have long regarded vaccines as the most effective medical intervention for reducing morbidity and mortality during a pandemic. This assumption, which makes sense, has never been tested in practice.

A vaccine has never been available quickly enough after the start of a pandemic to test its impact on morbidity and mortality. Nonetheless, it is reasonable to assume that vaccines provide the best population-wide protection." (source)

As a world, we seem to have a ghastly track record, of placing an unreasonable amount of faith in the ability of science to deliver efficaceous solutions.  And living to regret it afterwards.  Or not living, as is the case with millions and millions....



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Thu Mar 19, 2009 at 23:47:12 PM UTC

[ Parent ]

in the next diary

I will explore the demographic and security implications of pandemic flu, to complete this series.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Tue Mar 17, 2009 at 23:27:09 PM UTC

part 3 of this series

on H5N1 as the ultimate demographic timebomb, is up http://www.newfluwiki2.com/sho...



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Thu Mar 26, 2009 at 21:00:14 PM UTC

[ Parent ]