The following is an edited excerpt from and interview with Dr. Michael Osterholm, conducted in late 2005...

What is your sense of avian influenza as a threat to world public health?

One has to first understand that pandemics of influenza are like earthquakes, hurricanes and tornadoes. They will occur over some time, yet they’re unpredictable. We know we are overdue for another pandemic of influenza. There have been 10 in the last 300 years. Avian influenza clearly has to be at the top of the list right now of potential causes of that next pandemic influenza. For that reason, by itself we should be concerned.

But what’s making this particular avian influenza situation so serious is that it appears to be killing in a very similar way to that we saw in that 1918 pandemic flu virus, meaning that it actually uses the host immune response. When you combine that with the fact that we are overdue for a pandemic the potential for another 1918-like one is very real.

What was 1918 like?

The 1918 influenza pandemic began in the summer of 1918 and spread through the world over the next 24 months. It killed between 50 and 100 million people at a time when the world’s population was only 1.8 billion. (Today we have 6.5 billion people, you could understand the difference.)

Some may argue that today we have modern medical sciences and antibiotics and vaccines and therefore we would never experience another 1918-like experience. Unfortunately we don’t have the kind of vaccines that we need today to protect the world.

We don’t have antibiotics that would be effective against the primary way this virus kills. We might have an antiviral drug that might be effective, but it will be in very short supply.

Ultimately, we must use the strain of influenza virus that begins to be circulated in the population and causes the pandemic as the new vaccine strain. We are prohibited from making an effective vaccine before the pandemic ever occurs. This means that we’re talking anywhere from five to six months after the pandemic begins that we will have our first vaccine available.

In addition, we can only really make about a billion doses of the vaccine a year given our current buildings, our current bioreactors, our current expertise. That means that if everyone needs at least two doses to be protected, only 500 million people in the first year would actually even have access to the vaccine. It’s not actually going to be there for us in a real meaningful way in those first days of the pandemic.

People in public health say that in 1918 was little understood, that it was caused by a freakish combination of things like war, malnourishment and a virus that will never happen again – so it’s ridiculous to talk about 1918.

Pandemics of influenza have occurred dating back to antiquity and have been divided in two different camps. One camp of pandemics are those where a new strand emerges, but it typically kills the same way that the influenza seasonal virus kills (meaning that it does some damage to the lungs, but most of the deaths occurs as a result of secondary bacterial infections.)

On the other hand, 1918, which some describe to a unique situation will not occur again, actually has occurred in the past. We have evidence, for example, that in 1832 a pandemic of influenza even more sever than 1918 occurred. There is evidence dating back to the 1500 that this other type of pandemic occurs sporadically, where the virus actually does most of the damage by turning one’s immune system against the individual host.

So the idea that that couldn’t happen again is absolutely not correct, because it has happened multiple times in the past.

The second thing that people describe to 1918 is that there were these unusual conditions of crowding, that a war was going on. Well, that’s all true, but today when you look around the world you see first all the same kind of crowing for the vast majority of the population. Second we of all, we recognize that in 1918 that were many healthy individuals living in the rural areas of the modern and developed world who experienced the very same mortality rates that we saw for the soldiers in the battlefields or those whole lived in the concentrated and crowded areas. In that sense, there is no reason to think that that year was a unique factor.

In addition, there were 12 different studies that were done associated with the 1918 pandemic that looked at the actual deaths among pregnant women. There was a particularly high rate of deaths among these individuals. Studies showing between 35 to 70 per cent of women who died were pregnant. It did not differ whether you were in the United States or in Europe or even in Africa; whether or not you came from low, middle socio-economic classes; or whether you even had access to what was then called modern medical care.

And that’s why we are so worried today – because H5N1 in Asia has many of those same properties that the 1918 virus possessed.

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If something were to emerge today or tomorrow how would it spread around the world?

Today we are jetting around the world in almost unprecedented numbers. Wherever this influenza pandemic begins, it will be around the world in short order. We saw that with SARS, even though it emerged in the Guangdong province of China, it very quickly made it’s way out to Hong Kong. Just one visitor to one hotel sent it to six different countries and five different continents overnight. That type of spread will occur quickly with this and that is of great concern because it means we won’t have much time on a worldwide basis to prepare for the emerging pandemic.

What will be the effect on economies?

One of the most misunderstood aspects of a modern pandemic is not the medical side of the concern, but the social political economic side of it. One of the major differences between a potential impact of a pandemic today versus that of yesteryear is that of our global ‘just-in-time’ economy.

We all like to think that our borders will allow us some means to protect ourselves from the spread of the virus. What we fail to realize is the one global just-in-time economy has really eliminated those borders for all intents and purposes.

Today the critical goods and services that we enjoy in the developed world countries in many instances come from the developing world. If we were to put a rock in the gears of the global just-in-time economy, we would find many of the goods that we depend on every day for our daily lives would not be available. That in turn would create a spiral of other kinds of collateral damage problems.

Many of the medicines that we use in developed world countries would stop being shipping from one country to the other. Then there are critical medical devices: things like protective masks, or even machines that we use to keep people alive. We see that with our food supply. Today we have a global food supply and in many instances in Europe and in the United states the produce we eat comes from a developed country.

Suddenly the entire economy goes into a tailspin – when that happens, none of us have a clue as to what it might take as to bring that back out of that tailspin. I think that this is going to be an issue for economists, for policymakers, for leaders to begin to address because if we don’t the collateral damage from a pandemic could very well make the overall pandemic itself be just a small piece of the actual damage.

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How prepared are we for a pandemic?

Our group here in Minnesota has actually been on the leading edge of a number of emerging infectious disease issues dating back several decades. We were one of the first groups to actually sound the alarm back in 1981 around HIV/AIDS. We were early on into the area of antibiotic resistance; we were the ones talking about the problems with changing food supplies in the 1980s.

Every year we talked about pandemic influenza, particularly since 1997 and the first emergence of H5N1 in Hong Kong, we’ve recognized the potential for this virus to actually be the next cause of pandemic of influenza. And as each year has gone on since 1997, our lack attention as a world to preparing for this has become increasingly frustrating.

One day we will have a post pandemic commission looking at world leadership as to why we weren’t better prepared. I’m afraid that they will deliver a verdict that we were derelict in duty as public health officials, as government officials and even as a private sector in terms of getting prepared.

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We’ve been derelict in large part because of our lack of understanding of what this means and what we must do about it. The kinds of facts that we lay out as public health officials about the potential for a pandemic implication are not rocket science. When you understand the past and realize that we should have 20 years ago (after our first real scare with another pandemic and the swine flu situation) made a major investment into the vaccine development, procurement and delivery for flu. We didn’t do it. We just didn’t do it.

Today we live in a world with a 1950’s influenza vaccine technology supply chain. We also have to take head-on what kind of medications might we use if the flu were to occur and we weren’t able to get adequate vaccine supply. Our research and development around antiviral drugs for influenza has been miniscule. That’s why today we only have two drugs that could be potentially used, only one of them readily available and even that again in very short supply.

We’ve done very little. We’ve done almost nothing on our supply chain side to understand what are those critical goods or services that we must maintain during a pandemic. Today when we have a crisis, a bombing in the subway or we have a hurricane, any number of different things, we are able to respond because those are very limited interruptions in one given area for a very short period of time. We can bring in goods, we can bring in experts, we can bring in all kinds of services from other areas to help with that.

We are going to need those same kinds of goods, experts, or services and they won’t be there because we’ll be stretched so thin. It won’t last for a day, a week, or a month; it’s going to last for months and months and maybe several years. When we consider that we have done virtually no planning whatsoever as to how we may respond to that. How will we survive it?

One of the things I’m concerned about is influenza preparedness and planning. The Canadians are a good example. Two years ago they were given great credit for moving forward with vaccine production capabilities, to do the research necessary to find a better vaccine for influenza that could be utilized quickly in a pandemic situation. Virtually no funding was put forward for that and as such the Canadian research and development activity has gone nowhere. Why has that been allowed to happen? Why in the U.S are we investing so little into this particular situation when we look at all the money in many other areas in the world in many other issues?

I think it’s shortsightedness. We tend to be a reactionary world. We tend to not really think through what are those major causes of catastrophic damage that we cannot allow to happen. And what are those ones that if they do happen it’s unfortunate it’s sad, but we can get through it. We have never prioritized where our really most venerable spots are and what we must do about them. Influenza has to be at the top of the list.

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Having been involved on an international level with issues like HIV/AIDS, antibiotic resistance, even terrorism, I am convinced that at the end of the day there is nothing that will equal that of pandemic influenza.

For many years I was asked ‘How do you sleep at night with all that you deal with and you know about and that you are trying to address?’ And to some embarrassment I would always say, I’m sorry but I do.

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