Chinese officials have reported that the country’s fifth outbreak of the H5N1 avian flu this year is killing chickens in poultry markets in the southern city of Guangzhou. Although this particular outbreak is not known to have affected humans, China has already reported three human avian-flu deaths this year. Far more worrisome is the April 3 confirmation by the government of Pakistan and the World Health Organization of three cases in a family cluster in Pakistan’s North West Frontier Province late last year, suggesting limited human-to-human transmission.


Public health officials world-wide are concerned that eventually the highly virulent H5N1 flu, which now primarily affects birds, will mutate into a form readily transmissible from human to human. This transformation is made more likely by the cultural and animal husbandry practices that are prevalent throughout much of Asia, where domesticated fowl live (and are slaughtered) in close proximity with human populations.

Some critics have decried what they consider to be wealthy countries’ selfish attitude toward preventing and responding to a pandemic of H5N1 avian flu, proposing instead a major effort to improve health practices in Asia, where a pandemic strain would likely arise. However, the close proximity of billions of poultry and swine to humans, combined with unsanitary conditions, poverty and a grossly inadequate public-health infrastructure of all kinds, make it doubtful that a pandemic could be prevented or contained at the source.

It is noteworthy that China’s prodigious effort to vaccinate 14 billion chickens annually has been chaotic, compromised by the appearance of significant amounts of counterfeit vaccines and by the absence of protective gear for vaccination teams—who might actually spread disease by carrying fecal material on their shoes from one farm to another.

In theory, it is possible to contain a flu pandemic in its early stages by performing “ring prophylaxis”—using anti-flu drugs and quarantine aggressively to circumscribe and isolate relatively small outbreaks of a human-to-human transmissible strain of H5N1. Although ring prophylaxis might work in Minneapolis, Toronto or Zurich, in the parts of the world where flu pandemics begin the probability of success approaches zero. In places like Vietnam, Indonesia, and China—where the pandemic strain will likely originate—expertise, coordination, discipline and infrastructure are lacking.

If national governments are incapable of appropriate, timely actions to prevent or respond to a potential pandemic of avian flu, to whom could we delegate responsibility? The World Health Organization? Sadly, the WHO is a component of the scientifically challenged, unaccountable United Nations, which gave us the Iraq oil-for-food scandal and a botched investigation into the assassination of Lebanese politician Rafik Hariri. It’s hard to believe the U.N. would keep politics out of scientific and medical decisions.

Anti-flu drugs are extremely expensive and in short supply. If we were to supply them to poor countries for ring prophylaxis, history tells us that the medicines often would be administered improperly—such as in sub-optimal doses—in ways that would promote viral resistance and only intensify a pandemic. Or perhaps sold on the black market to enrich corrupt government officials.

A politically incorrect but more rational strategy would be for the richer countries to devote resources to developing countries primarily for surveillance, in order to obtain timely warning of the existence of an H5N1 strain that is transmissible from human to human, but to focus the vast majority of their funding on a variety of low- and high-tech approaches—vaccines, drugs, and other public health measures—that will primarily benefit themselves.

If the pandemic were to begin relatively soon—say, within a year or two—there would be little that could be done to attenuate significantly the first wave of infections. (If we’re ready to rush the pandemic strain into a crash program to manufacture vaccine, we could possibly blunt the second wave, however.)

A flu pandemic will require triage on many levels, including not only decisions about which patients are likely to benefit from scarce commodities such as drugs, vaccines and ventilators, but also broader public policy choices about how—among literally a world of possibilities—best to expend resources.