Intrepid reader,

Last week, I blogged about the possibilities of swine H1N1 to graft other genes onto its genetic construction. I have mentioned my concern that swine H1N1 could, in fact, easily pick up the amino acid combo which, in the aggregate, represents the Tamiflu Resistance Gene.

I also alluded to the potential for swine H1N1 to take a victory lap around the world and reassort with our old friend H5N1. Now I mentioned this only in passing. The reason should be obvious: A number of persons believe this whole H1N1 thing is either a gross overreaction by public health professionals, and/or a ploy by the Obama Administration to advance its public health agenda.

It is neither, although every time I hear an Obama official even mention health care "homes" in the same breath as H1N1, I cringe, because they need to put the Rahm Emanuel playbook down ("Rule 1: Never allow a crisisto go to waste") during this entire evolving event.  It is important to know that the Obama Administration is essentially running the Bush playbook on the management of this epidemic, and they have acknowledged as much and have been publicly grateful for its existence. So far, I have not seen any major mistakes, mea culpas or blown calls in the response to this unfolding situation out of Washington, excepting the Vice-President-in-charge-of-embarrassing-gaffes and soon to be Lame Duck, Joe Biden.  And even he was saying what everyone else was thinking, I suppose.  Still, as a recovering politician myself, I am amazed at this guy's lack of an "internal quip governor" (think NASCAR restrictor plate) and how Obama allowed him to get on the ticket. 

But I digress.  Back to the issue at hand, namely reassortment.  Bloggers have been understandably reluctant to stray too far into joining swine H1N1 with avian H5N1.  But when the world's leading influenza expert -- the "Pope of Influenza," Dr. Robert G. Webster of St. Jude in Memphis -- comes out and says what everyone else in Flublogia is thinking, I think it warrants a good blog.

Dr. Webster has dedicated his entire adult life to the understanding of influenza. He has learned much, but each answer generates a whole new set of questions. He, Edwin Kilbourne, John Oxford, and the late Graeme Laver stand as the true giants of modern influenza research. Upon their footpaths walk Kawaoka, Peiris, Webby (like Peiris, a protege of Webster) and others.

Kawaoka has taken some ribbing from this Blogger in the past, but let me assure you he knows his stuff and the world is a better place with him and all his skills on board.

When Webster talks, or even speculates, it is by definition informed, and we should do the old E. F. Hutton commercial and listen. Today, an AP article -- one of the best-researched I have read in quite some time -- speaks of the opportunity for swine H1N1 to reassort with avian H5N1 and produce -- something.  One treat is that it quotes from three of the best-known names on the influenza front, which is always fun.

I will give the article and its link later. What I want to talk about now is the situation in Egypt, and why the Egyptian government made the controversial move to slaughter all its pigs virtually overnight. Something feels Biblical in that decision, you know. It was met with hostility and violent demonstrations across the nation. Only Christians eat pork there, and the hogs slaughtered were destined only for Egyptian Christian dinnertables.

But I believe the Egyptian government had its own experience and that of Indonesia on its mind when it made the decision. The Egyptian government has been looking for a reason to wipe out the hog population since 2008, because there was and is growing concern that Egyptian pigs had become reservoirs for H5N1. Search "Egypt" on my blogsite to find everything of consequence that has happened in that country, flu-wise, since 2006. I'll wait. Especially read my January, 2008 blog here. It has a pretty graphic, too.

OK, welcome back. You should have seen the blog post fromEgyptian blogger Zeinobia, whose blog from January 2008 -- yes, I said January 2008 -- was an eerie foreshadowing of our current situation.

Short form: The Egyptian government is scared to death that H1N1 will come around and reassort with H5N1, which they believe to possibly be endemic in their pig population.  And if you look at the continuing increase in suspected and confirmed Egyptian H5N1 human bird flu cases, I think you'd agree there is much to be concerned about.

Likewise, the situation in Indonesia and in China also involoves informed speculation on behalf of animal and human influenza researchers that H5N1 may have made a small foothold in the hog populations there. Especially Indonesia, which remains Bird Flu Central for human cases and potential pandemic explosion, despite the competition from ongoing Egyptian human infections. Researchers already know that some 20% of the stray cat population in Indonesia has H5N1 antibodies. Likewise, some hogs in Indonesia have tested positive for H5N! antibodies. From the Website FluWiki, from2006:

Cat H5N1 sequences in Indonesia are apparently more similar to H5N1 sequences from humans than either are to H5N1 sequences from birds. What is the most logical interpretation of these results? I submit that there may be a mammalian reservoir for H5N1 in Indonesia and other countries and that H5N1 is under selection to adapt to mammals in this reservoir. Further, at least some of the human cases may be due to mammal-to-human infections. (See also Dr. Jeremijenko’s post at 23:14 in this thread, and here and here). In the recent large cluster of human cases in Indonesia, no infections of poultry were found in close proximity to the village where the outbreak occured. However, pigs with antibodies to H5N1 were found in this region reference. H5N1 infections in pigs would be particularly worrisome as these animals could serve as mixing vessels for the formation of a human-adapted H5N1 strain. (bold mine)

That is what everyone is worried about. That is the Elephant in the Room. That is why no one in Geneva, Atlanta or anywhere else is overreacting about this swH1H1 epidemic.

Now it is time to bring in the AP story. Here it is, in its entirety.

Top flu expert warns of a swine flu-bird flu mix

By MARGIE MASON, AP Medical Writer Margie Mason, Ap Medical Writer 2hrs29minsago

MEXICO CITY – Bird flu kills more than 60 percent of its human victims, but doesn't easily pass from person to person. Swine flu can be spread with a sneeze or handshake, but kills only a small fraction of the people it infects.

So what happens if they mix?

This is the scenario that has some scientists worried: The two viruses meet — possibly in Asia, where bird flu is endemic — and combine into a new bug that is both highly contagious and lethal and can spread around the world.

Scientists are unsure how likely this possibility is, but note that the new swine flu strain — a never-before-seen mixture of pig, human and bird viruses — has shown itself to be especially adept at snatching evolutionarily advantageous genetic material from other flu viruses.

"This particular virus seems to have this unique ability to pick up other genes," said leading virologist Dr. Robert Webster, whose team discovered an ancestor of the current flu virus at a North Carolina pig farm in 1998.

The current swine flu strain — known as H1N1 — has sickened more than 2,300 people in 24 countries. While people can catch bird flu from birds, the bird flu virus — H5N1 — does not easily jump from person to person. It has killed at least 258 people worldwide since it began to ravage poultry stocks in Asia in late 2003.

The World Health Organization reported two new human cases of bird flu on Wednesday. One patient is recovering in Egypt, while another died in Vietnam — a reminder that the H5N1 virus is far from gone.

"Do not drop the ball in monitoring H5N1," WHO Director-General Margaret Chan told a meeting of Asia's top health officials in Bangkok on Friday by video link. "We have no idea how H5N1 will behave under the pressure of a pandemic."

Experts have long feared that bird flu could mutate into a form that spreads easily among people. The past three flu pandemics — the 1918 Spanish flu, the 1957-58 Asian flu and the Hong Kong flu of 1968-69 — were all linked to birds, though some scientists believe pigs also played a role in 1918.

Webster, who works at St. Jude's Children's Research Hospital in Memphis, Tenn., said bird flu should be a worry now. Bird flu is endemic in parts of Asia and Africa, and cases of swine flu have already been confirmed in South Korea and Hong Kong.

"My great worry is that when this H1N1 virus gets into the epicenters for H5N1 in Indonesia, Egypt and China, we may have real problems," he told The Associated Press. "We have to watch what's going on very diligently now."

The U.S. Centers for Disease Control and Prevention are extraordinarily busy trying to understand the swine flu virus itself, and haven't had time to break off staff to look at the possibility of a swine flu-bird flu mix, spokesman Dave Daigle said.

Malik Peiris, a flu expert at Hong Kong University, said the more immediate worry is that swine flu will mix with regular flu viruses, as flu season begins in the Southern Hemisphere. It is unclear what such a combination would produce.

But he said there are indications that scenario is possible. Peiris noted that the swine flu virus jumped from a farmworker in Canada and infected about 220 pigs. The worker and the pigs recovered, but the incident showed how easily the virus can leap to a different species.

"It will get passed back to pigs and then probably go from pigs to humans," Peiris said. "So there would be opportunities for further reassortments to occur with viruses in pigs."

He said so far bird flu hasn't established itself in pigs — but that could change.

"H5N1 itself has not got established in pigs," he said. "If that were to happen and then these two viruses were both established in pigs in Asia, that would be quite a worrying scenario."

Michael Osterholm, an infectious disease specialist at the University of Minnesota who has advised the U.S. government on flu preparations, said while flu experts are discussing the scenario, he has yet to see specific evidence causing him to think it will happen.

"Everything with influenza is a huge guessing game because Mother Natureholds all the rules, and we don't even know what they are, so anything's possible," he said. "We don't have any evidence that this particular reassortment is that much more likely to pick up H5N1 than any other reassortment out there."

"We don't have to put these things together," he added. "This is not chocolate and peanut butter running into each other in the dark hallway."

But there is in fact discussion of putting them together — in a high-security laboratory — to see what a combination would look like, according to Webster. Similar tests have been done at the CDC mixing bird flu and seasonal human flu, resulting in a weak product, he said.

Daigle, the CDC spokesman, said the agency wants to look at the question in the future.

Webster has done groundbreaking work on both swine and bird flus in his 40-year career, and has followed the evolution of the current swine flu strain from a virus that sickened a handful of people who worked with North Carolina hogs into a bug that has spread from person to person around the world.

He is closely involved in the global effort to analyze what the virus might do next. It has killed 42 people in Mexico and two in Texas, but so far has not proven very deadly elsewhere, leading to some criticism that the World Health Organization's warnings of a potential pandemic have been overblown.

Webster said underestimating the swine flu virus would be a huge mistake.

"This H1N1 hasn't been overblown. It's a puppy, it's an infant, and it's growing," he said. "This virus has got the whole human population in the world to breed in — it's just happened. What we have to do is to watch it, and it may become a wimp and disappear, or it may become nasty."

___

AP Medical Writer Maria Cheng in London contributed to this report.

So there you go.  I hope wimp, but no one knows what it will do eventually.  However, it is this worry that, I believe, has led the Egyptian government to do what it could not do last year; namely, slaughter the mixing vessels of influenza.  They do not want the Next Pandemic to start on their doorstep.  In that regard, and now knowing what you know, let me ask you:  Have they made the correct decision?

The news stories are starting to come out of Washington, DC; Baltimore; and soon Sarasota (and that is rare to have that small retirement city mentioned in the same breath with two of the Big Cities on the East Coast!) that states just don't have enough Tamiflu to go around.

And here in sunny Florida, where we did not avail ourselves of the now-expired Federal coupon offer to buy Tamiflu at cheaper prices, people are openly questioning whether the state should, indeed, buy more.

I have a better idea. First, let me set some background.

I do not know if Roche can take enough plants offline, recommission them and start making Tamiflu again in any quantity. recall that Roche made a huge capital investment in more Tamiflu plants in 2005 and 2006, only to see global demand for Tamiflu abate as the concern evaporated regarding a bird flu pandemic. Roche then recommissioned the lion's share of these facilities to make other drugs instead.

Roche also made a huge breakthrough around that time, namely being able to synthesize the key ingredient of the antiviral drug: Something only found in Chinese star anise. Shikimic Acid. According to Wikipedia, Star Anise, under the influence of shimikic acid, fought Iron Man and Wolverine before being brought down by Captain America, who is now his old sidekick Bucky, the Winter Soldier.

No, that's not right. Damn that Wikipedia!  Anyway,Janapese star anise is right out; only Chinese star anise will work. So Chinese farmers began doing what American farmers have been doing with corn; plowing under all other crops to make the big cash (cow) crop. Chinese farmers were making the kind of money American farmers were making! BIG money from star anise, because it also took a long time to reap the fruit.

But then Roche spoiled the party by synthesizing shikimic acid, and now it can be mass-produced more cheaply. Roche will have to recommission those gleaming Tamiflu plants and also begin re-licensing other drug makers to make Tamiflu under license.

Or will they? Roche has been burned by the world's governments once already. I doubt if Roche will be as willing a corporate partner (meaning ready to heavily discount Tamiflu) as they were in 2006 and 2007. And maybe they shouldn't.

The other X-Factor (so you see a pattern here? Wolverine? X-Factor?) is the dreaded Tamiflu Resistance Gene, or the combination of mutations to neuraminidase of gene segments R292K, N294S, and H274Y. Widespread circulations of this set of anti-Tamiflu genes have rendered Tamiflu virtually useless against the non-swine H1N1 that is our seasonal bug.

In fact, a Scientific American article of March, 2009 coincidentally reminded readers of the presence of this gene set. Here's the most striking passage:

A whopping 98 percent of this year's circulating H1N1 flu strains are immune to Tamiflu, compared with only 12 percent during the 2007-2008 flu season. (bold mine)

"We don’t know what's physically happened to the virus to cause it to transmit more rapidly, but something has and even more so this year," says study author Nila Dharan, a fellow in the Centers for Disease Control and Prevention's (CDC) Epidemic Intelligence Service, which studies major disease outbreaks. Dharan tells ScientificAmerican.com that a spontaneous (natural) genetic mutation – and not overuse of Tamiflu — is to blame. She notes that additional structural changes to the virus (that scientists don’t completely understand) have enhanced the resistant strain's ability to grow and infect people.

The trend is alarming enough that Department of Health and Human Services (HHS) officials have been huddling for the past week to consider whether to adjust the composition of the federal pandemic flu drug stockpile, of which 40 million treatment courses (80 percent) is Tamiflu, says Robin Robinson, director of the Biomedical Advance Research and Development Authority(BARDA), an HHS arm that manages the stockpile.

I guaran-damn-tee you that in the back/front of every single influenza researcher's mind on this planet is the knowledge that these mutations could, at any time, by reassortment or recombination, get into the present swine H1N1. Mutations have already been seen in H5N1 avian flu, but not in large numbers.

But the movement from 12% to 98% in seasonal H1N1 is striking. And where those mutations first appeared is absolutely head-scratching. Rather than link you to all the blogs I have made on Tamiflu resistance, just search this Blogsite for the words "Tamiflu resistance." You'll read everything from the presence of Tamiflu in the water supply of Sweden to the lack of resistance in the most-prescribed Tamiflu nation on earth -- Japan.

OK, now let's assume you are a policymaker. Here are the facts:

• You are broke, out of money, laying off workers, cutting services.
• You have a pandemic-in-the-brewing called swine H1N1. Or H1H1 influenza A. Or "fluffy bunny slippers," according to this insane "let's not-p-off-the-pork-people" White House PC-silliness. Hey, let's just call this "PC FLU?"

But I digress.

• You also know you don't have enough Tamiflu to really get the job done.
• And there is this as-widespread-as-Jonas-Brothers-fever anti-Tamiflu gene that is found in 98% of all seasonal H1N1 flu this past season.
• Did I mention your state is broke?

I have a solution. Back in World War II, largely in the pacific, Corpsmen and medics were stretched to the limit on penicillin. They did not have enough to treat everyone with an infection.

Miraculously, they did have this relatively new anti-gout medicine called Probenecid. They knew one of the side effects of Probenecid was that people didn't pee as much as normal. So someone in some battlefield MASH unit said "What the Hell, let's see if it works," and co-administered Probenecid with penicillin.

And danged if it didn't work! The co-administration of Probenecid with penicillin stretched the effective supply of penicillin by a factor of 2.

A few years ago, people with long memories and concern over Tamiflu stocks began speculating about the effectiveness of Tamiflu and Probenecid. I have written about this many time before, but the definitive blog on the subject in my inventory is this shoulda-won-a-Pulitzer story:

Killing two birds with one stone

A portion of Roche's study of the use of probenecid in 2002 comes from the blogsite Smart Economy, and the story can be found at: http://smarteconomy.typepad.com/smart_economy/2005/11/smart_wartime_t.html.

Dr. Michael Greger, a person whom I communicate with occasionally, wrote in his seminal work Bird Flu: A Virus of our own Hatching:

Roche found that probenicid doubled the time that Tamiflu spent circulating in the human bloodstream, effectively halving the dose necessary to treat someone with the flu. Since probenicid is relatively safe, cheap, and plentiful, joint administration could double the number of people treated by current global Tamiflu stores. “This is wonderful,” exclaimed David Fedson, former medical director of French vaccine giant Aventis Pasteur. “It is extremely important for global public health because it implies that the stockpiles now being ordered by more than 40 countries could be extended, perhaps in dramatic fashion.”2495

So let's review:

• Probenecid is safe.
• It keeps the medicine in the body longer.
• It will effectively double our supply of Tamiflu overnight.
• It will free up Relenza for use exclusively by police, fire, EMT, emergency room staff, and otehr first responders.
• It will reduce the incidence of painful gout in Tamiflu takers.
• It will reduce the amount of Tamiflu that makes its way into the groundwater, thereby making it the "green" solution.

In short, the co-administration of Tamiflu with Probenecid is a solution that bears very close, careful scrutiny. 

Always glad to help.

You Twitterheads, or whatever you people call yourselves, can now get my comments and links on the 140-character social networking site.  I'm something like "@scottwmcpherson" or something like that.

You can also "follow me" from the link on the left side of this Blogsite.  Just scroll down to Twitter.

You'll get a lot of updates during the business day.  At night, I'm a normal human being again, reading Marvel comics, zombie novels or watching Fringe with the wife.  Isn't that what normal people do?  Well, we also watch American Idol (Adam's gonna win it) and Dancing with the Stars (Gilles/Lil' Kim tossup) so I'm not completely out there.....

Hurm.

Those of us who have been preaching pandemic preparedness for years are extremely and understandably interested to see how this entire swine flu situation unfolds. For us, the societal impact and response is almost as important (and perhaps more important) than the actual spread of the disease.

One element of pandemic preparedness and (now) mitigation is risk communication, or what you tell the public. And I am not at all sure that the government's risk communication aspect has been handled as smoothly or as honestly as it could.

Not at fault (yet) is the media. I have been very impressed with the coverage and the quality of reporting from NBC, CNN and FoxNews. Fox and NBC have relied upon Osterholm; CNN has Gupta On the Ground in Mexico City, and Fox has Geraldo warmed up in the bullpen to close. NBC's Bazell has been spot-on. These three networks have been quite good at educating the public and relating history.

These networks, however, will not "go it alone" and recommend certain actions unless and until the government does.  They are in the business of reporting news, not making policy.

What people want to know is exactly what to do right now. People are concerned-to-scared. Few people now are openly scoffing at the headlines since the WHO raised the pandemic threat level. That act by Geneva was, in and of itself, an act of risk communication.  It was an excruciatingly calibrated decision for the WHO to make. But they made it.

Why the decision-making angst in Geneva? The WHO has resisted the urge to raise the pandemic threat level for years. This blogger, along with hosts of others, have actively called for a Phase Four designation based solely on H5N1 human cases. Now, with the expansion of swine H1N1, that designation has been attained. And that is serendipitous good news for all who wanted stronger surveillance for all potential strains. Therefore, one "peace dividend" of the raising of the pandemic threat level may be to catch more human H5, H7 and H9cases.

The other dividend was clearly meant to get more Earthlings to take this threat more seriously. And that is the opening, the entree, that we cannot squander. To not use this opening that the WHO has given governments would be criminal.

So what should we be telling people? We should be telling them to prepare and to learn more about influenza. I am not talking about the Romero-esque TV commercials that the Ford Administration ordered up during the 1976 swine flu scare. I am talking about telling people to get their "hurricane kits" or "earthquake kits" restocked and brought up to speed. It is time to re-educate the American people on previous pandemics and previous near-misses, such as 1946 and 1951, with viruses that were also H1N1 but were much more virulent and, some thing, either swine-like or were actual swine influenzas that jumped the species barrier back in the day.

Telling people to buy one to two weeks' worth of food, water and medicines to prepare for hurricane season -- an annual hit-or-miss proposition with a clear historical precedent of occurrences -- is not considered folly; it is considered prudent.

Likewise, to tell people not to prepare similarly, in the face of the greatest threat to public health since SARS, also with a clear historical precedent, is equally prudent.

So why is everyone afraid to do so?

That brings up another issue: I wonder if anyone is testing this new swine flu against the antibodies of people who went through 1946 and 1951? Those people and their entire age group may be partially immune to this new strain and we may not even be aware of it. That may help explain the reason why older Mexicans and others are not falling in quantity.

By now, you should have a clear plan of action for Phase Four, Phase Five and the dreaded Phase Six. Phase Four should include beginning your "hurricane kit," or your all-hazards kit. It should include two weeks' worth of food, water and influenza and intestinal medicines and Gatorade to restore electrolytes. The Bush Administration was preaching this for three years, with not panflu threat! Emergency managers, including my very good friend and soon-to-be FEMA head Craig Fugate, have been preaching this Gospel of Personal Responsibility action item for years and years.

Why we are not telling people to do this nowis bizarre.

At some point, we need to tell people to update those kits and to prepare. To have told the American people to stock supplies from 2005 to 2008 and then NOT tell people to do so in the face of a potential pandemic sends a mixed message which is bad, bad, bad.

What I will call "cafeteria-style" preparedness also won't cut it. If you had a plan for Phase Four, stick to the plan. If that plan meant stocking, then stock. If it meant fleeing to the equator, bad timing, unless that's where you were headed anyway.

I can tell you that in my own plan, as one detail, I order a stop to all vacuuming in Phase Five. That is because vacuuming will stir up particles that had drifted to relative harmlessness on the rug, to dry out and become inert. Vacuuming reactivates those particles, kicks them up back into the air where they can be re-inhaled. Business and political leaders would do well to order the same action -- but in Phase Five.

As I mentioned in my Computerworld blog of 2008: For hurricanes and pandemics, plan one category higher.you need to assume ahead of the experts, the government spinmeisters and the virus/hurricane/calamity itself. You will never go wrong if you plan one category ahead of the approaching event.

If nothing else, you'll have a great ravioli supply for those midnight snacks if we all stand down.

DANGER!!!!  LONG BLOG AHEAD.

I was going to call this particular blog "We don't need a pandemic to show us the economic consequences of one." In it, I was going to talk about how the current recession -- and a possibly worse description lurks in the wings -- is mimicing how the global economy would recoil during a pandemic of any severity.

One look at the economic numbers draws a striking parallel. GDP in the US is down by about half the Congressional Budget Office's estimates for a severe, 1918-style pandemic. The CBO estimated (along with the World Bank, the IMF and just about every other financial entity) that a 1918-severity pandemic would reduce global GDP by 5% to 6%, and most of that would come in a huge shockwave with a 20-week duration.

Well, it's the first quarter of 2009, and the US GDP has declined by an estimated 3.8%, adjusted annually. And again, most of it happened in a very condensed timeframe.

The key difference? This recession will be with us for a long time. Comparatively rosy estimates of a 2010 or even a 2011 recovery are going by the boards. In the government sector, no one can seem to get the declining revenue numbers right.  (My advice to them is to take their most pessimistic estimates and reduce them another 20% and budget from there.)

Now imagine what would happen if the Next Pandemic were to occur just as the global economy attempts to restart its engine; say, in 2011. And imagine if this pandemic were as severe as 1918's. Imagine a 5% to 6% drop in global GDP on top of an annual 3% to 4% decline in 2009, 2010 and 2011.

This is enough to cause even the most optimistic among us start to head for the proverbial hills.

Making matters worse is the lack of funding to prepare for the first pandemic of the 21st Century.  Any pretense -- any possibility -- that the private and public sectors can adequately stockplie and purchase items for that event is now out the window.

But not for all. In Britain, even though its government is also dutifully doling out billions of pounds Sterling to banks and other institutions, its government has declared it is doubling its stockplie of antivirals -- and (wisely) increasing its reliance on the inhalant Relenza/zanamivir for prophylactic use by first responders and law enforcement/military.

What do the Brits know that we don't know?

I read the federal government's recent assessment of the fifty states' preparedness for a flu pandemic, and I am sorry, but I don't believe a word of it. It's not that I think anyone is lying, but I refuse to believe any state is truly, look-in-the-mirror-prepared for a killer pandemic with a mortality rate close to 1918's.

Why? I do not see any state moving beyond the 25% antiviral purchase goal. I see many states meeting their share of that 25% goal, but none really exceeding it.

Why? I see no state embracing innovative solutions, such as the co-administration of probenecid to effectively double the supply of Tamiflu.

Why?  I don't think the feds can plan their way out of a wet paper bag.

Why? There is no emphasis on information technology data center and network professionals as among the first to need antivirals, particularly those in the public sector's own front lines of defense -- namely social services, law enforcement and unemployment assistance. Nowhere, in any federal pandemic document, do I see anything other than a cursory reference to "critical infrastructure" as even acknowledging the essential role that government data center and application developer and system engineer and network engineer and cybersecurity professional employees will play in a pandemic.

Why does this matter? NOTHING is done on paper anymore. Further, try to move back to paper! You will fail, and fail miserably. You want to see civil unrest and civil disturbances? You want to see blood in the streets? Watch the computers fail and watch people already bone-weary from years of a severe recession lose their subsistence lifelines because a pandemic hit and the mainframes shut down. The quickest route to civil discord is if/when the mainframes fail during a severe pandemic.

Why does this matter? Computers will route the information that is needed for people to make decisions and move resources. Computers will tell us who is sick and where (look at the Google plan to match search expressions with geography and, in their plan, be able to predict where a pandemic has broken out). Computers will tell us how much of something is left and how much to ration. If data center people get sick (and because they work in enclosed spaces, they work in very close physical proximity to one another and they WILL get sick in disproportionate numbers to the general population), you will have staffing problems and you will have maintenance postponements and database reorgs gone undone and then you will have system failures. Big system failures.

Recently, I wrote a blog saying Nature has a way of hitting humankind when it is down.  Look at 1918 for confirmation of that fact.  War builds stresses within the system.  So does famine.  So does pestilence.  So does economic uncertainty and calamity.  Everything is interconnected.  The 1957 pandemic was facilitated by American servicemen returning home from tours of duty in Korea and elsewhere in the Pacific theatre. 

We all know that we are long overdue for an influenza pandemic. We also know that pandemic fatigue is now itself a pandemic. And we know that there are stresses upon the world's ecomonic system that are impacting virtually every person on the planet in one way or another. 

Governments in this country no longer have the money to buy adequate stockpiles of masks, gloves, and antivirals.  That time has come and gone.  The only things we can do now to prepare are to plan and to educate.  Fortunately, these things cost little money.  They do require time and leadership. 

If governments (and for that matter, the private sector) have no money to stockpile, manufacturers will have no incentive to produce items that are not wanted.  So you will see reductions in the production of masks and other items intended to brunt the effects of a flu pandemic.  This means that if/when a pandemic does occur, the supply chain will be absolutely empty at the first sign of trouble.  We knew that would be the case anyway, but we also figured the manufacturing capabilities of the world's producers would eventually catch up.

We are in worse shape now than we were in 2005, in my opinion. We are no closer to deciding if schools close in unison or not than we were three years ago. We are no closer to making final decisions about quarantine and isolation than we were three years ago.  And while we have made great strides in preparedness and contingency planning, I cannot help but feel we are overconfident and arrogant in our belief that we have done everything we can do to adequately prepare.

And now we have lost our opportunity to further our stockpiles.  We put off those difficult bioethical decisions for another day.  And now, we lack the capacity to buy our way into enforcement of bioethics and pandemic policy.  It's gone, and won't be back for at least two to three years.  Pity, since recent studies point to successes in mask usage, and of course the recent stories of Tamiflu resistance in H1N1 in this country point to a huge need for Relenza that now no one can afford to buy.  This bird flu blogger has been championing the increased acquisition of Relenza and the purchase and use of Probenecid for years. 

Every day that passes brings us closer to pandemic.  Every day that H5N1, or H9N2, or H2N3 human cases are found brings us closer to pandemic.  And we have learned that despite our best international efforts, H5N1 continues to evolve and claim human lives -- and now, apparently, without the deaths of "sentinel chickens" that have warned us of trouble.

While the world's governments have indeed made strides, we are far short of the goal.  So let us take the opportunity to do whatever we can do in this current economic climate to prepare.  That means we educate people like we have never educated them before on this topic.  And also, we must plan, plan and then plan some more.  As Ike said:  The plan's useless, it's the planning that's important.  We should be taking our pandemic plans and stressing them in tabletop after tabletop exercise.  We need to be reaching out and running these plans past citizens and the media.  And we must ask everyone, What have we not thought of yet?

Because one day the worst will happen, and believe me, we will get bitten on the rear end by the stuff no one took the time to find.