The pandemic clock is ticking, we just dont know what
time it is.
Ed Marcuse, 2003
The Forgotten Flu
In the spring of 1918, as the first great war of the modern age neared its close, a far more deadly adversary was just beginning its worldwide conquest. Stealthier than a German U-boat, the invading force circled the globe in a matter of months, leaving in its wake a level of carnage remarkable even against the novel horrors of the day. Even more surprising was the invisible agent behind this monumental assault: an influenza virus, blown into pandemic proportions.
Influenza carried much of the same benign implication in the years leading up to 1918 as it does today. Viewed with familiarity and little feared, the flu was accepted as a relatively harmless illness akin to the common cold a serious threat only to infants, the elderly or infirmed. This perception drastically shifted with the outbreak of an especially virulent strain that came to be known as Spanish flu. The killer virus swept the world in less than a year, spreading along trade routes and rail lines and touching nearly every human population on earth.
Equally extraordinary was its unusual mortality pattern, discriminately targeting the young, healthy adults that seasonal influenza typically spares. Out of the massive number of those infected, an unlucky 2.5% suffered a gruesome fate. Sudden spells of fever and weakness rapidly progressed into agonizing pneumonia as the lungs hemorrhaged and the telltale blue tint of cyanosis set into the skin. Death often came quickly, sometimes just hours after the initial symptoms.
After the last wave of the pandemic ended in June of 1920, Spanish flu had claimed some 50 to 100 million lives with one-third of the global population falling ill. The United States alone lost an estimated 675,000 people more than the total American casualties in every twentieth-century war combined. It was by a cruel and mysterious twist of fate that this plague, likely the worst in human history, emerged during the final stages of a bloody conflict that had already so deeply traumatized the world at large. Still reeling from the shock and hardship of four years at war, people had little chance to process the magnitude of the fleeting pandemic. Its not difficult to understand why the survivors of these devastating events chose to look to the future, and to bury their memories of Spanish flu along with the dead. As the historian Alfred W. Crosby puts it, as soon as the dying stopped, the forgetting began.
as soon as the dying stopped, the forgetting began.
Today the great influenza of 1918 is a minor bullet point in the annals of history. Memorials to Pearl Harbor and memoirs of economic depression far overshadow the Spanish flu tragedy despite its enormous impact. Even amid threats of bioterrorism and climate chaos, it is hard to imagine a disaster more catastrophic than a pandemic, with its unique ability to afflict the whole of humanity at once. While infectious disease probably ranks low among the worries of most Americans, health experts agree that future pandemic events are a natural inevitability. There have been 10 influenza pandemics in the last 300 years, and three of these occurred in the last century: Spanish flu, the Asian flu of 1957 and Hong Kong flu in 1968. While far less severe than their infamous predecessor, the past two outbreaks caused significant social disruption and resulted in around 2.5 million deaths worldwide. And if history is any indication, as many experts fear, we are perilously overdue for another round.
The Next Great Pandemic Threat
In May of 1997, a three-year-old Hong Kong boy died from a flu-like respiratory illness later identified as a highly pathogenic strain of the avian influenza A virus. Classified by the subtype H5N1, this variation had previously been known only to infect birds, and was responsible for the deaths of thousands of chickens in the area a few months earlier. By December, Hong Kong had reported an additional 17 cases of human H5N1 infection, five of which proved fatal.
The sudden leap across the species barrier meant that people had no protective immunity to the virus, a key factor in an emerging pandemic. With officials nervously monitoring the situation, the bird flu outbreak seemed to disappear. But in 2003, H5N1 resurfaced in Hong Kong in two confirmed human cases (one fatality), quickly spreading outwards to infect poultry across mainland China, Korea, and Southeast Asia. The next great pandemic threat had arrived.
Over the ensuing years H5N1 has continued to proliferate, taking hold in bird populations throughout Asia, Africa, and Europe. The virus is now considered endemic in many regions, despite efforts to eradicate it from domestic flocks. Especially hard hit have been developing countries like Viet Nam, Bangladesh and Indonesia where poultry farming is a vital means of subsistence for rural villagers. For every thousand birds that die from the flu, tens of thousands more are culled in desperate attempts to quash the runaway virus. The total number of culled poultry exceeds 150 million and continues to mount, placing significant economic stress on beleaguered farmers who arent always equitably compensated for their losses.
Most worrisome, however, is avian influenzas occasional ability to infect people in close contact with diseased birds. By the
current figures, there have been 382 confirmed cases of bird flu in humans in 14 countries. 241 of these resulted in death, for a Case Fatality Ratio (CFR) of 63% an exceptionally high proportion, considering that the lethal Spanish flus CFR was just 2.5%. H5N1 displays a curious similarity to Spanish flu in its abnormally high fatality rate among young adults, leading researchers to speculate that the viruses share some unknown biological traits. Incidents of human contraction, while still rare, are on the rise and regularly appearing in new locations, suggesting a slow but persistent trend towards easier transmissibility between species.
As viruses go, influenza is especially prone to such mutations. This is why, for example, we are urged to get a newly updated shot each fall to ward off another years iteration of the seasonal flu. Flu viruses are constantly undergoing small genetic changes, mutating gradually according to a process called antigenic drift. As slight alterations build up in its surface proteins, a virus can develop new behavioral characteristics such as the potential to cause more severe illness or to afflict a wider range of species.
Alternately, entirely new subtypes can form through antigenic shift, a dramatic process of gene swapping, or reassortment, that takes place between two or more distinct viruses present in the same host. Both methods have likely led to pandemics in the past. Recent studies suggest the gradual emergence of Spanish flu through antigenic drift in the avian influenza virus H1N1, a scenario once thought impossible by virologists. Conventionally, pandemics have been understood as products of sudden genetic reassortment; the 1957 and 1968 outbreaks were themselves reassorted from H1N1 to create novel human influenza viruses.
In order for a virus to become a full-blown pandemic, three conditions must be met. First, the strain must be one that has never infected humans before (or that has dropped out of circulation) meaning everyone is potentially susceptible. The virus must then develop the ability to cause disease in humans. Finally, a mutation must take place to allow for easy transmission between people, as occurs with the seasonal flu. At present, the first two of these conditions are clearly evident in H5N1. The key mutation needed to launch bird flu to pandemic status could come at any time, through a series of subtle changes or an abrupt genetic reshuffling in any infected host. Some experts believe the current avian flu is following in the footsteps of Spanish flu, incrementally building up mutations on a path to global epidemic.
For researchers tracking H5N1, the situation has grown unbearably tense. The unabated spread of avian flu in poultry is a serious concern, as each back-and-forth transmission among animals could potentially give rise to a new strain perfectly suited for human illness. The vast numbers of both animals and people alive today provide unprecedented mutation opportunities for the unstable influenza virus. Carried by migratory ducks and swans, the disease has traveled long distances to crop up in once-unaffected Western Europe. H5N1-infected birds have recently been identified in urban areas of Bangladesh
and South Korea, raising fears of widespread human infection. There is also evidence that the virus is becoming better adapted to infect mammals with reports oftigers, dogs, and domestic cats dying from avian flu. While it is possible that H5N1 will remain a threat only to chickens and their handlers, the virus seems to be inching ever closer to humankind.
Managing the Worlds Health
Leading the fight against bird flu is the World Health Organization (WHO), a Geneva-based offshoot of the United Nations that plays a pivotal role in combating disease and setting global health policy. As reports of bird or human H5N1 cases arise, WHO researchers investigate the outbreak, collecting background information along with serum samples from infected hosts to determine if critical changes have taken place in the virus. Using this data, officials attempt to gauge the risk posed by avian influenza.
According to the agencys six-phase Pandemic Alert System, the global bird flu situation is currently poised at phase 3, indicating no or very limited human-to-human transmission. A jump to a phase 4 alert would point to evidence of increased human-to-human transmission a subtle difference, but a significant one in terms of perception of the current threat. Raising the alert status would likely precipitate immediate public concern, mobilizing governments and local communities around the world for an imminent pandemic. Because of the huge consequences of such a change, a 2005 press release explains, WHO is following a cautious approach.
The world has been locked in a phase 3 pandemic alert since January of 2004 despite a growing number of infection clusters which suggest that direct transmission of bird flu between humans may be taking place more readily. The most striking example of this came in May of 2006 when an Indonesian family of seven fell ill from avian flu in the largest cluster to date. Six people died, most of whom had no contact with poultry and likely contracted the disease from another family member. This rattled the nerves of many officials, particularly due to genetic clues hinting that the virus had passed between individuals and onto a third a two-generation or human-to-human-to-human (H2H2H) chain that had never been seen before.
Following a flurry of attention surrounding the incident, WHO resisted calls to boost the pandemic alert citing insufficient evidence that the threat had advanced. Specific guidelines for raising the alert level dont exist, leaving many experts wondering what must happen before WHO will take this critical step.
In a statement following the Indonesian report, Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP), expressed concern over the ambiguity of the alert system:
Im personally confused about the difference in what a phase 3 and phase 4 alert level is. The WHO has not clearly described the difference. Thats important. Im personally aware of a number of companies that have pegged certain levels of their pandemic flu plan on a change from phase 3 to phase 4.
As the de facto authority on pandemic preparedness, it is understandable that WHO would be careful in making a judgment that could have dramatic worldwide effects, from reduced tourism to a global economic slump. An event from the recent past serves as a cautionary tale for policymakers weighing the ill-defined risk of an H5N1 pandemic: the U.S. swine flu scare of 1976.
The Swine Flu Factor
When a freshly mutated strain of influenza A linked to the dreaded Spanish flu killed a soldier at Fort Dix, New Jersey, officials feared a massive outbreak was at hand. Acting on the urgent recommendations of his health advisors, President Gerald Ford promptly announced plans for a nationwide immunization campaign during a televised address. It was a brash move (perhaps motivated by election-year politicking and pressure from pharmaceutical lobbyists) but some regard it as an ethical and defensible action considering the potential consequences of an uncontrolled epidemic.
As it turned out, the swine flu threat never materialized and only resulted in the initial fatality. Instead, hundreds of people developed a rare nervous system disorder, Guillain-Barré syndrome (GBS), shortly after receiving a dose of the hastily developed vaccine. The program was cut short in a wave of controversy following 25 GBS-related deaths, to the great embarrassment of all involved. Although there
remains speculation as to whether the flu vaccine was truly at fault, the episode humbled the medical community and left a legacy of public distrust in government-sponsored health initiatives.
The lessons of the swine flu fiasco have doubtless informed WHOs guarded approach to H5N1. But by all indications, the current situation is considerably more threatening. Whereas swine flu caused just a single death and infected only a handful of Americans, the avian virus circulating the globe has killed hundreds over the past five years, to the grave concern of health officials worldwide. Moreover, the entire notion of tracking an emerging pandemic is unprecedented; never before has a society seen one coming, let alone attempted to stop it.
In a May 2006 document, WHO acknowledges the dangerously uncharted territory it treads: Given the unpredictable behaviour of influenza viruses, no one can know in advance whether the start of a pandemic will begin gradually or be announced by a sudden explosion of cases, thereby precluding any attempt at containment.
In this light, WHO officials might be viewed as overly cautious when faced with the tough decisions that could mitigate an H5N1 pandemic. The prominent bird flu blog Effect Measure has censured WHO for its reluctance to raise the alarm about ominous developments in the virus: Admittedly this is a tough call for public health and there are two ways they can get it wrong: failure to warn when it turns out the warning was justified, or warning when it turns out otherwise. If you are going to get it wrong, it is better to err on the side of precaution than the reverse.
Other experts disagree, insisting that the agency is performing admirably under challenging circumstances. I dont think [WHO] are going to undersell this, says Thomas Voss, Assistant Professor of Immunology and Microbiology at Tulane University. If you go to Geneva and talk to the WHO, theres not a person in the hallway whos not concerned about pandemic flu. They are on top of this in a big way, and I think theyre fully invested in sounding the alarm when it needs to be sounded.
Further controversy surrounds WHOs position of withholding recovered genetic data from researchers in the public domain, thus obstructing the efforts of the greater scientific community a stance Effect Measure denounces as "unconscionable. Most recently, the agency caught flak for a series of retractions and conflicting reports on an H2H-suspected cluster of four persons in Pakistan. Initially reporting the cluster as a confirmed human-to-human event, WHO denied this claim just days after in a Reuters news release. Then a full three months later, WHO changed its story a third time, concluding that limited human-to-human transmission likely occurred after all.
Given the degree that this autonomous organization is entrusted with the worlds safety, these incidents raise troubling questions about the management of our global society. The demand for surveillance and communication grows as avian flu spreads to far-flung and remote areas, making control through a centralized authority increasingly difficult. Whether by negligence or sheer logistical overload, the probability for error climbs as new circumstances emerge. Certainly the world is better off with a powerful ally like WHO, but its blackout policy towards crucial data is only harmful. The stakes are high in the crusade against bird flu, and humanity risks much in the gamble.
Avian Flu Today
As a battle for the White House rages on, candidates from both parties are enthusiastically laying out their platforms on the major issues of the day: global warming, the economy, and the Iraq war, to name the top few. Yet in all the endless speeches and debates, none have addressed the looming specter of bird flu a scenario that conceivably poses a greater national security threat than any subprime loan or terrorist cell.
If the rhetoric of politicians echoes the concerns of the people, it seems any fears of avian flu have faded from the public consciousness. Major media outlets abandoned the H5N1 story after an initial buzz, afraid of turning off audiences with persistent doomsaying about sick chickens in China. Experts worry that the world is giving in to
bird flu fatigue, complacently shrugging off the pandemic threat after years of fruitless warnings.
But unlike the publics flighty attention span, the advance of avian flu has been
tireless. First-time reports of H5N1 infection saw an alarming spike in 2006 with 19 new countries identifying the virus in dead or dying birds. Egypt has experienced a spate of 50 human cases since March of 2006, establishing a substantial bird flu presence on the resource-starved African continent. Most recently, the South Korean capital of Seoul ordered the culling
of its entire poultry population more than 15,000 chickens, turkeys, ducks, and pheasants after H5N1-infected fowl were discovered in an open-air market. The massive cull was the latest in a series of slaughters across South Korea that has claimed some seven million birds in just over a month.
Currently, the island nation of Indonesia is ground zero
for pandemic flu with 133 confirmed human cases and 108 fatalities more than any other country, and nearly half the total deaths worldwide. The conditions in Indonesia are dire; containment efforts have been a near-complete failure, and bird flu is now considered entrenched in all but 2 of the nations 33 provinces. To make matters worse, for the past year the Indonesian government has resisted
international surveillance programs, withholding new isolates of the virus from WHO and US Navy scientists. Their defiance is in protest against the Wests dominance over medical technology and pharmaceuticals, arguing (justifiably so) that any vaccine produced from Indonesian bird flu samples would be priced out of reach of developing countries.
India recently joined
Indonesias blockade, announcing they will no longer share viruses with WHO until arrangements for affordable vaccines are made. Indonesian health minister Dr. Siti Supari raised the issue at the annual World Health Assembly in Geneva earlier this May, although nothing substantive was decided. Friction between Western authorities and the flu-stricken peoples of the East adds another layer of complexity to the bird flu predicament, as matters of culture, politics, and science collide under the darkening shadow of a global emergency. Without full cooperation and trust among the worlds leaders, what seems a nearly impossible feat predicting and thwarting a pandemic disease becomes even more so. But the issue raised by Indonesias stand is an important one. During a pandemic, one can rightly imagine that the inequities of society, globally and otherwise, will be suffered to their fullest extent.
The Pandemic Scenario
Based on historical accounts, experts anticipate an avian flu pandemic to last between one and three years as it travels the globe. Infection will roll through communities in waves of 6-8 weeks, repeating several times until the virus has run its course. The vast number of humans on the planet today, coupled with the rapid-fire global transportation of people and goods, creates a perfect storm for a virulent influenza to quickly reach all corners of the world. By the current estimates, a pandemic on par with the 1918 flu would claim over 142.2 million lives.
Treatment options could be extremely limited. Already overburdened hospitals would quickly overflow, and trained healthcare personnel would fall among the viruss first victims. Since a sample of the active strain is needed to make a suitable vaccine, immunizations wont be available for at least six months after a pandemic starts. Modern vaccine manufacturing methods still use technology from the 1950s to grow viruses in chicken eggs, a delicate and lengthy process. Even operating at maximum capacity, all of the worlds vaccine facilities can only produce enough doses for 350 million people annually roughly 6% of the world population. If the virus circulating among people mutates at any point, the old shot may provide little protection.
Although new research to advance vaccine science is underway, some major obstacles remain. A big challenge here is the need for industry to play a big role in this, notes Voss. The people who make those decisions at the [pharmaceutical] companies want to see a return on their investment. Everybodys trying to position themselves so they have the least amount of risk, and the sick people are right in the middle.
Antiviral medicines, the next best pharmaceutical defense, would be equally limited in quantity and accessibility under pandemic conditions. Swiss pharma giant Roche holds the patent to the most promising of these drugs, Tamiflu, which it currently produces out of a single factory. When taken at the onset of flu symptoms, the drug could potentially slow the damage done by the virus and boost the chance of recovery, although results
against bird flu so far have been poor. Nations around the world began stocking up on the drug as fears of a pandemic mounted, earning windfall profits
for Roche. However several reports suggest new strains of H5N1 are already showing a resistance to Tamiflu, rendering strategic stockpiles potentially
useless. Furthermore, reports
from Japan linking the drug to 18 teenage deaths from bizarre and self-destructive behavior make the dubious treatment even less attractive. Medical solutions, it appears, are not likely to have much impact on pandemic influenza.
For those not immediately afflicted with disease, the pile-on effects of a crashing global society could be equally devastating. Absenteeism among workers in critical jobs such as power generation, communications, and border control could quickly lead to chaos as interdependent support systems fail and national security is compromised. President Bush suggested in 2005 that martial law might be instituted if avian flu broke out in the U.S., prompting much
criticism. In a recent statement, the ACLU
has expressed concerns that federal pandemic plans rely heavily on a punitive approach and emphasize extreme measures such as quarantine and forced treatment. The possible scenarios are endless, and the worst cases are ultimately bleak.
As both an infectious diseases expert and an official with the U.S. Department of Homeland Security, Michael Osterholm is particularly qualified to speculate on life during pandemic influenza. As laid out in a
feature article for Foreign Affairs, his vision is chilling:
In short order, the global economy would shut down There would be major shortages in all countries of a wide range of commodities, including food, soap, paper, light bulbs, gasoline, parts for repairing military equipment and municipal water pumps, and medicines, including vaccines unrelated to the pandemic. Many industries not critical to survival electronics, automobile, and clothing, for example would suffer or even close. Activities that require close human contact school, seeing movies in theaters, or eating at restaurants would be avoided, maybe even banned.
In a recent New Scientist article, Debora MacKenzie argues the complex structure of modern civilization makes it especially vulnerable to collapse during a severe pandemic. She echoes Osterholms fears that the just-in-time delivery system of global commerce, where small shipments of goods are made round the clock, could leave communities destitute within days of a world-stopping event. The frenzy of stockpiling likely to occur when panic sets in could clean a supermarket of its inventory in a matter of hours. But going a step further, MacKenzie believes the diverse network of key individuals that keep society running smoothly might be impossible to restore after a devastating pandemic. As one expert quoted in the article puts it, people are the critical infrastructure.
Think Globally, Prep Locally
Regardless of its shortfalls or successes, an international crusade against bird flu is only viable during the pre-pandemic stage. Once the virus mutates and begins to spread among humans, the scope of action becomes highly localized. The U.S. government has drawn up strategic
plans in case of pandemic influenza, addressing concerns of essential functions and public health. But many critics feel these efforts are shortsighted and increasingly under-prioritized, especially amidst the political distractions of an election year. Even those officials who show deep concern about pandemic influenza acknowledge that the massive scale of such an event happening everywhere at once would limit their ability to help most citizens. The message being handed down to the public is: Youre on your own.
Speaking to an assembly of hospital operators and emergency responders in 2006, U.S. Health and Human Services Secretary Mike Leavitt was unequivocal
on the matter:
Any community that fails to prepare [for a bird flu pandemic], with the expectation that the federal government or, for that matter, even the state government will come to their rescue at the final moment will be tragically wrong.
Each state, city, business, and institution is responsible for its own contingency plans, but there has been little uniformity of action across the country. Some analysts insist that the best
response lies at the grassroots level of neighborhood and community planning. Based out of Nez Perce County, Idaho, a volunteer group called the Get Pandemic Ready Team has compiled an indispensable archive of preparedness advice for concerned citizens and local leaders. Visitors to their website GetPandemicReady.org can browse downloadable guides on topics ranging from water purification and food stockpiling to Dealing with Death. Initiatives like this encourage community-wide participation rather than go-it-alone survivalism, and serve as much-needed insurance against any disaster where government assistance is unlikely.
For those frustrated by the limited efforts of bureaucrats and the indifference of the general public, the Internet has provided a welcome home. A thriving online subculture has emerged around avian influenza with countless blogs, open-source databases, and heavily trafficked forums dedicated to helping individuals plan to weather a severe pandemic. One of the most popular resources is FluWiki, an exhaustive collection of user-created diaries that track H5N1 information, offer prepping tips, and help spread awareness of the pandemic threat. Another handy site is BirdFluBreakingNews.com, a minute-by-minute headline ticker of avian influenza happenings around the world, essential for the self-reliant flu watcher looking to get a jump on a potential global outbreak.
So Will It Happen?
Among all the scientists, bloggers, and government leaders anxiously following the H5N1 virus, one question weighs on everyones mind: Will avian flu go pandemic?
Unfortunately, theres no way to know the answer in advance. But all experts agree that even if H5N1 never fully mutates to humans, another pandemic flu of some kind will happen one day. As certain as hurricanes and earthquakes will continue to rock the earth, influenza will rise again.
In the case of bird flu, however, some important questions remain. Is the H5N1 virus on a path towards becoming a pandemic? And if so, could we see a repeat of the 1918 influenza event or worse? Here, the opinions couldnt be more different.
Its one thing to say therell be a pandemic, cautions Voss. But is there going to be a pandemic with mortality like what we saw in 1918? Probably not. Even in developing countries, modern healthcare systems are light years ahead of where they were in 1918, he explains. Its a different world.
Osterholm is less sanguine in his appraisal and more certain. The current national disaster response system will collapse in a minute, he warned
the crowd at a Rochester, Minnesota lecture earlier this May. This is the one I know is going to happen, and I fear desperately that the world is going to wake up one day and be surprised.
In the end, the debate and the reaction over avian flu may hinge on ones disposition. Osterholm admits to being a Chicken Little, while Voss confesses, I hate to be one of those doomsday people. For those of us whose outlook lies somewhere in the middle, Voss offers some practical advice:
First and foremost, get a flu shot every year. If theres not a pandemic virus, itll protect you from the seasonal virus. If there is a pandemic, you might get some protection as well. And then, watch what is happening around you. If there are stories about poultry deaths, those are signs that there are viruses circulating in birds that may eventually make it to people and some of those things make the news.
Pandemics were once no different than tornadoes and earthquakes, catastrophic events which strike at random and with little warning. But at this unique moment in history, we are able for the first time to watch a potentially devastating natural disaster coiling up in the distance, poised to strike. Whether the next pandemic hits tomorrow or twenty years from now, it will eventually happen. When faced with an inevitable crisis, making preparations now is the only sensible action.
How to Prepare
(The following are a sample of recommendations from the InSTEDD manual, Pandemic Influenza Preparation and Response: A Citizens Guide. You can download the entire manual by clicking here, or from the attachment below.)
Store 1-3 months of
non-perishable food for every family member. Choose foods that do not require refrigeration, preparation
(including water), or cooking. Dont forget pet foods.
Store a one-month supply of
fresh water for each family member. Plan to use 1-2 gallons of water per person
Ensure that you have
necessary medical supplies if you have a chronic disease condition. Talk to
your healthcare provider about obtaining an extra months supply of
Build a pandemic flu
emergency kit containing disinfectants/chlorine bleach, water purification
tablets, surgical masks and gloves, and pain relievers/cough medicine.
Healthy Habits and Virus
Clean your hands frequently
and thoroughly using soap and water or alcohol-based hand rubs.
Cover your coughs and sneezes
and ask others to do so as well.
Keep living and work area
Practice social distancing
techniques. Avoid crowds and public gatherings. If you or anyone in your home
is ill, or if you may have been exposed to an ill person, stay at home and
isolate yourself as much as possible.
Neighborhood organizations can
help fill the gap left by an overwhelmed infrastructure. Highly desired
volunteers include but are not limited to:
Retired healthcare personnel
People who have recovered
from previous infection with the circulating pandemic influenza strain.
People with medical training.
Mental health and spiritual
People with disaster response
Here are some suggestions for the
types of neighborhood volunteer roles that you might need. Meet with your
neighbors and family, and talk about what would work best for you.
Volunteer Recruiter and
Medical Operations Manager
Mental Health Monitor
World Health Organization
Avian Influenza page:
U.S. Government avian flu and
Centers for Disease Control and
Prevention Resources for Pandemic Flu:
Center for Infectious Disease
Research and Policy:
Pandemic Readiness info:
Avian influenza database and
Avian influenza global headlines,
Michael Osterholm video
presentation Pandemic Influenza: A Harbinger of Things to Come (2005)
Images by Instedd.org, aburt, Quiplash!, and bigbold, used under Creative Commons license.