When Drugs Aren’t the Answer
We Must Look Beyond Vaccines and Pharmaceuticals in Pandemic Preparedness
SOURCE: AP/Gregory Bull
Public health measures that reduce the potential for spreading disease through groups of people present a strong defense in the face of an outbreak. We should have been talking about them earlier.
The unfolding global swine flu outbreak is providing the first test of the United States’ pandemic influenza preparedness efforts. Although this virus is genetically distinct from the avian influenza on which planning was focused, the similarities between the two diseases mean that much of the extensive pandemic planning ought to be adaptable to the new threat. But already, the limitations of available medical countermeasures and the tremendous public alarm surrounding reports of cases in Mexico, the U.S., and elsewhere underscore the need for a greatly enhanced public dialogue regarding the value of disease control strategies beyond pharmaceuticals or vaccines.
Simply put, the antiviral drugs and vaccines that have been the focus of much pandemic planning and media attention are of limited use or unavailable during this pivotal early stage of the current outbreak. We have badly needed a fuller, more frank national discussion of the importance and ethics of other methods that can limit the spread of the virus in communities and worldwide. These strategies include voluntary and involuntary social distancing, which reduces transmission by, for example, closing schools or other locations where large groups assemble; isolation; and quarantine. Developing thoughtful policies and broad support for them is difficult enough in the absence of an imminent public health emergency. Attempting to do so in the midst of an unfolding outbreak and resulting media frenzy is all but impossible.
The severity of swine flu or any potential pandemic will be determined in large part by how quickly those infected or exposed are identified, located, and separated from the healthy.
Public health officials have long warned that antiviral drugs such as Tamiflu will be of uncertain value in a pandemic. Early evidence suggests that the current swine flu shows some susceptibility to this class of drugs. However, the modest benefits they provide for most influenza viruses, coupled with the rapid spread of the present threat suggest that antiviral stockpiles will be of limited use in reducing the extent or severity of this outbreak. Similarly, talk of a swine flu vaccine is highly premature, as it will require at least six months to produce the first doses of a new vaccine, a time frame identical to the forecast for an avian influenza vaccine. For this reason, several hundred million dollars in government contracts have been spent on so-called “pre-pandemic” avian flu vaccines, products intended to provide some benefit until a specific vaccine can be produced at the start of a pandemic. The rapid emergence of swine flu renders this option moot for the current outbreak.
In either case, producing sufficient pandemic flu vaccine doses for large numbers of Americans, let alone international populations, would take years, even if significant financing, production, safety, and distribution challenges could all be resolved successfully and quickly. Moreover, the unintended consequences of the 1976 swine flu vaccination program, which resulted in far more vaccine-related injuries and deaths than confirmed cases of the disease itself, is a clear reminder of the perils of a rapid mass vaccination effort against a threat of uncertain severity.
The limited value of pharmaceuticals and vaccines in the early stages of a potential influenza pandemic is well known to public health officials and diligent readers of the vast planning documents issued by the federal government since 2005. Instead, the severity of swine flu or any potential pandemic will be determined in large part by how quickly those infected or exposed are identified, located, and separated from the healthy. This is the decidedly low-tech but life-saving work upon which many of the achievements of public health in the past century have been based. Evidence from past pandemics, most notably research by Howard Markel and colleagues on the 1918-19 influenza pandemic, has shown the positive effects of such non-pharmaceutical interventions for those communities that used them early and extensively in disease control efforts.
The public stance of federal pandemic preparedness, however, has been overwhelmingly centered on vaccines and pharmaceuticals. Hardly a month has passed since 2005 without press releases announcing new contracts to fund several generations of pre-pandemic vaccines, additions to antiviral stockpiles, or further modifications to the complex framework developed to allocate scarce supplies of vaccines and drugs fairly and effectively. In this context, it is no surprise that media coverage of the current swine flu outbreak has repeatedly turned to vaccines, with health officials asked to explain if there is a vaccine available, why there is not, and when one may become available.
In contrast to vaccines and antivirals, discussions of the role of social distancing, isolation, and quarantine in pandemic influenza response have most often been buried deep within government websites or little-publicized reports. While a significant public engagement effort was developed to build support for vaccine and antiviral allocation strategies, no comparable program has aimed to educate Americans on the importance of non-pharmaceutical interventions in limiting the impact of an outbreak. This is unfortunate, as widespread public support for voluntary isolation and quarantine programs is critical for their success, while also reducing the likelihood that far more controversial and ethically problematic compulsory measures may be required.
How might this disparity in attention be explained? The medical profession and the general public have long been transfixed by the potential for “wonder drugs” or “magic bullets.” The allure of scientific innovation as the key to preventing mass casualties in a pandemic is understandably difficult for politicians or scientists to resist. Announcements of sizable contracts to develop and produce new vaccines or the image of a national stockpile ready to be deployed in a crisis are far more likely to attract headlines than, for example, a public education project on the benefits of simply staying home from work when showing flu-like symptoms during an outbreak. The development and production of drugs or vaccines also bring economic benefits to participating companies and their communities, part of the profitable, if not somewhat opportunistic, industry emerging around pandemic preparedness.
Beyond these cultural, political, and economic explanations for the focus on vaccines and drugs, non-pharmaceutical interventions have been largely overshadowed in pandemic planning likely because the mere suggestion of isolation and quarantine programs is certain to be controversial and alarming. Even if such programs were voluntary in all but the most severe and limited circumstances, the word “quarantine” calls to mind scenes from the movies of entire communities cordoned off and placed under military control—like in the 1995 movie Outbreak. These unrealistic fictional depictions, coupled with documented historical abuses of quarantine powers by public health officials, create considerable challenges for public health officials charged with organizing non-pharmaceutical interventions and building support for their use as part of effective and just disease control strategies.
In contrast to voluntary programs, compulsory isolation and quarantine force us to examine the tension between individual liberty and the common good in public health, in addition to the contentious political and ethical debate over the role of the state in restricting civil liberties during a crisis. The overwhelming public interest surrounding the 2007 case of Andrew Speaker, the American traveler infected with a drug-resistant form of tuberculosis and placed under a federal isolation order, provided clear evidence of the mass concern such actions can create, even when applied to only one individual. Since then, however, there has been no visible effort to engage stakeholders and the public regarding when similar measures may be required in a pandemic, how their use will be overseen, and why they are critical to preserving public health.
More practically, the reality of our vastly underfunded public health infrastructure makes it difficult to imagine how large-scale social distancing, isolation, or quarantine programs would succeed in the face of widespread public opposition, making preemptive public education programs inseparable from disease control goals. With respect to the eventual allocation of scarce supplies of vaccines and antivirals, pandemic planners have realized the importance of the methodical, thoughtful engagement with stakeholders and the public. An analogous program examining policies for voluntary or compulsory non-pharmaceutical interventions would have been similarly worthwhile.
For the unfolding swine flu outbreak, it is already far too late to begin this vital work. Government officials who are already justifiably concerned about creating unnecessary panic may be forced to introduce targeted social distancing, isolation, and quarantine programs to a public that has heard too little about their tremendous importance and too much about vaccines and antivirals that are barely relevant to the immediate health challenges at hand. Through the efforts of the public health community coupled with a bit of luck, swine flu may dissipate without becoming a full-blown pandemic, giving health policy-makers a second chance to revisit these critical aspects of a comprehensive, just approach to pandemic preparedness.
Jason L. Schwartz is a researcher at the Center for Bioethics and a doctoral student in the Department of History and Sociology of Science at the University of Pennsylvania. He is most recently the author of “Disease Control Policy: Individual Rights versus the Common Good” in the Penn Center Guide for Bioethics (Springer, 2009), from which parts of this essay are adapted.
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