Don't Be Chicken: Bioethics and Avian Flu

If you go running in Chicago in the early morning, as the first light glances and reflects on Lake Michigan, you can hear the great flocks of wild geese stirring and calling before you can see them. They have come down from the Artic where as the winter comes to the Midwest, just as the flu season begins. They crowd in the cove with the gulls and the dogs run toward them, and they scatter and fill the air. They will land at the high school in town, in the farms along the interstate, and in the City zoo, with the ducks and the pigeons. A pandemic that (hopefully) has not yet occurred dominates the newspaper headlines this winter—avian flu. Avian flu is on the front cover of most popular magazines, and news agencies like CNN frequently report on the spread of avian flu around the globe: an infected parrot found in Britain, a swan in Belgium, a flock of ducks in Turkey. There are also reports from China about a group of children with pneumonia who initially test positive for H5N1, the scientific name for the strain of influenza known as avian flu. Even before the test results are confirmed, tens of thousands of chickens in the region are killed, just in case (CDC 2005; Russert 2005). Avian flu also tops the agenda at the European Union, the United Nations, and the White House. As we were writing this article, the United States Congress added a billion dollars to the proposed flu budget, the World Health Organization met to craft a plan to stockpile vast amounts of the anti-viral drug Tamiflu (even though we don’t know if it is effective against the H5N1 strain), and the American Centers for Disease Control proposed new regulations requiring airlines and shipping companies to maintain electronic records of all passengers. Nevertheless, America lags far behind many other countries in preparing for a potential pandemic. Despite four years and billions of dollars spent on Operation Bioshield, we’re still putting our faith in a flu vaccine prepared by using 19th century technology and chicken eggs as the base medium How should bioethics think about the problem of avian flu, as the fear of its coming rises like the call of the geese in the wintering air? There are two equally powerful narratives we encounter when we reflect on the ethical dilemmas raised by the growing crisis about H5N1 and the threat that it will mutate into a pandemic viral disease that will alter human history. The first scenario involves what we call “feverish thinking”—namely, that flu fears are an absurd moral panic, the latest hyped-up fear campaign to divert us from real problems in health care, such as the malaria, tuberculosis and infant diarrhea that kills millions of people every year. In this story, the risk of the H5N1 stain of influenza mutating into a variant that would pose danger to humans is so extremely small as to be meaningless. Furthermore, the way the modern medicine is structured with our ICUs and our ventilators and our antiviral drugs and our ability to quarantine means that pandemics cannot affect the world in the same way that the 1918 pandemic did. Hence, to worry about avian flu is to be duped. In this story, the ethical issue is about how to refocus our attention on the real issues. The second scenario is what we call “fair warning.” We are now faced with the very disaster that we have been warned about for decades. As Gina Kolata warned in her 1999 book, “perhaps as we grow smug about influenza, that most quotidian of infections, a new plague is now gathering deadly force” (Kolata 1999). The emergence of a new strain of influenza, H5N1, is closely linked by virulence, genetics and epidemiology to the 1918 strain that killed 50 million worldwide, nearly 5% of the world’s population (Frist 2005). The 1918 pandemic also sickened millions more, overwhelming the American health care system, stopping most modern commerce, and even bringing an abrupt halt to World War I (Barry 2004).According to this narrative, we need to reflect immediately on what to do to prevent another pandemic and set in place a fair and just system that will distribute limited health care resources in order to save the greatest number of lives. Getting it wrong is an all-or-nothing problem—if we turn from the tasks that our second narrative suggests and the worst (or even the pretty dreadful) happens, we truly will have failed. Overreacting will have a far less catastrophic effect for, at the worst, we could end up thinking about how to create a health care system that is responsive to and serves the interests of the majority of the peoples of the world. Planning for pandemic disease might actually allow Americans to end up with things that they need, such as an effective public health system that serves poor and marginalized populations, a coherent system for delivering of a decent minimum of health care access and service to all, a systematic way of organizing and distributing medical data, a plan for the production and wide-scale distribution of vaccines, and a deeper respect for how genetic medicine and a firm grasp of evolutionary biology can be useful.