“He who desires, but acts not, breeds pestilence.”

-William Blake

Too little too late?

For years, scientists have requested detailed operational blueprints—country by country down to neighborhood by neighborhood—on how best to make it through 12 to 24 months of a pandemic.²²²³ “If the greatest pandemic in history is indeed on the horizon,” wrote the editorial board of Lancet, “that threat must be met by the most comprehensive public-health plan ever devised.”²²²⁴ Indeed, Senator Majority Leader Frist has called for an unprecedented effort rivaling the Manhattan Project in scope and intensity to prepare the nation’s defenses.²²²⁵ “We have only one enemy,” CDC director Gerberding has said repeatedly, “and that is complacency.”²²²⁶

Unfortunately, no country is prepared.²²²⁷ In the policy journals like Foreign Affairs, senior officials admit that planning for what they call “the most catastrophic outbreak in human history” is “abysmally inadequate.^”2228 Despite repeated warnings over the years that a new pandemic is inevitable and repeated prods by the WHO for countries to draw up preparedness plans, only about 50 of more than 200 countries have done so.²²²⁹ Some of these “plans” are as stunted as a single page²²³⁰ and most, as described in the science journal Nature, are “very sketchy.”²²³¹ The WHO calls for countries to “put life in these plans” by carrying out practice simulations. “One has to be very vigilant, honest and brave,” asserts Margaret Chan, now the WHO’s chief of pandemic preparedness. “Sometimes you need to make unpopular, difficult recommendations to political leaders which may have a short-term impact on the economy and on certain sectors.”²²³² As the Los Angeles County Disaster Preparedness Task Force motto reads, “The only thing more difficult than preparing for a disaster is trying to explain why you didn’t.”²²³³

Fewer than 10% of the countries with plans have taken the necessary further step of translating the plans into national law.²²³⁴ The chair of the Infectious Disease Society of America’s Pandemic Influenza Task Force is concerned about the state of U.S. preparedness. “Although many levels of government are paying increased attention to the problem,” he said, “the United States remains woefully unprepared for an influenza pandemic that could kill millions of Americans.”²²³⁵ Osterholm was, as usual, more direct. “If it happens tonight,” Osterholm said at a forum sponsored by the Council on Foreign Relations, “we’re screwed.”²²³⁶

Osterholm laid it out on The NewsHour with Jim Lehrer: “We can predict now 12 to 18 months of stress, of watching loved ones die, of potentially not going to work, of wondering if you’re going to have food on the table the next day. Those are all things that are going to mean that we’re going to have to plan unlike any other kind of crisis that we’ve had in literally the last 80-some years in this country.”²²³⁷

The U.S. pandemic preparedness plan has been long in the making. The planning process started in 1976, only to become one of the longest-standing incompleted processes in Washington.²²³⁸ Various drafts emerged in ’78 and ’83, but were reshelved and forgotten until the latest effort to update and implement such a plan began in 1993.²²³⁹ The Government Accountability Office—the watchdog arm of Congress—scolded the Department of Health and Human Services on six separate occasions for failing to develop a national response plan despite many years of “process.”²²⁴⁰

In October 2005, a draft of the plan was obtained by the New York Times. The “preparedness plan” highlighted how poorly prepared the country is for a pandemic. The headline read, “U.S. Not Ready for Deadly Flu, Bush Plan Shows.”²²⁴¹ In the Boston Globe, Massachusetts Senator Edward Kennedy noted that other nations like Canada, Britain, and Japan had completed their plan a year or years before. “They’re putting their plans into action right now,” Kennedy wrote, “while we’re waiting to read ours for the first time. America deserves better.”²²⁴² Senator Arlen Specter agreed. “Could we have acted sooner to avoid the situation we are in now, in effect running for cover?” he asked. “We need a better way of finding out what the hell is going on.”²²⁴³

One of the factors blamed for the 29-year delay in producing a plan was the difficulty of interdepartmental coordination. A pandemic would impact all agencies of government, but they don’t all have the same priorities. Senior policy analysts describe the Department of Agriculture and the Department of Health and Human Services, for example, as “not exactly good bedfellows.” The USDA’s traditional mission to defend the economic interests of the agricultural industry sets up a natural tension with agencies prioritizing broader concerns.²²⁴⁴ Experts predict the economic impact on U.S. agriculture will be nothing compared to the havoc wreaked by the virus more generally.²²⁴⁵

The official plan was finally released in November 2005. The CDC planners did not mince words: “No other infectious disease threat, whether natural or engineered, poses the same current threat for causing increases in infections, illnesses, and deaths so quickly in the United States and worldwide.”²²⁴⁶ In terms of preparedness, though, the New York Times editorialized that it “looks like a prescription for failure should a highly lethal flu virus start rampaging through the population in the next few years.” The editorial noted that experts find the plan “disturbingly incomplete,” particularly because it “largely passes the buck on practical problems” to state and local authorities, “none of which are provided with adequate resources to handle the job.”²²⁴⁷ Redlener called it “the mother of all unfunded mandates.“²²⁴⁸ Laurie Garrett of the Council on Foreign Relations has long advocated an integrated public health infrastructure. “If such an interlaced system did not exist at a time of grave need it would constitute an egregious betrayal of trust,” she wrote in a book bearing the same name, Betrayal of Trust: The Collapse of Global Public Health.²²⁴⁹