The Futurist Interviews Tyler Kokjohn, PH.D.

During the first week of May, 2009, the World Health Organization called an H1N1 influenza pandemic "imminent." The largest pandemic on record, the 1918 Spanish flu, spread to nearly every corner of the world and killed as many as 100 million people. Today, we are more capable of dealing with flu, but because of global interconnectedness, we're more capable of spreading communicable diseases as well.

Are governments treating the current flu with enough urgency? Too little? Too much? More importantly, if we have indeed entered a new "Age of Pandemics" (as the Wall Street Journal announced on May 2nd) what can we do to better prepare for the epidemics of the future?

We turned to Daniel J. Barnett , M.D., M.P.H., assistant professor in the department of environmental health sciences at the Johns Hopkins Bloomberg School of Public Health, and Tyler Kokjohn, professor of microbiology at Midwestern University and author of the "In The Shadow of Pandemic" to parse the future of flu (May 4, 2009).

Interview by Rick Docksai

THE FUTURIST: In your 2006 article on bird flu, you called proper vaccination of national populations “the most reliable and effective way to limit a bird-flu pandemic’s destructive scope.” But you also warned that a new flu could outpace our ability to manufacture and distribute vaccines. How ready are most countries to vaccinate their populations against swine flu? What could they be doing now to increase their readiness?

Kokjohn: We’re really caught here. This is a classic problem with the flu, it’s that you don’t know what it’s going to be until it finally shows up. If it shows up at the wrong time of the season, you're in great difficulty. We have to grow new chicken-egg stocks. We have to mass-produce chicken eggs, produce millions of them. We ramp up production over the summer to have the flu vaccine ready in October. But if the flu doesn’t cooperate, we’re in trouble.

THE FUTURIST: You specifically identified health organizations’ ability to respond as an area where improvement is needed: Influenza surveillance is “an especially weak link in the chain of public-health protection.” According to a Washington Post story, Mexican authorities first saw unusual cases of pneumonia within Mexico on April 6 but only notified the World Health Organization and the Pan American Health Organization by April 16. Do you think this 10-day waiting period was appropriate, or do you think they should have acted sooner?

Kokjohn: I’m not sure they could have expedited this. One problem is that, at the local level, all they knew was they had a type of flu they could not type. After that, they had to gather samples and send them to a more personalized facility. That takes more money and infrastructure. It also takes considerable time. Some of that delay is just that the pipeline can’t accommodate such a quick turnaround.

You have to have some sympathy for the authorities here. The CDC is overwhelmed because their turnaround time can only be so fast. They only have so many people and so many infrastructures to work with. Their turnaround time is going to be slower than it was a few weeks ago, because they have so many more samples to test.

You’ve got to have enough machinery in place and enough people to get answers quickly. If you don’t, you’re going to hit the turnaround bottleneck. It’s possible everything stopped on a weekend. We’re not on a war footing all the time. Several days could have gone by.

It’s a wakeup call to see how we can get all the infrastructure elements in place quickly. The WHO and other organizations have asked the U.S. authorities to get the infrastructure built up for years. We could put every penny we have into the flu problem but that’s not realistic. We need to strike a balance. This is not the China SARS situation, where they covered it up. We’re not dealing with that at all.

THE FUTURIST: It sounds like health organizations and government agencies really have considered flu a high priority.

Kokjohn: I think so. And I think one of the challenges will be sustaining the priority status even after the threat dies down. I’m not a big fan of the Bush administration, but one thing the Bush administration did was that they were very proactive on flu and on looking at this as a long-term problem. My gut feeling is the Obama administration is going to continue this. I hope that we will sustain that. Just because this one went away, the next thing could come along and it could be much different.

We don’t know what makes killer flu a killer and we don’t even know whether this particular flu will qualify as a killer. There are too few cases as of now for us to get a handle on that.

THE FUTURIST: It’s largely a matter of wait and see?

Kokjohn: It is. In about two weeks, we’re going to know all. Once the flu gets into an area and starts going, it starts to break out. We’re going to see if we reach a strange plateau, or a rise in new cases, or if it starts to die down. Another possibility is that the flu is very seasonal. It could come roaring back in the fall. The big thing now is getting the numbers. There’s a major push to take samples in and see who has what.

THE FUTURIST: What does getting a sample involve?

Kokjohn: A sample can be a nasal wash or swab. They’ll send it to a lab, and they can detect the type of flu, whether or not it’s the H1N1, how often we’re seeing the H1N1, and whether we’re seeing more of it compared to what we had in the past.

Last year’s vaccine had an H1N1 flue virus in it, but those people that got the vaccine are not going to be protected against this new form. These viruses reassemble and re-assort. What I’ve heard about the current strain of swine flu is that it seems to incorporate parts from bird, pig and human: multiple sources combining in a new way, into a new virus. Our vaccines won’t work against it. A lot of us are not going to be immune to it.

On top of that, it mutates at a higher rate. It’s an RNA virus. And those have a much higher mutation rate. Someone taking an antiviral drug, they’ll adapt to that the antiviral drug and become resistant to it.

THE FUTURIST: In what way does the virus incorporate parts from birds, pigs, and humans?

Kokjohn: It has viruses that were once associated with birds, pigs, and humans. There are different types of flu floating around.

THE FUTURIST: It must get difficult for the monitors on the local level who might, in this case, have seen a few cases of flu out of season but had to decide whether or not to call up global health organizations and sound the alarms. Perhaps it is only fair that a government such as Mexico’s make sure a disease outbreak in its borders is truly serious before getting the rest of the world worried over it. When is too soon to notify global health organizations? Where to draw the line between prompt communication and alarmism?

Kokjohn:That’s a very tough call. Not long ago, people were trying to predict where the next flu virus was going to come from–Mexico in May was not anywhere near the top of the list. The current outbreak very much illustrates how the flu does what it wants to do. And it’s impossible to predict it when we see the bird flu build up in Asia and we try to confront it. We killed birds, but that didn’t work.

The best avenue for local monitors is to send samples to the WHO or PAHO but wait for more cases before issuing an alarm. We need to separate the idea of an alarm from the idea of analysis.

This is where Janet Napolitano, the CDC, and the Mexican authorities are truly going to earn their money. If they overreact now, they are going to kill tourism-—and that’s the last thing anyone would want to do, given the economic trouble we’re all going through. But if they under-react, it is going to get away from them. The whole goal of the WHO is to catch disease outbreaks early and respond early. You want to act fast, but there are consequences to acting too fast. Either way, the info they have is minimal.

THE FUTURIST: How big a priority should we make the flu, considering there are so many deadly diseases and health risks out there?

Kokjohn: There are a billion other justifiable needs out there. That’s a reasonable thing. We just don’t want to forget about flu.

Now that the flu is in the United States and Europe, what about Mexico? Who is going to get the vaccine? That is going to be more difficult. The United States will be somewhat protected. Europe will be protected. Nations wealthy enough to afford large vaccine stockpiles will be protected. But a large part of the world is just going to be left to its fate. That’s something we haven’t dealt with.

If we could develop means to vaccinate against the flu that are less costly, like RNA vaccines--you look at the virus, copy the genetic code, put it into the person and have them respond to it--that would be tremendous. It’s fewer steps. The efficacy of this is yet to be determined, but it will not involve raising millions of chicken eggs. The DNA could be handled more easily. It’s very stable. But we have to prove that it works. The NIH now has impetus to develop it.

This is all in the future. But one of the things we would like to do is get away from our dependency on the chicken egg as our sole source for producing a flu vaccine. We’ve been using this method for 62 years. And it works, but you can see that it has some drawbacks. This is going to be a long-term research program.

THE FUTURIST: A lot of experts see two critical trends in demographics taking place in the next few decades: Growth of elderly populations, and growth of populations of all ages in developing countries. This would sound like two groups that are more vulnerable than others to disease outbreaks. How worried should we be that future outbreaks will claim more victims?

Kokjohn: You’re absolutely correct. This is something people have seen for a while. And a part of the impetus for the programs we have now for dealing with this proactively is the growth of elderly populations, because one of the big problems we have with elderly patients in particular is even if we vaccinate them, many have an immune systems that are not able to respond. We have some significant gaps here. Those gaps are growing.

In the developing world, many of these problems have never been addressed. We can’t keep thinking “Fortress America." We’re not going to be healthy while the rest of the world is dying. We have to consider what the concept of “Lifeboat Earth” really means.

In the United States, we have a high standard of care, but if we have an outbreak, we’re going to quickly overwhelm the health infrastructure. It doesn’t matter how many ventilators we have, they’re all going to be in use. We’re not fully prepared for the real deal.

THE FUTURIST: Your article worried that global mobility might be a risk factor: “People and products traverse the world with ease, meaning that a future flu pandemic may engulf the world with unprecedented speed.” But perhaps a slowdown is in the cards. European officials warned their citizens recently to avoid travel to Mexico or the United States on account of the flu. What are the long-term implications for tourism in general? How many would-be tourists around the world will forego future vacation plans and only travel within their home countries, so as to be safe?

Kokjohn: I think you’re on target. You’re going to see a definite impact in travel. Some cruise lines have already ceased their Mexico stops. People don’t make these warnings lightly because the economic suffering they create. So this is definitely an issue.

Much will depend on how far this goes. If this dies down in a week or 10 days, we’ll be fine. Life will go back to normal. But if it’s sustained, the first thing people will do is not travel on vacation.

For business travelers, one of the first things you can do is know about where you’re going and make sure all your vaccinations are up to date. The SARS outbreak, they started looking at people on the airlines. And if they had a fever, they wouldn’t let them travel.

After the 9/11 attacks, air travel was significantly slowed. I remember. I flew in a few planes after the attack. Pretty lonely. The flue season was delayed two to four weeks in the 2001-2002 season. And some people ascribed that partially to the slowdown in air travel. That suggests we might be able to slow this down enough by slowing travel and closing borders. If we ever do have a formal advisory, I think that will kill tourism.

We have to worry about a comeback. In 1918, the flu showed up and faded away, and then it came back and it came back early. If we have a repeat of that, we’re in trouble.

We’re managing on the basis of anxiety.

About the Interviewee
Tyler A. Kokjohn Ph.D., is a specialist in bacteriophage biology with special emphasis on the identification and characterization bacteriophages lytic to the human bacterial pathogen Pseudomonas aeruginosa. Dr. Kokjohn was Assistant Professor of Microbiology, School of Biological Sciences, University of Nebraska, Lincoln, from 1992 to 1997. He is currently Professor of Microbiology, Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ. He is a member of the American Society for Microbiology, the American Association for the Advancement of Science, and the Society of Protozoologists. He is a member of the World Future Society and a frequent speaker at World Future Society conferences.