Should We Aim to Defeat the Flu?

The campaign against coronavirus has had the side effect of reducing the spread of contagious disease more generally. The standard long–term plan for containing coronavirus involves a massive increase in testing so that we can identify and isolate those who have the virus. When disease rates become low enough, massive testing regimes, taking advantage of techniques such as test pooling, can be used to identify cases and prevent spread. If we are undertaking such testing for COVID-19, should we simultaneously be testing for flu? And if we do so, should we maintain such testing even after COVID-19 is defeated?

Globally, flu kills between 290,000 and 650,000 people per year. Placed in perspective, this is less than one-hundredth of one percent of the population. There is a strong argument that the costs of maintaining a test, trace, and isolate policy would not be worth that level of risk. The costs include the maintenance of testing equipment, the operation of such equipment, the hassle of periodic testing (more frequent when outbreaks are observed), any loss in privacy associated with the need to maintain records, and the loss of freedom inherent in quarantine policies (especially "smart quarantine" policies). Some of these will be offset by reduced treatment costs (roughly $10 billion per year in the U.S.) and reduced death and suffering as a result of containing the outbreak.

Yet perhaps the strongest argument for aiming to defeat the flu is that the annual exercise might leave us much better prepared to address a future pandemic, including one that could be worse than COVID-19, such as one that is the result of bioengineering, including bioterrorism. The COVID-19 pandemic has illustrated the proverb "for want of a nail." For want of hand sanitizer, masks, ventilators and the like, we have suffered massive consequences in both economics and health as we have sought to "flatten the curve." Even without any of those items, if massive testing capability had been deployable early in the year, we could have identified and contained small outbreaks.

In principle, we can increase our ability to fight the next pandemic without going after the flu each year. Increasing funding for the National Stockpile is a simple solution and need not be terribly expensive. If N95 respirators sell for 50 cents each, then a mere $1 billion a year would be enough to stock up on billions of masks over a few years, for example. But this solution requires constant vigilance. We can't change course in tough economic times when few are thinking about pandemics anymore. Moreover, merely having the relevant supplies is not enough. We need to make sure that we know how to deploy them at scale. For testing, this means not just having a much larger number of RT-PCR machines and supplies than currently exist, but also labs and personnel capable of using them.

A policy of attacking the flu could serve as a fire drill to prevent a more serious pandemic later on. If we can contain outbreaks of flu, then we will be in better position to contain some future virus early on. Of course, there is no guarantee. Flu is less contagious than COVID-19. If we rely on national testing capacity that can handle only a few local outbreaks simultaneously, then that provides no guarantee that we will be able to handle a greater challenge. The goal must be to be able to contain outbreaks locally, without the need to break in the CDC or even a state agency. In a regime in which flu outbreaks are used as drills for other more serious outbreaks, failure to achieve local containment ideally would be seen as a failure leading to a policy response. Local officials could learn from their own failures and from the failures of others.

Flu would not just serve as a drill to ensure that we have sufficient equipment and well-trained personnel. It would also serve as a drill for the legal system. In the COVID-19 pandemic, there have been many questions about the permissible and appropriate use of legal power, and more such questions await a "test, trace, and isolate" regime. When should we start a policy of social distancing? What should social distancing entail? Should workplaces have mandatory testing? What sick leave should those who test positive receive? Should we reduce privacy protections when an outbreak is suspected and if so, in what ways? How should we test new vaccines, and should we mandate or subsidize them? An annual flu outbreak would give an opportunity to address these questions, leaving both our medical and our legal apparatus better situated to handle more serious challenges.

I am not at all sure that an annual battle against the flu would be justified. The battle may not be winnable, given the high number of flu cases. Another concern is that if we start preventing the flu annually but then stop, our natural defenses might be considerably weaker. There is also a danger that we might focus our energies too much on potential dangers that look a lot like the flu, ignoring other dangers. But in looking at our past response to the pandemic danger, the problem has not been that we only considered the most obvious scenario; the problem has been that we ignored the most obvious scenario. The cost-benefit analysis must take into account costs and benefits beyond those focused specifically on the fight against flu. The real value of an annual battle to defeat the flu would be in better preparing ourselves for the next COVID-19 or worse.

Still, there is a danger of sacrificing too much to defeat the flu and to gain practice in defeating the next pandemic. While we're at it, should we attack the common cold? How about bacterial infections such as strep throat? There is some danger that in attacking small medical risks, we might adopt the principle that no amount is too much to spend to save a life. We do face trade-offs, and the conventional wisdom right now is that COVID-19 is worth containing, but the flu is not. My point here is merely that learning to contain lesser threats may help us learn to contain greater threats.