The recent cover stories in USA Today, beautifully depict the potential spectrum of disease and the implications of human vulnerability to pandemic flu and specifically the H5N1 avian flu strain.

But the real threat lies not in the obscure genetics of a common virus or in the family lineages of its victims. The true impact of this disease lies in the numbers. In 1918 100 percent of the entire world was exposed to what would later be called the Spanish Flu. This new strain of avian flu had never been encountered before by a human population, and as a result, there was no immunity to this particular strain. Of that world population, one third would ultimately fall ill, in fact, 50 to 80 percent of the youngest, healthiest, and strongest would fall ill when future generations would divide out the victims.

Of those that fell ill, half ultimately required some assisted care. They were placed in infirmaries or makeshift hospitals in warehouses, wharfs, and military barracks. In today's world, they would qualify for hospital care or home health nursing.

Of those hospitals and infirmaries, half suffer extreme respiratory difficulties as their lungs filled with fluid and blood, the result of their own bodies' counterattack on the viral invasion. Coughing and frothing at the mouth, occasionally spitting up blood, these individuals would have a disease that today's medical professionals call ARDS, Acute Respiratory Distress Syndrome. In the modern medical age, these patients would have a plastic tube placed into their lungs to assist their breathing and a ventilator would force air in and out of their lungs. Half of the ARDS patients 1918 died.

But it's not percentages, but real numbers that portend the severity of this disease. There are over 300 million people in the United States and over 6 billion worldwide.

One third of those will fall ill. One hundred million here at home and two billion across the planet.

Half of those individuals will qualify for hospitalization. Unfortunately, in a survey performed by the American Hospital Association in 2005, there are only 955,768 hospital beds in the United States, far short of the 50 million that would be needed. To make this situation work, at the peak of cold and flu season in 2005, only four percent of these hospital beds were available and unoccupied. That means that there will be fewer than 40,000 hospital beds available for this onslaught of 50 million patients.

Of the 50 million patients who qualify for hospitalization, half or more will need ventilators. Dr. Michael Olsterholm in a New England Journal of Medicine article in 2004 found that there were only 105,000 ventilators in the United States. Of these, a high percentage were either already in use for chronic ventilator-dependent patients such as small children and spinal cord patients, or were out of service for cleaning and repair, leaving just over 16,000 ventilators available nationwide to help 25 million flu related ARDS victims breathe.

Of the 25 million with ADRS, with or without ventilator care, half would be expected to die. This 12.5 million people will pass away in waves as pandemic influenza spread over a span of only 12 to 18 months.

Now, admittedly, these are the most dire numbers. The pandemic flu could prove to be far less deadly, far less contagious. On the other hand, H5N1 has already proven to be a formidable foe with death rates initially greater than 70 percent and now still hovering around 50 percent.

The Centers for Disease Control (CDC) have given optimistic sounding percentages but as the old adage goes, the "devil is in the details". Let's look at the percentages and the details.

* One third of 100 percent is 33 percent.
* This is the "attack rate".
* Half of 33 percent is 16.5 percent.
* This is the number of people who qualify for hospitalization, but the CDC knows that in the event of a pandemic, only the most sick will actually be placed in the hospital. Clearly the most sick will be those with ARDS.
* Half of 16.5 percent is 8.25 percent.
* These are the sickest of the sick, those with ARDS. Rounded off, this is 8 percent, the number that the CDC says to expect for hospitalization.
* Half of 8 percent is 4 percent.
* This is the expected death rate predicted by the CDC.


The "devil in the details" is that these percentages are based on "the total population." Physicians, medical planners, and other pundits usually discuss percentages based on "those with the flu". We are not talking about "those with the flu" we are talking about a number three times that size.

USA Today showed us how two third world countries are struggling and in some cases failing to deal with the crushing weight of a comparatively small outbreak of avian flu (H5N1). In Indonesia, the efforts are crippled at best. In Vietnam, the efforts are being met with greater success, but the disease rages on. The industrialized world relies on the fact that its health care is unmatched. The United States likes to believe that US health care exceeds all other. The numbers show that when this disease strikes the whole world is at peril.

What are the answers? As with any impending disaster, the answers lie in preparation, planning, and practice; Repeated, Relentless, and Rigorous practice. It is the responsibility not just of government but of private health care institutions, hospitals, health care professionals, businesses, corporations, and yes, even individuals, to prepare now for the worst while hoping for a reprieve. We can no longer afford to prepare for the best and then stand awestruck when the worst occurs.