n engl j med
would not prevent further spread, but it might re-
duce the shedding of the virus and would, in any
event, be required for ethical reasons. All these ac-
tions rely on early recognition through good sur-
veillance and the ability to deliver the antiviral drug
at a time when transmission might still be ineffi-
The logistic hurdles are formidable. A mobile
stockpile of the drug would have to exist and be
made available in the affected country. Oseltamivir
is now being stockpiled by a number of developed
countries for use once a pandemic virus becomes es-
tablished and begins to spread rapidly around the
globe. Developing a stockpile in an attempt to re-
strict the spread of the new virus at its source might
mean diverting drugs from other national stock-
piles. However, this diversion must happen. The
notion of trying to control a pandemic at its source
would have been considered laughable just a few
years ago — but that was before SARS transmis-
sion was controlled by public health measures. We
have no idea whether a type A (H5N1) virus that
was fully adapted to humans would continue to be
highly lethal, but it is nevertheless incumbent on
the global community to try to contain it.
The avian origin of previous pandemic viruses
was recognized only after the fact; this time, we have
been given a warning. We really are not sure when,
or whether, the type A (H5N1) virus will start to
spread among humans, but we must be ready to
stop it if we can — and, if we cannot, at least to mit-
igate its effects through the use of stockpiled anti-
viral drugs and, eventually, strain-specific vaccine.
Dr. Monto reports having received consultation fees and grant sup-
port from Roche.
Li KS, Guan Y, Wang J, et al. Genesis of a highly pathogenic
and potentially pandemic H5N1 influenza virus in eastern Asia.
Govorkova EA, Leneva IA, Goloubeva OG, Bush K, Webster
RG. Comparison of efficacies of RWJ-270201, zanamivir, and osel-
tamivir against H5N1, H9N2, and other avian influenza viruses.
Antimicrob Agents Chemother 2001;45:2723-32.
Monto AS. The role of antivirals in the control of influenza.
Merck’s withdrawal of rofecoxib from the market
last September and Pfizer’s announcement in De-
cember of possible cardiac risks associated with
high doses of celecoxib reignited long-simmering
controversies regarding drug promotion, in part be-
cause both cyclooxygenase-2 inhibitors have been
heavily marketed directly to consumers. Indeed, af-
ter discussion with the Food and Drug Adminis-
tration (FDA), Pfizer suspended all direct-to-con-
sumer advertising of celecoxib. Adding fuel to the
fire is class-action litigation filed against Astra-
Zeneca alleging that its direct-to-consumer adver-
tising misrepresents the superiority of its proton-
pump inhibitor esomeprazole over less expensive
Although the information made public in these