Ali Khan has been worried about bird flu ever since the H5N1 strain first appeared in China in the mid-1990s, when he was a disease detective at the Centers for Disease Control and Prevention. It spread quickly in China and Hong Kong, mostly through wild birds and poultry, and had all the hallmarks of potentially becoming the next pandemic.

“Despite that,” he said, “it’s been almost 30-odd years, it has not yet become the next pandemic.”

But Khan, who’s now Dean of the University of Nebraska’s College of Public Health, is worrying more about that prospect again now. 

“My concern increases when there’s more virus in the community,” he said. “In people, in animals.”

These days there is a lot of the virus, all over the world, again — in birds, pigs, cows, cats, all sorts of wild animals, and in people. H5N1 is now widespread on both poultry and dairy farms in the U.S. More than 166 million chickens and other poultry have been killed in the last few years, the virus has been identified in herds of dairy cows in at least 17 states, and 70 people have tested positive, most of them farm workers. 

“In the U.S., we have never seen this many H5 cases, ever. And we just had our first death,” said Seema Lakdawala, co-director of the Center for Transmission of Airborne Pathogens at Emory University. 

That’s one major concern right now. Another? 

“It is in a species of animal, in dairy cattle, where there is a high level of interaction with humans,” she said. “And there’s a lot of potential for infections from humans from the handling of these animals.”

Depending on whom you ask in public health, the federal government’s response to the outbreak so far has been “mixed,” “disappointing,” “reactive” and “inadequate.”

“It just feels very sluggish, very underpowered, very slow, and I think, in some cases, in denial,” said Jennifer Nuzzo, director of the Pandemic Center at Brown University School of Public Health. 

President Joe Biden’s administration put more than $2 billion into bird flu monitoring and preparedness, much of that through the U.S. Department of Agriculture to monitor and prevent outbreaks in poultry and dairy cows and reimburse farmers for losses, and some through the Department of Health and Human Services to monitor outbreaks in people and prepare for the possibility of a pandemic. 

“There’s been money allocated to vaccine companies, there’s also been money allocated for the provision of testing on farms, and money to reimburse farmers whose animals experience lost milk production as a result of being infected,” Nuzzo said. 

There has also been money for developing better tests and antivirals, and helping hospitals and communities prepare for the possibility of a bird flu pandemic. But Nuzzo and many other public health experts say more needs to be done, especially to ramp up surveillance on farms.

“Making money available to farmers is really important, not just to protect us against the economic damages that this virus can pose,” she said, “but also to incentivize farmers to test their animals, so that if their animals test positive, that they can be reimbursed for that.”

More also needs to be done to encourage dairy workers to come forward if they’re sick, which, right now, is not happening, according to Elizabeth Strater with the United Farm Workers union.

“There are so many workers that are sick and are not being tested or treated because they fear retaliation from their employer,” she said. 

Or because they’re afraid of being forced to take unpaid time off from work if they test positive for bird flu. 

“These are workers who are some of the poorer workers in the United States,” Strater said. “These are people that are excluded from a lot of the social safety net, and so they simply can’t afford to be directed to go home by the public health agencies and go unpaid.”

On top of that, many dairy workers are undocumented. 

“And imagine, how willing and prepared are those workers to come forward and get themselves tested and enter a system of observation and tracking and surveillance if they feel like that itself may enhance their risk of sudden deportation?” said J. Stephen Morrison, who directs the Global Health Policy Center at the Center for Strategic and International Studies.

Incentivizing testing — of dairy cows, their milk, and dairy workers in particular — is critical to preventing a pandemic, experts say; that’s the main place more money needs to go.

Last week, in an op-ed in the Wall Street Journal, President Donald Trump’s Secretary of Agriculture Brooke Rollins announced that USDA will spend up to $1 billion on a new “comprehensive strategy to combat avian influenza.” That strategy centers on preventing bird flu on poultry farms, reimbursing farmers who lose birds to the virus and trying to lower the price of eggs. 

“They’re worried about the strain on the poultry industry, and they’re worried about the consumer discontent over the high price of eggs,” Morrison said. “It doesn’t speak to the evolution of the virus and the presence in the dairy industry. However, it tells us that they recognize the complexity of and the long-term nature of this problem.”

The status of other bird flu funding the Biden administration approved in its final days to monitor outbreaks in farm workers and help hospitals and communities prepare for the possibility of a pandemic is unclear, as is a $590 million contract with Moderna for late-stage development of a bird flu vaccine. 

“The reports on what has happened are mixed, contradictory, confusing, and in the midst of this chaos, it’s just been very difficult to get a straight answer,” Morrison said. “But that money is very much needed to strengthen the response.”

Because bird flu is not going away. Jennifer Nuzzo, at Brown’s Pandemic Center, said there is no scenario in which the Trump administration won’t have to put more money and time into dealing with the virus. 

“And the reason why I say that is that this is an important economic threat, this is an important occupational threat,” she said. “And allowing this virus to spread unchecked is just not an option.”