Monday, October 17, 2005

Die Fogelgrippe

Despite comments from reliable friends that the bird flu ("Die Fogelgrippe" in German) is being over-hyped, I'm coming back to the subject AGAIN today. I am sensitive to the cynicism induced by the current U.S. government's tendency to promote a culture of fear, both to further its nefarious schemes and to distract attention from its misdeeds (Plamegate?) And it is true that events like disease pandemics are notoriously unpredictable. However, it is worth noting that most of the hype has NOT been coming from the Bush Administration in this case, but from public health professionals. It seems much more like the pre-Katrina warnings of inadequate flood protections, when Bush and his cronies were actually late to the game, not promoters of mysterious (and often bogus) terror alert levels. This is for real, I have come to believe, and it has ample historical precedent. (Reliably left-wing Mike Davis, who recently published a book on this, agrees with me--or, rather, I agree with him given his much longer interest in this subject!)

I can approach this subject from several angles, all of which are underplayed in the individual-preparedness-dominated coverage of this threat: For starters, what is the humane response? More specifically, for believers like me, what is the Christian response? For intellectuals, what is our response based on our reading of relevant fields such as environmental history and the history of medicine? And for social-justice minded progressives, what is our response to this threat based on our convictions about the equal dignity of all people everywhere?

Let me roll all these perspectives into one brief list of big issues, which I hope can help focus the debate:

1. Poverty and Inequality: If a world flu pandemic hits, the most vulnerable will be the poor, as always. Yet much of the U.S. media coverage has focused on OUR OWN lack of preparedness--most specifically our government's relative negligence in stockpiling drugs to treat the bird flu--which may affect even our wealthy and middle class people. But what about the poor people of the world? Is it even remotely conceivable that people throughout much of Latin America, Africa, and South Asia can afford treatment? And who within the U.S. will suffer most? Those living in concentrated poverty, almost inevitably. We need to think about these issues, not as some kind of throwback to early 20th-century stigmatization of poor people (or those of a particular racial or ethnic group) as having poor hygiene or being sources of disease, but in recognition of the complex interdepency of all people and the need for special attention to the suffering of the most vulnerable.

2. Long-Distance Environmental-Economic Systems: If environmental history has taught us nothing else, it has shown us how truly dependent modern, industrial society is on complex webs of worldwide human-nature interconnections to feed ourselves, clothe ourselves, give ourselves energy sources, etc. As many commentators note, we may not be able to stop a flu pandemic, but we can certainly prepare to deal with the secondary effects when our supply chains are disrupted. Rugged and self-reliant as we Americans like to view ourselves, our life-sustaining systems of provisioning nowadays are more fragile than ever before in a world pandemic situation, dependent as they are on just-in-time delivery of natural objects and their processed forms for our daily survival. How will we feed ourselves? Our neighborhoods? The least fortunate among us?

3. Political Opportunism: As I suggested in my last post, my other big worry is that Bush could be preparing to use a flu pandemic for his political advantage, projecting himself as a strong leader in a time of crisis. We know, of course, that his preparation for such a crisis has been terrible by comparison with other countries in the world, and that he has ignored persistent warnings until very recently, but no matter. (Didn't seem to hurt him on 9/11, did it?) But I really do believe that we need to be ready to respond with informed opposition when Bush proclaims that he needs to annul posse comitatus (thus allowing U.S. troops to operate at Bush's whim on American soil), repress civil liberties, or whatever. And, of course, we need to avoid letting a bird flu crisis give Bush a free pass on the many other brewing and real scandals that he and his cronies are facing. Because after all, this is not about "winning" in politics as if it were a sporting event. This is about holding a government accountable so that it will become more competent over time and better be able to deal with crises such as disease pandemics in a responsible way.

For a really good analysis of the bird flu situation, which deals nicely with my issues #1 and #2 (but carefully stays away from #3), see this link I got from the bird flu blog that I recommended on my previous post. Skim lightly through the first few points (although frustrated union organizers might take some of the analysis to heart) and on to some of the later points, which address issues from a less individualistic and less medical-solution-obsessed point of view than many other commentators. Hope this helps stimulate some thought and debate.


Ambivalent_Maybe said...

I can't disagree with the points Christian_Left made above about the need to look beyond individual and national needs in addressing a possible pandemic flu. It would be nice if the pandemic flu preparedness efforts, and the media coverage thereof, truly concentrated on such global issues. If it did, I might be able to accept that the hype was at least being applied to worthy issues. But it is not, and the hype is unjustified.

A simple test for determining if a topic much of the media is concentrating on is to ask, 'what are the news events that have triggered such coverage?' Avian flu has been around for years, and deaths are usually reported in small sidebar articles in the science section, if at all. In the US, the current pandemic flue preparedness pandemic was triggered, as far as I can tell, by a government effort to focus attention on the subject. After the hype kicked off here, we learned that some fowl have died in Turkey and Romania, and that a group of scientists have found that the H5N1 virus bears a fair resemblence to the virus that caused the post-WWI pandemic. These stories might have passed quietly unnoticed in the American media had not news outlets been on guard for flu-fear-inspiring stories.

The media and popular reaction to the possibility of a pandemic--or even the certainty of one at some unknown point in the future--is out of proportion to the danger posed by the avian flu. How many people have died of the deadly avian flu? According to the flu web log Jeremy recommended, since December 2004, avian flu has killed 36 people around the world. (The number is on the right sidebar, beneath the many Google ads hawking anti-viral meds.) According to this NY Times article, the virus H5N1 has killed 60 of the 116 people it is known to have infected since it was first discovered in humans, in Hong Kong in 1997. No avian flu that I have read about has yet been passed from human to human, and the transmission rates from fowl to human are exceedingly low.

Making some preparations for combatting a flu pandemic is a good thing, and I don't mean to say we should pay no attention to the problem. But there are many other more pressing concerns we could be spending time and money on. Want to stay worried about infectious diseases? Why not worry about the flesh-eating bacteria popping up in various places around the world? In 2002, 9,00 cases of invasive flesh-eating infections were found in the US alone. Yikes! The death rate from such cases is 10-13%--so more people in the US died in 2002 of flesh-eating bacterial infections than have ever died from avian flu. And don't get me started on the strains resistant to antibiotics...

Okay--so that example was more sarcastic than convincing: flesh-eating bacteria are not going to cause a pandemic like a flu virus can, and it's true that past mortality statistics are not a reliable predictor of future threat. But still, there are any number of far deadlier diseases stalking the world--particularly the poor of the world--right now. What's more, many of the most deadly diseases are easily preventable or treatable with currently available technology, unlike a pandemic flu, which won't happen soon, may not happen at all, and if it does happen, we may not be able to do much about anyway. According to WHO estimates, in 2002, more than 2.7 million people died of HIV/AIDS; 1.5 million people died of tuberculosis; 485,000 people died of nutritional deficiencies; 172,179 people died in war. (If you access the WHO link above, you will have to download an Excel spreadsheet to view the statistics I cite; try it--it's fun!)

The pandemic flu hype gives media and politicians the chance to scare people, which is how they best attract viewers, readers, and voters (or distract them from something else). Allocating resources toward preparing for a flu pandemic is a good idea, but such resources will not be allocated wisely in an atmosphere of over-stated threats and unecessary fear such as prevails in the US at least at the moment. The pandemic flu threat is at the moment small, but may become a larger threat at some indefinite point in the future. Some preparedness efforts now--particularly those along lines proposed by Christian_Left, that concentrate on improving global medical and health inequalities--will be valuable in the long term. Other efforts, such as stockpiling vaccines of uncertain efficacy for a disease we haven't identified yet, or working on plans to have the military enforce quarantines, are probably a waste of time and money, and could prove harmful in the long run. There are far larger problems facing the world where those resources we devote to allaying our pandemic panic could make a big, immediate, and certain difference.

Ambivalent_Maybe said...

Oops--in the fourth paragraph, that should be 9,000 cases of flesh-eating bacteria in the US in 2002; not "9,00."

christian_left said...

There are two critical fallacies in ambivalent_maybe's thoughtful response: 1) Just because the federal government is starting to make a big deal out of the bird flu crisis--thereby making us suspicious of their motives--does not mean that it isn't a major problem. 2) Just because bird flu is presently afflicting only a small number of people does not mean it is unlikely to explode into an global pandemic in the near future. Current disease-rate statistics can be a poor guide to future planning.

Is this Tom Ridge recommending duct tape, or is it the New Orleans levees? I would argue that the relevant precedent is the latter: the Bush administration is VERY late in the game. Other countries have been taking the lead, global health professionals have been sounding the alarm for quite awhile now, and U.S. media and government have finally, at long last, started to care.

I would caution against dismissing this issue as a manufactured crisis designed to serve government and elite media interests. Of course, no one can say FOR CERTAIN that a bird flu pandemic will occur, but the signs are mostly pointing in that direction. Look at the history of epidemics, particularly the flu. These epidemics happen a few times each century, and they spread expontentially from a small number of cases. And look at the genetics of viruses, which are constantly evolving. All it will take is a new mutation (or recombination) event that makes human-to-human transmission easier.

If all the people who are capable of strongly critical thought regarding the motives of the Bush Administration take a pass on this issue out of denial that it is really a major problem, then the discourse about how to respond will be impoverished.

Ambivalent_Maybe said...

Yes, past fatalities caused is not a good predictor of future threat. (I tried to innoculate myself against this counter-argument by mentioning it in my original post, but it seems not to have had the desired effect.) The avian flu has not killed many people yet, but at some point it *might* develop into a less lethal (pandemic viruses can't kill people until they have a chance to spread the virus around) human-to-human form. Should we make some preparations for this possible event? Sure--that's only sensible.

But the threat posed does not warrant the level of hysteria I feel eminating from the US press. (I confess that I don't read much of the European press beyond a couple UK papers.) Some disease experts think a pandemic flu is possible, maybe within a decade or so. Others think that the world is simply overdue for a pandemic, and that a pandemic is inevitable sometime in the next few decades. If a pandemic flu develops, it may not be the avian flu everyone has their eyes on at the moment; it may not be a flu that responds to current vaccines; the vaccines people are talking about stockpiling now (some people are even talking about preemptive vaccination) require continued doses of the sort that have proven very difficult to sustain in a large population, especially one lacking basic healthcare infrastructure. So, like I said before, many of the preparations now are likely to be of little or no help should a pandemic actually begin.

And what would a pandemic flu look like if it did begin? Most media reports look back to the deadly 1918 pandemic, which developed in the very peculiar conditions of WWI trenches. Those conditions are no longer present, and medical care--even against viruses--is much better now than in 1918. Many of those killed in 1918-19 died, for instance, from secondary bacterial infections, not from the flu itself. Those sorts of illnesses would be treatable today with antibiotics. A better comparison might be the 1968 Hong Kong flu, which caused about 34,000 deaths in the United States, and is still around today. Something like that is certainly worth preparing for, but the world did not end in 1968 (well, a world-system ended, if you listen to Immanuel Wallerstein, but it wasn't killed by the flu), martial law did not need to be declared (well, okay, federal troops were deployed in some US cities that year, but not because of the flu), and no system of national or regional quarantine was imposed.

A still better comparison with the current hysteria might be the Swine Flu non-pandemic in the 1970s, when in a similar pandemic panic the US government decided to preemptively vaccinate the entire country. A nice description of that fiasco can be found on this Haverford web page. In short, the national preparedness program prepared for a pandemic that never came, wasted a lot of money and time, and caused some people unnecessary suffering from some bad side-effects of the vaccine. Similar wasteful efforts are likely if people don't put the possibility of a pandemic into a proper historical and world-health perspective.

The best preparation for a pandemic is building up global access to basic healthcare services. This will be a very slow process, requiring long-term commitment and lots of money from the richer nations. Such an investment will make the richer nations safer from any emerging infectious diseases, and, incidently, will have a tremendous positive impact on the lives of many more people in the poorer nations who are suffering right now from all sorts of easily preventable or treatable diseases.

Nothing about the current pandemic flu hysteria seems likely to inspire that kind of long-term commitment. Indeed, if the usual pattern of media pandemic is followed, these weeks of dire warnings about the coming pandemic will be followed by a week or two of coverage saying the whole thing was completely overblown, and then it's on to some other hysteria. (Karl Rove should be indicted by then, so maybe we'll move on to that; or maybe Michael Jackson will get arrested again.)

I don't think the pandemic hysteria should be dismissed because it all began with a government program. It should be dismissed because it's hysterical. Frankly, I don't know why media outlets have suddenly latched onto this pandemic hype. Like a pandemic flu, media feeding frenzies are inherently unpredictable. But like I said before, media outlets like stories that are--or can be made to sound--scary and threatening. It's one of the best ways they've found to compel people to watch and read their programs and articles.

One thing the pandemic theme has going for it is that it plays on people's fear of other people--particularly poor third-world people. Perhaps it's an expression of deeply embeded guilt in the West for being so rich while much of the rest of the world is so poor that we have to recurrently lapse into spasms of fear about the latest threat to our comfort and well-being coming from the third world. Though I know the more sensible people at the head of the pandemic preparedness efforts will have none of this, I still detect a lot of xenophobia in the over-heated US media coverage of the pandemic threat. The reflexive feelings of fear inspired by the hype are exactly the opposite of those needed to work toward the establishment of the long-term healthcare access programs I mentioned before.

christian_left said...

There is an amazing amount of agreement between the views that ambivalent_maybe expresses and the ones I have summarized and cited in my posts. We all seem to agree that there should be more emphasis on global health inequalities and basic public health infrastructure, that we should focus less on explicit medical/drug solutions to emerging viruses and more on the surrounding systems that cause secondary problems when an epidemic hits, and that the Bush Administration may exploit any such crisis to pursue its own political objectives, with marginal (or counterproductive) effects on the actual problems. Those were, in fact, my three main points in my last response and I cannot see that ambivalent_maybe disagrees with any of them.

Where we DO seem to differ is in our estimation of the likelihood of a global flu pandemic. I think it is relatively likely--that the risk is large enough to justify taking action to prepare for it--while he thinks that the alarm is overblown hype, i.e. "hysterical". I am quite sensitive to the position that there are currently other global health threats that are much worse in the present day. Yet, as he correctly points out, his own initial reply post concedes that "past mortality statistics are not a reliable predictor of future threat" (though he still chooses to quote extensively from such sources). I would put the point even more strongly: current disease-rate figures have no relevance at all when considering a potentially explosive epidemic disease.

Now I am quite happy to concede the insightful caveats that ambivalent_maybe has issued regarding past flu scares in the 20th century, some of which turned out to be false alarms. And I am very much in agreement with his point that the hype, to some extent, plays upon fears of poor people in Third World countries. Yet one does not have to engage in stereotyping to believe that the crowded, shantytown conditions in many Third World cities, swelling in population during the past few decades of rampant de-ruralization in the Third World, can create a fertile environment for the spread of disease.

Surely, ambivalent_maybe would not argue that it was healthy to live in early 20th century crowded urban slums in industrial cities just because such observations by Progressive-Era middle-class observers were usually accompanied by racial and ethnic stereotypes. Whether such present-day concentrations of urban poverty are equivalent to World War I trenches, I cannot say, but I do not think it is wise to ignore the material conditions that provide reservoirs for disease (thereby also insuring that people living in such places are hit the hardest) in order to focus on First World discourses about them.

And I suspect that ambivalent_maybe does not either. It is not that poor people carry diseases because of anything inherent about THEM, it is because we live in a world where massive inequality means that poor people will usually be hit harder because of the material conditions that we collectively allow to remain.

I happen to think that the "bird flu" hype is founded on actual solid evidence, much like global warming, the vulnerability of New Orleans to flooding before Katrina, etc. While there is no CERTAINTY, we should act on the best knowledge we have.

And, in any event, the discourse about how to prepare for and respond to a bird flu pandemic is already beginning. Do we choose to sneer at the whole debate? Or do we choose to engage ourselves in projecting humane values into that discourse to influence it away from its obsession with First World drug treatments and towards more fundamental solutions?

Ambivalent_Maybe said...

Christian_Left has characterized well the differences between his position and mine on the pandemic flu threat. As is common for us, the area of our disagreement is dwarfed by the areas we agree on. We both would like to see a broad, long-term effort to build up basic health care services in the poorer parts of the world. This would not only help fight any future outbreak of a flu pandemic, but would make a great, more immediate and certain, impact on a long list of health problems plaguing poorer nations. But I believe that the threat of a catastrophic pandemic flu in the near future is vastly overstated in the US media, and that the concentration on this single issue--like most media firestorms, intense but brief--will do more harm than good to the cause of establishing global basic health care programs.

I don't 'sneer at the whole debate.' First of all, what debate? Coverage is virtually unanimous in declaring the dire threat posed by avian flu. I wish there was more of a debate, and I wish discussion of the possiblity of a pandemic flu was carried on with a more calm and reason, less rush and fear. Congress, for example, has approved roughly $4 billion to help fight a possible pandemic of avian flu, mostly by stocking up on anti-viral drugs of uncertain effectiveness, even assuming they have targeted the correct family of viruses as the cause of a future pandemic. I don't think that money is being spent wisely, but the hype makes politicians want to spend.

We won't know if the money--that certainly could have helped a lot of people, right now--was well spent unless a pandemic flu erupts in the next decade or so, and it's a type of flu that responds to the antivirals stockpiled, and doses of the antivirals can be delivered and sustained while the flu is prevalent. If that happens, then I was wrong. I'll admit it and get in line for some anti-virals. But if it doesn't happen, then I'll wonder if perhaps a broader and more informed discussion of global health issues might have led to more rational, and more globally helpful, spending policies.