H5N1

Like catastrophic flooding in New Orleans, an influenza pandemic is not a matter of if, but a matter of when and how bad. Fortunately, John M. Barry has written books about both. Until the definitive story of Katrina is told, Rising Tide, Barry’s book on the 1927 Mississippi River flooding that left some parts of the Delta a 100-mile-wide swathe of water, will stand as the classic work on power and high water and the Crescent City.

The inevitability of floods in New Orleans is a matter of geography; the inevitability of a flu pandemic is a matter of genetics. The natural reservoir for influenza viruses is in birds.

Massive exposure to an avian virus can infect man directly, but an avian virus cannot go from person to person. It cannot, that is, unless it first changes, unless it first adapts to humans.
This happens rarely, but it does happen. The virus may also go through an intermediary mammal, especially swine, and jump from swine to man. Whenever a new variant of the influenza virus does adapt to humans, it will threaten to spread rapidly across the world. It will threaten a pandemic. — The Great Influenza, p. 102

The first question about a species-jumping influenza is how virulent it is. H5N1, one of the current avian variations — the letters and numbers refer to variations in the proteins that allow virueses to bond to cells — has been worrying observers because the disease it causes in birds has had fatality rates of up to 100 percent.

By comparison, the 1918 virus, the most pathological pandemic known, had a global fatality rate of 5 percent to 10 percent. This was much higher in some populations that had had virtually no prior exposure to influenzas, but even the lower figure was sufficient to kill probably more than 50 million people globally. Because it killed so many younger people, the 1918 influenza reduced statistical life expectancy in the United States by 10 years.

Influenza is a particular problem for two reasons: its fast rate of mutation and the gap between infection and symptoms.

Since the 1918 pandemic, many lessons have been learned. The top one is monitoring. There is a global system for monitoring flu outbreaks and watching for new strains. This is what brings the annual flu shots, which are the best guess about the winter’s dominant strain and give a certain amount of immunity. But flu’s ability to mutate rapidly can mean that the several months still required to make a vaccine are too long to provide relief.

A person who shows flu symptoms has had the virus for some time — days, even — and has been shedding virus all the time. Influenza can persist on hard surfaces much longer than, for instance, SARS virus. So containing an outbreak through quarantine is much harder. The most effective preventative measure at the moment is slaughtering animals before the new strain can make the jump to humans. This was done for H5N1 in Hong Kong in 1997 and in the Low Countries and Germany in 2003 for H7N7.

But a pandemic really is only a matter of time: there were at least three and possibly six in Europe in the 18th century; at least four in the 19th; and three in the 20th. Chances are very good, though, that the next one will not be as lethal as 1918. Those of us old enough to remember the “swine flu” scare of the late 1970s will have heard this before. That disease did not live up to the hype, which is just as well. Because it really does seem to be a matter of chance and mutation as to how lethal the disease will be.

On the other hand, there are social conditions that affect outcomes, too. One of the reasons 1918 was so bad is that wartime conditions in Europe offered unusually dense concentrations of people, mixing endemic diseases from many different areas. Wartime privations also weakened immune systems; when flu struck, secondary infections found the going that much easier.

Finally, secrecy contributed to both the spread of disease and the ineffectiveness of public health measures. Newspapers in the United States, under extreme pressure not to undermine morale, did not report the full danger. Local governments lied about the disease, and higher levels of government subordinated the fight against the flu to the war. All of these actions and inactions made the casualty level higher than necessary.

In today’s world, southeasrn Asia is one of the areas where a species jump is most likely to happen. Closed societies, repressive or ineffective governments and a willingness to whitewash events all add to the overall danger.

The EU has official information here, and there is a cooperative web-based effort to increase public awareness here.

The book does much more than tell the story of the disease. It begins at a time when medicine in America was little more than quackery, and any doctor who wanted to be scientifically trained had to travel to Europe. The founding of the Johns Hopkins University was the decisive step that launched graduate education in America (what the Brits call post-graduate study) and eventually gave the world institutions like today’s Harvard and MIT. Barry tells the story of the men who fought those battles. He also captures a sense of how medical science moves forward, in normal times and under the great stress of an epidemic. And finally, almost as a coda, he tells how it was discovered that DNA carries genes, who made that discovery and what it has to do with the great pandemic of 1918.

7 thoughts on “H5N1

  1. I have to say that I’m disturbed by the constant refrain of “flooding in the mississippi delta is inevitable”. Of course this is true, but it carries an implication that people should just live somewhere where bad things don’t happen. The question is: where is this shangri-la?
    Britain and Ireland seem pretty safe from natural disasters, but the rest of the world has volcanoes, earthquakes, floods, landslides, is a desert, is cold beyond belief and so on.

    My point is that, as in so much of life, where you live is a tradeoff. The appropriate response to something like the location of New Orleans is surely not to say “how stupid” but an accurate quantification of the pros and cons. It may well be that, after the sums are done, the conclusion remains “how stupid”, but it’s not a priori obvious.

  2. I’m sorry if “how stupid” is how I came across — as I might have said on the blog before, South Louisiana is where I grew up, it’s home, and by no means do I think it is stupid that people live there. In fact, as long as the United States wants to use the Mississippi River and its tributaries to ship commodities to the world, there will have to be a port somewhere near the mouth of the river. Even if another big one comes down the pike, breaks the Old River Control Structure and sends the Mississippi down the Atchafalaya, there will have to be a port.

    But even when I did hurricane training before I could work at a refinery back in the mid-80s, they told us there were two places in the world whose geography set them up in a particular way for a catastrophic hit by hurricane-driven flooding: Bangladesh and New Orleans.

    The Big One will come to San Francisco; another Big One will shake the San Andreas near Los Angeles. These are as near to certain as anything on this earth. Likewise, another hurricane will pass close enough to New Orleans to drive the waters of Lake Ponchartrain toward the city. In fact, in sufficient time, every spot on the Gulf Coast will get whacked by a jolly big hurricane. I can’t rattle the names off from the last 10 years of storms because I’ve been living further away, but saying that low-lying areas near the shore will face occasional destruction from hurricanes is like observing that Minnesota gets cold in winter.

    The conclusions to be drawn from these facts are, as you say, not immediately obvious. San Francisco is one of the great drivers of the world economy, to say nothing of Tokyo, and the threat of massive earthquake destruction is not about to dislodge either. To my mind, the response is in the planning for the inevitable natural catastrophe. Human nature being what it is, this is hard to sustain over the long term.

    And I find that the biggest mistakes responding to Katrina were at the federal level. I’ve refrained from writing a prolonged piece about it because AFOE is not really the place, but one of the most obvious aspects of a real catastrophe is that local authorities are by definition overwhelmed if not obliterated. Many of the specific problems in New Orleans also happened in Miami in 1992 in the wake of hurricane Andrew. The Clinton administration learned from that experience; the Bush administration chose to forget those lessons. Getting 80 percent of the city’s population to evacuate — particularly after three evacuations and near-misses within two years — was an extremely high level of response. (Less than a month later, and with the damage of Katrina in plain view, Key West had a mandatory evacuation for hurricane Rita, yet only half of the people left.) Not having the federal response pre-positioned and ready to move in as soon as the storm had passed was inexcusable.

    I see I have made a short story long. I will close by adding that the “Delta” is a bit of a term of art, which I did not use entirely felicitously. The Delta can be anywhere downriver from Memphis (hence Delta blues), while in more common geographic usage the delta is downriver from New Orleans, where the river actually empties into the Gulf. Flooding in the lower Mississippi valley after 1927 has been remarkably limited, not least because the Army Corps of Engineers abandoned its “levees only” policy and took a much more flexible approach to flood management. But New Orleans getting flooded by the lake or the Gulf is a different matter.

  3. Sorry Doug, I didn’t mean to criticize you specifically. That was a rant aimed more at the blogosphere as a whole.

    I’ve just finished John McPhee’s _The Control of Nature_ which, while full of some very interesting details, is just dripping with this sort of immensely irritating “everyone is doomed, doomed I tell you” attitude. I’d love to read something rather more balanced which discussed such as is known about ways in which disaster planning works well. In spite of McPhee’s doom and gloom regarding Los Angeles, the basic issue there, the attempt to deal with aggressive rock slides from the San Gabriel mountains, seems to have been mostly under control in the recent past (though, as with all such things, who knows how much skrimping and lack of maintenance there’s been in the last few years, just building up to disaster). More generally US attempts to control nature have, IMHO, been pretty damn successful in spite of the naysayers. Sure, perfection is not achieved, but that was not what was attempted. On the other hand, the US attempts to prepare for disaster that involve dealing with humans, whether it’s health matters, preparations for evacuation, or preparations for nuclear war, have been pretty damn pathetic, and, as far as I can tell, that’s a constant throughout the 20th century. Meanwhile the USSR apparently had a pretty serious, well-thought-out and well-budgeted nuclear war mitigation plan, both China and Cuba seem to be able to move their citizens out of the way of hurricanes, and, I am guessing, Europe will cope with the coming flu better than the US.

  4. Of course this is true, but it carries an implication that people should just live somewhere where bad things don’t happen.

    As you stated that is not possible. But having preparations and plans and executing them when needed is a necessity. Failing in that is stupid.
    Several levels of US administration are stupid by this criteria. Even Bangladesh has a working system of storm shelters. They are surely not as a pretty as a superdome, but they work.

    I am guessing, Europe will cope with the coming flu better than the US.

    I am afraid Europe has some disadvantages here, such as a higher population density and more reliance on public transport.

  5. The more I hear about this inevitable flu, the less I feel like going outdoors. Not your fault, of course. I’d rather be in the know than blissfully ignorant.

  6. I’d love to read something rather more balanced which discussed such as is known about ways in which disaster planning works well.

    Maybe the problem is “good news is no news”? Though if I remember right, the afterword to Rising Tide talks about lessons learned and the success in keeping the lower Mississippi River valley from flooding catastrophically since 1927.

    Can’t find the reference right now, but was reading today that the measures the US most needs to take to prepare for a flu pandemic are not things like quarantines, command-and-control, and martial law, but rather rapid recognition of a problem, distributed resources, speedy distribution of vaccines and so on. All of which would also be helpful in dealing with a biological attack and/or numerous other potential disasters. This administration being what it is, I wouldn’t look for any federal improvement before 2009, but states and localities may prove better.

  7. @Maynard: “Meanwhile the USSR apparently had a pretty serious, well-thought-out and well-budgeted nuclear war mitigation plan”
    Could you provide me with references? I have a hard time believing this.

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