Philip Alcabes discusses myths of health, disease and risk.

Bed Bug Worry, Mosquito Mayhem

You hear a lot about bed bugs these days, here in New York City.   The bed bug infestation has become part of New York angst, the newest of our plagues.  The NY Times had its top infectious disease writer cover the recent CDC-EPA joint statement on bed bug control.  There’s even an iPhone app with GPS-enabled bed bug maps of New York and other big cities.

Early this month, a couple of friends, thinking they might splurge on a downtown hotel to celebrate their tenth wedding anniversary, were soliciting bed bug reports before choosing where to stay.  And at a family gathering last week, one young man — recently graduated from an elite college, an intellectual usually given to ironic mockery of the nuttier trends evident in the generation that still uses e-mail — told me that while he’s afraid of bees and doesn’t like mosquitoes, bed bugs really terrify him.

Bed bugs are unpleasant.  Their bites can itch.  Their feces and molted shells can set off asthma attacks or other allergies.  It’s sensible to avoid them, and get rid of them if they’re in your home.  I wrote a few months ago that it makes perfect sense that health authorities do something to limit bed bug woes.

But if you ask me what insects worry me most as a public health professional, I certainly wouldn’t say “bed bugs.”  Ticks, especially as Lyme disease spreads geographically.  Phlebotomine (sand) flies, as leishmaniasis becomes a more serious problem.  Mosquitoes, always.   Bed bugs are far from the top of my list.

The Aedes mosquitoes that carry yellow fever, dengue, rift valley fever, and chikungunya viruses, are most troubling right now.  Ae. aegyptii most of all, of course, but increasingly Ae. albopictus.

An extensive outbreak of rift valley fever in South Africa produced dozens of human cases earlier this year, and seems to be continuing among livestock.  An epidemiologist friend in Europe told me a few weeks back that he and other European disease control specialists, already concerned about dengue and yellow fever, are looking at RVF exposures in the southern part of the continent — a worrisome finding for a virus that has primarily been African.   The European Center for Disease Control is, appropriately, concerned about the establishment of Ae. albopictus in Europe.

Ditto chikungunya, which as produced 33 cases in Delhi, India, this year, possibly including an illness in the city’s mayor.

Dengue  demands control most pressingly of all.  Although the CDC is busily advising Americans not to worry (“Nearly all dengue cases reported in the 48 continental states were acquired elsewhere by travelers or immigrants,” its info page reads), there is active spread through much of the Caribbean basin — see the map at Dengue Watch, for instance.  The Mexican ministry of health reports dengue transmission in areas bordering the U.S.  There has already been an outbreak in Texas (in 2005).  And other highly industrialized countries with strong surveillance and control systems are experiencing dengue cases, including the first report of domestic transmission within France this summer.

(Hats off to Crof at H5N1, who has been following both chikungunya and dengue assiduously.)

The expansion of the range of Ae. albopictus, a secondary but by no means ignorable vector for dengue, makes the geographic extension of these pathogens worthy of concern.

With climate changing, trade routes always in flux, area spraying of insecticide disfavored because of environmental considerations, and of course mosquitoes evolving to take advantage of new niches, it seems unlikely that North Americans can go on counting on the mere improbability that virus and vector will coincide.

Mosquito control programs are in place, and U.S. authorities expend considerable effort at controlling Ae. aegyptii in Puerto Rico.  But the West Nile fever outbreak of 1999 and its subsequent extension in North America reveals the porousness of mosquito control.

Mosquitoes are much more worrisome than bed bugs.

By Philip Alcabes | October 31st, 2010 | Categories: climate change, Disease, epidemics, Outbreaks, public health, Uncategorized | Tags: , , , , , , | Comments Off

In the mouth of death

The Miami Herald‘s article yesterday on cholera reaching Port-au-Prince quotes a homeless resident of the Haitian capital, fearful at the approach of the disease:  “Of course I’m scared — we’re in the mouth of death.”

Haiti today: in the mouth of death.  Not just Haiti, of course.  Deadly, gruesome, and hard to stop, cholera seems emblematic of the many failures that preceded the earthquake and have been exacerbated since.  We Americans are paying attention to Haiti lately — because of the earthquake; because of proximity; or because however bad things are here, what with high unemployment and poor economic prospects, Haiti conveniently reminds us of what we’re not.  But really much of the world, of the dollar-a-day world, is in the mouth of death much of the time.

With cholera, the relief agencies are hard at work.  Ansel Herz, a freelance journalist who blogs at Mediahacker, writes that there have been five cholera deaths in Port-au-Prince as of this morning, although the authorities say those people came to the capital from elsewhere and that cholera isn’t yet spreading in Port-au-Prince.  Still, cholera mortality is over 200 nationally.   Herz describes the earnest efforts of aid workers.  But his reportage, along with that of the Miami Herald, the NY Times, and others, also reveals the shortcomings of relying on aid organizations to contain the complex problems — of which cholera is the latest.

Partners in Health, to my mind the most earnest and committed of the aid organizations, is compiling reports on the spread of cholera and, of course, trying to do something about it.  But here’s the problem: if it’s the aid workers who are trying to stop cholera, it’s too late.  I don’t mean that they’ll fail; I mean that there should have been infrastructure in place to make sure cholera doesn’t break out at all.  And if there’s no such infrastructure, cholera will happen again, however well it’s halted this time.

It’s hard to escape the image, provided by Herz, of a new water tank installed near Cité Soleil by the International Organization for Migration — which stands empty, because nobody has provided clean water to fill it.

This is the problem with aid:  of course there must be organizations, like Partners in Health or MSF, that provide relief to the suffering.  But if there’s no support, or demand, for permanent public health infrastructure, the aid workers will always be scrambling to keep up with crises, and the crises won’t stop happening.

In the New Yorker this month, Philip Gourevitch takes a skeptical view of humanitarian aid (abstract here; full article requires subscription).  He summarizes the message of Dutch journalist Linda Polman sympathetically:

The scenes of suffering that we tend to call humanitarian crises are almost always symptoms of political circumstances and there’s no apolitical way of responding to them – no way to act without having a political effect.

Now, Gourevitch is talking specifically about crises created by political conflict.  But something of this dilemma pervades the problem of relief.  Public health is political.  It takes political will — not just oral rehydration therapy — to install water supplies and sewage systems, and housing with running water even for the poor.

Canada is going to send a million dollars to Haiti to help with the cholera problem (thanks to Crof at H5N1 for picking that up).  No doubt the U.S. will outdo its neighbor in looking mournful and concerned, and donating even more money.  But where’s the support for good government, and real public health, and necessary infrastructure?

What are we doing to promote the implementation of good public health? What are we doing to generate the political will to install even just the ordinary civil engineering works that we take for granted in America, but which would make a difference to the people who are living in the mouth of death?

By Philip Alcabes | October 24th, 2010 | Categories: epidemics, News, Outbreaks, public health | Tags: , | Comments Off

A Blog Worth Following

If you haven’t already, put Crawford Kilian’s H5N1 blog on your regular reading list.  There, while you’ll still get updates on the H5N1 avian flu virus and occasional pieces on H1N1 flu (and you can see a multitude of archived posts from 2009  filled with international material on the progress of last year’s flu — and the reaction to it), you now get a much-expanded scope, including news and commentary on the spread of infectious diseases of different sorts.

What I value about H5N1 is the tracking of the mosquito-borne viral diseases, like dengue and chikungunya as well as H1N1, that reveal the effects of the elision of ecosystem boundaries; the close attention to outbreaks that stem from changes in human-animal interactions — like the recent outbreak of plague in Tibet and, of course, H5N1; and the watch it keeps on the vaccine trade, as in yesterday’s post picking up a report in The Nation on the purchase of flu vaccine from France and one last week on a US tech company’s trials of a new flu vaccine (which won’t help the public but is, apparently, already helping the company to get richer).

The kind of close attention to the details of complex interactions amongst humans, animals, and both the natural environment and the economic one that H5N1 shows is indispensable.   It should spur more interest in wresting public health away from the simple-minded mass-vaccination schemes of medical officials in the U.S. and other wealthy countries — the point of which is usually to transfer public monies into the hands of pharmaceutical companies.  And move us to toward a more complex and inclusive view of the nature of health.

By Philip Alcabes | September 28th, 2010 | Categories: climate change, Disease, epidemics, Health Professions, News, Outbreaks, Physicians, public health | Tags: , , , , , , , , | Comments Off

Public Health Priorities: Follow the Money

Thanks to Crof at H5N1 for bringing to our attention a strong editorial in yesterday’s Bangkok Post.   The editorialists note that H1N1 preparedness efforts were not always successful and that WHO, fresh from announcing that the H1N1 pandemic is over, is now promoting fears of renewed outbreaks of H5N1 (avian) flu.  The editorial continues:

While it would be foolish to dismiss such warnings as this latest one on bird flu, it is important we keep a sense of proportion and not let them distract us from countering the unfashionable but widespread potential killers such as tuberculosis, HIV/Aids, diabetes, cancer, dengue and malaria. These are the diseases already causing widespread illness and economic harm….

Rather than competing for cash, the threat from newer diseases should serve as a catalyst to combat existing epidemics.

Competing for cash is key.

Funding for TB languishes, dengue incidence expands, more people with the AIDS virus are getting treated but new infections continue to occur, water scarcity (and displacement because of wars and natural disasters) makes diarrheal illness a persistent problem, and malaria transmission continues to threaten billions of people who live in tropical and subtropical regions — but flu preparedness dominates the public health scene.   Why?

Here’s the infernal logic of WHO and the public health officers of wealthy countries (U.S., U.K., etc.):  (a) At the start of the H1N1 outbreak in 2009, a sensible worst-cast forecast was about a million deaths worldwide; the more likely scenario was well under 500,000 deaths.  (b) TB + malaria + diarrhea + AIDS together kill 6 or 7 million people a year.   (c) Immunization against flu is notoriously variable in its effectiveness and mass immunization is almost never effective (except if instituted in an isolated population well before the flu virus makes inroads into the population).

Sounds like it would be worth it to pump lots of resources into reducing the incidence of malaria, TB, AIDS, and diarrhea.  But that’s hard.  It takes political will.  Whereas immunizing against flu is easy: it just takes money.  And national health officials were eager (it turned out) to transfer billions of dollars, pounds, and euros into the hands of vaccine manufacturers in order to be able to immunize their populations against H1N1 flu.

To an official whose job is to watch out for the needs of the economic machine, immunization pays.

One flu vaccine manufacturer estimates that in the U.S., employers lose $2.1 billion each year in productivity because of flu-related absences from work.  Let’s be skeptical about this estimate, coming as it does from one of the beneficiaries of federal largesse in response to flu fears.  But the point is clear enough:  it was a great boon to the private sector to have the federal government spend $1.6 billion of taxpayer money on flu vaccine in 2009 even though the outbreak was mild and vaccine did virtually nothing to stop it.  Because with the feds footing the bill, the burden on corporations was slight, whereas the private sector would have lost a lot of money if many Americans had fallen ill with flu.

It’s not just the vaccine manufacturers and pharmaceutical companies who stand to capitalize on the absurd calculus of protecting American businesses instead of poor people’s lives:  scientists do, too.

Robert Webster is an eminent virologist who has become dean of those American scientists who purport to be able to foresee a future flu catastrophe.  Perhaps he’s right, but of course nobody knows.  So when Webster says

We may think we can relax and influenza is no longer a problem. I want to assure you that that is not the case,

as he just did in a meeting in Hong Kong, it’s a good sign that the preparedness crusaders are worried about their funding.  They should be.

The preparedness crusaders have been unmasked as shameless shills for the private sector,  even if the vaccine and antiviral manufacturers aren’t paying them directly.  And the ones who are scientists have been revealed as self-important promoters of their own research — so fiercely protective of their own turf that they might use their prestige and the imprimatur of science to hoodwink officials into ignoring the more serious, and more certain, problems of the developing world.

Let’s hope that more opinion makers take the stand that the editors in Bangkok just did.

By Philip Alcabes | September 5th, 2010 | Categories: Disease, epidemics, Outbreaks, public health, Uncategorized | Tags: , , , , , | Comments Off

Transparency on Pandemics

How bad would it be for officials to be more open about how they make decisions on “preparedness”?  Should the public know more about how so-called experts forecast coming danger?  What’s the influence of media reports, like the coverage of last year’s flu outbreak which suggested, from day one, that it would resemble the 1918 flu?  How influential are the pharmaceutical companies and other vaccine makers?

At H5N1 yesterday, Crof picked up the U.K. government’s announcement that it would sponsor an independent review of decision making in response to H1N1 swine flu last year.  The U.K.’s Minister of Health, Liam Donaldson, told WebMD that it is

vital that we learn from what we have seen in this pandemic, for the sake of those who find themselves tackling … the next. It is likely to be worse.

Anybody who claims to know what the next pandemic will be like is asserting a special ability to read mysterious auguries that nobody else can see.  So it’s all the more shocking that Donaldson goes on to obfuscate his own failure to ask critical questions by claiming to have been using expert predictions:

Would it have been acceptable to hide and conceal statistical projections provided by statistical modellers of international standing, even though releasing them publicly caused alarm in some quarters?

As if the flak he had taken last July were for a perfectly rational assertion, not an apocalyptic forecast — when he said that there could be 65,000 deaths from flu in Britain.  Donaldson later dropped the forecast to 19,000 deaths.  (The actual number was less than 400 during 2009, 457 to date.)

And as if Donaldson had not made the same off-base prediction back in October 2005, when he said that there would be an avian flu outbreak in the U.K. with 50,000 deaths.  That was Donaldson’s excuse to use public money to purchase two and a half million doses of antivirals for stockpiling.

As if, that is, the problem were that people are just benightedly opposed to science — not genuinely concerned about malfeasance.

To its credit, the Parliamentary Assembly of the Council of Europe continues its investigation of decision making around the H1N1 outbreak response, holding a second public hearing on Monday.  Briefs of experts’ statements at the first hearing, back in January, are available here, and links to full statements and video are at the PACE site here.

Some of my friends and colleagues in public health wonder if this kind of questioning comes from misunderstanding the seriousness of flu and others are fearful that it will diminish the authority of public-health physicians.  A few, but too few, back the redoubtable Tom Jefferson, who has been questioning the reliance on flu vaccine for a long time.  Shouldn’t scientists — especially scientists — question authority?

Officials’ legitimacy ought to be diminished if they’re not serving the public.  Particularly when their decisions mean that private companies benefit from taxpayers’ monies.  Clearly, the transfer of funds is what happened with the H1N1 flu response.  Was it based on sound decision making?  More transparency would be a good thing.

Now that the Council of Europe and the U.K., are investigating official responses to H1N1 flu, could we please hear from the United States?

By Philip Alcabes | March 26th, 2010 | Categories: Disease, epidemics, Health Professions, News, Outbreaks, Physicians, public health, Uncategorized | Tags: , , , , , | 1 comment

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