Philip Alcabes discusses myths of health, disease and risk.

Pandemics, politics, poverty

At Junkfood Science yesterday, Sandy Szwarc exploded some of the myths about the swine flu outbreak.  Although much is made of the fact that the hospitalizations and deaths associated with H1N1 flu infection have predominantly been among children and young adults, Junkfood notes that those numbers are no higher than in past flu seasons.  Her post quotes Dr. Anne Schuchat of CDC, who reminded the media at a May 28th briefing that seasonal flu generally comprises a mixture of H1N1, H3N2, and B influenza strains – and that H1N1 strains tend to cause relatively more illness among the young.

“Declaring a pandemic has more to do with politics than with medicine or helping you to stay safer. In fact, responses to fears about a pandemic are far more frightening and dangerous than the flu itself,” Junkfood Science points out.

At Effect Measure, a post by revere on 6 June voices skepticism over the utility of the W.H.O.’s pandemic threat alert system.  revere writes, “The WHO pandemic alert system, which was instituted in 2003 and had never been seriously tested until this outbreak, immediately met a pandemic it couldn’t handle, not because it was so severe but because it wasn’t severe enough. “  revere finds the threat alert system to be “more of a problem than a help.”

A report out this month on “Pandemic Flu” from the Trust for America’s Health, asserts that “Investments in pandemic planning and stockpiling antiviral medications paid off,” but “even with a mild outbreak, the health care delivery system was overwhelmed.”  Still, this report noted that the “WHO pandemic alert phases caused confusion.”  This is reassuringly un-martial talk for a group whose report is subtitled “Lessons from the Frontlines” and which is partially funded by the Center for Biosecurity.

We agree that the pandemic alert causes confusion – and, we’ll add, consternation – and concur with Junkfood that the alert is about politics.  But W.H.O. gets an overly bum rap.  The agency has been trying to leverage its clunky threat-alert barometer to help health officials in poor countries to plead their case for more funding or better programs, and to get us in the rich countries to notice that it’s the poor who suffer when a disease spreads globally.

The pandemic barometer as constructed is too crude an instrument for that.  As revere points out at Effect Measure, the system could be “scrap[ped]… in favor of an up-to-date information system.”

But the important point will be to shift the focus.  The medical and public health industries have to stop thinking about flu (and other contagions of world importance) as a problem only when Americans’ health is threatened.  The health sector has to start paying much more attention to the conditions under which viruses become epidemic (i.e., human disease) problems:  the many ways that humans and animals interact, especially through markets for wild-animal meat, and the interactions of wild with domesticated animals; economic conditions in poor countries that make it impossible for people to stay out of the way of virus traffic; and the poverty, crowding, and compromised health that make it easy for some viruses to spread once they start adapting to humans.

Instead of worrying about airplane passengers landing at U.S. airports, the focus should be on the real conditions that most of the world – and its viruses – lives in.

It isn’t health if it isn’t for everyone

A couple of weeks ago we toured the Wildlife Health Center at the Bronx Zoo with Dr. William Karesh, director of the field veterinary program for the Wildlife Conservation Society and VP for WCS’s Global Health Program.

We learned that veterinarians from the Wildlife Health Center do rounds for all animals in NYC’s zoos and aquarium; animals needing special care are brought to the center.  Health records for all animals in zoos are electronic and are maintained with common software – making it straightforward for health records to be transferred whenever the animal is transferred from zoo to zoo, anywhere in the world, and of course facilitating research.

Animal health seems far removed from human health – not only in that it’s much harder for caregivers to see any person’s prior health records than it is for vets to see an animal’s.  We think of wildlife health as distinct from our own.  Even when an event like the 2001 foot-and-mouth disease outbreak in Britain causes us economic distress and affords people the ghastly sight of piles of cow carcasses piled up in farm fields, we don’t see the connections easily.

Increasingly, it’s becoming apparent that the health of human populations depends on equilibria in the wider world.  We have our military-style campaigns to defend Fortress Humanity from microbial invaders:  we use antibiotics, vaccination, and close monitoring of routes of ingress via food and water.  They work, at least up to a point.  But the evidence of MRSA, antibiotic-resistant TB, avian flu, S. Saintpaul in jalapeño peppers, and the new swine flu is that those measures aren’t perfect.  There’s not going to be any Conquest of Contagion (as Charles E.-A. Winslow put it in 1943),  and so-called victories such as the use of immunization to eradicate smallpox and control polio won’t be repeatable for every germ.

In the long run, as the One World, One Health movement suggests, we’ll have to shift to a much broader view of the planet as a system – in which we humans are co-resident with other species.  We might manage to ward off a serious flu outbreak with vaccine (the jury’s still out on whether the current swine flu strain can become highly damaging or not, but it’s reasonable to think that some flu strain might).  And we should improve food-safety systems to guard against outbreaks of salmonellosis and the like.  But we have to move toward a more complex understanding of how human health, animal health, environmental conditions, and international transfers of food, animals, goods, and people interact, especially with respect to the movements of microbes.

In that regard, it’s  troubling to learn from DemFromCT’s post at DailyKos yesterday that Sen. Max Baucus says that a new healthcare plan in the U.S. will not cover undocumented immigrants. It’s cruel, of course, to deny care to immigrants.  But it’s also shortsighted.

If we continue to have a huge, frequently mobile proletariat of migrant workers  forced by economic duress to travel from country to country in search of a living wage and we also make it impossible for them to get care, we’re harming ourselves.  Even those who aren’t moved by the humanitarian aim of ensuring all individuals a decent life should be moved by self-interest.  Creating a means by which disease and disability can move around with the people who suffer from them will undermine whatever arrangements we make for health.

One Health means we have to think about the interactions of many species – and it’s ridiculous to exclude some members of our own.