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Global Health Update, May 5 2009

Author: Laurie Garrett, Senior Fellow for Global Health
May 5, 2009
Council on Foreign Relations


This is an e-newsletter produced by CFR's Global Health Program. The text of the newsletter appears below. You can read the full newsletter as a PDF here.

Dear Friends and Colleagues;

It is hard to believe that only days have passed since the world grew fixated on spread of influenza in Mexico. Harder, still, is coming to grips with the notion that it's all over, no dangerous pandemic is imminent. The Global Health Program of the Council on Foreign Relations has been overwhelmed with demands on our time and attention since the H1N1 A virus emerged into public light in Mexico.

This brief Update will draw you attention to a few of the most interesting insights into the flu situation, as well as the activities of the Program.

Worth Reading, Watching or Listening to:

Within the scientific community, the current focus is on understanding the genetics of the Mexican H1N1 strain, its phylogeny and its limitations. It has been breathtaking to witness how swiftly these details have been worked out by scientists around the world, in a feat made possible by attention to flu virology brought to bear by the H5N1 threat. Samples of the strain did not undergo genetic analysis until around April 23rd, initially in a shot-gun crude form. And in a mindboggling eight days, scientists all over the world had compared notes and assembled the entire family tree of this strain.

The evidence reveals that H1N1 A is the direct descendant of influenza strains that have circulated for 20 years or more. Far from being a "Mexican" virus, this flu has genetic fingerprints from all over the world, but has largely circulated in the United States of America. Indeed, in scientific circles it is dubbed H1N1 A California - as apt a moniker as any.

New Scientist magazine and Wired have both run with stories charging that the entire outbreak is rooted in industrial pig farming., and

Needless to say, the pork industry begs to differ. See Chris Olsen's "INFLUENZA: Pigs, People and Public Health," a Public Health Fact Sheet distributed by the National Pork Board:

Peter Palese of Mt. Sinai Medical Center in New York is one of the world's top influenza virologists. He has long been something of a pandemic naysayer, in contrast to Robert Webster, of St. Jude's in St. Louis. Both viewpoints are vitally important and valuable. Palese is confident that the H1N1 A California lacks most of the genetic tools necessary for it to cause severe disease in human beings. Further, he doubts the necessary reassortments or mutations can occur.  
See: "Why Swine Flu Isn't So Scary," Peter Palese, Wall Street Journal, May 2, 2009.

In the same issue of the Wall Street Journal Larry Brilliant (formerly of, now with Skoll Urgent Threats Fund) offers a lengthy and helpful discourse on factors responsible for disease emergence, and appropriate ways to countervail them.
See: "The Age of Pandemics," Larry Brilliant, Wall Street Journal, May 2, 2009.

Much praise has been heaped upon the U.S. public health system and WHO for timely responses and coordination. Much more should be directed to Mexico. Some of the comments made by Dr. Bhagirath Singh, the scientific director at the Canadian Institute of Infection and Immunity, are interesting in "21st century world better prepared for pandemic: experts /Canwest", May 3, 2009.

Of course, we have not been challenged with a truly virulent virus. If we were, the systems might not be able to handle more than a few days of flu; they would quickly be overwhelmed. In that case, argues Joel K Kelso, George J Milne and Heath Kelly, the key to limiting spread would be convincing people to stay away from one another. See: "Simulation suggests that rapid activation of social distancing can arrest epidemic development due to a novel strain of influenza," BMC Public Health, 2009.

As we have come to expect, Bob Blendon, of the Harvard School of Public Health was swift in producing polling data on American reactions to the H1N1 outbreak. Some of his findings illustrate just how steep the public education curve is for a fairly benign virus - we can only imagine what these numbers would look like if a genuinely virulent germ were in circulation.

Larry Gostin of Georgetown's law school has literally written the book on public health law. In an op-ed in the May 1st Washington Post Gostin argues that WHO does not have the sorts of legal instruments it needs to deal with genuine pandemics:
"Fighting the Flu With One Hand Tied,"

Former CFR Global Health Program Research Associate, Scott Rosenstein, now an analyst with Eurasia Group, started wondering a week ago about another drawback in the WHO legal apparatus: The Pandemic Threat System. There is only one more stage to consider - Level 6 - and according to WHO's parameters the world is already in a Pandemic. Where do we go from there?

The problem is that the World Health Assembly reached many compromises in designing this system, in the end dumping all language that could possibly link the system to specifically required actions on the part of any nations. Poor countries can't afford to comply, and many other nations choose not to institute actions that they deem inconvenient for political, cultural, or economic reasons.

Thus, the WHO Pandemic Threat system has absolutely nothing to do with the severity of the risk any given microbe poses for human health. Nothing. The alert system is entirely based on geographic distribution of "sustained spread" within human populations. Absent in the threat classification system is danger. Thus, a completely benign organism could meet all the criteria for Level 6.

Given there appears to be sustained transmission now in Spain, WHO should, based on the above, bump the situation to Level 6. The political and economic consequences of doing so are considerable. This is a real mess.

The Institute of Medicine in the United States has just pulled together years of influenza studies and special reports, compiling a very useful scientific guide that should be invaluable for policy makers, human resources managers, and the just plain curious among you:

IOM Releases Guide to Recent Work on Pandemic Flu

Cases of the novel strain of H1N1 (Swine Origin [SO]) influenza that spread rapidly through Mexico in April 2009 now span the globe, and pandemic response plans are being activated to meet the threat to public health. In the past several years, the Institute of Medicine (IOM) has released a number of reports and workshop summaries related to major policy issues for pandemic influenza and other infectious disease threats similar to the current spread of H1N1 (SO) influenza. This guide highlights action and information that could be useful for near-term implementation of pandemic planning and response in the following areas:

  • Communicating with and engaging the public
  • Use of masks and personal protective equipment
  • Use of antiviral drugs and vaccines
  • Outbreak mitigation (e.g., social distancing, school closures)
  • Surveillance, research, and evaluation during a pandemic

The guide is available online or for download as a PDF.
In addition, President Harvey V. Fineberg has made his book on the 1976 swine flu outbreak, The Swine Flu Affair: Decision-Making on a Slippery Disease , available as a free PDF. The book examines the U.S. government's swine flu immunization program in the wake of an outbreak of the disease among a small group of soldiers at Fort Dix. The program was marked by controversy, delay, administrative troubles, legal complications, unforeseen side effects and a progressive loss of credibility for public health authorities. The book is dedicated to co-author Richard Neustadt, and extracts lessons to help cope with similar situations in the future.
The report is available for download as a free PDF.

The Global Health Program is slightly amused by all the talk of vaccine preparedness. The global manufacturing capacity, because flu vaccines must be made on live chicken eggs, is just over 400 million doses. That is a big improvement over a couple of years ago, but abysmal given there are more than 6 billion people who would need immunization. Though many breakthroughs are coming, it will be years before innovative technology can change this picture.

Global Health Program and the Media

Laurie Garrett has appeared on far too many news programs, and been interviewed for too numerous websites and news organizations to offer a list. We would only draw your attention to a few key contributions.

The current issue of Newsweek features a cover story authored by Garrett. The key point in the article is that the H1N1 virus has circulated in pigs in North America for many years, and caused sporadic human infections. Only recently did the virus spread human-to-human in any significant numbers.  The ecology that spawned this outbreak will bring more surprises in future. Like the chicken production ecology that has sustained spread of H5N1 (aka bird flu), the manmade ecology of pig production must be made far safer.

In 2007 Garrett gave a presentation to the annual TED Conference, warning of failures in pandemic flu preparedness. TED has posted the talk on their website in light of the current outbreak. We would remind Update readers that this talk was delivered in early 2007, and best reflects a snapshot of readiness circa late 2006. Nevertheless, many, if not most, of the problems underscored in this 15 minute talk plus Q&A pertain today.
Ted: Talks Laurie Garrett: What can we learn from the 1918 flu pandemic?

In October 2008, Garrett gave a 20 minute presentation at the annual POPTECH! Conference. Poptech! has posted the talk, along with this blurb:

From Poptech!
Renowned global health expert Laurie Garrett gave a powerful and frightening talk at PopTech 2008 on how countries deal - both effectively and ineffectively - with pandemics. Examining China's response to SARS, she asked: what if this happened here? How would we respond? Her presentation is essential viewing right now:

Before the World Health Organization to raised the threat level from a 3 to a 5 (on a 6-point scale), Garrett gave a wide-ranging press teleconference on Swine Flu. The full transcript can be found on the CFR website:

Garrett appeared on "The Charlie Rose Show":

And Garrett was interviewed on National Public Radio's "Weekend All Things Considered":

And on "Morning Edition":

We will endeavor to keep you, and the general public, informed. We have received a few queries asking if it is okay to forward these Updates: By all means!

Laurie Garrett

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