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Tuesday, May 26

H1N1/swine flu: USA continues to play Typhoid Mary to the world, CDC continues to dither, but York Chow's John McClane moment is a beacon

“We are doing everything we can to protect public health and teach children how they can stay healthy and safe,” said Secretary Kathleen Sebelius. “Elmo, Gordon, Sesame Workshop, and the Ad Council are delivering an important message to our kids.”

On May 14 Hong Kong's Secretary for Food and Health, Dr York Chow Yat-ngok, born in 1947 in Hong Kong, raised under the territory's British common law and schooled in its British education system, had a John McClane moment.

I'm talking about the moment in Die Hard when McClane throws a corpse out a window, in a last-ditch effort to clue a member of LA's Finest that all is not well at Nakatomi Plaza, then yells over machine-gun fire, "Welcome to the party, pal."

The moment came at the May 14 presser when Chow was asked what the response had been to the letter he'd faxed Kathleen Sebelius, U.S. Secretary of Health and Human Services.

In the letter Chow requested that the United States implement exit screening measures equivalent to that of Hong Kong international airport's arrival facilities, in order to prevent infected airline passengers from the USA from boarding flights to Hong Kong.

York Chow replied:
"We have not received any response right now. But what we have informed the American government is, since they are a representative of the WHO and a signatory to the International Health Regulations, I think that everyone has the responsibility to ensure that they do not allow any infection to go outside their country or territory.

"I think that Hong Kong is fulfilling that duty and responsibility and I hope that other countries will do that too." (1)
At first it looked as if Dr Chow's McClane moment was indeed just a moment because four days later, when he came face-to-face with Secretary Sebelius at WHO's general assembly meeting, he'd considerably scaled back on his statements -- at least the ones made publicly available.

Chow asked only that the USA issue a travel appeal and that visible signage be erected at US airports to warn travelers, particularly students returning to Hong Kong for the summer. The response?
The US side said they have implemented aggressive measures, including a public education campaign and an advisory for people not to travel when they are sick. (2)
Ms Sebelius then toddled off to take more aggressive measures, which The Washington Post dutifully reported on March 23:
Sebelius was at the [Department of Health and Human Services] day-care center with Elmo, the "Sesame Street" character who appears in a new television public service announcement showing children how to properly cough, sneeze and wash one's hands during a flu outbreak. Elmo initially covered his cough with his hands. He was gently corrected by Sebelius, who demonstrated that the crook of the elbow is the proper body part to use. (3)
Meanwhile, over on China's Mainland, as they chased down infected passengers who'd flown in from the US and Canada, the logic of Dr Chow's argument was seeping in. So, with 11 documented cases of swine flu on the Mainland, they're no longer just relying on thermal imaging machines. At Shanghai's Pudong International Airport, protective-suited health inspectors are going seat to seat, right on the plane, and taking every passenger's temperature.

Okay, so the suits aren't biosafety Level 4 Hazmat contraptions with their own oxygen supply, but the inspectors are wearing enough gear to protect them against swine flu. (4) Now that's an aggressive measure to battle a highly mutable new virus!

If you say that Shanghai's response is a bit over the top considering that swine flu is about as a lethal as regular flu --

Well, if you ignore the symptoms of diarrhea and vomiting that accompany many cases of swine flu (which don't accompany regular flu), if you ignore the cytokine storm reaction that have been responsible for some swine flu fatalities, if you don't factor in co-infection (e.g., catching regular flu and swine flu at the same time), if you don't read between the lines of official statements that most of the swine flu fatalities involve pre-existing chronic medical conditions, if you ignore the meaning of "highly mutable," then yeah, sure, Shanghai is making much ado about nothing.

And realize the devastation wrought by even the present form of the swine flu could be on a scale so vast in the poorer countries it's hard to contemplate -- a point I didn't consider until I received a comment from a reader. Writing under the nom de plume "snake oil baron," he observed in part:
The fact that this flu has the odd trait of diarrhea and vomiting would mean that dehydration would compound the problem where poor health care levels existed. [...]

A virus which is more lethal than anticipated, combined with dehydration from diarrhea and vomiting in dense poverty-stricken slums where AIDS and TB are already endemic, could cause a humanitarian disaster. Even a death rate well below the 1918 one, when played out in mega-cities and slums, could quickly become a nightmare.
What I find most striking about his observations is that it wouldn't even take a more lethal form of the virus to skyrocket the death count in many such regions, given the dehydration that accompanies diarrhea and vomiting. That's because many people in the world can't simply turn on a spigot to get water, and the water they can access is very limited.

When seen from that angle, Dr Chow's May 14 statements take on great urgency. I should also mention that the press conference came after Hong Kong's public health department had to chase down 20 disembarked passengers from a Cathay Pacific flight inbound from San Francisco who were likely exposed to a passenger who was sick with swine flu; three relatives of the infected man; three flight attendants, who then had to be quarantined for a week; ambulance personnel and immigration officers who were exposed to him; and the man's girlfriend, who arrived on a later flight. (5)

The department also had to alert their counterparts in Singapore, Malaysia, and India because 45 of the passengers on the Cathay Pacific flight had continued from Hong Kong to those countries.

Welcome to the party, Thomas Frieden and Kathleen Sebelius.

If Dr Frieden replies that there's nothing to be done except treat the disease outbreak on a case-by-case basis until a vaccine is ready -- I think the real core of the "aggressive measures" that Kathleen Sebelius mentioned is the "Manhattan Project-style" crash vaccine-development program that Dr Frieden called for recently, and which he'll surely push once he leaves his job as New York City Health Commissioner and takes up the head position at the CDC.

However, there are strict limits on how fast such a crash program can proceed, which leaves NPIs -- non-pharmacological interventions such as quarantine, school closings, close monitoring of airline passengers, and so on.

Dr Frieden, and indeed the entire public health regime in the United States government, have not been fans of NPIs for dealing with the swine flu beyond encouraging proper personal hygiene. This, on the flawed rationale that once a virus enters a country there's nothing that can be done to stop its spread.

From the beginning the objective should have been to slow the rate of infections, and the objective should never have changed. But the objective was never even tried by U.S. public health officials. This has hit the United States very hard, and turned our country into a kind of Typhoid Mary, given that the majority of initial infections flown around the world have come via U.S. airports.

Dr Chow's purely ethical argument exposes the theorizing of U.S. health officials for what it is: an attempt to avoid responsibility. Yet not to try everything you can think of, even in the face of seemingly insurmountable odds, is to betray the public trust. That, I believe, was York Chow's ultimate message to governments around the world. His own government listened. When will ours?

1) Channel News Asia: Hong Kong wants US to screen outgoing passengers at airports; Leslie Tang; May 14 May 2009

2) Hong Kong government website: H1N1 suspected in transit passenger; May 18, 2009

3) The Washington Post: U.S. Asks Firms to Make Swine Flu Vaccine; by David Brown and Rob Stein; May 23, 2009

4) Associated Press: Mexico, US, Canada announce swine flu deaths; May 26, 2009

5) The [Hong Kong] Standard: Another one down; Nickkita Lau and Patsy Moy; May 14, 2009
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This entry is crossposted (with lots of pictures!) at RBO.
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Previous Pundita posts on swine flu
May 21
H1N1/swine flu. Have CDC and Dr Thomas Frieden clouded NYC Mayor Michael Bloomberg's mind?
May 20
Stop misleading the public about the true lethality of H1N1/swine flu virus. Memo to CDC, WHO, New York City Department of Health
May 19
Mr President, fire NYC health commissioner Thomas Frieden from his post as CDC director before he even starts to work there
May 15
Say, whatever happened to that 2007 Senate subcommittee report on CDC fraud, waste, galloping mission creep, and failure to control disease?
May 15
Enraged U.S. lawmakers, union leaders, attack Homeland Security's negligent swine flu policy
May 14
H1N1/Swine Flu: Was Cuba's airport blockade an over-reaction to the outbreak?
May 13
H1N1/swine flu: CDC and WHO help unleash a pandemic
May 11
Swine flu/H1N1: Your life, riding on the CDC's slow boat from China
May 4
What Joe Biden knows about the jet-setter swine flu that you don't
May 2
H1N1 swine flu: WHO circles the wagons in response to criticism they were slow to warn
April 30
H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world
April 27
Mexico-U.S. swine flu outbreak and the U.S. Department of Slime
April 26
Mexican-U.S. swine flu outbreak. Caution: blind curves and fog ahead
Comments:
I just found this video on You Tube that really shows how germs and viruses spread. It is so cool. It's meant for kids but I even learned a lot!

http://www.youtube.com/watch?v=56mq1t1BqfY
 
With various health care reform bills floating around both the House and the Senate, President Barack Obama is pulling out all the stops to get the votes that the bill needs, which is good news for the public option. President Obama continues to rally behind health care reform. I am really concerned that the fiasco of this reform may make Obama a one-term president.
 
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