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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

Friday, May 22

Note

Three posts up this morning; none them about swine flu, although Doc Jim left very interesting observations related to the flu issue in NYC in the comment section for the "Governmentarian" post. Other interesting new comments/data links in the comment sections of the most recent swine flu posts.

I'll try to put up a post today about swine flu although if it happens it'll probably be late, around 8:00 PM ET. Otherwise the next post will be on Tuesday morning.

Regards to all,
Pundita

Governmentarians and the rising protests against juggernaut governments

Yesterday, while I was mucking around at Dan Riehl's site looking for the link to his mention of a Pundita post on swine flu, I stumbled across this Riehl gem:
[...] It seems to me [Lindsey Graham's] from another wing of the GOP, the one currently controlling the GOP in DC: Governmentarians.

They sometimes masquerade as Conservatives and sometimes Libertarians, but they're for Big Government whenever it means good press, or a boost for their personal political career. Scratch an alleged Right-leaning moderate and you get a Governmentarian every time. [...]
Governmentarian! That is exactly the word I've sought for many years! By gum that's how so many on the Right have gotten away with being socialists while wrapping themselves in the language of capitalists! They're not Marxists, they're, they're -- Governmentarians! Hah!

Dan's observations make a good introduction to Newt Gingrich's op-ed today for The Washington Post, which is ominously titled A Rising Anti-Government Tide. Somehow I don't think Newt is the best person to consult if one is truly bent on breaking free of Governmentarian rule, but I grudgingly concede he keeps his ear to the ground:
A Rising Anti-Government Tide

By Newt Gingrich
The Washington Post
Friday, May 22, 2009

Americans should look carefully at the anti-politician, anti-government mood exhibited in California this week. Just as Proposition 13 and the anti-tax movement of 1978 were the forerunners of the Reagan presidential victory, so the results of Tuesday's vote are a harbinger of things to come.

The repudiation of the California establishment in the series of initiative defeats could hardly have been more decisive. Five taxing and spending measures were rejected by 62.6 to 66.4 percent of the voters. That is a consistent majority of enormous potential. An even larger majority, 73.9 percent, approved the proposition limiting elected officials' salaries when there is a deficit.
This vote is the second great signal that the American people are getting fed up with corrupt politicians, arrogant bureaucrats, greedy interests and incompetent, destructive government.

The elites ridiculed or ignored the first harbinger of rebellion, the recent tea parties. While it will be harder to ignore this massive anti-tax, anti-spending vote, they will attempt to do just that.

Voters in our largest state spoke unambiguously, but politicians and lobbyists in Sacramento are ignoring or rejecting the voters' will, just as they are in Albany and Trenton. The states with huge government machines have basically moved beyond the control of the people. They have become castles of corruption, favoritism and wastefulness. These state governments are run by lobbyists for the various unions through bureaucracies seeking to impose the values of a militant left. Elections have become so rigged by big money and clever incumbents that the process of self-government is threatened.

Sacramento politicians will now reject the voters' call for lower taxes and less spending and embrace the union-lobbyist-bureaucrat machine that is running California into the ground, crippling its economy and cheating residents. This model of high-tax, big-spending inefficiency has already driven thousands of successful Californians out of the state (taking with them an estimated $11 billion in annual tax revenue). The exodus will continue.

Gov. Arnold Schwarzenegger is a smart, tough, charismatic leader who has been forced to submit to policies he knows are ruining California on behalf of interests he knows are cheating the state. His failure to tame the union-lobbyist-bureaucrat machine that owns the legislature is a symptom of just how powerful it is.

Albany is even more corrupt and dysfunctional. The special interests that own the legislators in both parties have been exploiting New York for two generations. They have impoverished the Upstate region to the point where it is a vast zone of no jobs and no opportunities. Their predatory tax and bureaucratic union behavior is beginning to cripple New York City. More and more successful New Yorkers are leaving the state. In the face of multiple crises, Gov. David Paterson has shown himself incapable of carrying out reform.

In other words, the political machines in California and New York are wrecking the states' economies and driving out successful residents. But the machines don't care because all they want to do is own the wreckage.

This system of ruining communities on behalf of interest groups first appeared in Detroit. Bad government, bad politicians and bad policies drove a city that had, in 1950, the highest per capita income of any large American city to No. 62 in per capita income as of 2007. The population has declined from 1.8 million to fewer than 950,000. Recently, 1,800 homes were sold for under $10,000 each. The human cost of bad politics and bad government in Detroit is staggering.

Now President Obama, House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid want to impose on the nation this style of politics in which interest groups, politicians and bureaucracies dominate. Look at their record: a $787 billion stimulus no elected official had read, 8,000 earmarks, an Environmental Protection Agency plan to control the economy through carbon regulations, the government threatening retaliation against those who would protect their property rights against theft in the Chrysler bailout -- again and again, this team is moving toward a government that owns the country rather than a government that is owned by the people.

Watch Sacramento politicians and interest groups work to overrule the people of California. Watch Albany politicians and interest groups continue to undermine the economy of New York. Watch the arrogance of the elites in Washington as they impose their costs and special deals on the American people.

Then look again at the 62 percent-plus majority in California in favor of smaller government and lower taxes.

In the great tradition of political movements rising against arrogant, corrupt elites, there will soon be a party of people rooting out the party of government. This party may be Republican; it may be Democratic; in some states it may be a third party. The politicians have been warned.

Rant on, RBO, rant on!

The biggest occupational hazard for journalists and bloggers who investigate serious issues that are off the mainstream's radar? High blood pressure brought on by shouting to warn while the mainstream media wander around in a fog.

This morning RBO's Procrustes -- a heavy-duty researcher, analyst, and blogger -- let loose about Fox News' slowness to discover the ACORN issue. It's a wonderfully satisfying rant for anyone who's ever gone hoarse shouting inside a glass booth.

Obama math

Cuba, Iran, Venezuela tiny countries compared to the Soviet Union = they deserve the same level of US diplomacy accorded Soviets

Venezuela's economy 600 times smaller than America's = Hugo Chavez not a threat to USA

Throw America under the bus = save my war policy in Afghanistan

While listening to Obama's speech at the National Archives, in which he somehow managed to throw the entire nation under the bus in an effort to appease his political base, it dawned on me that from now on every presidential contender should be tested for math literacy. That would be in addition to submitting to a psychiatric exam.

For Americans who find nothing strange about Obama's figuring with regard to Chavez, stop and think: What is al Qaeda's annual budget?

True, the size of a nation's economy can be a significant factor in its ability to build and maintain a large military. But unless you want to consider begging and thieving legitimate economic enterprises, Pakistan mocks the idea that it takes a large economy to build a nuclear weapon arsenal and maintain large military.

And 9/11 and the rise in power of transnational crime syndicates during the past decade demonstrated that neither a standing army nor a large national budget are prerequisites for mounting successful attacks on a nation.

Luis Fleischman had fun correcting Obama's bizarre math about Chavez but there's nothing laughable about the corrected total he came up with. In his report, The growing Afghanization of Latin America he observed:
[...] Today, Venezuelan airports are being freely used by drug cartels to export drugs to Europe and the U.S.; Chavez and Correa have helped the FARC in the fight against Colombia; Hezbollah cells have increased their fund-raising and other activities in the area with the support of Hugo Chavez; Iran and drug cartels cooperate under the auspices of Chavez; the Maoist Shining Path is reviving its activities in Peru, probably with the help of elements associated with Chavez. In Venezuela Hezbollah and other Islamists are empowered by the regime while Chavez, himself, has made chaos into official policy.

It has been reported that 454 leaders of independent unions have been murdered by parallel official "union" mercenaries. It was also reported that the union leader representing the Toyota workers was murdered after reaching a deal with the Japanese company. The government did not like the deal because an official union leader was able to negotiate a peaceful resolution to a labor conflict. These mercenaries are allegedly criminals recruited in the prisons by the Chavez government.

Criminality has already taken on a life of its own which would be difficult to control even if Chavez were no longer president. High-level criminality could serve drug cartels and radical Islamist groups like Hezbollah, or the FARC. More and more potential seditious, underground and criminal groups are encouraged as these Chavez-type regimes advance in the region.

In other words, the monsters fed by the Chavista alliance now have a life of their own and are likely to survive even after their sponsors are gone.[...]
Put another way: This country is facing one set of problems if it turns out that Barack Obama is very smart but also insane. We'd be facing an entirely different set of problems if he's a stupid man whose only talent is an ear for the speech patterns of intelligent people.

Wednesday, 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

Officials at the above-named organizations have deployed a verbal sleight-of-hand in their communications with the public that is as dangerous as the swine flu virus itself:

The officials have announced that the death rate from swine flu infections is low. They have leapfrogged from this fact to the inference that the virus is not particularly lethal. Would that be with or without the administration of Tamiflu to affected patients?

Now let's stop clowning around. Officials do not know for certain how lethal swine flu is. But it doesn't take a lot of data collection to figure out that if a teenaged healthy patient presents with symptoms of a 103 degree and rising fever, and who is unable to move, and who "looks as if she was run over by a truck," as the father of one swine flu sufferer described his daughter's condition, she might not be long for this world without rapid medical intervention. The student in question started a quick recovery after two doses of Tamiflu.

From this, and from many aspects of the data so far, it is very likely that Tamiflu, and not a wimpy version of a swine flu virus, explains the low death rate so far from H1N1 infections.

That also explains the higher death count in Mexico. Money says that many of the Mexico deaths occurred before doctors in Mexico realized they were dealing with more than an ordinary flu virus and thought to administer Tamiflu or Relenza.

When we drill down into the data we also see that anecdotal reports about some of the deaths in Mexico, and recent research in Hong Kong, suggest that deaths from swine flu among the young and healthy are not so much from the virus itself as from a "cytokine storm" -- a healthy immune system overreacting to an unknown invader with such force that it kills the flu sufferer. (1) I believe it's been scientifically established that the cytokine storm reaction killed many who contracted the 1918 flu virus -- if not, the researchers have made a reasonable guess.

To put all this another way: Health officials should stop putting all their eggs in the vaccine basket, if you'll pardon the expression. Act with intelligence in the face of what might be a mass murderer of the young if not for the limited supply of anti-virals:

  • Alert the public that just because people exposed to swine flu don't get ill, that doesn't mean they're not a carrier for the disease.


  • Hospital emergency rooms should immediately establish separate interview/waiting room areas for people who have a fever. Temperature should be taken even before the interview process starts.


  • Close entire school systems on a regional basis (e.g., one borough) on the first sign of a flu outbreak in a school. In New York City, Mayor Bloomberg should immediately declare a city-wide school holiday for at least eight days. (2-7 days are the best estimate of the virus's incubation time.)


  • Ask close family members of flu sufferers to self-quarantine, after explaining the true seriousness of the situation. I do not recommend at this point that the National Guard be called up to enforce government-imposed quarantines in the USA. That shouldn't be necessary unless Tamiflu stocks run low.


  • It is not possible to close down all airport traffic to and from the United States for eight days, although that would be the most humane thing to do at this point, but in the strongest manner possible urge Americans to forgo all but essential overseas air travel.


  • Officials at the CDC should tell trade, airline, and diplomatic representatives that they're going straight to hell if they continue trying to block rational measures to fight swine flu. And if the officials hear as much as one peep in argument from those parties, they should threaten to read the riot act during nationally televised press conferences.


  • Those items are just to get the ball rolling in the right direction. More later this evening. For now, two closing points:

    Officials should stop yammering that 36,000 people die every year from flu. I understand that's a well-intentioned effort to calm fears about swine flu. However, the statistic is very misleading; all health officials know this, and when the general public discovers this, it's gonna be furious.

    If there is intelligent life in the infectious disease division at the National Institutes of Health, they should step up to the plate and recommend that the US follow Hong Kong's lead in battling the swine flu virus and that as many temperature monitors as possible be immediately installed at ports and airports.

    NIH shouldn't worry about ruffling feathers at the CDC; just tell them, 'Get the hell out of our way.'

    I address the same advice to the Department of Homeland Security.

    Let's move it, ladies and gentlemen; you've lost almost a month to crapping around with data collection.

    1) From a May 11 Bloomberg report:

    "About 56 percent of people who died from flu in Mexico showed signs of a “hyper-immune reaction” according to the health ministry, which didn’t give details."

    That would be the cytokine storm reaction.

    7:30 PM Update
    Email from a reader:

    "My memory is that there are limited Tamiflu stores, not nearly enough for the multiple doeses needed; none for the underclass in the fifth world"

    I believe the reader's memory is correct, although it's not just the underclass in the poorest countries that don't have access to Tamiflu. Reports surfaced early on from WHO sources that there were horrific fights going on about which governnments got how much of the presently available anti-virals. Japan snapped up a huge supply of Tamiflu. Looks as if they're going to need it, if the disease keeps spreading there. The Indian pharmas might play deus ex machina here; days ago WHO talked about getting the patent rights waived and allowing generic versions of Tamiflu to be produced. Somehow I doubt Indian (and Chinese) companies are waiting around for the red tape to be cut.
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    Previous Pundita posts on swine flu

    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
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    This entry is crossposted at RBO.

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    Tuesday, May 19

    Mr President, fire NYC health commissioner Thomas Frieden from his post as CDC director before he even starts to work there

    I had high hopes for Dr Thomas Frieden's tenure as director at the CDC, which is supposed to start in June pending confirmation, after reading about his work in New York City and India to battle tuberculosis epidemics. I'd hoped that he'd modernize the CDC's approach to dealing with highly-infectious disease outbreaks.

    Yet after studying Frieden's muddled approach over the past two weeks to dealing with swine flu in New York I'm almost speechless about the level of incompetence. And he's supposed to be an infectious disease expert.

    Margaret Chan, the present director-general of WHO, was almost run out of Hong Kong on a rail for the same muddled approach she took toward dealing with SARS.

    The argument was that she wasn't really muddled; she was just being a good soldier for Beijing. I find that hard to believe given the extreme lethality of SARS. My guess is that she screwed up because SARS was imported to Hong Kong from the Mainland and so she accepted the same fallacy that's guided CDC actions in the face of the present swine flu epidemic.

    I gave much discussion to the fallacy in my CDC's slow boat from China post. The fallacy translates into the silly idea that once a highly-infectious virus arrives in a country it's no use to deploy measures to prevent more infected people from entering the country. The same reasoning takes quarantine off the table.

    It's looking as if Frieden accepted the same fallacy, unless you want to argue that he was under pressure from Mayor Bloomberg not to institute quarantines. If that's the case, all the more reason not to allow Frieden to run the CDC if he caves into pressure that easily.

    By the way I don't want to hear about John Barry's thesis regarding quarantines in New York City in 1918. We desperately need a biomedical specialist who can think outside the 1918 box and who knows what century this is.

    If we can't find that person, I fear America's response to a modern version of the lethal 1918 virus will parallel our lack of readiness to deal with the 9/11 attack, which was a brilliant application of asymmetrical warfare reflecting an understanding of the modern era in air travel. Oddly enough the swine flu virus has the same understanding, in a manner of speaking.

    As to the situation in New York I won't even bother to direct my advice to Frieden. If there's someone who can chew and walk in New York City's health department: Can you find a quarantine operations manual? If so, OPEN THE MANUAL and FOLLOW INSTRUCTIONS.

    If you can't find a manual, speed dial Hong Kong and ask them to email their copy. They have a manual, because they sure as hell learned their lesson after Margaret Chan.

    And if I hear from New York City, 'Oh it's too late; that's shutting the barn door after the horse is out' -- the screaming and yelling reaching your ears will be coming all the way from Washington, DC.

    Get it straight: a virus is not a horse.

    As you can see I'm not quite speechless; I'll have a lot more to say about this matter later in the week. For now:
    No Guidance on How to Rein in the Flu
    By DONALD G. McNEIL Jr.
    The New York Times
    May 18, 2009

    As schools shut down because of the flu — with a dozen closed in New York and hundreds in Texas and Japan — health officials are asking a question for which there is little guidance, even in pandemic plans: what is the best way to stop an epidemic that spreads mostly in schools rather than in nursing homes?

    Many school officials have shut the doors and had the custodians disinfect the empty buildings.

    But that leaves parents confused and frustrated. Those whose schools remain open may fear that their children are in danger, and those with healthy children whose schools close may feel that officials have overreacted, burdening them with day-care costs and denying their young ones an education.

    Even guidance from the top is ambivalent.

    On May 4, the acting director of the Centers for Disease Control and Prevention, Dr. Richard E. Besser, said “closing schools is not effective” at halting the spread. Previously, the centers had advised schools to shut for up to two weeks if a confirmed case was found.

    On Monday, New York City closed four more Queens schools after outbreaks of flu symptoms, bringing the total to 16 ordered shut since last week. In Texas, hundreds have been closed at various times.

    “There’s no right answer,” Mayor Michael R. Bloomberg said at a news conference. “I’ve asked the question, ‘What would you do, Dr. Frieden, if you wanted to prevent the spread of flu around the entire student population?’ And the answer is, ‘Closing the schools for a month, prohibit all interaction among kids outside of school, and even then there’s no guarantee that you can do that.’ The bottom line is, case-by-case basis is probably the right thing.”

    (Mr. Bloomberg was referring to Dr. Thomas R. Frieden, the city’s health commissioner, who has just been nominated to be chief of the C.D.C.)

    Many parents and teachers have been calling local lawmakers wondering if their schools would be closed, said Eric Gioia, a City Council member from Queens who wants parents to be given the results of flu tests at their local schools and daily attendance figures.

    “The lack of definitive information is causing great stress on families,” Mr. Gioia said. “If a school is safe, then the city needs to not only say it is but give parents all the information they need.”

    Before closing one, Dr. Frieden said, officials look at documented fevers in students and how fast they are increasing. They also call families to see if children are really sick, not just staying home out of fear.

    One thing is clear, infection control experts say: disinfecting closed schools is pointless. Flu viruses are believed to live on objects for perhaps two to eight hours, so a week’s closing will kill them. But when students return, if a few are sick, every cafeteria table, desk, lab beaker, doorknob, bathroom tap and basketball will soon be recontaminated.

    Washing schools “is done for looks,” said Michael Olesen, a Minnesota infection control specialist. “It’s not a rational approach.”

    The C.D.C.’s swine flu Web sitehas infection-control guidelines for many settings: hospitals, nursing homes, day-care centers and even dialysis clinics. But it has nothing specific to the core of this outbreak: schools full of teenagers.

    Teenagers, experts say, are different from the victims of seasonal influenza. The bed-ridden, the very ill and infants can be forced to practice good hygiene, or isolated or sent home if they won’t.

    But teenagers resist tedious advice to wash their hands for 20 seconds, cover every cough with a tissue or sleeve and stay away from other teenagers. If school is closed, they are likely to get together at the park or the mall.

    Keeping sick students out of school is the most crucial step, said Dr. Yoko Furuya, an infection control specialist at NewYork-Presbyterian/Columbia hospital.

    But that can be impractical. And students can shed virus for a day before they are sick.

    “I’d lean toward getting surgical masks on them and trying to get to the end of the school year,” said Mr. Olesen, who is reluctant to see schools shut. “The masks capture all those droplets at the point of release.”

    And how, he was asked, could students be made to do that?

    “I don’t know how, but they make them do other things,” he said.

    Amy D. Nichols, chief of infection control for the University of California at San Francisco Medical Center, said she would like to see “schools just as awash in alcohol hand rubs as hospitals are, so it’s easy and quick to clean one’s hands.”

    Ms. Nichols favors making students disinfect their hands before entering each class, the gym or the cafeteria.

    “In junior high, you want to be like everyone else,” she said. “So schools should have wall-mounted push dispensers. That way it becomes part of the culture of the schools. The more people push the handle, the more everybody else does.”

    She also favors cleaning surfaces as often as is practical, because other risks like antibiotic-resistant bacteria persist longer than flu.

    What to do with sick students whose working parents cannot afford babysitters is another problem.

    Asked if schools could set up cots in a gym for ill students, Mr. Olesen demurred.

    “I don’t know,” he said. “Cots for kids in puberty with their hormones raging? That’s a whole other public health problem.”

    Even if schools make it to summer break, hot weather may slow, but not solve the problem, the C.D.C. said Monday.

    “We’d love to see a decrease in cases, but in the past there have been outbreaks of seasonal influenza even in summer camps,” said Dr. Anne Schuchat, the agency’s interim deputy director for public health.

    Confirming anecdotal observations that this flu concentrates in young people, Dr. Schuchat said preliminary studies of family transmission showed that when one member gets infected, the most likely to follow are those under 18, not parents or grandparents.

    [...]

    Friday, May 15

    Say, whatever happened to that 2007 Senate subcommittee report on CDC fraud, waste, galloping mission creep, and failure to control disease?

    President Obama will announce today that Thomas Frieden, M.D., the New York City health commissioner, is his pick to become the CDC director.

    Frieden has been at his post since 2002. He's an infectious disease specialist who's credited with leading successful battles against tuberculosis epidemics in New York City and India. He has worked for the CDC before and with WHO.

    He seems a very energetic fellow. We'll see if he can get the CDC on track. However, the 2007 subcommittee report (PDF) reveals deeply entrenched problems with the agency. (Thanks to CGardner for alerting me to the report.) Just the report's introduction and table of contents are unsettling reading:
    A review of how an agency tasked with fighting and preventing disease has spent hundreds of millions of tax dollars for failed prevention efforts, international junkets, and lavish facilities, but cannot demonstrate it is controlling disease.

    THE UNITED STATES SENATE
    SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT,
    GOVERNMENT INFORMATION AND INTERNATIONAL SECURITY
    MINORITY OFFICE
    UNDER THE DIRECTION OF SENATOR TOM COBURN
    RANKING MINORITY MEMBER
    JUNE 2007

    [...]
    EXECUTIVE SUMMARY
    I. BACKGROUND

    The Centers for Disease Control and Prevention (CDC)
    • CDC’s History
    • CDC’s Funding

    II. FINDINGS

    CDC Facilities: Lavish Spending or Priority Needs?

    • CDC’s $106 million Thomas R. Harkin Global Communications (and Visitor) Center

    • CDC’s new $109.8 million Arlen Specter Headquarters and Emergency Operations
    Center has $10 million in furniture

    • CDC’s $200,000 fitness center includes $30,000 saunas and rotating light shows

    • CDC’s new Hawaii office announced by Hawaii Senator who oversees CDC funds
    CDC Targets Diseases … Results Still Pending

    CDC’s prevention funding for HIV/AIDS: $5 billion over seven years

    • Of CDC’s $2.6 billion in HIV/AIDS grants, some have no objectives and are “abysmal,” yet funded anyway

    • CDC’s domestic HIV/AIDS program: results not demonstrated

    • CDC-funded events featuring porn stars, transgender beauty pageants, and flirting classes

    • CDC’s $45 million for conferences featuring prostitutes, protests, and beach parties

    • CDC announces plan to eliminate syphilis: five years later rates up overall and 68
    percent among men

    • CDC’s $335 million kid-targeted media campaign to fight obesity: advertising success but health impact unknown

    • CDC addresses serious health issues like land development and bike paths

    • CDC and guns as a “health problem”

    CDC’s Statistic Problems and Fraud

    • CDC revises U.S. obesity deaths by 1,400 percent in nine months

    • CDC Inspector General investigations find over $1 million in fraud in just three cases

    It Pays to be a CDC Employee

    • CDC pays $1.7 million to Hollywood liaison; ex-employee runs liaison shop

    • CDC’s top financial officers take home a quarter of a million dollars in bonuses

    • The revolving door: how a former CDC executive lands CDC contracts worth millions
    for minority-owned companies

    • CDC pays two former employees $250,000 to help build morale

    • HHS Secretary uses CDC’s leased jet for meetings and speeches: CDC defends use

    How CDC Funding is Counterintuitive

    • CDC-funded bar night and manual on how to throw an alcohol party

    • CDC sets bioterrorism results-oriented goals after spending billions

    III. RECOMMENDATIONS
    IV. CONCLUSION
    APPENDIX
    • AIDS Funding Chart

    Thursday, May 14

    H1N1/Swine Flu: Was Cuba's airport blockade an over-reaction to the outbreak?

    Let me put the answer this way:
    Several Pacific island territories were particularly hard-hit [by the 1918 swine flu]. The pandemic reached them from New Zealand, which was too slow to implement measures to prevent ships carrying the flu from leaving its ports.

    From New Zealand [which had a 5% mortality rate] the flu reached Tonga (killing 8% of the population), Nauru (16%) and Fiji (5%, 9000 people).

    Worst affected was Western Samoa, a territory then under New Zealand military administration. A crippling 90% of the population was infected; 30% of adult men, 22% of adult women and 10% of children were killed.

    By contrast, the flu was kept away from American Samoa by a commander who imposed a blockade.
    Any other questions about the Cuba airport blockade?

    Next question: Was Castro right to accuse Mexico of being tardy to issue a flu warning for fear it might have led to the cancellation of President Obama's April visit?

    Castro is factually incorrect if he thinks Calderon's government had identified the swine flu virus prior to Obama's visit. As to whether the government had exerted itself to alert all countries of the outbreak of a 'regular' influenza -- I don't know.

    But I think Castro is asking for an era that's not quite here, if he wants nations to issue a strongly worded flu alert every time the flu strikes. Yet I also think the world changed forever during the past month because of the realization that the outbreak of a new virus was initially camouflaged by a routine influenza.

    Probably Castro became so very angry with Calderon's government when he realized that, given the way the swine flu progressed, it could just as easily have alighted in Cuba from a country other than Mexico. As the Western Samoa example illustrates, an island becomes a death trap when a highly lethal infectious disease breaks out there.

    I think that's why his government sent out teams of doctors to scour Cuba, looking for signs of swine flu, even though they had caught and quarantined the one case that was in the country before the government ordered suspension of flights to and from Mexico.

    Below are links to the big news of the day on the swine flu front, which point to a gathering storm emanating from the poorer countries about how to divide up the swine flu vaccine when it's ready.

    WHO estimates that if the vaccine manufacturers go full tilt, they can still only crank out about one-two billion doses this year. So it's coming down to a very ugly triage situation -- who gets thrown off the lifeboat. The Cuban government's decision to suspend Mexico air traffic is even more reasonable in tight of that grim question. Castro knows that his country would be among the last in line for the first batch of the swine flu vaccine. And that the same would happen if demand for Tamiflu and Relenza exploded around the world.

    To give you some idea of how seriously the swine flu virus is being taken in the developing countries, China has given the green light for Taiwan to attend the upcoming WHO assembly meeting, which will be dominated by discussions of the swine flu pandemic.

    WHO met yesterday to discuss the production of swine flu vaccine. Two reports, one from AP and the other from AFP, portray somewhat contradictory views of what happened at the meeting.

    The AP report conveyed that the decision had already been taken to start production and that only the details had to be worked out.

    The AFP report indicates that WHO ended up the meeting by sitting on the fence. Or else they're easing up on the pace of decisions in order to placate concerns that the manufacture of swine flu vaccine is very problematical at this time:
    WHO puts off decision on swine flu vaccine

    GENEVA (AFP) — The World Health Organisation said Thursday that scientists will need more time to decide whether to start mass production of vaccines against the swine flu virus.

    Acting assistant director-general Keiji Fukuda told journalists there have been "no big decisions" from a meeting of experts on Thursday on an A(H1N1) vaccine.

    He added that more meetings were needed to examine the technical process for manufacturers to ready themselves to go into mass production which will "require several weeks."

    "It's not possible to say that there will be a decision by this date, really it's a painstaking and difficult process," said Fukuda.

    Marie-Paule Kieny, WHO director for vaccine research, said last week that the manufacturers and experts meeting Thursday would decide whether to ask the UN agency to give the go ahead for large-scale manufacturing of a vaccine.

    But Fukuda said production of vaccines against the new virus could disrupt production of seasonal flu vaccines and so needed careful thought.
    It could be that WHO is also trying to head off that gathering storm of fury, or at least delay its onset.

    The storm has been building for a long time; the general perception in the less-rich countries and the poorest ones is that the wealthier nations have always given them the short end of the stick when it comes to which nations have the most access to critical drugs. Whether or not the perception is overblown, it'll set off crises if the swine flu virus begins taking many lives.

    Wednesday, May 13

    H1N1/swine flu: CDC and WHO help unleash a pandemic

    Aside
    I've taken up a new hobby: collecting definitions of "pandemic" that have emerged since swine flu became news. I suspect that as with stopping genocide, the closer officialdom is pushed into battle mode against pandemic, the more the goal posts move ever so slightly as to the meaning of the word. This means, at least as of this minute, that WHO still hasn't raised their pandemic threat level to Pandemic.

    How about if we keep it simple? When a lot of people on a continent or all over the world are getting sick from a human-to-human transmitted disease that can't be contained, that's close enough.
    ****************
    "On April 17, 2009, CDC and the California Department of Public Health determined that two cases of febrile respiratory illness occurring in children who reside in adjacent counties in southern California were caused by infection with a novel influenza A (H1N1) virus."
    -- CDC influenza surveillance report, week ending May 2

    May 1, 2009 - AAAS ScienceInsider:
    Exclusive: Interview With Head of Mexico's Top Swine Flu Lab

    Microbiologist Celia Alpuche heads the laboratory in Mexico that has become ground zero for the country's outbreak of swine flu. Alpuche spoke to Science yesterday from her office at the Instituto de Diagnóstico y Referencia Epidemiológicos (InDRE) in Mexico City.

    Many people have raised questions about whether Mexico could have detected this outbreak earlier and contained it before it spread elsewhere. But as Alpuche explains, InDRE had a confusing situation because the virus surfaced in the middle of flu season--and it may not have originated in Mexico anyway. Alpuche also sets the record straight about why it took several weeks to link the outbreak to the first case with symptoms, a 4-year-old boy from La Gloria in Veracruz state. And she frankly describes the limitations of her own lab.

    InDRE has worked closely with the Public Health Agency of Canada and the U.S. Centers for Disease Control and Prevention (CDC) to identify the virus as the cause of the outbreak, and Mexico continues to collaborate to test samples of suspected cases.

    [...]

    Science: When did you learn of the first two California cases of swine flu that were reported in the MMWR on April 21.

    Alpuche: CDC sent me a preprint. I'm not sure exactly when.

    Science: When were samples sent to Canada and CDC?

    Alpuche: April 21. We asked for help from both at same time. The CDC is my collaborating center in the WHO network. They always help us, doing quality assessment for us, giving us reagents, doing training, transferring technology. But to do shipping for both of them, it was kind of hard. It was a little delayed to get all the permission from the U.S.

    Science: Was your decision to send it to Canada also because U.S. authorities were holding up your samples?

    Alpuche: No, not at all. I sent these samples to the CDC because they are my collaboration center. That's the way to do it. We get all the help we need from the CDC.

    Science: But I think it's important for the United States to learn from this. How long were your samples held up and why?

    Alpuche: It was just 1 day difference. I cannot tell you if this is because it is more difficult to send things from Mexico to the U.S. instead of Canada. To be honest, I cannot explain that.

    Science: I imagine you were frustrated by the delay.

    Alpuche: Yeah, but we knew we were going to get the help that we needed, and we got it. It was just a small difference.

    Science: When did you first hear back from Frank Plummer [head of the National Microbiology Lab at the Public Health Agency of Canada] about your samples?

    Alpuche: We got the preliminary results April 22. Dr. Plummer got the samples at 3:00 in the afternoon, and by midnight he was calling me to say we had influenza A. Some of the samples I sent him, we knew they were influenza A. That week, we started seeing the A's and we started to change our mind about this influenza B prolongation of the seasonal influenza.

    Science: When did you learn that they were positive for a new swine flu virus?

    Alpuche: I first learned that it was swine from Frank Plummer; that was in the afternoon of April 23. And later that night Dr. Nancy Cox [of CDC] in a teleconference we had with Mexican experts, we were discussing this and she gave us the preliminary results that we have some swine strains, the ones that just arrived that day at CDC.

    [...]
    The entire interview is riveting but here I only quoted from a small part of it. If you ask whether it was really an interview or the Third Degree -- well, I doubt AAAS applied thumbscrews but it's a scientific organization that's concerned with science policy. So there are parts of the exchange that read more like a cross-examination than an interview.

    Three days later ScienceInsider published another riveting interview. May 4, 2009:
    ScienceInsider Exclusive: SARS Sleuth Tracks Swine Flu, Attacks WHO

    HONG KONG: Yi Guan has plenty of experience at ground zero of an epidemic. In spring 2003, the virologist at Hong Kong University (HKU) isolated the SARS virus from masked palm civets in a wild animal market in China’s Guangdong Province. When the virus flared up again in late 2003, his team’s recommendation to slaughter all captive civets in the area may have been the key to stopping SARS in its tracks: The virus has not reemerged since.

    Although SARS is his claim to fame, Guan has spent most of his career studying influenza after earning a Ph.D. in swine flu under eminent flu expert Robert Webster of St. Jude Children’s Research Hospital in Memphis, Tennessee. He is currently collaborating with Webster’s group.

    Guan has been highly critical of what he sees as WHO’s slow response to the H1N1 emergency. He took a break from marathon hours in the lab and 3 a.m. conference calls with U.S. colleagues to speak with ScienceInsider.

    —Richard Stone

    Q: Where did WHO go wrong?

    Y.G.: Friday night [24 April], I was in Bombay airport, waiting for a flight back to Hong Kong. They [WHO and CDC] already knew the situation in Mexico. Mexico said they had human-to-human transmission, and MMWR [Morbidity and Mortality Weekly Report] reported three cases in America—these cases were community cases. Already it was an outbreak in the U.S., although it wasn’t severe, it didn’t kill people. I was still optimistic we could contain H1N1. Then nothing happened all weekend.

    Q: So WHO should have raised the alert level sooner?

    Y.G.: Yes! WHO should have gone to level 4 or even level 5 on Friday.

    We missed the golden period to contain the virus. Several hours could be another couple hundred cases. Every second was valuable at that time. We made a huge mistake. From then on it was countdown to the pandemic.

    [...]
    Do you get the feeling it's a good thing he wasn't in the room when Alpuche told the interviewer that a one-day delay was just a small difference?

    On Monday, April 27 at approximately 3:30 PM ET, Reuters reported that an unnamed U.S. official had said that the CDC and probably the U.S. Department of State would announce, later that afternoon, a travel warning about Mexico.

    At approximately 4:25 PM ET on the same day, the news broke that WHO had raised their pandemic alert to 4.

    It seems that WHO (headquartered in Geneva) coordinated their announcement with the U.S. one.

    Just so we're clear on what we're dealing with, here's a quote from a ScienceInsider report on the key role that U.S. Navy researchers played in spotting the new form of swine flu. The report puts the day back to April 16 when the CDC knew that an unusual new flu had appeared in the USA. That is one day earlier than in the CDC report I quoted above:
    Late on the afternoon of 16 April, 5 days before the public first learned about the current outbreak of swine flu, Michele Ginsberg ... chief of community epidemiology for the San Diego County Health & Human Services Agency ... received word from the U.S. Centers for Disease Control and Prevention (CDC) that a 10-year-old boy in San Diego County had tested positive for the rare infection.
    To make extra sure we know what we're dealing with, U.S. News and World Report's May 11 article on swine flu quotes Gordon Dickinson, chief of infectious diseases at the University of Miami Miller School of Medicine and the Miami VA:
    U.S. public health departments are so overwhelmed [with testing for swine flu] Dickinson said, that they are asking facilities not to send samples for testing unless there is a cluster of outbreaks or a particular clinical need.

    "They can't keep up," he said.
    If you're wondering whether a congressional inquiry would help, there's already been one. A House of Representatives panel was convened on May 7:
    The swine flu outbreak revealed gaps in pandemic preparedness, including inconsistent regulations and response practices, witnesses told a House committee Thursday.

    "We discovered that we did not have a system in place to track and report the individual schools that had been ordered to dismiss students due to H1N1," state Superintendent of Public Instruction Jack O'Connell said during an Education and Labor Committee hearing about pandemic readiness in schools and work places.

    "Another issue that certainly needs addressing in order to improve our response to such outbreaks is school nurses."

    [...]

    Representatives from the government and business agencies said pandemic plans put in place in 2006 to respond to the avian flu provided guidelines that helped communities deal with the swine flu virus. However, they said they would continue working to better coordinate responses.[...]
    The panel didn't take the CDC to task for dragging their feet about warning the public and firing up their emergency operations center, but drag their feet they did. They should have issued a travel advisory about Mexico at least as early as April 22, when Canada's government issued theirs, and warned the public in other ways as well.

    I think it's taking time we don't have at this point for Congress to launch a thorough investigation of the CDC's actions because the agency seems to have a lot of problems. Over the years it's taken on a dizzying array of functions, which extend around the globe.

    The worst of the problems might be solved by breaking the agency into a few smaller ones and absorbing some functions into other agencies, but any such solutions couldn't be implemented quickly.

    The United States seems to be catching a break with the swine flu's first pass through North America. Yet if our luck holds, that should be viewed as buying us a couple months to retrench before the bug returns. Retrenching might include placing CDC's infectious diseases threat assessment and emergency response operations under an agency that's dedicated to handling such challenges.

    That could mean moving those national defense-related functions under the authority of a defense agency. Right now all the CDC centers are under the Department of Health and Human Services.

    If anyone has a better suggestion I'm all ears. It's not as if the CDC isn't trying. It's just that their best wasn't good enough this year, when Nature sprang a surprise. So instead of heading off a humanitarian disaster they might have helped create one.

    Notes

    Thanks to CGardner for the link to the ScienceInsider report about the Navy's role in spotting swine flu, which introduced me to the very valuable SI website.

    This post builds on four earlier Pundita ones:

    April 30
    H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world

    May 2
    H1N1 swine flu: WHO circles the wagons in response to criticism they were slow to warn

    May 4
    What Joe Biden knows about the jet-setter swine flu that you don't

    May 11
    Swine flu/H1N1: Your life, riding on the CDC's slow boat from China

    Monday, May 11

    Swine flu/H1N1: Your life, riding on the CDC's slow boat from China

    Introduction

    I wanted to plunge straight into my argument with the Centers for Disease Control and Prevention (CDC) but I decided to first outline my basic position.

    There have been several developments on the swine flu front since I last posted, which produced reactions in many Americans that range from, "Whew! We dodged the bullet!" to "I knew from the start the government was making a mountain out a molehill because, after all, 36,000 Americans die every year from regular flu."

    From where I sit both reactions miss the point, which is that the CDC's approach to crisis management is on par with the state of Louisiana's before Hurricane Katrina struck. And the CDC's approach to intelligence-gathering about emerging disease threats makes the pre-9/11 CIA's intelligence-gathering efforts look cutting edge.

    From top to bottom, the CDC's management of the swine flu outbreak has been an unmitigated disaster. They are so far behind the times, and their crisis management is so completely disorganized, that you don't want to think about how many Americans would be dead today if the Piggy Flu, as one British wit dubbed it, had been an evil genius.

    As for the 36,000 influenza deaths per year, which has been quoted ad nauseam by commentators since the swine flu outbreak in the effort to put the outbreak in context: it turns out that the number is a great illustration of the dictum, "Lies, damned lies, and statistics."

    The CDC has no idea how many deaths there are each year from the flu because the number is a computer-generated guess based on mathematical modeling -- a model that's been used for more than 40 years, and which needs serious updating.

    As the CDC's spokesman, Curtis Allen admitted a few years ago to medical journalist Kelly O'Meara, it's not a "real" number. He told her, "There are a couple problems with determining the number of deaths related to the flu because most people don't die from the influenza...We don't know exactly how many people get the flu each year because it's not a reportable disease and most physicians don't do the test [nasal swab] to indicate whether it's influenza."

    However, using the CDC's own data, O'Meara managed to turn up that, "The greatest number of actual influenza deaths recorded since 1979 were 3,006 in 1981." (1, 2)

    (A big hat tip to Deirdre Imus, writing for The Huffington Post, for digging up O'Meara's reports.)

    Yet the same pesky computer modeling that's greatly overestimated the number of regular flu deaths in the USA is now greatly underestimating the number of swine flu cases and for the same basic reason -- hospitals and physicians are not swabbing every patient who presents with the symptoms of swine flu -- even when the patient is in a region that has shown swine flu infection.

    The CDC is making a guess based on the number of swabs that have been tested and found positive. Yet even with all the will in the world to obtain a fairly accurate count, the CDC and public health officials at the state and local levels would be unable to do so because they were caught flat-footed by the outbreak.

    They simply didn't have the protocols in place for dealing with that kind of emergency. It wasn't until the weekend of May 2-3 that the CDC finally got a testing kit to several localities, including New York City -- which had been a region hard-hit by the new swine flu virus. (3)

    What did New York health officials do before that weekend? They did what health officials in every other U.S. state did: twiddled their thumbs waiting for the CDC laboratory to plow through the mountain of swabs for swine flu cases. That lab was the only place in the country that was equipped to test for the new virus. And it wasn't until May 5 that the CDC got test kits to all 50 states.

    To put this all another way: While the CDC does the noblesse oblige thing for other nations and tests for diseases all over the world, such as hoof-and-mouth disease in Pakistan, citizens of the United States of America and their tax dollars have to make do with a horse-and-buggy version of infectious disease management.

    But all that outrage pales next to the antiquated reasoning that informs the CDC's view of how best to handle a deadly epidemic that's jumped the US border from another country.

    Following the swine flu story has not been easy for me -- and most others, for that matter. Often, news reports seemingly contradict each other, sometimes on an hourly basis or supersede each other at the same rate; there are significant gaps in the timeline of events; and parts of the story are incomprehensible to someone without a degree in a biomedical field.

    Because I was out of my depth in the scientific/medical areas I chose to study the situation from the viewpoint of national defense, which I'd gotten familiar with during my years of closely following the Iraq theater of war and the war on terror in general.

    I focused on news reports about how the Centers for Disease Control and Prevention and other U.S. government agencies were handling an emergency response to the swine flu outbreak.

    I wasn't long into the task before I noticed a glaring contradiction in how officials at the CDC thought about emergency measures for dealing with a highly infectious disease outbreak. It doesn't take a degree in a scientific field, or even extensive knowledge of facts on the ground, to notice a sloppy premise and to argue against it. That's what I began to do in the last post, and that's where I pick up from in this one.
    *****************************
    "One reason for the delay in stronger guidelines is that swine flu caught [CDC] planners off guard; they had anticipated being able to recognize a pandemic overseas, weeks or at least days before it hit the United States." (4)

    In the old days -- the really old days -- a virus that started a pandemic far from home had tremendous character. Clinging to the wings of migrating fowl for days and weeks on end, getting buffeted by high winds and pelted by driving rain and snow, the virus that wanted to see the world had true grit.

    Then, in the eras of globalized ship travel, an adventurous virus had to endure life in the bowels of a floating shack while cooped up for months with a bunch of smelly ill-tempered rats.

    Travel conditions greatly improved for the intrepid viral world traveler with the advent of commercial air travel. These days the pampered virus takes an air-conditioned taxi to the international airport, flounces to a first-class seat, then disembarks a few hours later on the other side of the world, fresh as a daisy.

    Yet planners at the CDC are laboring under the somewhat romantic notion that they have as long as it takes a clipper ship to sail from Old Shanghai before they must leap to defend the USA against a deadly viral outbreak on the far side of the world.

    How did the planners arrive at such an antiquated notion? From the same report I quoted above:
    [T]he official Pandemic Influenza Operation Plan, or O-Plan, of the U.S. Centers for Disease Control and Prevention, is based in large part on a history lesson -- research organized by pediatrician and medical historian Dr. Howard Markel of the University of Michigan. Markel was tapped by the CDC to study what worked and what didn't during the 1918 flu disaster>
    In other words, the CDC's O-Plan is based in large measure on lessons learned from the 1918 outbreak.

    If you say, "B-b-but this isn't 1918" -- Exactement!

    While it is true that those who do not know history are doomed to repeat it, it's also true that those who don't factor present circumstances into their historical analyses can get us all killed.

    Markel's research on the 1918 pandemic actually turned up some excellent advice. He stressed the importance of non-pharmacological interventions or "NPIs," as they're called, such as isolation of infected patients. However, from the viewpoint of dealing with a highly infectious disease, here is the critical difference between 1918 and 2009:

    Today, a superkiller virus from the other side of the world can alight in large numbers on the same day at several U.S. international airports scattered all around the USA -- even before the lethality of the virus has been discovered by a government.

    The key concept here is "appearing at several points at roughly the same time."

    This is a very different concept from "spreading from one point."

    Several days ago CNN showed a computer model of how ten isolated disease cases in California can, through exponential growth of infections, infect the entire country. This happens because each one of those ten people is assumed to infect an average of say, three people, and those infect three more, and pretty soon you need higher math to keep count.

    That's not what happened in the USA with the swine flu virus. Infected people got off airline flights from Mexico at different points around the USA within a short period of each other.

    New York City caught a break because for reasons known only to itself, the swine flu virus that arrived from Mexico with a bunch of private school students seemed to fizzle after clobbering 1,000 New Yorker within a few days. Medical detectives are all over the case. (5)

    But the flu's behavior in New York, and the fact that it seemed relatively benign, tended to mask the critical need to update emergency planning for an era in which a serious disease outbreak can suddenly appear at several different points -- near large population hubs -- within a matter of hours.

    Instead of updating the CDC stodgily clung to a fallacy, which they foisted on every U.S. official who had to comment publicly on the outbreak. On April 27 Janet Napolitano told a reporter:
    "You would close the border if you thought you could contain the spread of disease, but the disease already is in a number of states within the United States."
    Mr Obama echoed her statement. When asked at his April 29 press conference whether he was considering shutting the border with Mexico, he replied:
    "I've consulted with our public health officials extensively on a day-to-day basis, in some cases, an hour-to-hour basis. At this point they have not recommended a border closing. From their perspective it would be akin to closing the barn door after the horses are out, because we already have cases here in the United States."
    Ms Napolitano and Mr Obama were accurately outlining the reasoning that dominates at the CDC.

    The problem is that the reasoning is based on the fallacy that stopping a viral outbreak is the primary goal once a highly infectious disease has arrived in a country. That thinking is dangerously wrong because at that point it's critical that the primary goal be shifted from containment to slowing the rate of infection. Why? I'll let a top CDC consultant, Dr Ira Longini, explain:
    "The name of the game is to slow transmission until a well-matched vaccine can be made and distributed." (6)
    A more precise statement of the goal is simply to buy time:

    Yes, time until a vaccine can be developed, tested and distributed. But also time until health facilities can gear up to deal with an epidemic. And time so that the health facilities, and the society in general, won't be overwhelmed by the lightning-fast spread of an infectious disease.

    This time-buying strategy is particularly vital today in the USA, given that the average of "3" (the "R" number or number of people that one infected person can in turn infect) is based on analysis of the 1918 pandemic in the USA not on the way things are today. (4)

    Not only was the US population much smaller in 1918 and much less densely packed, but the volume of interstate travel and even travel within a city was much smaller. In 1918, many city people in America rarely if ever left their immediate neighborhood.

    And there was no real suburbia, as we have today, from which millions of Americans in the workforce commute round-trip to a major population hub during the work week.

    Also, you didn't have 4,000 flights a day between Mexico and airports all around the USA, and God Knows how many flights between many points in the USA and other areas of the world that are incubators for lethal exotic virus combinations.

    So it's a safe assumption that the average number of people who can be infected by one disease carrier is higher today than it was during 1918.

    More importantly, statistical averages go out the window when the disease enters the USA at several points within a short period. The R number might initially be 3 in Atlanta but in the densely packed mega-city of New York, R could be initially higher -- or vice versa, depending on the number of infected people who alight daily from the nearest airport hub near both cities.

    The planners seem to have discounted the fact that the United States of America takes up much of a big continent. So the thinking about how to slow the speed of disease transmission should have been directed to seeing where the rate of infection could be slowed from region to region of the country.

    In short, the United States isn't a barn and a virus is not a horse.

    So of course it slows the rate of infection to suspend air flights and order a border and ports blockade when the country next door is in the middle of a deadly epidemic. Critically, in the early stage of the epidemic, the rate could vary wildly from region to region of the USA for several days or even weeks or months. The variables would translate into many lives saved if time-buying measures were immediately deployed.

    If it still doesn't make sense to you to deploy draconian measures when a government knows that the measures have no hope of actually stopping the virus, think it through:

    If 5 infected people slip through a border blockade or get past a temperature monitor every day during the outbreak -- if the measures halt 20 infected people every day, that's 20 people a day who've been stopped from infecting an average of 3 additional people each, per day. That's stopping those people who in turn would infect 3 more, and those who would infect 3 more -- and pretty soon you need higher math to keep count.

    In short you're racing to brake the speed of the infection transmission in many regions around a vast tract of land, and for this you do everything you can think of:

  • Temporary border blockade


  • Quarantine of a suspected cluster of infected people


  • Temporary suspension of airline flights to and from a country that has a widespread outbreak of the highly infectious disease


  • Installment of "temperature-taking" thermal imaging machines at all ports -- I repeat "ports" -- in conjunction with tactics to offset the limitations of the machine's camera


  • Temporarily stopping all but essential off-loading at ports from a country with a highly infectious disease outbreak


  • "Social distancing;" e.g., urging the population to stay away from situations that have crowds of people, urging them to avoid close quarters with non-family members, etc.


  • PSAs hurled within hours onto every major media outlet to warn people to pay scrupulous attention to personal hygiene, such as hand-washing.


  • Again, no one of these tactics or a combination will stop a highly infectious disease from spreading once it arrives in a country. But if they can just slow the rate of infection by a fraction, while that won't stop deaths from a killer disease epidemic it would translate into thousands or even millions of human lives saved -- and a nation's social fabric hanging together during a deadly pandemic.

    Realize that the most drastic measures; e.g. blockade, would not need to be lengthy. How long? Until officials got a handle on the estimated length of the virus' incubation time.

    Yet what's most striking about the pattern of swine flu infection is that it didn't spread upward and outward from the U.S.-Mexico border region. The early pattern of the swine flu outbreak in the USA points to airline travel as the fast disseminator of the virus, not the Mexico-U.S. cross-border vehicular and foot traffic.

    It could turn out that some infected truckers who were heading from Mexico to various points in the USA or Canada helped spread the disease at pit stops across the country. But from what the numbers were saying up to May 5 (the date of the report I'm referencing) there's not much infection in the U.S. border states in relation to other states that have seen outbreaks. (7) And it's the early data on this phenomenon that count most.

    With three possible exceptions, which I'll discuss in my next post, virtually all the swine flu cases in the USA represent infected people who recently arrived from Mexico by plane, who were infected by contact with disembarked infected passengers from Mexico, and who in turn passed the infection to others. (6)

    ************************
    May 12, 12:40 PM ET Update
    I'm going to interrupt myself here. I've just realized there's a glaring contradiction in my reasoning. I note in this post that swine flu test kits didn't arrive in all the states until May 5. And even if the border states were among those that received kits as early as the May 2-3 weekend, that doesn't necessarily mean that the test results show up in the numbers quoted in the report I reference.

    And the numbers in the report don't necessarily mean that the CDC had been able to test their own backlog of swabs from the border states by May 5.

    Yet despite these considerations I assert "it's the early data on this phenomenon that count most."

    Yeah, well, that's true in principle. But in this case the "early data" aren't necessarily a good picture, or even a good estimate, of the early number of swine flu infections in the border states. Duh, Pundita.

    So, with regard to my assertion in the third paragraph above, I think I should hedge by substituting "a great many" for "virtually all."

    This chart, dated May 11, 11:00 AM, shows the number of confirmed swine flu infections by state. Here are the numbers for the four border states:

    AZ 182, CA 191, NM 30, TX 179

    The question is whether those numbers reflect recent cases or clearing of a backlog.

    That's why I've inserted this correction rather than simply editing the paragraphs; the original writing illustrates the difficulty in this situation of arriving at valid conclusions when reasoning from very incomplete and imprecise data.

    Now to continue:
    ************************

    Although it was known early in the U.S. outbreak that initially the biggest known cluster of infections came from a school trip to Mexico by New York students, there was nothing more than a passive effort at U.S. airports to screen incoming passengers from Mexico. (E.g., airline personnel eyeballing arrivals and asking them how they were feeling if they didn't look well.)

    And there was no action to suspend incoming or outbound flights to Mexico. This, despite the fact that officials knew that a highly infectious disease had reached epidemic stage in Mexico's capital city.

    When did they know? The answer is still speculative; I've touched on the issue in earlier posts and in the next post I'll grapple with it again. However, from all I've read, it can be argued that CDC officials were tardy by several days about alerting the U.S. public, and that their refusal to recommend suspending flights to and from Mexico explains how swine flu appeared in the majority of U.S. states within less than two weeks.

    Yet again and again the negligence was rationalized with the argument that because the disease had already entered the USA, there was no use taking measures to attempt to prevent its fast encroachment from Mexico.

    What if the disease had been a superkiller and stayed as highly infectious as it did when it first struck in Queens, New York? How many American dead would we be looking at by this time if we multiply the number of inbound infected airline passengers by the number of people they infected and keep multiplying from there?

    If Ms Napolitano would tell me that of course the U.S. government would have suspended flights from Mexico if the virus was highly lethal -- according to CDC's guidelines that would be a useless gesture. Ms Napolitano and the CDC can't have it both ways: talk gibberish when it suits them then fall back on reason when it doesn't.

    It's not the lethality of the virus that's at issue here. Yes or no: is it good practice to attempt to slow the rate of infection from a highly infectious disease?

    If yes, then: Does suspending air flights from an infected country help slow the rate of infection?

    If yes, I believe this is where I get to say "Checkmate."

    Given that my argument is hard to answer why do officials at the CDC refuse to consider it? Because they've continued to listen to Dr Longini and other members of his biostatistician tribe who advise the CDC.

    Longini and his colleagues have recently made public declarations that back them so far away from their assertion that an infection rate should be slowed at the start that they're making as much sense as Wonderland's Red Queen.

    Why would several mathematicians start talking gibberish about such a serious issue? I don't know. But TIME magazine's April 30 report, Why Border Controls Can't Keep Out the Flu Virus could be subtitled, "Lies, damned lies, and economics."
    "Once the virus has spread beyond its initial focus, travel restrictions just aren't effective," says Ira Longini ... With 4,000 flights a day between the U.S. and Mexico, "it's not worth the social disruption it would cause."

    That's not to say that very strict restrictions wouldn't have some effect on slowing the virus. In a 2006 study, Harvard epidemiologists John Brownstein and Kenneth Mandl examined the effect of the sharp reduction in air travel after the Sept. 11 attacks on that year's flu season. They found that the initial flight ban and general decline in air travel in the weeks after delayed the onset of the flu season but did little to reduce the overall number of infections and deaths that year.

    The data matches computer models run by biostatisticians like Longini, who found that even the strictest limits on air travel would only slow the start of a flu pandemic, not stop its spread. But, again, while that strategy may benefit countries that have not yet been infected with swine flu, there's still no way to know when it would be safe to lift those restrictions.

    "There's no question that air travel spreads the flu," says Mandl, a physician and researcher at the informatics program at Children's Hospital Boston and an associate professor at Harvard Medical School. "But the impact of limiting flights at this point is difficult compared to the downside of the economic impact."
    The observations overlook that no special measures were needed or taken in the USA against the 2001-2002 flu, which was seen as common. Yet a "delay in onset" would give health professionals a huge edge in preparing to deal with a superkiller virus.

    What I find particularly outrageous about the economic and "social disruption" arguments is their almost inhuman cruelty. I am haunted by a news photograph of an exhausted Mexican mother and her two daughters, slumped in exhaustion against her shoulders as they waited to be examined at a health clinic in Mexico. They were all wearing face masks.

    Here's a news flash: all decent people everywhere want to live. Parents don't want to see their children die before their eyes of an infectious disease.

    What the CDC and their scientific and medical advisors refuse to consider is that a failure to suspend cross-border and air travel traffic means that the infections are not one-way. Americans infected with swine flu who travel to that country can infect Mexicans -- in a country that is more poorly equipped than the USA to face a killer virus.

    So I don't want to hear about social and economic disruption. Memo to all concerned U.S. and Mexican agencies: Coordinate and do something called contingency planning. This, so that disruptions from a temporary border blockade and suspension of flights between Mexico and the USA are not catastrophic for people on either side of the border.

    If you don't know how to do contingency planning, if the concept is foreign to you, talk to major corporations and defense departments to find people who are experts in business and military logistics.

    Face it; you were lucky. If the death count from swine flu would have been high, all of you would have been straight on your way to Hell, where I sincerely hope you would have spent the rest of eternity sharing a slow boat from China with a particularly mean virus.

    1) INSIGHT MAGAZINE via Sci-Tech Archive: Flu Secrets You Should Know; Kelly Patricia O Meara; June, 2004

    2) Moms Against Mercury: A Shot in the Dark - Part 1; Kelly O'Meara; 2004?

    3) The New York Times: New York’s Lab (Don’t Ask Where It Is) Readies Its Own Tests for the New Strain; Anemona Hartocollis; May 3, 2009

    4) CNN: Scientists dig for lessons from past pandemics; Caleb Hellerman; April 30, 2009

    5) The Associated Press: Medical detectives probe flu virus spread in NYC; David B. Caruso; May 4, 2009

    6) CNN: Expert on flu's spread says new strain here to stay; Patrick Oppmann; April 28, 2009

    7) Phoenix [Arizona] Business Journal: Border states show no swine flu spike; Mike Sunnucks; May 5, 2009)
    **********************************
    This entry is crossposted at RBO. Thanks much to Procrustes for proofreading.

    Monday, May 4

    What Joe Biden knows about the jet-setter swine flu that you don't

    I want to start by noting that when I warn on the matter of infectious disease, I do so only with good cause. That's because Pundita is the anti-scaremonger blog. It's a long story but in one sentence: In 2005, with the help of several readers and a Chinese translator, I ran a panic to ground that'd broken out in East Asia over a mysterious illness. The panic was threatening to waft to Europe and the USA.

    I meant to put a file on the sidebar with all the posts about the mystery illness; I suppose I kept forgetting because after a month of thinking about China's pigs I never wanted to see the word "pig" again -- or the word "China," for that matter.

    I exerted myself to locate the source of the most sensational rumors about the mystery illness because I knew that few things are more dangerous than to sound a false alarm about a superkiller pandemic. "Fool me, fool me twice." It's the same problem that hurricane forecasters face every year; if the big threat is a dud, many people won't react to the next warning a killer storm is headed their way.

    However, after Hurricane Katrina, governors in U.S. states that were at highest risk during hurricane season finally confronted the reality that this was no longer 1902; large numbers of Americans were now living in coastal regions and key industries were perched on the shores.

    The governors realized they should worry less about angering constituents and the local Chamber of Commerce, and focus on getting across that from now on, obeying evacuation orders during hurricane season should be considered a way of life. If that caused great inconvenience and unnecessary loss of income when the storm wasn't as severe as predicted -- deal with it by learning to do contingency planning.

    This updated approach to the threat that hurricanes pose in this era has not yet been applied by the nation's public health regime to managing government responses to the viral version of hurricane season.

    To give you a small idea of how antiquated the regime's thinking is, it would come as a surprise to Americans to learn that the United States has seen several pandemics during the past decade. This isn't generally known because the pandemics are referred to by U.S. public health officials in somewhat Orwellian terms as "flu season."

    If it's hard to feature that the annual influenza outbreak in the USA is often a pandemic, that's due to confusion about term. A pandemic doesn't refer to the severity of an infectious disease or the number of people stricken; it simply refers to the amount of territory affected by the outbreak. So there are country-wide pandemics and continent-wide pandemics, and global ones.

    Because it's hard for a microbe to create a pandemic unless it's aerosolized
    (transmitted by airborne means), pandemics are associated with such means of transmitting viral infections even though AIDS, which is not aerosolized, is considered a pandemic infection.

    But again it's the amount of ground covered that defines a pandemic.

    As to why the U.S. public health regime doesn't call a spade a spade every year -- if I wanted to be mean I could say it's because they've taken what could be considered an actuarial view of the number of deaths associated with annual influenza outbreaks. Yet it's not that cut-and-dried. A modern society can't function if schools, government, and industry have to shut down every time an influenza season shapes up to be a pandemic.

    So, the bottom line is that roughly 30,000 Americans die every year from influenza, many of them elderly, and private and public work sectors are affected by large numbers of absences during an influenza pandemic. But the thinking for many decades has been that the measures needed to drive down the death rate from an influenza pandemic, which includes quarantine, are unacceptable and encroaching on people's freedoms.

    However, the federal public health regime, which advises government administrations at all levels in the USA, has their head stuck in the mid-1950s when it comes to dealing with influenza outbreaks. The outmoded view is very dangerous given the realities in this era. And it's prevented the regime from making a distinction between how to treat the present swine flu outbreak and a routine influenza.

    Plan A -- for the routine outbreaks -- has been to urge Americans to get a yearly flu shot. Because there is no vaccine available for swine flu, Plan B has boiled down to telling Americans to cover their mouth when they cough and sneeze into their sleeve.

    Joe Biden took one look at Plan B and blurted: And stay out of crowded closed environments.

    He could have put it more diplomatically but his advice is good. I can only imagine what he advised behind closed doors at the White House. Money says that if he'd still been a U.S. Senator he would have been leading calls to suspend airline flights between the U.S. and Mexico, temporarily suspend cross-border vehicular traffic, and quarantine crews arriving at U.S. ports from Mexico.

    What does Joe Biden know that the general public doesn't about the swine flu outbreak? He knows what everyone in government knows by now:

  • There's not enough time before the onset of flu season in the U.S. to develop and distribute a safe vaccine for swine flu. The emphasis is on safe. If the vaccine is rushed into production without adequate testing, the vaccine can be dangerous. Dr Henry Miller stressed that angle during his conversation on last night's John Batchelor Show.


  • The swine flu is not exactly 'tapering off' in Mexico, as the Mexican authorities are announcing. It's hopping a plane or hitchhiking to the Southern Hemisphere because the weather is getting hot and humid in Mexico and cool, drier temperatures are coming to the Southern Hemisphere. Flu bugs of all kinds hate hot and humid weather.(1)


  • The swine flu is not only a new bug, it's also very unusual -- unusual since science has been keeping a record of virus types. So far it doesn't appear to be particularly deadly but it's already shown a tendency to mutate more quickly and broadly across species than the average flu bug. That's what is worrisome.


  • The estimates, which are based on early studies of the genes it picked up from other viruses, are that the new bug is less than six months old -- maybe three or four months. Yet at its tender age it's already picked up genes from human, bird and swine influenzas. So it's a toss of the coin as to how many times it'll mutate during its jaunt around the Southern Hemisphere, and whether a particular mutation will be highly lethal or even less lethal than its present form. Yet because it's already aerosolized, a very lethal form could touch off a superkiller global pandemic.


  • The particular problem with the Southern Hemisphere in this case is that it has a lot of open-air farms that keep both chicken and pigs, often very poor sanitation and health care facilities, and so on. All that ups the chance that the swine flu bug will be in hog heaven down south.


  • By the time the swine flu bug returns this fall to the Northern Hemisphere in its mutated form -- even if a safe vaccine is ready, it'll only give limited protection against the mutation. If the mutation is particularly deadly to humans -- then, how to put this.....unless the public health regime improves on Plan B, we could be facing a high human death toll within a very short period, and with all the dislocations in society that would go with it.


  • A glimmer of hope is that people in the Northern Hemisphere who were born before 1957 were repeatedly exposed to swine influenzas. That might -- I repeat might-- explain why the swine flu outbreak in Mexico didn't seem to be as hard on older people.


  • The CDC is dealing with such a big backlog of samples to process that the extent of the infection in the U.S. and its demographics are still not known. But if the pattern of skipping over the elderly holds in the USA, then it could be that our society has caught a break. The bad news is that if the mutation is highly lethal when it returns this fall, it will strike down many Americans in the prime of their life -- those too young to have been exposed to the earlier swine influenzas.


  • That's what Joe Biden knows.

    So this is not the time to ask whether to panic or shrug; those questions went out the window a week ago.

    This is the time to realize that there's a storm out at sea and that our nation has five months to prepare, if it hits our shores. Adequate preparation can't go forward until our public health regime updates their thinking about the way that influenzas act in today's era.

    To gauge how far behind the times the thinking is, consider the language used by officials last week to describe the progress of the swine flu virus. They repeatedly spoke of the virus as "spreading" around the world.

    This virus has not "spread" around the world. This virus has alighted around the world. It's alighted from jet planes. That's how it managed to create a global pandemic in little more than a week, and with a very low number of infected people.

    The last time I checked Wikipedia's chart, the bug's presence is suspected in more than 70 countries on all continents except Antarctica. The number of confirmed countries is much smaller; WHO's latest confirmation is 21 countries. But every laboratory processing the samples is dealing with a backlog of cases. So we definitely have a global pandemic on our hands, and WHO will get around to confirming that in another day or two.

    Yet there are huge differences between the jet-setter viruses of today and the ones who used air travel in the early decades of transnational commercial air travel:

    The earliest transnational commercial jet passengers were mostly from developed countries and the majority traveled to other developed countries, which have modern public health facilities and sanitation, and which have fewer of the rural conditions that are laboratories for influenzas. And the volume of transnational air travel was small.

    Today there is a huge volume of air travel between the developed and less-developed countries, and which goes both ways. And the country that has a very high volume of international flights from around the globe -- the USA -- shares a southern border and a large daily volume of cross-border vehicular traffic with a country -- Mexico -- that is a chaotic mix of first-, second-, and third-world living conditions.

    The globalized aspect of the swine flu bug -- it has genes from both a 'Eurasian' and North American virus -- means that the index case (the first case of a person infected with the virus) may never be found. The person could have flown into Mexico from somewhere in Eurasia, or driven across the border to Mexico from the southwestern USA, or arisen in Mexico or even further south.

    What is known is that humanity's famous luck has been running on fumes since the H5N1 type of bird flu made its appearance; mercifully, it's not in aerosolized form but that could change at any second if it hooks up with the right human, pig, or bird flu genes.

    If you say, 'First 9/11, then Katrina, then the financial meltdown; I can't take any more this decade,' all those events are just different statements of the same problem.

    The new century arrived right on time with globalized asymmetric warfare and globalized banking but monitoring and crisis-management systems weren't in place to deal with them. That's because the systems were geared to a different set of conditions in an earlier era. The same has happened with the emerging threat from highly infectious lethal diseases that daily travel in high volume around the globe as quickly as a jumbo jet.

    And just as with the outbreak of global terrorism starting in 2001, and the 2008 global financial meltdown, there have been warning signs that the public health regimes in countries around the world were living in the past.

    That means it's time to update our thinking about how to deal with today's jet-setting viruses.

    In the next post I'll talk about what I think is the number one dangerous fallacy U.S. public officials are clinging to, and which they've passed along to President Barack Obama and his Cabinet. If the fallacy can be dislodged from the public health regime, then we can mount an intelligent, humane defense against the worst that a superkiller virus could throw at us.

    1) A big thanks to John Batchelor for pointing all that out during his show last night.
    ****************
    This entry is crossposted at RBO and Uppity Woman.

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