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May 10

The Explainer: Pandemic pandemonium

You’ve been following the headlines, and perhaps, pardon the pun, breathing a sigh of relief that the H1N1 Influenza or swine flu, hasn’t turned into some sort of real-life disaster movie.

But there’s a reason public health officials are saying it’s better to be safe than sorry; and that has to do with a flu epidemic in 1918 and warnings it could happen again.

So tonight, a crash course in Influenza, then and now. I’m Manolo Quezon. The Explainer.

 

I. Consider the pig

 

We’ve had swine flu scares before. As this Wired Magazine story reminds us, back in 1976, the US government got alarmed over the death of a soldier and undertook a national effort to immunize people against swine flu.

All varieties of influenza or the flu, are viruses. And here’s a nice little animation on how viruses work:

A virus is sort of like a genetic Xerox machine: it’s not alive, but it has genetic information it reproduces by invading healthy cells and turning them into virus factories.

And just like the way the same image, when Xeroxed over and over again can start being blurry and ending up unrecognizable, viruses mutate all the time.

If you visit the Global Disease Health Map online, you’ll see all sorts of illnesses, including viral diseases, popping up and affecting people everywhere all the time.

Since April, the latest flavor of influenza virus to gain global attention is a variety of Influenza A virus known as H1N1. This is what’s been clogging the headlines for weeks now.

Since it was first reported, information has steadily increased, and you can visit sites like Flu Tracker which puts together the latest news and statistics on where confirmed cases of H1N1 Influenza have been reported.

Chances are, you’ve been spooked at how quickly cases were reported around the world; and while, so far, the actual deaths have been relatively few, there’s another spooky aspect to the outbreak. And it’s that the influenza came from pigs –and involves a creepy mixture of human, pig, and bird flus.

Now a brief word on the “vessel” in which the spooky combination of human, swine, and bird flus seem to have mixed: the pig. Also in the same year (2006), as the Harvard study, a marvelous article appeared in Harper’s Magazine titled Swine of the times: The making of the modern pig by Nathanael Johnson. It tells the story of modern breeding and farming methods for commercial pork in the United States, and the dangers that have arisen from these practices: briefly, unhappy, unhealthy pigs too susceptible to disease because too genetically uniform and raised by means of bombardments with antibiotics.

In a Wall Street Journal article titled “Understanding the Swine Flu,” Henry I. Miller pointed out that when people live and work literally check-by-jowl with farm animals, the mixing and mutation of viruses is a risk we increasingly have to confront. Canada recently reported a case where an unfortunate pig got H1N1 flu from a human who’d recently visited Mexico!

As he puts it,

Unfortunately, conditions in many countries are conducive to the emergence of such new infectious agents, especially flu viruses, which mutate rapidly and inventively. Intensive animal husbandry procedures that place poultry and swine in close proximity to humans, combined with unsanitary conditions, poverty and grossly inadequate public-health infrastructure of all kinds — all of which exist in Mexico, as well as much of Asia and Africa — make it unlikely that a pandemic can be prevented or contained at the source.

Here’s how it happens, in the case of the Influenza A type of virus. What takes place is an “antigen shift.” Let’s watch.

Now the H1N1 merry mix up of swine, bird, and human influenza occurred in Mexico and as the blog of Daniel Hernandez detailed, that country had to basically shut down all large-scale opportunities for human contact.

In Mexico City, the Catholic Church brought out the heavy ammunition:

Later in the day, an image of Christ on the cross — known as the “Lord of Health” — was removed from its spot in the cathedral for the first time since 1850 and carried in a procession around central Mexico City. The “Cristo,” as the image is known, has been credited with past miracles, including intervention in an 1850 cholera outbreak.

Another country with which Mexico shares historic ties, is, of course, our own. The Philippines and past influenza pandemics, when we return.

 

II. Waves of epidemics

 

In front of the Manila Cathedral, the statue of the Spanish King Carlos IV pays tribute to his sending smallpox vaccines to colonies like the Philippines, in 1802. We’re no stranger to epidemics, and neither is the world.

The World Health Organization lists three pandemics during the 20th Century: “Spanish influenza” in 1918, “Asian influenza” in 1957, and “Hong Kong influenza” in 1968 but the Mother of All Outbreaks was the 1918 pandemic.

Back in 2006, the Harvard School of Public Health warned Recurrence of a Flu Pandemic Similar to Infamous 1918 Flu Could Kill 62 Million. The article adds an additional insight into the Philippine fatalities in 1918. Let me read you part of it:

The disparities between the developed and developing worlds during this period are striking. For example, in Denmark 0.2 percent of the population succumbed to the flu. In the United States, that figure is 0.3 percent (based on data from 24 states). In the Philippines, the mortality rate was 2.8 percent, in the Bombay region of India, 6.2 percent, and in central India, 7.8 percent, which was the highest rate of the countries and regions analyzed. According to this data then, from Denmark to central India, death rates from the 1918-1920 flu pandemic varied more than 39-fold.

Influenza 1918: The American Experience has this animated graphic of the spread of the flu in the United States, where the pandemic seems to have begun (it ended up being called the “Spanish flu” because Spain was the first and most open to report about the pandemic).

In a time before commercial air travel, see how quickly the influenza spread from September 14 to October 5, 1918…

The flu then traveled the world, in waves. This rather weird Wikipedia map traces the various courses the virus traveled.

The Harvard article predicting 60 plus million deaths was meant to herald the publication of Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918—20 pandemic: a quantitative analysis, which is freely available, in full, online. But let’s zero in on the 1918 Pandemic and us.

The fascinating book Colonial Pathologies by Warwick Anderson mentions the 1918 flu pandemic. First, though, this extract concerning the at times heavy-handed efforts of the Americans in their campaigns against rinderpest, malaria, tuberculosis, leprosy, and cholera.

He reproduces some extracts from an outraged letter by Trinidad H. Pardo de Tavera (himself a physician, and a member of the Philippine Commission) to Governor-General William Howard Taft:

…the people fear the Board of Heath a great deal more than they fear the epidemic. The sanitary inspectors, white, brown, black, civil and military have committed and still commit all kinds of abuses… [there are complaints] against the barbarities of the health agents… [In Pasig, the provincial treasurer] set fire to a house where a victim of the cholera had died and the flames extended to two neighboring houses…. [while the provincial inspector] went about with a gun on his shoulder in order to intimidate the people in order to make them obey sanitary laws…

Anderson writes that American public health officials were often mistrustful of Filipinos and skeptical of the capacity of Filipinos to undertake public health, with every possible shortcoming being used as proof of the incapacity of Filipinos to govern themselves:

[Public health director] Hesier and most of his compatriots continued to find in the failures to enforce smallpox vaccination, the recurrence of cholera, and a rising death rate in the archipelago evidence of the unreadiness for office of the Filipinos they had trained. American papers unsympathetic to the Democratic administration declared that “the full harvest of the ‘new era’ is now in the reaping in the Philippines.” “The Filipinization wind,” warned the New York Herald, had caused the incidence of plague to “jump” in the islands. Even the increasingly Filipinized health service conceded that in Manila the mortality rate for each one thousand inhabitants -42.28 in 1903, at the end of the war, but as low as 24.48 in 1913- had risen in 1918 to 46.33, and in 1919 was 27.55. To Heiser this was a clear indictment of Filipino management. But Dr. Vicente de Jesus, the acting director of public health, had another explanation: the influenza pandemic of 1918 had exacted a heavy toll in lives and caused “a weakened organic resistance” to other diseases among the population.

 

Concerning the Philippines, here’s the relevant passage in America’s forgotten pandemic by Alfred W. Crosby:

The flu morbidity and mortality statistics of the Philippine Islands, which had a population of 9 to 10.5 million, depending on which authority you consult, are undependable. Something like 40 percent of Filipinos contracted the disease, and 70,000-90,000 died. By even the most conservative estimate, the pandemic killed 2 percent of those it made ill. In many villages in the worst days there weren’t enough well people to bury the dead. The pandemic seems to have wreaked the worst damage in the remote areas, such as in Cotobato province in Mindanao, where 95 percent fell ill.

 

In Crosby’s book, he says that the worst-affected populations in the world were those in the aboriginal populations of the small Pacific islands. For example, The 1918 flu pandemic in New Zealand History online; says Maoris were heavily affected by the influenza epidemic.

Our nearly forgotten pandemic by Emmy Fitri and Arie Rukmantara, details Indonesia’s 1918 flu pandemic experience:

Around 1.5 million people died in Dutch East Indies, which was then home to just some 30 million people.

The first case was reported on the east coast of Sumatra. By July 1918, it had spread to Java and Kalimantan before reaching Bali and Sulawesi. It then reached the eastern part of the archipelago in Maluku and Timor.

It seemed to die down for several weeks, but soon reemerged.

The second wave came in October 1918 and was more widespread. Like the pandemic in the US and Europe, the second wave brought the most deaths.

 

See 1918 pandemic in Polynesia and Fiji in the blog Grassroots Science for additional reports on how the Second Wave of the Influenza caused the most fatalities

John Keegan, in his book, The First Word War, mentions that the last German offensive during World War I was affected by the Flu pandemic of 1918.

Thousands of malnourished German soldiers came down with the flu…

Contributing to the failure of that offensive, which led Generals like Field Marshal Paul von Hindenburg deciding to throw in the towel;

And marking the collapse of the German Empire.

And  so, as John M. Barry, in a recent New York Times commentary asked, it’s important to bear in mind that the first outbreak of a new flu virus is often mild, but that there are subsequent waves that could get more virulent.

 

As he says,

In all four instances [1889, 1918, 1957 and 1968], the gap between the time the virus was first recognized and a second, more dangerous wave swelled was about six months. It will take a minimum of four months to produce vaccine in any volume, possibly longer, and much longer than that to produce enough vaccine to protect most Americans. The race has begun

 

There are also political effects from an epidemic, as governments rush to control panic and marshal resources. In Slate Magazine, a commentary by John Ackerman suggested the President of Mexico may have used the crisis to gather power, even unconstitutionally, into his own hands.

Whatever unfolds, information is your best weapon. There are many sources for scientific information at your fingertips, like the American Center for Disease Control in Atlanta, Georgia.

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