Pondering a pandemic

(above, screen cap of Heathmap: Global disease alert map)

“Containment is not a feasible operation,” the World Health Organization said, as it raised the pandemic level from 3 to 4 (see WHO warns: No region safe). 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.

For updates and for local color on the goings-on in Mexico City, check out Intersections, the blog of Daniel Hernandez:

On Monday authorities here canceled school across the country and elevated the number of suspected swine flu fatalities to 149. The ‘suspected’ there is important. Keep in mind Mexico is not yet equipped to test for and identify the virus. The number could rise, or just as well, it could fall. Also, more than 1,600 people have been treated for swine flu, but the majority of those have been released and sent home. So even if you do catch swine flu, it’s more likely you’d recover and live than it is that you’d die from it.

Also, in case you were wondering, it is still perfectly OK to eat pork. (I mean if that’s your thing.)
Yes, the swine flu could mutate and become more dangerous. It could spread farther and further. Things could change at any moment. But again, as I argue today, what’s more worrisome is the corrosive and contagious quality of the fear, not the flu. And frankly the economic impact of this outbreak has the potential to be even more painful and long-lasting for all of us.

The progression of the swine flu doesn’t seem to have reached exponential levels, but developments are enough to make things trackable day-by-day. Last night, if you consult H1N1 Swine Flu Google Maps, the result would have been this (purple balloons are confirmed cases; pink are probable cases; yellow, disproven cases):

swineflue google map

Today, as I’m writing this, here’s the map, showing the newly-confirmed cases in Europe:

swineflu google map

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 (see also History of pandemics). Recent articles (see Flu in Mexico City May Be Next Pandemic: Firsthand Account of 1918 and 1957 for example; more can be found in the PanFlu Storybook) haven taken to putting the present, and past, outbreaks in the context of the Mother of All Outbreaks: the 1918 pandemic.

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):


The flu then traveled the world, in waves.

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.

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:

For many decades, published epidemiological literature assumed that mortality rates from the 1918-20 pandemic were distributed fairly equally. A simple population count from that period would lead to the conclusion that about 20 percent of all fatalities occurred in the developed world. “But when you look at the data,” said Murray, “that number shrinks to about three or four percent.”

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.

The researchers then took the relationship observed in 1918 between per capita income and mortality and extrapolated it to 2004 population data. After adjusting for global income and population changes, as well as changes in age structures within different populations, the research team estimated that if a similarly virulent strain of flu virus were to strike today, about 62 million people worldwide would die.

The article above 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.

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.

Returning, briefly, to Crosby’s book, he says that the worst-affected populations in the world were those in the aboriginal populations of the small Pacific islands. See 1918 pandemic in Polynesia and Fiji in the blog Grassroots Science; and also, The 1918 flu pandemic in New Zealand History online; and finally, Our nearly forgotten pandemic by Emmy Fitri and Arie Rukmantara, which 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. These deaths were recorded in the Dutch Kolonial Verslaag (Colonial Journal).

Some of Brown’s reports show the horror of the pandemic situation. In Southeast Sulawesi, a Catholic missionary was quoted as saying that “deaths are everywhere”. According to the report, in one Sulawesi village, 177 of its 900 people died in a period of just three weeks.

In Tana Toraja, 10 percent of the population reportedly died from the flu. Meanwhile, according to the Dutch regional administration, 36,000 people in Lombok, or 5.9 percent of the island’s population, died.

Statistics are scarce and it is hard to gain a sense of what truly happened. Brown’s research shows that most fatalities occurred in people aged between their mid-teens and mid-fifties, the same age bracket that has been most affected by the bird flu in Indonesia.

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.

This isn’t the first time humans have been concerned over the spread of swine flu (see March 24, 1976: Ford Orders Swine-Flu Shots for All) and for information, visit the Center for Disease Control of the USA.

Manuel L. Quezon III.

31 thoughts on “Pondering a pandemic

  1. Now the issue of the Separation of Church and State, and the role that Science plays in Democracy and the formulation of Public Policy becomes not the usual boutique discussion topic among academic types — but a matter of life and death for potentially hundreds of millions of human beings. The lesson will be learned one way or another. Darn bishops better keep their miraculous wooden idols to themselves to themselves, and wait until it’s safe once more for their Hocus Pocus.

  2. DJB: The bishops are much more astute than you are. They did not roll out the Cristo because they expect embarassment.

    In Mexico, what will happen is either (i) there are a couple more hundred deaths, and the virus disappears. [The bishops then claim ‘Victory-of-prayers’.];
    (ii) the flu spreads; several more hundred Mexicans die — the bishops repeat their mantra and gain more of the followers to pray. [Some thing about your neighbor dying unexpectedly makes people want to pray.] And a few weeks or a few months later, the flu virus disappears. The bishops declare “Victory-of-prayers” (the flu has been conquered) and for everyone who are still alive (the victorious!!!) to bow their heads.

  3. what the Mexican bishops will NOT do is to do processions to invoke the heavens to stop the drug gang wars in Mexico. Victory-of-prayers is not guaranteed for that particular cause.

  4. Advisory : Buy now six or more surgical masks. And always carry a spare — to give to someone who has caught the flue so when that sick person sneezes, the virus don’t spread to other people.

  5. leave it to the catholic church to exploit a situation into their favor. Seizing an opportunity to increase the flock IMHO.

  6. Mexico is a favorite watering hole for very cheap pretty chicas and drugs, an intoxicating cocktail for the summer fun.

    Not at this time though. Being the ground zero for at least 3 disasters (drug wars, earthquake and swine flu) converging at the same period, the Mexicans are beginning to see the wrath of God. It doesn’t need even the intervention of the Bishops as they closed down public masses. There is just no one else to look up to when getting medical help is another personal battle.

  7. I worked at WHO during the SARS and avian influenza epidemics and if the science behind the WHO projections for the current epidemic is as flimsy as that for the earlier outbreaks, WHO will almost certainly be overestimating the impact of swine influenza.

    WHO has a vested interest in exaggerating the severity of epidemics. Partly this is because it wants to scare governments into taking appropriate preventive measures. Less laudably, it is because WHO wants to attract more funding for its own disease control program (SARS and avian influenza were very effective fundraisers for the organization).

    In the end, WHO knows more about these new zoonotic diseases than you and me, but not that much more. It does not have its own laboratories or research program, relying on four or five high-level “reference laboratories” throughout the world. However, even these cannot really provide us with useful information to predict the course of a pandemic. In the end, the WHO projections are 95% informed guesswork.

  8. the filipino people have been suffering from swine flu for at least six years already and it’s just getting worst! the swine flu i am talking about is not that kind that is going around lately, it is from the kind of swine that inhabits the congress and the government, have caused deaths and misery of thousands of filipinos! and the filipinos have been bearing crosses on their backs for a long time with no help or cure in sight.

    our kind of swine flu is far more deadlier than the one that is going around the whole world. we know the cure for our kind of swine flu, and i do not know what are we still waiting for?
    maybe for some kind of miracle?

  9. After the global financial meltdown, I have seen some televangelists urging their flock to give their tithes and offerings as soon as possible, in order to be spared from losing all their hard-earned savings. Apparently, some Christian ministries encourage a concept of a God who can be bribed with material offerings. In a reciprocal arrangement, God will cast his blessings on those who give to their Church.

    Reminds me of the Catholic Church selling indulgences. I think that was one of the things that provoked Martin Luther to break off and establish the Protestant movement. Well, some protestant ministries are practicing the very same thing.

  10. “cdc has implemented its emergency response,” according to cdc update on April 29, 11:00 AM ET.

    prompted by the WHO exaggeration (according to torn on Wed, 29th Apr 2009 7:24 am)?

  11. Torn on, “WHO will almost certainly be overestimating the impact of swine influenza.”

    Since the swine flu is sharing the same genetic make-up as that of the deadly 1918 Spanish flu which killed 50 million people, the heightened alert by WHO officials is necessary. Virologists and CDC scientists have still no answers why certain flu strain have devastating results than others.

  12. Predicting the course of a pandemic will be virtually impossible, considering the facility of global travel in this day and age. It’s amazing how, a few days after the swine flu was reported to have broken out in Mexico, incidents of contamination were reported in such distant places as New Zealand and Israel.

  13. expect extra vacation-days should the swine-flu hit metro-Manila with same severity as it has hit Mexico.

    MEXICO IS SHUTTING DOWN : Decision comes as the World Health Organization warns of pandemic

    Health Secretary Jose Cordova said nonessential federal government offices will be closed from May 1-5. Friday is a national holiday in Mexico and many government offices are usually closed. He said all nonessential private businesses must also close for that period but essential services like transport, supermarkets, trash collection, hospital will remain open.

  14. Torn on, “WHO will almost certainly be overestimating the impact of swine influenza.”

    …better safe than sorry. What remains to be seen is the response to this strain to current antibiotics/vaccines/etc., considering our abuse of these medicines and the subsequent resistant strains developed, I don’t think the WHO or anybody can underestimate this threat…

  15. “Swine flu” hmmmm, could this be WMD, biological in nature that will spare a certain group that does not eat the portly, hoofed creature? 🙂

  16. ramrod, odds are, they have a lesser risk in dominant countries, but not necessarily spare. Remember that those countries also have people coming from all over the world.

  17. ramrod: getting swine-flu from a pig only happens if you are super-close to a pig (and breathe the air they breath, or their cough mist gets onto you and into your lungs).

    Just like how J-Lo caught the swine flu. “Go moderate” was J-Lo’s practice / he did not abstain. J-Lo was susceptible and many of the pigs were his drinking buddies — J-lo and the swine were “that!!!”-close.

  18. On a serious note, in case swine flu takes down a few metro-Manila residents in mid-May. Word to the wise — buy now those super-fine face-masks.
    cut-and-paste from New York Times article:

    In the 1918 Spanish flu, American cities that reacted quickly had fewer deaths than those that acted slowly and used fewer precautions, according to a 2007 study of 43 cities by researchers from the University of Michigan and the Centers for Disease Control. The most common combination was school closings and bans on public gatherings, which in 34 cities lasted for a median of four weeks.

    Stay away from hospitals and clinics.
    Many people do not realize how long measures take to work. A child can shed flu virus for 10 days, Dr. Imperato said, an adult for 5.

  19. d0d0ng and Ramrod — As you say, better safe than sorry and WHO is only doing its job in encouraging countries to protect the health of their citizens. Let’s see how this turns out.

  20. Considering, we went on vacation passing through a major airport with inbound and outbound traffic to Mexico and then my family again flew separate planes this week without any untoward effects, the danger might have been over.

  21. Has anybody seen the movie “Andromeda Strain?” (oops shows my age). It was about a virus that caused havoc because it couldn’t be stopped by anything modern medicine can throw at it, it was resistant to everything, constantly evolving that no vaccine could be made against it, even when they were able to isolate the cases so there is no chance of physical contact by either victim or possible carriers (ie rats, etc) it became air-borne…it was the proverbial end-of-days story and looked like it was going to wipe out humanity…but then its strength became the solution – it was constantly changing, eventually it changed to a harmless strain…talk about anti-climactic…

  22. What is essential is invisible to the eye…the truth is never obviously spoken…
    I couldn’t believe it at first, but this Swine Flu issue is not the real issue, its something else the US is unwilling to come up front with…in time all will be revealed…

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