Plagues in World History (26 page)

that “we will see a return of the 1918 flu virus.” In addition, the 1957 and 1968

pandemics had demonstrated the costs in thousands of lives lost when vaccine was delivered too late or in too few doses. But this was also an election year (as well as America’s bicentennial), and Ford faced strong challenges first during the Republican primary from California governor Ronald Reagan and then in the general election from his Democratic opponent, Jimmy Carter. Editorials in the New York Times
indeed accused the vaccination program of being primarily motivated by politics. In the event, the ensuing “fiasco” or “debacle,” as it was called, probably cost Ford more in political capital than he gained. When an epidemic failed to materialize in the fall, this only reinforced his popular image as an in-competent bungler.36 I still remember watching a satiric spoof of the U.S. presidential debates by the
Saturday Night Live
comedy program, in which comedian Chevy Chase appeared as Ford with a vaccine shot still stuck in his arm! (A picture of Ford receiving his flu shot was published on the wire, perhaps to increase confidence in the vaccine.)

By mid-December the vaccination program was canceled, largely due to fears of side effects when several hundred vaccinated individuals came down with a rare and sometimes fatal neurological disease called Guillain-Barré syndrome.

Although subsequent studies claim that those receiving a vaccine had a five times higher (yet still pretty remote) chance of contracting Guillian-Barré than those who did not, a more than circumstantial connection has still to be proven with this particular vaccine, since such complications can occur with any foreign substance introduced into the body.37 Despite this setback, some would argue that the 1976 vaccination was a success, in that it demonstrated how a large number of vaccine doses—over forty-three million, representing 50 percent of the high-risk group (double what is normally covered in most vaccine programs) or nearly a quarter of the general population—could be mobilized in a short amount of time. Edwin Kilbourne, who served as medical adviser and advocate of the program, summed up his justification, and that of the CDC, thus: “Better a vaccine without an epidemic than an epidemic without a vaccine.”38 Two National Immunization Conferences were also held in the immediate aftermath of 1976 under the succeeding Carter administration, which resulted in proposals for a permanent flu vaccination program supervised by the federal government as well as increased awareness of the necessity for better immunization against other infectious diseases, such as polio, measles, and diphtheria.39

But aside from the monetary cost, these benefits did not come without a price.

Hostility to government vaccination programs was given free rein during the presidency of Reagan in the 1980s, which helped scuttle funding for immunization against the flu as well as against other preventable diseases like measles, while the initiative for developing future vaccines was hereafter surrendered to private Influenza y 127

industry.40 The experience of 1976, however, proved this to be a mistake, for pharmaceutical companies found they could not get insurance on their own to cover their liabilities from potential lawsuits (to date over six hundred million dollars in filed claims), which instead had to be covered by a special appropriation from Congress, and difficulties ensued with the distribution and administration of the vaccine, which was left up to local state control and was therefore very uneven. A more general fallout, but no less tangible for that, was a loss of public confidence in vaccinations, which was due to not only medical complications but also faulty manufacturing, in which one set of trial lots of the vaccine was made up with the wrong virus. All these misunderstandings could probably have been avoided or at least mitigated with better sharing of information amongst the media and the public, especially in the context of the widespread disillusionment with the federal government engendered by the recent Watergate scandal.41 It is a failure that still haunts vaccination efforts against flu to this day.

In recent years, fears have been raised about a possible pandemic of avian flu, caused by the H5N1 virus. The virus first came to the world’s attention in 1997

with an outbreak in Hong Kong, where an epidemic was averted by the culling of about one and a half million market poultry, a policy that Hong Kong has adopted ever since in response to any reported outbreak of avian flu. As of the end of 2009, WHO reported a total of 467 human cases of avian flu around the world, resulting in 282 deaths, representing a mortality rate of just over 60 percent.42 Some would argue, however, that this vastly overstates the virulence of avian flu, since many more cases where flu symptoms are quite mild simply go unreported. Over half of the known cases occurred in Indonesia and Vietnam, with the next most numerous cases occurring in Egypt, China, Thailand, Turkey, Cambodia, and Azerbaijan, in that order. Again, this may reflect honesty of reporting just as much as actual cases. Typically, those who have come down with avian flu contracted it directly from domestic birds, who are likewise highly susceptible to the virus (to date millions upon millions have died); in most cases, the virus was transmitted either by eating infected poultry products (such as raw duck blood, considered a delicacy in Vietnam) or by breathing in dust particles contaminated with bird feces, within which the virus is shed in huge numbers.

However, clusters of cases of human-to-human transmission have also occurred, although these are usually confined to family members where close contact with infection sources likewise seems to be a prerequisite and where the virus seems to have weakened in virulence with each subsequent transmission. Some flu victims exhibited symptoms of a cytokine storm, or immune overreaction to the virus, much like what happened during the 1918 pandemic, but in other cases symptoms were delayed or much less severe; such variations seem to be due to different genetic responses to the virus in respective hosts.43

128 y Chapter 5

There is much debate about whether an avian flu pandemic is likely to occur outside what so far have been very localized outbreaks. Some say it is inevitable that the H5N1 virus wil undergo a genetic shift and thereby evolve an ability to pass directly from human to human in a far more efficient manner than hitherto, since this has always been the past history of influenza. Others counter that the “not if but when” fears of an avian flu pandemic is all a hoax perpetrated largely by the media establishment and the pharmaceutical industry, who stand to benefit substantially from manufacturing an avian flu vaccine or antiviral drugs.44 In this scenario, avian flu wil simply be a dead-end disease in its animal hosts, never breaking out widely in humans because its unique genetic and protein makeup is incompatible with that of human cells, as seems to have been the case with the overblown “swine flu” of 1976. In the case of avian flu, it is thought that the surface proteins of the virus are unable to bind to the sugar molecules in the cells of our nose and throat but can do so once the virus is deep in the lungs in the alveoli; this is why it is hard to contract yet is deadly once it happens. A sanguine view of avian flu also depends on the notion that a genetic hybrid or mixing (reassortment) of bird and human strains in a third host, such as a pig, is naturally impossible, which hasn’t stopped recent efforts to artificially create one in the lab in the hopes of heading off its occurrence in nature, another Frankenstein’s monster experiment that, as with the resurrection of the 1918 virus, is controversial.45

A further focus of debate concerns the source pools of infection for avian flu.

In most literature this has been identified as the poor, rural areas of southern China, such as the Guangdong province, where human populations mingle with huge flocks of domestic ducks, geese, chickens, and turkeys that roam freely or are transported across vast areas of land with ample opportunities for contact with wild birds harboring the H5N1 virus; from there, the virus is then alleged to spread out to Hong Kong, Korea, Japan, and Southeast Asia. However, as was noted toward the start of this chapter, China’s poultry farming practices go back to time immemorial, and so far, it does not seem that the virus has migrated with wild bird flocks outside its endemic areas, perhaps because most carriers die before they can get very far, as happened to wild geese and other waterfowl in some of China’s nature reserves in 2005. Although other H5 and some H7 bird flu strains have appeared in the West, including the United States, Canada, Italy, Ireland, and, most recently in 2003, the Netherlands, these have been confined to animals or have not been very deadly to humans.46

An alternative hypothesis places the blame squarely on the industrialized production of food and factory farms, or Concentrated Animal Feeding Operations (CAFOs), the so-called bird jails where enormous numbers of poultry are kept confined at close quarters in cages and often in contact with other animal Influenza y 129

populations, such as pigs. This “livestock revolution” has been a relatively recent phenomenon, cresting, it has been noted, in the 1990s at the same time that avian flu first made its appearance. It is associated with Asian conglomerates such as Charoen Pokphand (CP) based in Bangkok, Thailand, and with American versions such as Tyson Foods and Perdue. These food monopolies produce mass quantities of chicken manure, which are sometimes used as fertilizer or otherwise present run-off hazards for the environment; appropriate or drive out smaller, free-range family farms; use antibiotics or genetically engineered embryos to maintain product quality (while increasing the risk of drug-resistant viral strains); adopt risky feeding practices such as the chopped-up remains of other animals (which is how bovine spongiform encephalopathy, or “mad cow disease,”

emerged); and can best absorb the costs of governmental oversight aimed at preventing or halting disease migration from animals to humans, such as the culling of at-risk herds or monitoring programs such as the National Animal Identification System (NAIS) proposed by the U.S. Department of Agriculture.

Although claims are made that such confinement operations are healthier because they keep their animals separate from wild reservoirs of disease, it is just as likely it is the other way around, that wild birds have picked up exotic viruses from chance encounters with artificial environments that receive little ventilation or sunlight and whose denizens are forced to defecate on each other and otherwise live in incredibly unhygienic, not to say inhumane, conditions.47

What is the solution, or rather denouement, to the avian flu dilemma? Even if we don’t have to worry about a pandemic of avian flu, we probably would be wise to keep searching for better ways to medically prevent and treat the disease.

Some antiviral drugs, like oseltamivir and zanamavir that inhibit the N protein responsible for new viral copies budding out from the host cell, may have some effect against avian flu, but the most they do is alleviate symptoms—they are not a cure. The drugs’ main use, if stockpiled and administered shortly after flu symptoms appear, is to buy some time for vaccine development and distribution.

Current vaccines for H5N1 are only 50 percent effective and must be administered in doses twelve times higher than that for regular vaccines, which increases the likelihood of side effects and makes them almost impractical for inoculating large numbers of people quickly in response to an emerging pandemic. Avian flu vaccines are notoriously hard to produce because they naturally kill off the fertilized chicken egg cultures in which the formulas are usually grown; genetically engineered vaccines may get around this problem and would also be far easier to manufacture at short notice. Another possibility is to use the antibodies of those who have survived or who happen to be immune to avian flu; this possibility parallels similar work being done with AIDS. Still a third alternative in the vaccine arsenal uses the harmless adenovirus to carry the H surface protein of avian 130 y Chapter 5

flu, which seems to be effective against multiple strains caused by antigenic drift since it stimulates both antibodies and immune cell activity in the host. This would make for a vaccine that could be effective year to year, until a major genetic shift occurs. The holy grail of this kind of vaccine would be one that focuses on a protein common to all flu strains, meaning that one shot would confer immunity to flu for all time.48 This would then set up an eradication campaign for flu equivalent to what was done for smallpox in the 1970s.

Until and if that happens, however, the socioeconomic and cultural dimension of avian flu cannot be ignored. This means that, for the time being, perhaps flu can best be fought with lifestyle and behavioral changes that limit the opportunities for flu to make the leap from animals to humans. Within the endemic foci of avian flu in Asia, this would entail changing farming practices in order to better respect the boundaries between wild and domestic fowl, increasing hygiene at live poultry markets and farms, scrupulously reporting cases of sick birds or humans, and changing the ways in which poultry products are handled, cooked, or consumed. These policies have already been proven to be successful in Thailand, for example, after avian flu returned to Southeast Asia in 2004. But we must also recognize that currently there are major disincentives for doing almost all these things, such as the loss of families’ livelihood and food source should their flocks be culled, or the potential damage to developing countries’ economies in terms of tourism and exports should flu outbreaks be made public. Probably the only way to counter these negatives is with financial compensation forthcoming from the richer nations of the world, and perhaps the only way to persuade others to render such aid is by casting avian flu as a health problem that affects us all as part of a global network of disease, in the same way that attempts have been made to mobilize a global response to the environmental disaster of global warming. This also means that the inhabitants of the wealthier West will not be exempt from making similar social, economic, and cultural choices, such as shifting consumer patterns away from mass-produced foods and toward locally sustainable sources.49 (This is indeed the subject of the 2009 documentary
Food, Inc
.)