Plagues in World History (27 page)

The many issues surrounding flu were recently brought back into focus with the occurrence of an H1N1 pandemic in 2009, the first flu pandemic to occur in over forty years, if one does not count the 1976 scare. The first wave in the spring was first reported in Mexico, where flu may have been present as early as January, with a second wave occurring in the autumn. (A third wave expected for the winter–spring of 2010 never materialized.) By June of 2009, the flu was officially declared a pandemic by WHO and the CDC. In the United States alone, it is estimated that to date forty-seven million people have come down with “swine flu,” representing about 15 percent of the total population, and that over Influenza y 131

two hundred thousand victims have been hospitalized and almost ten thousand people have died.50 While this is by far the largest number of flu mortalities reported in any country in the world, anecdotal evidence suggests that the flu was a lot more severe and deadly in developing countries, where access to vaccines and quality health care is quite a bit lower than in the United States.51 Moreover, the designation of “swine flu” by the media to this pandemic is an unfortunate misnomer, since the genetic makeup of the virus has been revealed to contain elements from swine, avian, and human influenza strains. Although the virus has been found in pigs in some countries, it is only transmitted person to person and has not been communicated from pigs to humans, nor by eating pork products.

Nonetheless, this has not stopped some countries, such as Azerbaijan and Indonesia, from banning imports of pork, and Egypt decided to slaughter all pigs in the country (numbering over three hundred thousand) in April, despite reporting no flu cases.

In terms of socioeconomic and cultural responses, the flu of 2009 produced an interesting mix of reactions, some familiar and some new. The fact that most flu deaths have occurred among healthy, vigorous adults aged between eighteen and sixty-four and among pregnant women raised fears of another pandemic like the one of 1918, even though mortalities, at least in the United States, have actual y been below what is to be expected in an average flu year. In some cases, victims indeed succumbed rapidly to a cytokine storm as their robust immune systems overreacted to the new strain. Yet, the superior, modern health care now available—at least in developed countries mostly in the West that have better diagnostic techniques and treatment therapies, such as antiviral drugs like Tamiflu and antibiotics to ward off bacterial pneumonia—and the fact that this time most people’s nutritional health and immune systems are not being compromised by a world war, seems to have kept such deaths to a minimum compared to 1918.

Some countries, such as China, Japan, Australia, Egypt, Russia, and Taiwan, have adopted or announced quarantine measures against travelers suspected of harboring the virus, isolating them in their hotels or on cruise ships, and new technologies, such as thermal imaging systems that can detect feverish conditions in the body, have been employed at airports to keep pace with worldwide airline travel.

Wearing of masks once again came into fashion, particularly in countries like Japan, where they are culturally accepted and often used to ward off pollution.

Some countries have also felt a severe economic fallout from the pandemic. In Mexico, for example, the local tourism industry, such as to Cancún and other popular destination resorts, simply collapsed during the summer in the wake of its spring scare, and the country has received mil ions of dol ars in loans from the World Bank to cope with the crisis, partly it seems as a reward for its brave, early reporting of the outbreak. In spite of fears to the contrary, the pandemic did not 132 y Chapter 5

dim proceedings at the 2010 Winter Olympic games in Vancouver, Canada, which is currently ranked ninth in the world in terms of flu incidences and deaths. And yet, this flu has also defied expectations and posed some continuing challenges: it is still not known whether the flu will come back as a cyclical, seasonal virus or if it was just a one-off occurrence; in a high proportion of cases there were no telltale symptoms of fever and cough even though the victims were still highly infectious and remained so for up to three weeks after recovery; and, as already noted, there was a great discrepancy around the world in severity of the pandemic based on the availability of vaccines and medical care.52

Here in the United States, responses have been mostly organized at the local school and state level, some of whom had already in years past been making similar preparations in expectation of a pandemic of avian flu. At the col ege where I teach in Vermont, for example, regular e-mail updates on the pandemic and information fact sheets were posted campuswide, and student health services geared up for a 30 percent infection rate. Advisories included commonsense precautions, such as the washing of hands and face, coughing or sneezing away from others, self-isolation at home—if infected—for at least twenty-four hours after symptoms fade (even though this particular outbreak of flu can be contagious for far longer than that), seeking medical help if symptoms persist beyond three days or are extreme, and so on. This also meant I had to suspend my normal absentee and assignment deadline policies, which I’m sure my students appreciated! A massive vaccination program, one not seen since the polio vaccine of the 1950s, was geared up by WHO and the U.S. government in response to the pandemic, although here in the States delivery of the vaccines came late, in November, when the second wave of the flu had already struck in early autumn. This was attributed to difficulties in culturing the vaccine in fertilized chicken embryos; the virus was claimed to be exceptionally slow to replicate. It is also possible that delays came from elaborate testing protocols and safeguards for the vaccine, given the experience of 1976. An underground drumbeat against vaccination surfaced on September 26, 2009, when political commentator and cable TV talk show host Bill Maher published a brief broadside on Twitter: “If u get a swine flu shot ur an idiot.” In the second week of January 2010, U.S. president Barack Obama declared it by proclamation to be “National Influenza Vaccination Week,” and the U.S. Department of Health and Human Services editorialized in local newspapers to encourage people to get vaccinated for swine flu, indicating that we are still haunted by the ghosts of 1976. But just like back then, the state delivery system of the vaccines has also been very uneven. In my home state of Vermont, H1N1

flu clinics were mobbed, and the state ran out of vaccine early due to higher than normal demand. I remember standing outside in the cold for two and a half hours to get my own shot. But in New York City, the
New York Times
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clinics were deserted, which again echoes 1976, when New York had only a 10

percent vaccination rate. There has also been some debate about who should get the vaccines and who should administer them. In Vermont, vaccines were, at least initially, restricted to certain “priority” or high-risk groups, which included pregnant women, health care workers, those aged between six months and twenty-four years, and those with preexisting health conditions that made them more susceptible to flu (of which I was one). But if fulminant cases of flu are also striking down healthy, prime-age adults in other categories due to their vigorous immune systems, shouldn’t vaccines also be made available to them (perhaps on a first-come, first-served basis), especially since they would be the ones, through their active lifestyles in the workplace, who would be most likely to spread the flu?

At the Vermont college where I teach, for example, I attempted to get an H1N1

vaccine offered at health services, but I was told that shots were restricted to students. This makes sense if students are spreading flu in their dorms, but professors are also at the “flashpoint” of this pandemic and their sick leaves, it could be argued, will have a greater impact on the continued viability of campus life, particularly in terms of instruction. In the event, hundreds of elementary and secondary schools throughout the country did temporarily close in response to the pandemic, in spite of CDC recommendations against this. I also question the delivery method of special public clinics for the vaccines, since the holding area where my wife and I along with dozens of other families were milling around fil ing out paperwork seemed a perfect environment for spreading the flu. Instead, perhaps flu shots and live vaccine nasal sprays would have been better administered at general practices, where staggered appointments could be made. Despite these difficulties, however, my overall impression as of 2010 is that the pandemic was successfully contained. The disaster that some of us anticipated did not happen, and 1918 was not repeated. Indeed, the fact that a pandemic has taken so long to reemerge, whereas previously a pandemic was to be expected every decade, is a very hopeful sign. We can all congratulate ourselves for that. But there are still some lessons to be learned with regard to the next flu pandemic, when and if this should occur.

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AIDS

Of all the deadly infectious diseases that are discussed in this book, acquired immune deficiency syndrome (AIDS) is perhaps the most culturally constructed one, whose ever-shifting “metaphors” relative to each society’s attitudes and behaviors are intimately connected with the clinical and biological manifestations of the disease. There is no better illustration of this than the tale of “two AIDS”

that can be told in the three decades since its discovery at the dawn of the 1980s.

One tale takes place in the countries of the West, primarily the United States and Western Europe (what are sometimes called Pattern I countries by those tracking the global spread of AIDS), while the other is set mainly in sub-Saharan Africa and the Caribbean (Pattern II). What will happen in those countries where AIDS is still emerging, such as Eastern Europe, Asia, and the Middle East (Pattern III) remains to be written. Indeed, the differences between these tales is so striking that some “AIDS dissenters” go so far as to say they are about two different diseases entirely, which of course is not true. But let us look at each of these tales in turn.

First, we should briefly recount what we know thus far about the unique biology and origins of this complex disease. AIDS is caused by the human immunodeficiency virus (HIV), which, like the viruses that cause influenza, mutates rather prolifically, about once in every replication cycle, making the disease difficult to counteract with a vaccine or a cure. However, HIV is different from smallpox or influenza viruses in that, with the aid of an enzyme called reverse transcriptase, its RNA is able to make DNA copies of itself, which it then incorporates into the nuclear chromosomes of the host cell so that it manufactures 135

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more viral RNA and hence more viruses. Microbes with this ability are called retroviruses, because they actually reverse the normal order of cell biology, which is to transcribe DNA into RNA. The advantage for the retrovirus is that the cell can keep functioning and remain alive to serve the replicating needs of its viral guest, rather like a body taken over by some alien avatar or possessing spirit, whereas other viruses would kill off their host once the lysis or release of new copies from the cell membrane is complete. (Retroviruses instead “bud out” from the cell in immature form without apparently compromising the membrane’s integrity.) Retroviral DNA can also lie hidden or dormant within their cellular crypt, doing nothing for years until suddenly and mysteriously called back from the dead to compel the cell to do its replicating bidding once more.

Within this devious family of retroviruses, HIV has the further dastardly capacity of specifically targeting cells that are crucial for marshaling our immune defense system. These are namely the helper T-lymphocytes, or T-4 cells, which signal other cells to start producing antibodies in our blood and which also mobilize a cellular immune response to the virus; yet, T-4 cells are particularly prone to invasion by HIV because they contain CD4 protein molecules on their surfaces with which HIV happens to bind. Another type of immune cell called macrophages, which are phagocytes or white blood cells that devour other, viral-infected cells, also contain the CD4 receptor and thus can be infected by HIV.

Unlike other retroviruses, however, HIV usually kills off the T-4 cells after it has used them to replicate, although in some of these cells and in macrophages it becomes latent, only to be reactivated later. So far as we know, HIV and related viruses in animals—including monkeys, cats, sheep, goats, and horses—are unique in terms of this immune-suppressing quality, forming their own genus or subclass of retroviruses known as lentiviruses (meaning slow to cause disease).

HIV is therefore a particularly insidious kind of disease organism in that it seeks out and destroys or else incapacitates the very cells upon which our bodies rely in order to fight off an infection. And unlike any other microbes that simply compete with the body’s immune defense system for control of our nutritional resources, HIV actually harnesses that system to manufacture more of the virus it is supposed to be defending against, thus turning our body’s would-be saviors into its own worst enemy.1

But because HIV is a latent and slow-acting virus, usually patients will go for long periods, often years, without any noticeable symptoms (and are therefore called asymptomatic), during which time they might be blissfully unaware that they have the disease even as they are still infectious in terms of the virus passing through their blood, semen or vaginal secretions, and breast milk, although it should also be pointed out that HIV’s presence in these fluids is often low or variable. However, some do show symptoms immediately upon infection with AIDS y 137

HIV, which can include a flulike illness and swollen lymph glands, or what is called acute infection syndrome, which is nonetheless practically indistinguishable from many another disease. Later, some more characteristic symptoms might manifest themselves, including low T-4 cell counts, night sweats, persistent low-grade fever, diarrhea and loss of appetite (often brought on by thrush) accompanied by a dramatic drop in weight, and general nausea and fatigue; these symptoms were originally referred to collectively as AIDS-related complex (ARC), but this term is now no longer used in the field because it tends to confuse people as to whether or not patients actually have AIDS. Instead, experts prefer to see ARC as part of a continuum eventually leading to full-blown AIDS, especially given that the same symptoms can reappear at that time.