How governments concealed the extent of the H1N1 pandemic and risking the outbreak of a virus that's even more deadly.
As swine flu was spreading around the globe this spring, a senior disease specialist from the World Health Organization (WHO) held an urgent conference call with top British health officials. In the conversation this May, later described as "aggressive" by sources familiar with the discussion, the WHO official accused the British of concealing the extent of their country's swine-flu outbreak. Among those with swine-flu symptoms, Britain was only counting people who had traveled to places that, like Mexico, had already confirmed an outbreak of the virus, known to scientists as H1N1. Their method left much to be desired in a country where the virus was already spreading fast. Countless Britons fell sick and were intentionally left uncounted.
Governments, of course, have a long history of concealing outbreaks, and this year's flu pandemic, while the first of this particular century, was certainly not the first to be brushed under the rug. The consequences of cloaking swine flu weren't disastrous on this occasion, but the result will not always be so benign. In fact, at this very moment, another virus -- with the potential to be far more devastating -- is continuing to seed infections, frustrating efforts to root it out. That virus, H5N1, or avian flu, is a far more lethal strain. And you guessed it: front-line countries' records in candidly reporting the disease's spread don't bode well.
If there's one thing past pandemics have taught, it's that curing the world of flu is impossible unless countries are upfront about their outbreaks. Armed with that vital information, health officials can take steps to slow the spreading infection and, if containment fails, ramp up emergency medical care and other vital services. Without timely disclosures, it's much harder for virus hunters to discover how an emerging disease attacks its victims and transmits to others; it's also much tougher to get virus samples for study in the lab.
Given all this, why would governments try to keep down their official infection tallies? Most likely, fear of stigma and all the economic consequences that follow. When the WHO placed its call to London last spring, the agency was still weighing whether to raise its state of alert and declare that the swine flu epidemic was a full-blown pandemic, a dramatic step that would signal all countries to ready themselves for the brunt of the new virus. It was clear that the virus was spreading in the Western Hemisphere, especially in the United States and Mexico. But under the agency's criteria, a pandemic could be declared only if "community-level outbreaks" were confirmed in more than one region of the world. If Britain acknowledged that the virus was spreading widely, that would add Europe to the list and push the outbreak across the pandemic threshold.
London's concerns are understandable. The epidemic of 2009 might have been dubbed the British flu, just as the Spanish flu of 1918 got its name not from its place of origin but from one of the first countries to honestly report the epidemic's arrival. (In 2009, perhaps having learned their lesson, the Spanish also withheld information about their swine-flu outbreaks, according to sources familiar with Spain's reporting.)
Of course, some countries do get high marks on swine flu, including the government of Mexican President Felipe Calderón, which has won international credit for sharing information about the epidemic in his country and acting very aggressively to contain it. Even China has been open this time, having been burned by criticism of a completely opaque epidemic of Severe Acute Respiratory Syndrome (SARS) that went on for three months in 2002 before the epidemic was confirmed.
But the world hasn't changed. And the H1N1 flu experience recalls concerns over the emergent H5N1 strain, which is still circulating silently in Asia and Africa. For most people sickened by swine flu, it's no worse than the regular, seasonal bug. But avian flu kills more than half of those who catch it. Until now, bird flu hasn't gotten the hang of passing easily from one person to another. But it might take only a few genetic tweaks for this virus to become highly contagious. Tens of millions could die.
Already, a number of Asian governments have covered up their bird-flu outbreaks. Part of the reason for the opacity is that bird flu mostly afflicts chickens and ducks, not humans. That puts the disease squarely in the purview of agriculture officials, who often have an interest in protecting farming businesses and promoting exports rather than publicizing outbreaks that could spook consumers, precipitate culls, or prompt export bans. In many countries, those agriculture officials wield huge government budgets and associated patronage that can easily outmuscle their technocratic counterparts at health ministries.
Chinese government scientists, for instance, were aware that bird flu was sickening livestock in Guangdong province as early as 1996, but agriculture officials over the following years refused to acknowledge repeated outbreaks. Beijing responded furiously after international researchers a decade later identified southern China as the source of several waves of infection that had spread both westward toward Europe and south into Southeast Asia. In Vietnam, local livestock officials and veterinarians at the agriculture ministry had proof in the summer of 2003 that H5N1 had struck commercial poultry farms outside Hanoi. But only after people started dying did Vietnam confirm the outbreaks early the next year.
In Thailand, it took several months of private sleuthing by an elderly virologist at Mahidol University to force the Bangkok government to confirm that bird flu was burning through the country's flocks in early 2004. Senior Thai agriculture officials had been reassuring farmers that the poultry deaths were just a minor case of fowl cholera, complicated by bronchitis and aggravated by an abrupt change in the weather. Indonesian agriculture officials were notified of bird-flu outbreaks in mid-2003 too, but by the time Jakarta acknowledged them in early 2004, the virus had spread throughout much of the archipelago. The country's director of animal health later said that eight of the country's largest farming conglomerates lobbied top agriculture officials and even then-president Megawati Sukarnoputri to keep the outbreaks quiet. Today, the virus is endemic across almost all of Indonesia, making the country perhaps the most likely source of any new pandemic bird flu strain.
Chastened, some Asian governments have become serious about eradicating bird flu, in particular Vietnam and Thailand. But the virus keeps coming back, and there are still many reasons to doubt that agricultural authorities are reporting each new outbreak.
It's not just in Asia or the developing world that agricultural interests wield such influence. This year, the U.S. pork lobby successfully convinced Washington policymakers to stop referring to swine flu by that name, though the virus almost certainly came from a pig. At the same time, the U.S. Department of Agriculture, allied with the U.N. Food and Agriculture Organization and the World Animal Health Organization, successfully prevailed on the WHO's leadership to drop the label swine flu for the unwieldy designation of "Pandemic (H1N1) 2009."
With their livelihoods on the line, farmers and their government advocates from Cambodia to Kansas are wary of efforts to identify new virus strains in their flocks. Meanwhile, most of the previously unknown diseases that have struck people in recent decades have originated in animals, ranging from SARS and West Nile virus to HIV/AIDS and Ebola. The link between animal and human health remains largely ignored. We believe swine flu originated in pigs, but no one detected the virus before it infected people. And as bad as swine flu may prove to be, the next infectious disease to jump from livestock to people could be far worse. We need to be able to see it coming.
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