Commentary

Following Swine Flu

in Program

By Julie E. Fischer – Crowds in surgical masks scurry between skyscrapers, grimly focused on getting from point A to B while evading a contagion that could be anywhere. In 2003, it was SARS in Hong Kong, Taipei, Beijing. Now, it’s swine flu in Mexico City.

Outside of countries plagued by a devastating combination of poverty and HIV/AIDS, most of the world’s citizens are both safer than ever and more sensitive to risk. Although SARS claimed only about 800 lives worldwide (in a year when measles reaped more than 500,000), its terrifying emergence resonated politically, socially, and economically. SARS demonstrated that viruses now circumnavigate the world in days, catalyzing adoption of a new global health framework for detecting and responding to potentially catastrophic health threats. Health authorities have spent the last five years building national and global preparedness for scenarios just like the current swine flu outbreak. Their warnings have clearly not inoculated the world against dread.

From the US perspective, the current crisis began on April 21, when CDC reported the detection of a novel influenza virus combining genetic sequences from swine, human, and avian strains in two children living in a California county bordering Mexico. CDC officials announced on April 23 that intensified disease surveillance had uncovered more cases of swine flu in California and Texas, but could not confirm reports that the same strain might be circulating in Mexico. On April 24, the World Health Organization (WHO) announced that Mexican health authorities had begun investigating a widespread outbreak of unusually deadly influenza-like illnesses as early as March 18, now laboratory confirmed as a swine flu strain genetically identical to the California viruses.

Health officials in the US, Canada, New Zealand, and Europe have since identified more cases of swine flu daily, all marked by relatively mild illnesses. In contrast, Mexican health officials report that close to 2,000 people have been hospitalized with almost 150 deaths, despite fairly aggressive social distancing measures.

Unofficial tracking sites, blogs, and Twitter amplified official alerts. Are the current reports self-feeding hysteria? Is the new swine flu the “big one?” Right now, too many questions remain unanswered to say for sure, including why the US outbreaks appear much less deadly than those reported among Mexico City’s 20 million inhabitants. Typical seasonal influenza generally hits young children and older adults the hardest; reports from Mexico cite fatalities in otherwise healthy young adults, as during the 1918 “Spanish flu” pandemic that claimed an estimated 50-100 million lives.

The response to the current swine flu outbreak represents the first test of systems put into place after the 2003 SARS epidemic. Media reports have attempted to divine significance from official proclamations – WHO raised the pandemic alert level and declared swine flu a public health emergency of international concern, the US declared a public health emergency. In fact, these declarations reflect processes through which WHO and the US mobilize resources for a public health response.

WHO, working within the revised International Health Regulations (2005), a global framework for disease detection and reporting by member states, has shared information, issued guidance, and mobilized an international team to supply technical assistance to Mexico’s outbreak investigation.

US law requires the Secretary of Health and Human Services to declare a public health emergency in order to set Federal programs, policies, and resources into motion. Absent a confirmed HHS Secretary and surgeon general, the Secretary of Homeland Security (DHS) and a deputy national security advisor stepped in to support the acting CDC director, a trained epidemiologist, for the first-ever declaration for an outbreak. DHS Secretary Janet Napolitano, whose own department lacks key confirmed officials in health affairs and FEMA, continues to lead the domestic Federal response (diverging slightly from a National Pandemic Strategy on its maiden voyage). CDC, acting upon lessons learned during the 1976 swine flu outbreak, has reached out to the media daily to describe unfolding events and plans for releasing antiviral drugs to state authorities.

The US government’s slow recognition of an unfolding health crisis in a neighboring state raises serious concerns about intra-regional communication. Although Mexican authorities reportedly notified PAHO (the Pan American Health Organization, a WHO regional office that includes the US and Mexico) of an unusual influenza outbreak on April 16 or 17, they did not apparently share the information with visiting US officials. In 2006, the leaders of Canada, Mexico, and the US agreed to the North American Plan for Avian and Pandemic Influenza; its promises to strengthen communications among all three countries during potential pandemics have not been conspicuously fulfilled.

Although CDC serves as a WHO collaborating center and reference laboratory for influenza diagnosis, Mexican Federal health officials chose to send their samples to the National Microbiology Laboratory in Winnipeg rather than CDC. The reason? Easier paperwork, according to an April 26 article in the Washington Post. Whether this refers to the paperwork burden of the Select Agent Rules (put into place after the 2001 anthrax assaults to control access to specific pathogens in U.S. laboratories), CDC itself, or other customs demands, this claim bears further examination to determine the impact of U.S. regulations on the timely investigation of a potentially catastrophic outbreak, and on US access to partner nation specimens, information, and good will.

The numbers are likely to get worse before they get better, even if this outbreak burns out quietly as the northern hemisphere influenza season draws to a close in May. As public health authorities intensify surveillance for influenza-like illnesses, they will undoubtedly find them. Officials in affected communities may enact social distancing measures that include school, daycare, and public building closures. A private sector already strained by the economic downturn may be ill-prepared for absenteeism due to illness or lack of childcare. “Presenteeism,” sick employees showing up because they can’t afford not to, should also be anticipated where planning and resources fall short.

In the best case scenario, Mexican health authorities backed by the international community will contain the outbreak, which will not return with the fall flu season. It will leave questions: is the U.S. failure to notice an emerging health crisis in Mexico an exception, or a warning of more pervasive blind spots? How far can WHO stretch its experts – and its bare-bones budget – if faced with a pandemic and another simultaneous crisis? Will the developed and developing worlds willingly choose to soften the impact of agricultural, trade, travel, and environmental practices on the world’s health?

In the meantime, take the CDC’s advice: it never hurts to wash your hands.


Dr. Julie E. Fischer leads the Global Health Security program at the Stimson Center.

 

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