And another (Hanoi)

Now Hanoi. Xinhuanet says local media are reporting another confirmed case of bird flu is under treatment at the Tropical Disease Institute. That brings the total cases in Vietnam since late December to 21. The fifth case in a week.

Update, 3/1/05, 7 AM EST: Overnight, the Vietnamese government announced that the 21 year old man (victim number 18) has died. He had been on a respirator with a high fever. His 14 year old sister, the 19th case, remains hospitalized (HiPakistan).

Additional details on the new Hanoi case have also become available. She is a 35 year old refuse collector who was frequently seen collecting trash in the poultry markets, although she herself did not eat poultry. Tissue samples tested positive for H5N1 according to the director of the tropical disease unit at Bach Mai Hospital in Hanoi (AP via NDTV [Delhi, India]).

Update, 3/1/05, 9 pm EST: Confusion reigns regarding the vital status of the 21 year old brother of case 19 (case 18). The young man's doctors are denying the spokesman for the official statement of the health ministry that he had died on Sunday at the Tropical Disease Institute Hospital. Since the treating physicians are in a better position to know than the health ministry, we believe this patient is still alive, although reported to be gravely ill. It is a small morsel of good news, and perhaps only temporary, but we are grateful nonetheless. (Report from Agence France Presse [who first reported the death] via INQ7, Philippines).

Another new case in Thai Binh and the question of "clusters"

The 14 year old sister of the 18th case, originally reported as "negative" for H5N1 infection, has now been confirmed positive, according to both AFP and AP reports. Hospital officials say she has a serious lung infection but is not on a respirator. The 21 year old brother remains in critical condition. The siblings are from Thai Binh province, where a 69 year old man died last week. A 36 year old man from Thai Binh was reported as the 19th case this weekend. The family of the siblings did not raise poultry but there have been outbreaks in the area and they were said to have eaten chicken during the New Year holiday meal.

Thus there have been four reported cases from Thai Binh province in the last week. This raises the issue of "clusters" which I would like to discuss briefly. There is no technical definition of cluster in epidemiology. It is a word used to describe cases that seem to be related by some underlying factor, usually geographic area, time of occurrence or (most commonly) both simultaneously (a time-space cluster). A cluster may also be related to a common source (for example a restaurant meal) or contact with each other within specific time windows. The Thai Binh cases represent a cluster if you use "province" as a marker for some geographic factor, as Niman (Recombinomics) does here, or in the case of two of the siblings, family, which could represent either a common source (a holiday meal) or person-to-person transmission.

Familial clusters need not be time, space or time-space clusters. The well-known Thai person-to-person case reported in The New England Journal was none of these. The interpretation of human transmission depended upon the fact that the mother did not become ill after residing in the same area as her daughter or at the same time as her daughter. Thus a common source was eliminated. The timing of her illness, a suitable interval after her daughter's disease onset, also contributed to the interpretation of person-to-person transmission. This is all to say that the use of the word "cluster" in describing the bird flu cases in Vietnam or elsewhere may be confusing. The underlying question is whether the cases are related in some way besides contact with diseased poultry within the incubation period of their disease onset.

There is one final point about clusters worth mentioning. In a series of email communications with Dr. John Field, a physicist trained in quantum optics and atomic physics, he pointed out an analogy between cooperative phenomena that occur in laser action, liquid crystals, and a large variety of other situations in physics that involve "phase transitions." He is not the first to notice this and there is a small group of researchers who are attempting to apply a variety of mathematical techniques from cooperative phenomena and also from network theory, percolation theory and cellular automata to the problem of infectious disease spread. Without going into the technical details (which are quite interesting), Field notes that an early warning sign of an impending pandemic might not be the number of cases that appear or the number of clusters but the increase in the average size of the clusters that appear. This makes biological sense, since the size of the cluster should be related to the ease of transmission of the virus involved in that cluster.

In that regard, Field points out that some of the outbreaks that might be H5N1, like the Baguio meningo-like cases Niman has been discussing at Recombinomics, are potentially of great importance as early warning signs because they are large clusters. Ruling out H5N1 in these instances, especially as we now know that the virus can have an atypical presentation, should be a priority.

There has been no response to my Open Letter to WHO requesting confirmation or disconfirmation of several important questions, including that one.

Public health doctor sued over warning

If you aren't Australian you probably haven't heard of Gunns, Ltd., that country's "largest fully integrated hardwood forest prodcuts company." But if you are Australian and you care about forests, you've heard of Gunns. In particular, you've heard of them if you are a public health physician by the name of Dr. Frank Nicklason, a specialist at Tasmania's Royal Hobart Hospital, or if you are one of his 19 codefendants named in a $5 million law suit by Gunns for "damaging the companies business activities."

As related in a news story in the British Medical Journal (subscription not required)

Dr Nicklason said the case may stop doctors raising legitimate health concerns because of fear of being involved in prolonged and expensive legal action. He said that although the case would not silence him it had already affected the forestry debate, which is dividing Tasmania.

"It has succeeded in shutting other people up in Tasmania, mainly small local environmental and community groups," he said of the writ, which was served in December.

Dr Nicklason faces years of legal action and a damages claim of $A250 000 for calling for an independent risk assessment of large piles of woodchips in the port of Burnie. He made the call in 2002, as a spokesman for the non-aligned lobby group Doctors for Forests.

He said the Hippocratic oath required him to prevent illness not just in patients but in society as well, and he believed, after talking with experts, that the stockpiles of shredded wood on the wharf posed potential health risks to Burnies citizens.

His research showed that legionella bacteria, fungal organisms, and wood dust, all of which posed health risks, could have been in the stockpiles, some of which had been undisturbed for years. The local medical community, however, had said nothing.

The chairman of the Tasmanian Australian Medical Association said, quite correctly:

"In principle I feel that using the law to control the expression of concern about public health is wrong. If Gunns had any concerns they should have replied to Dr Nicklason with scientific arguments."

Bravo to Dr. Nicklason and his co-defendants. Tasmania is a long way away from most of us, but Gunns exports a wide range of timber products to overseas markets. If any reader knows of companies that sell Gunns products, we invite them to email us or use the Comments to alert other readers.

In addition, Gunns bought Tamar Ridge Wines in 2003. The wines are distributed by Robert Whale Selections, Ltd. in Washington, DC. You can email them at:

• Robert@robertwhaleselections.com;

and

• in Canada by Appellation Wines in Toronto (Ken.hayden@primus.ca);
• in the UK by Vinus Vita U.K. (St. Merryn, Henley);
• in Denmark by New World Vinimport (nwy@nwy.dk);
• in Finland by E. A. Hjeldt (eahjeldt@valdosta.iniet.fi);
• in Germany by Linke Weinhandellsgeschellschaft (linke-weine@t-online.de);
• in Ireland by TDL Distributor, Ltd. (John@tld.ie);
• in The Philippines by Zen Asia, Inc. (Zenasia@broadbandphilippines.net);
• in Singapore by Crystal Wines, Pty Ltd. (Whtan@crystalwines.com).

Feel free to drop the distributor in your area a line if you feel that Gunns has stepped over the line. There are lots of other great wines from Australia and New Zealand.

Vietnam, new bird flu death reported

Last night we reported a new confirmed case of bird flu in Thai Binh province (in the north). This morning comes word (via The Irish Examiner) of the death of a 69 year old man in the same province (death number 14 in Vietnam). Relatives say the deceased and his family had eaten a traditional chicken dish over the Tet Lunar New Year holiday. It is not clear if this is a previously reported infection or not.

The situation in Thai Binh bears watching.

No sense of a real emergency

The regional conference in southeast asia aimed at stemming the bird flu that has become endemic in the region is now over. With a few exceptions, the warnings were coming thick and fast, even as another human case was diagnosed in Vietnam.

“We at WHO believe that the world is now in the gravest possible danger of a pandemic,” the director of World Health Organization’s Western Pacific office, Shigeru Omi, told the conference.

“The health impact in terms of death and sickness will be enormous and certainly much greater than SARS,” he said, referring to an outbreak of severe acute respiratory syndrome that killed nearly 800 people two years ago. (AFP via Manila Times)

At the same time all concerned acknowledged that no one can predict if and when the feared pandemic will occur. As one expert said, it is like tossing a coin. But of the two ways we can get it wrong--not being prepared for an actual event versus preparing for an event that doesn't happen--it is clear which mistake is the one we prefer.

The outbreak of Highly Pathogenic Avian Influenza (HPAI) in poultry is unprecedented in its size and geographic scale. The virus has also mutated, increasing its host range to encompass mammals, including humans. Experts at the conference now say there is little hope of eradicating it from southeast asia any time soon, but strenuous efforts can still be made to control it by strengthening veterinary services, surveillance, research into how the virus is spread from bird to bird, what are its most important reservoirs in nature and what are its biological mechanisms of infection. The cost of this was put at between $100 million and $300 million. In an earlier post, we compared this sum to two days of the war in Iraq. The FAO's Vietnam representative Anton Rychenar, being more diplomatic regarding the UN's chief donors, still had an apt comparison:

“By the time the sun sets [on the three-day conference], the rich countries will have spent $3 billion to subsidize their farmers,” he said, referring to subsidies that amount to $1 billion a day. [my emphasis]

Asked how much he was hoping for, he said, “One percent of that is $30 million.”

And despite what some called the “alarmist” message of the Ho Chi Minh City meeting, “Many donor countries say they didn’t get a sense of real emergency,” Rychener said.

Maybe CDC Director Julie Gerberding should do more to promote that sense of urgency among her bosses. Or did I say that already? (here, here, here, here, . . . )

Lakoff - XIV: public health

[Preamble: This is one of a series of posts about the relevance of the work of George Lakoff for public health. First a disclaimer. My aim here is not an explication of all of Lakoff, or where he stands in cognitive science versus analytic philosophy, or whether there is a "there, there" as Gertrude Stein once wondered about Oakland (where Lakoff is now situated at UC Berkeley). It is rather to take some elements of Lakoff's writings (and I think genuine insights), and see how they might illuminate a central problem in public health, having a Central Problem. Posts will be relatively short, as befits the medium. PF is Lakoff's book, Philosophy in the Flesh (1999). MP is Moral Politics (2002)]

The Strict Father model for politics explains much about what ties the Conservative Agenda and its seemingly contradictory political positions together. It is one solution, but a very plausible one, to the puzzles Lakoff posed earlier (see Lakoff V). You can find his exposition of it in MP or Elephants.

But I admit to not feeling the same way about Lakoff's "liberal" counterpart, The Nurturant Parent. Nurturant Parent Family Morality takes as its foundation the infant's experience

. . . of being cared for and cared about, having one's desires for loving interactions met, living as happily as possible, and deriving meaning from mutual interaction and care.

Children develop best in and through their positive relationships to others, through their contribution to their community, and throgh the ways in which they realize their potential and find joy in life. Children become responsible, self-disciplined, and self-reliant through being cared for and respected and through caring for others.

[ . . . ]

Though this model is very different from the Strict Father model, they both have one very important thing in common. They both assume that the system of child-rearing will be reproduced in the child. (PF, p. 315)

One can recognize in Lakoff's formulation many liberal positions and attitudes, but the "family" model never seemed quite appropriate. Lakoff admits that the family model metaphor for politics is speculation on his part (see Lakoff XII). Because it worked so well for the nuclear family model I am myself speculating that Lakoff was seduced by the symmetry of having a comparable "family model" for liberals. But I don't feel it works as well as "glue" to keep liberal positions together as the Strict Father model does for conservatives. Moreover it imposes a particular social structure, The Family, onto politics that doesn't work for all settings. In particular I don't think it works for public health.

"Families" are local and individual and are imbued with notions of blood relationship. A natural inference (to use Lakoff's fertile idea of embodied reason) of blood relationship, consciously or unconsciously, is tribalism and its various forms: nationalism, religious identification, political sectarianism, etc. Would not a better metaphor for liberal thought be a "community" rather than a family? Communities are unrelated groups of people who recognize a common interest. Admittedly, one can blur the distinction by talking about The Family of Man, as Lakoff does at one point, but the most important feature of The Family of Man is that is not a real family.

I think it bears repeating here that the salient feature of public health, what sets it apart from clinical medicine, say, is that its subject matter is populations. Thus the polarity between populations and individuals is mirrored here as well. The difference between a clinician and a public health practitioner is not that individuals are treated or regarded differently but that in public health we don't treat individuals at all.

What I am suggesting, here, is two things. One, that the Nurturant Parent model makes it difficult for public health to "frame" its arguments adequately. It is a foreign landscape that treads too close to the enemy's own territory and risks confusion with problematic underlying companion metaphors. And two, that using the model of The Community or The Village or The Band makes more sense. In a setting where public health is a global enterprise, the only view that makes sense is the one that recognizes that "we are all in this together." I will try to develop this in subsequent posts, but in the meantime I welcome contrary views. Use the Comments.

[Links to previous posts in the sidebar]

Third Skeptics' Circle invites submissions

Thursday, March 5 is the deadline for submissions to the third-ever Skeptics' Circle, this week hosted by Radagast at his home at Rhosgobel. Revere participated in the second circle over at Orac's and it was great. Here's the idea, as conceived by St. Nate:

My vision is to create a carnival for bloggers who'd rather think critically than criticize thinkers. More specifically, some of the things I'm looking for are posts about:

* Urban legends and hoaxes. If you spotted an oft-reported story that doesn't hold up to critical thought, this is the perfect opportunity to let people what you found.

* Pseudoscience. Those who know their facts can take this opportunity to correct those who don't. Sean at Preposterous Universes shows how a good report can get misinterpreted by the mainstream media.

*Pseudohistory. Don't like the lessons we all should learn being denied or rewritten? Check out how Orac is continuing his long-running battle against Holocaust denial.

*Hysteria. We've all heard countless stories about what is the greatest threats in the world today are, so now it's time to hear why we can still count on the sun rising tomorrow. RealClimate does this well by examining a popular argument against global warming.

*Quackery. Any stories either about potentially harmful alternative medicines or misleading reports from medical news stories. Dr. Charles has a good example of how he works a little magic on his prescription pad to save a witch.

So if you have a story you'd like to contribute to the third edition of the Skeptics' Circle, send the permalink to rhosgobel2@comcast.net.

Here is the Skeptics' Circle archive page if you want to see the past editions.

Vietnam, 19th case

Another new case of bird flu has been confirmed in Vietnam, according to Xinhuanet.com. (PR China). The new case, a 36 year old male from the north (Thai Binh province) was confirmed as Vietnam's 19th case since December of 2004, according to a Saigon newspaper. The patient is hospitalized at the Tropical Disease Institute in Hanoi, the same hospital where the 18th case, a 21 year old male, lies gravely ill on a respirator. That previous case is now said to have eaten goose before his illness, although no details are yet available as to how long before his illness the meal was taken or if the bird was known to be sick. No information on what exposures the new case might have had to birds or other sources of infection is available at this time.

Thus after a space of three weeks where no human cases were reported, two have appeared in three days.

Bird flu on NPR

Yesterday (Friday, February 25) there was an informative 17 minute segment on NPR's "Science Friday" radio program in the US. Guests were Klaus Stohr of WHO and Tony Fauci of NIAID. Worth listening to. Link to get the streaming audio here.

The story is finally penetrating to the US media. There is a New Yorker story this week (which I haven't seen yet) and CNN, wireservices and other major media sources have covered it. About time.

Afraid of commitment

When last we saw the Atlanta-based databroker ChoicePoint, it had sent letters to 35,000 Californians alerting them that personal information had been inadvertently given to criminals bent on committing identify theft (some previous ChoicePoint posts here and here). But the problem was not limited to Californians. It was just that only California required notification. Now the company admits that the number of compromised individuals may be as high as 150,000 and that the leak occurred over a year's time. ChoicePoint knew of the problem in October but notified no one until January.

An excellent article in SFGate.com by David Lazarus contains more gory details:

As many as a dozen accomplices -- still at large -- are suspected to have been part of the scam. Among the information they obtained were people's credit reports, driver's license numbers, bankruptcy files and property records.

Investigators believe the perpetrators were in the process of changing the mailing addresses of at least 750 consumers -- a common first step before running up bills with fraudulently obtained credit cards.

[ . . . ]

ChoicePoint, based outside Atlanta, was created in 1997 as a spin-off from Equifax, one of the leading credit-reporting agencies. Its original purpose was to analyze claims on behalf of the insurance industry.

That mission evolved and expanded as ChoicePoint went on a buying spree, acquiring about 60 other firms with businesses ranging from data collection and background checks to DNA analysis and direct marketing.

ChoicePoint is now one of the leading data brokers in the country, acting as a sort of private intelligence service for both corporate and government clients (including the FBI).

The company had about $900 million in sales last year and is believed to have more government clients than its two main rivals, LexisNexis and Acxiom.

"Any interaction where you give up personal information can create an opportunity for them to obtain it and put it in their database," said Chris Hoofnagle, who heads the San Francisco office of the Electronic Privacy Information Center.

"You get arrested, you get married, you have a child -- ChoicePoint can get copies of the records and sell it," he said. "If you've ever had dealings with the government, they have information about you."

Bad news. So now there are calls for some federal oversight of what is essentially an unregulated business activity.

"ChoicePoint is not averse to regulation," Jones said. "ChoicePoint is in favor of a broad-ranging national discussion on this to make clear the parameters of the privacy-versus-security issue."

But he disputed charges that his company casts an unacceptably long shadow over the lives of virtually all Americans.

"That's one perception," Jones said. "But individuals who hold that perception are not cognizant of ChoicePoint's sincere commitment to a more secure society through responsible use of information."

OK. Now I'm "cognizant" of it. What about all the people they sold my personal information to? Do they share ChoicePoint's commitment? Like the thieves ChoicePoint gladly gave it to and now are upset because they won't get paid?

Maybe I'm just afraid of commitment. Read Lazarus's whole article. (hat tip: Dan Gilmor's blog)

Blogrollin' Friday: Majikthise

Well the post is on time this week, instead of a day late (and many dollars short) as in the previous two weeks. So here we go, obeying the injunction of PSoTD and using the space ordinarily reserved for cats and dogs in other blogs to highlight other blog wildlife that strikes our fancy. Community building, you know.

Surprisingly, today it's the turn of Majikthise. I say surprisingly because I can't figure out why I didn't do this right away since I read her blog almost every day and am never disappointed. As I look back I see my first choice for this space many weeks ago was James Walcott, whose stylish writing I admired. And it was through Walcott I discovered Majikthise because he admired her writing. If that's the criterion to get on his blogroll I guess I'll resign myself to not making it there, but I am more than pleased to direct others to Lindsay Beyerstein's Majikthise site. (That is if you don't know it already. Her blog is considerably bigger and more popular than this one, and deservedly so.)

Announced theme is "analytic philosophy and liberal politics" but that doesn't begin to describe the stuff you'll find there, all with a quirky twist. Recent posts: On Art Linkletter and Richard Nixon; Prescription Drug Advertising; Abstinence "Education"; new UN blog. Frequent science topics, especially public health and medicine. Enjoy.

Bird flu: a day late and a dollar short

The war in Iraq costs about $140 million per day. At a meeting of regional leaders in Ho Chi Minh City yesterday a UN Food and Agriculture Organization (FAO) official showed dismay that world governments have so far given a total of only $18 million to prevent bird flu from spreading and mutating into a devastating pandemic. Samuel Jutzi of the FAO said the attitude of donor nations like the US and others was that "[t]he problem is far away, so why should they invest in Indonesia or Vietnam.'' The virus is now endemic in the region so the costs of eradicating it are climbing.

Bird flu experts at [a] three-day meeting in Ho Chi Minh City say the virus has become so entrenched in parts of Asia that it will take many years to eradicate. The cost of a sustained effort to detect the virus, equip laboratories and vaccinate birds was now probably $300 million, Mr Jutzi said. (Reuters via Bangkok Post)

Even if the investment were made, it is not completely clear what strategy to employ. FAO and WHO are advocating campaigns that would in effect destroy the rural economies of the area and encourage large industrial poultry farms where modern "biosecurity" measures could be employed. Some believe this would have a devastating impact on the rural poor and stimulate the very conditions that allow Highly Pathogenic Avian Influenza (HPAI) viruses like the H5N1 strain to develop and spread. Bird vaccination is also debated since vaccines may produce enough protection to prevent disease but not enough to prevent infection. Thus the virus can circulate silently in the bird population and the usual tracking methods which look for antibodies to the virus will no longer work. The theory behind vaccination is that it greatly raises the dose needed to infect a bird and once infected the birds shed much less virus than unvaccinated birds. However there is some evidence that shedding can increase over time as the virus mutates. There is so little experience with vaccination as a means to control HPAI viruses that its use is a high stakes gamble. There is too much that we don't know at this point.

There needs to be a rapid and intense investment in closing important information gaps. That investment hasn't been and isn't being made. Currently some countries like Thailand are wary of vaccination because international regulations require the exporting country where vaccination is done to prove their birds are virus free, a difficult task if they have been vaccinated. Thus policy impedes vaccination. Now WHO is considering changing the regulations to allow export of vaccinated birds from special "disease free" zones (Reuters via MSNBC). This policy would encourage vaccination. Maybe this is a good idea, but one can envisage a future dilemma when we discover that the zones are not truly disease free (there will be strong disincentive to reveal infection) but the disease can no longer be detected.

Meanwhile, a possible Virus of Mass Destruction is gestating in southeast Asia, but our government isn't aware enough to invest the trivial sum (in Iraq War terms) that's needed.

We are indeed a day late and a dollar short. Or should I say, two years late and "two-days-of-the-War-in-Iraq" short.

Thanks for "keeping us safe," George.

Vietnam, 18th case

Xinhuanet (PR China) is reporting that a 21 year old male has been diagnosed with bird flu, confirmed, the newservice says, by the director of the Thai Binh Preventive Medicine Center. He is being treated at the Tropical Disease Institute in Hanoi and is said to be "facing difficulty in breathing." This is the 18th bird flu case in the current outbreak, not counting the Cambodian woman who died in Vietnam after crossing the border for treatment. The patient's 14 year old sister is also reported hospitalized with fever and is a suspect case. There is no information at the moment on exposure to infected birds.

This is the first reported case in Vietnam in three weeks. Thus the current outbreak, the third in Vietnam since 2003, is not over.

Influenza and bioterrorism: a note of caution

influenzapandemic.blogspot.com commented recently that the blogosphere is about dialog. I couldn't agree more. So here is an attempt to contribute to the conversation. Recently Recombinomics, Laurie Garrett and Philalethes over at Bouphonia have commented on the question of influenza and bioterrorism, a subject I believe was first raised by Henry Niman at Recombinomics (see posts here and here) in connection with the unexpected appearance of WSN/33 sequences in Korean swine influenza reported to GenBank in October of 2004.

Before this topic goes much further, let me sound a note of caution. Bioterrorism is an issue in this instance only because it shows that the huge amount of time, effort and money fed willy-nilly into the bioterrorism maw has bought us little of real substance. But it is not the main issue or even close to it, as I shall argue below. I have real discomfort raising the flag of bioterrorism whenever it suits us to raise the visibility of a problem. If we are going to beat up on public health officials and their political bosses (and we should when we see the need) it should be for the right reasons. This was an alarming episode, not because it revealed a chink in our bioterrorism armor (armor which doesn't exist and probably cannot exist), but because it raises the alarm about surveillance and our preparedness for influenza and other emerging infectious diseases. If the WSN/33 sequences in Korean swine escaped notice by everyone but the sharp-eyed Henry Niman, even in the midst of world-wide concern over pandemic influenza, then this is a genuine problem, but a problem about influenza, not bioterrorism. I commend Niman for alerting us to the problem, but I think raising the terrorism bogeyman in the process is not the right way to do it.

Let me quickly sketch my argument. The kind of sophisticated molecular biology we are talking about isn't done in an apartment in Hamburg or a ranch in Montana. It involves advanced technical expertise and sophisticated equipment. The experiments are not likely to work immediately, if ever, as any graduate student in molecular biology is only too aware. Terrorists have far more numerous "soft" targets and ready weapons at hand. Why would they bother with a long shot like this? Explosives are their weapon of choice and explosives spread more than enough terror. So a terrorist development of influenza as a bioweapon doesn't make any sense nor is it likely to succeed. Only a state-sponsored bioweapons effort could do this. But for the same reasons we are concerned about protecting ourselves against it, any state would have to worry about the "blow back" on their own troops or population. They could much more easily and successfully use one of the more likely agents like tularemia, Q fever or anthrax. They have no incentive to start an influenza pandemic. It doesn't make sense as a bioweapon in this case either, which is why the virus is not one of the Category A agents (nor should it be). This is not to say this couldn't have happened from a lab accident or even be the kind of clerical error WHO claims it to be. Lab accidents are worrisome. But these kinds of accidents proliferate with the proliferation of "anti-bioterrorism" research laboratories. And clerical errors or deliberate dysinformation could produce extremely difficult issues of another kind connected with our very concern for bioterrorism, as Laurie Garrett has so rightly suggested.

This is more than a quibble about words. Talk of bioterrorism itself has had a baneful effect on public health. The billions in federal dollars poured into the public health system has had the effect of severely rearranging and distorting priorities, to the point where routine public health activities are suffering severely. Recently I heard a public health leader describe "bioterrorism preparedness" as a cancer hollowing out public health from within. I couldn't agree more.

Bird flu on its own is a major public health problem looming on the horizon. We don't need to mix it with questionable issues that have the unintended consequence of hurting public health.

CDC's little corner of the world

If you were at this week's plenary session at the American Association for the Advancement of Science (AAAS) meetings in Washington, DC, you would have heard the head of CDC's influenza program, Dr. Nancy Cox, tell scientists that if the feared mutation in avian influenza A/H5N1 (bird flu) allowing the virus to pass easily from person to person comes about it could produce the worst pandemic in human history. And if you stayed to the next day you might have heard CDC Director Dr. Julie Gerberding tell the assembled audience that the current situation " 'probably' resembles the period before the 1918 Spanish flu outbreak when the virus was quietly mutating into a strain that would eventually leave 50 million people dead."

And if you stayed in Washington to the next day, again, and ambled over to the National Press Club, you would have heard the same CDC Director, Dr. Gerberding, tell the press establishment that ". . . the State of CDC is Great! and getting even better." In an address of over 3000 words, not one of them mentioned avian influenza.

Instead you would have heard a half hour's pep talk about how CDC was:

• establishing two Centers of Excellence in Health Promotion Economics devoted to defining the most cost-effective ways to achieve health impact (I'm thrilled)
  

• making efforts to find out what could have the biggest impact on health, efforts supported by the Administration and both Houses of Congress (makes you wonder about this one)
  

• hiring seven new Chief Management Officials to improve their service and accountability to internal and external CDC "customers," and their accountability to taxpayers for stewardship of our funds (thanks, Julie; I appreciate it. And with the extra $120 from my tax cut I'd like to buy some public health protection--because I know what to do with my money better than Washington)
  

And you would have heard that CDC was taking steps to assure that

"the budget is linked to the goals…and that ultimately everyone will be able to see our progress. This is truly a transformation change. Change for any organization does not come easily, and there will be many bumps in the road as we evolve. Nevertheless, we are committed, we are making progress, and we will learn as we go, and we will succeed." (I hope you learn enough before the virus mutates)

Returning to the day before her cheerleading gig at the Press Club, Gerberding told the scientists at AAAS that

"We have to have incredibly fast communication and we have to have, most importantly, fast action," she said. Currently the CDC can tap into medical data that's just days old, but "if this were SARS or avian flu," she added, "that would not be fast enough."

[. . . ]

"A problem in a remote corner of the world becomes a world problem overnight," she said. "A world problem quickly becomes a local problem, in every corner of the world."

Maybe she should alert her Boss. He doesn't seem to get it.

Lakoff - XIII: Strict Father

[Preamble: This is one of a series of posts about the relevance of the work of George Lakoff for public health. First a disclaimer. My aim here is not an explication of all of Lakoff, or where he stands in cognitive science versus analytic philosophy, or whether there is a "there, there" as Gertrude Stein once wondered about Oakland (where Lakoff is now situated at UC Berkeley). It is rather to take some elements of Lakoff's writings (and I think genuine insights), and see how they might illuminate a central problem in public health, having a Central Problem. Posts will be relatively short, as befits the medium. PF is Lakoff's book, Philosophy in the Flesh (1999). MP is Moral Politics (2002)]

Time to shove my bird flu and Taser obsessed Revere colleagues aside and return to our examination of George Lakoff's views and their relevance to public health. I noted in Lakoff XII that the Strict Father Family metaphor of politics has gained wide currency and seems to have impressive explanatory power. The details can be found at the Rockridge Institute site here. Some salient points:

The strict father's moral authority comes from his natural dominance and strength of character. His moral strength and self-discipline make him the fitting embodiment of morality, a model for his children.

[ . . . ]

Reward and punishment are moral in this scheme, not just for their own sake, but rather because they help the child succeed in a world of struggle and competition. To survive and compete, children must learn discipline and must develop strong character. Children are disciplined (punished) in order to become self-disciplined. Self-discipline and character are developed through obedience. Obedience to authority thus does not disappear when the child grows into adulthood. Being an adult means that you have become sufficiently self-disciplined so that you can be obedient to your own moral authority--that is, being able to carry out the plans you make and the commitments you undertake. (PF, p. 314).

Stated in this way it is easy to see George Bush, fascism and the cold-hearted attitude of conservative Republicans shining through. But Lakoff makes another important point: all of us, to some extent, buy into and approve of various versions of this. It is part of our culture. Thus when a black pro-football player buys his mother or grandmother a house in gratitude for the "tough love" she gave him as he was growing up in the mean streets of wherever, we nod in approval. Or when we liberal academics hold our students to strict standards of scholarship, instill notions of intellectual self-reliance and punish transgressions like cheating or plagiarism with the academic death penalty (dismissal), we are acting like the strictest of Strict Fathers. We may not transfer this to our politics, but we all understand it at some basic level. And it his further point that we need to "reframe" the discussion to make it congruent with our own liberal model of the family.

How did the Nuclear Family become the dominant political paradigm today? Lakoff doesn't say, but he implies that "Family" metaphors are somehow basic and pre-existing political models in our culture. I think this is an empirical question that awaits historical study, but I am aware that the "nuclear family" is not a historical constant, even in this country. It is clear, however, that the right wing has vigorously promoted the nuclear family as an Ideal over the last 30 years, taking one model among many and somehow elevating it to the dominant one. (Digression: Before the 1980s I do not remember hearing anything about "family values." Family values seem to have popped up at exactly a time in our history when the nuclear family and things related to it have begun to crumble. I suspect this is not an accident. Indeed, one can view the worldwide rise of Fundamentalism as a reaction to the inevitable power and force of modernization in a similar light. But this is a matter for another discussion.)

Family models acquire their power from their primary metaphor components, building blocks related to well-being and survival. Lakoff contrasts the Strict Father conservative family model with the Nurturant Parent liberal family model. What I want to ask here is whether Lakoff's "family model" metaphor for politics is suitable and appropriate for public health. I will argue next that it is not.

[Links to previous Lakoff posts on sidebar to left]

This week in Tasers

Houston, Texas: A 52 year old psychiatric patient with a heart condition died after being hit with a Taser by constables from a mental health unit, executing a "mental health commitment" warrant. "A person with heart problems should never be Tasered," [the Chief Deputy] said. "We would have handled it a lot different if we would have had better information." (Houston Chronicle)

Toledo, Ohio: A 41 year old man died in the Lucas County jail after he was shocked nine times. "[N]o policy violations were committed and no charges would be filed" according to an AP report in the Chicago Tribune. Toledo police have suspended their use of Tasers until more safety studies are done.

Orlando, Florida: To round out the week in real Taser style, an off-duty police officer patrolling Universal Studios Theme Park Tasered a 45 year old disabled man, Christopher Traub, who was visiting (fittingly enough) Halloween Horror Nights as part of a family reunion (local6.com via Officer.com).

Traub, who had both of his ankles crushed in an elevator accident in the '80s, said during his visit to the theme park, he was abused by police and shot with a Taser gun, according to the report.

"I just couldn't believe what happened," Traub said. "I was like, one minute we were at a park and happy, and the next minute, I'm on the floor and I hit my head."

An off-duty Orlando police officer working security at the theme park literally blew Traub off his feet, Local 6 News reported.

"He pulled out his Taser gun and shot me," Traub said. "I was 4 feet away from him on the other side of the ropes."

Tom Luka, who is representing Traub in a possible legal case against Universal Studios, said his client was just trying to reason with the officer to keep his son from being kicked out of the theme park before he was shot with the Taser gun.

"He used brutal force against a man who could not even defend himself," Luka said. "He (Traub) posed absolutely no threat to this officer. This officer turned around, pulled his Taser and shot him once in the chest."

Traub was thrown into a beverage stand and cut his head, nose and eye, according to Luka. He was reportedly refused any medical treatment, Local 6 News reported.

[ . . . ]

Orlando police say the officer in this case has not been disciplined and even though he was "off-duty," by law, he is still authorized to use his Taser gun.

Universal Studios says they often hire police to patrol the park and have no plans to change their policy to prevent off-duty officers from using Taser guns against other Universal customers, according to the report.

One gaffe does not a Summers make

The "Larry Summers" show is still reverberating around the Main Stream Media and the blogosphere (for one of many accounts and some pertinent links, see this post at Majikthise). The wingnuts and their MSM fellow travelers are portraying him as the intellectually honest but innocent academic who got his weenie caught in the Political Correctness door (presumably Ward Churchill is not worthy of such solicitude). Poor guy. Lest you feel too sorry for him, though, consider a little bit of Larry's prior history, courtesy of the sadly hilarious site, The Whirled Bank Group: Dedicated to a World Full of Poverty.

Here is the full text of a leaked memo from the World Bank's Chief Economist in 1991, one Lawrence Summers:

DATE: December 12, 1991
TO: Distribution
FR: Lawrence H. Summers
Subject: GEP

'Dirty' Industries: Just between you and me, shouldn't the World Bank be encouraging MORE migration of the dirty industries to the LDCs [Less Developed Countries]? I can think of three reasons:

1) The measurements of the costs of health impairing pollution depends on the foregone earnings from increased morbidity and mortality. From this point of view a given amount of health impairing pollution should be done in the country with the lowest cost, which will be the country with the lowest wages. I think the economic logic behind dumping a load of toxic waste in the lowest wage country is impeccable and we should face up to that.

2) The costs of pollution are likely to be non-linear as the initial increments of pollution probably have very low cost. I've always though that under-populated countries in Africa are vastly UNDER-polluted, their air quality is probably vastly inefficiently low compared to Los Angeles or Mexico City. Only the lamentable facts that so much pollution is generated by non-tradable industries (transport, electrical generation) and that the unit transport costs of solid waste are so high prevent world welfare enhancing trade in air pollution and waste.

3) The demand for a clean environment for aesthetic and health reasons is likely to have very high income elasticity. The concern over an agent that causes a one in a million change in the odds of prostrate cancer is obviously going to be much higher in a country where people survive to get prostrate cancer than in a country where under 5 mortality is is 200 per thousand. Also, much of the concern over industrial atmosphere discharge is about visibility impairing particulates. These discharges may have very little direct health impact. Clearly trade in goods that embody aesthetic pollution concerns could be welfare enhancing. While production is mobile the consumption of pretty air is a non-tradable.

The problem with the arguments against all of these proposals for more pollution in LDCs (intrinsic rights to certain goods, moral reasons, social concerns, lack of adequate markets, etc.) could be turned around and used more or less effectively against every Bank proposal for liberalization

The Whirled Bank site adds this Postscript:

After the memo became public in February 1992, Brazil's then-Secretary of the Environment Jose Lutzenburger wrote back to Summers: "Your reasoning is perfectly logical but totally insane... Your thoughts [provide] a concrete example of the unbelievable alienation, reductionist thinking, social ruthlessness and the arrogant ignorance of many conventional 'economists' concerning the nature of the world we live in... If the World Bank keeps you as vice president it will lose all credibility. To me it would confirm what I often said... the best thing that could happen would be for the Bank to disappear." Sadly, Mr. Lutzenburger was fired shortly after writing this letter.

Mr. Summers, on the other hand, was appointed the U.S. Treasury Secretary on July 2nd, 1999, and served through the remainder of the Clinton Admistration. Afterwards, he was named president of Harvard University.

Bird flu "Sword of Damocles"

Joseph Domenech, Director of Animal Health at the Food and Agriculture Organization (FAO) likened bird flu to the sword that hung above the flatterer Damocles as he ate a sumptuous banquet. The sword was suspended by the most delicate horsehair. It did not improve Damocles' appetite, nor did the image seem to appeal to the assemblage of experts in Ho Chi Minh City, Vietnam this weekend discussing the threat of avian influenza. Interestingly, Domenech said the sword not only hung over public health but over rural economies. Considering that the FAO has advocated policies that themselves endanger rural economies by encouraging factory farming, it is hard to know what to make of this statement.

Domenech warned that countries that are claiming victory now over the disease are likely incorrect. There remain many unknowns, including the relative importance of commercial versus migratory bird movements internationally. But efforts to combat the disease cannot be relaxed.

That is exactly what Thailand seems to be doing, to the dismay of some in its own government. The Independent reports that the emergency plan proposed by Thailand's Deputy Prime Minister to cull ten million ducks and chickens and distribute face masks has been shot down on the grounds it would alarm the public.

Thailand's decision not to act, the personal initiative of its Prime Minister, Thaksin Shinawatra, marks the second time in two months that it has failed to take life-saving action in the face of a looming disaster. On Boxing Day, it was one of only two Indian Ocean countries to receive an immediate warning of the tsunami. But it failed to relay this to its coastal people or to tourists on the beaches until long after the wave hit. Experts suggested that the warning was delayed because it might damage tourism.

The contrast is with neighboring Vietnam, where 1.5 million birds have been culled or killed by disease since December and where raising poultry has been banned in the capital. These Draconian measures have slowed but not stopped the disease there.

The most disturbing news, however, comes from CDC's Dr. Nancy Cox, head of the influenza division, speaking at the AAAS meetings in Washington, DC:

"We found that for the 2003 virus, the virus had actually changed its receptive binding or its ability to bind to the receptors that are in human cells," she said.

"This shows that the virus can actually change in such a way, or has actually changed in the past in such a way, that might make it more easily transmitted from person to person." (BBC via ABC.Net [Australia])

The information that the hemaglutinin receptor binding site has altered is, as far as we know, completely new and ominous. We need to hear the details. CDC should make them available at once.

Mercury: Clear Lies

Impact Analysis is doing a super job of keeping on top of the Clear Lies - Mercury story, some of which we noted here. Our post was a notice that the House Resources Committee (RNC RC) had issued a Report alleging the mercury "problem" has been overstated by scientists. Impact Analysis (IA) has a good deconstruction of the attempted destruction of science by the RNC RC. Go over and read it if you have a strong stomach. The IA analysis alerts us that the likely source (.pdf!) of the "report" is the right-wing funded "don't-think" tank, Frontiers of Freedom, whose patrons include Exxon-Mobil.

Now we find that on the Senate side, notorious political hack James Inhofe (Oklahoma Republican Senator representing the oil industry) has asked to see the financial and tax records of two associations of state air pollution regulators who testified in front of his kangaroo court Committee opposing the Bush Administration Clear Skies Lies bill that would allow continued mercury emissions from power plants.

The committee's majority staff director, Andrew Wheeler, said the request for the groups' documents did not stem from their criticism of the legislation. He said the panel wanted to determine whether the groups represented only regulators' views or whether they also were subsidized by outside interests, including environmentalists or foundations.

The funding, Wheeler said, "goes to who they're speaking for."

Did I just hear someone say "hypocrite"?

"How we doin' ?"

Former Mayor Ed Koch of New York used to greet voters on the street with that famous phrase (too bad he never asked me; I'd tell him he was an asshole). It's a fair question. Earlier we posted on the cost in lives to Iraqis. Enough about them. What about us? (from Chris Bowers over at MyDD):

More soldiers have already died in February of 2005 than in February of 2004.
More soldiers died in January of 2005 than January of 2004.
More soldiers died in December of 2004 than December 2003.
More soldiers died in November of 2004 than November of 2003.
More soldiers died in October of 2004 than October of 2003.
More soldiers died in September of 2004 than September of 2003.
More soldiers died in August of 2004 than August of 2003.
More soldiers died in July of 2004 than July of 2003.
More soldiers died in June of 2004 than June of 2003.
More soldiers died in May of 2004 than May of 2003.
More soldiers died in April of 2004 than April of 2003.
March looms.

Source for above statements. The same goes for wounded soldiers.

Daily coalition fatality rate before Saddam Hussein's capture: 2.03
Daily coalition fatality rate after Saddam Hussein's capture: 2.55

Daily coalition fatality rate before the transfer of power away from the CPA: 2.09
Daily coalition fatality rate after the transfer of power away from the CPA: 2.8

"How we doin' ?" indeed.

Blogrollin' Friday, Saturday edition: The Skeptics Circle

Once again, a day late and a Euro short. This week I invite everyone to visit The Skeptics Circle, second edition. You will find a contribution by Revere there (a post from December). It is hosted this time around by Orac at Respectful Insolence, a site well worth regular visits independently of the aforementioned event. I like the site despite the fact that its template is overdone and Orac is a surgeon.

Stockpiling bird flu vaccine

New Scientist has reported that WHO is changing its position regarding stockpiling of H5N1 vaccine prior to influenza season. The story quotes Klaus Stöhr, chief of WHO's Global Influenza Programme: "When we realised H5N1 is not going to be eradicated in poultry in Asia for at least another couple of years, that made the risk of H5 much higher." Ordinarily WHO advises waiting until there is better information regarding which strain of flu is responsible for a pandemic.

A follow-up to this story by the Center for Infectious Disease Research and Policy (CIDRAP) confirmed WHO will shortly advise member states regarding the advisability of stockpiling vaccine in advance of a pandemic, although WHO did not characterize it as a major policy shift:

"There is a paper which WHO has been developing, which looks at the pros and cons of stockpiling H5N1 vaccine," Thompson told CIDRAP News in [an] e-mail message. "The paper, which will be formally published in about 4 weeks time, states that those which can (wealthy countries) may want to consider stockpiling H5N1 as part of their larger flu pandemic preparedness as it could serve as part of a first response."

But he said the paper also describes three disadvantages of stockpiling: H5N1 may not match the pandemic strain, the vaccine's shelf life of up to 2 years is relatively short, and, because companies have not yet begun clinical trials, licensing of the vaccine is months away.

It is thought that for strains like H5N1, not previously encountered by human populations, two shots may be necessary. It is thus possible that a "generic" (not perfectly matched) H5 vaccine might still provide partial protection and serve as a priming stimulus for a second shot which would provide full protection.

However, even getting this kind of a head start will be difficult as there is little production capacity given the size of the global population. The US plans to stockpile 4 million doses but so far only half has been produced by the US firm of Sanofi-Pasteur (formerly Aventis-Pasteur). Amazingly, the US turned its order for the other half over to Chiron, the company that sent half of this year's influenza vaccine down the chute when its plant in the UK became contaminated. That pilot factory, at the same site in Liverpool, cannot start to make the genetically engineered viruses until the contamination problems at the regular vaccine plant are fixed. Jeez.

Meanwhile some limited safety and dose ranging trials are set to start in the US with the H5N1 strain now circulating in Asia. Similar trials are planned for Japan, Australia and the Netherlands. The New Scientist notes there is some disagreement among experts as to whether stockpiling H5 vaccine, or stockpiling antivirals like oseltamivir (Tamiflu), is the proper route to take, although for oseltamivir, too, production capacity is limited.

It seems clear to us that governments should be taking every available route as quickly as possible. If some vaccine or antivirals go to waste, so much the better because it will mean there is no pandemic and we have more time to prepare. What is distressing is the failure to work out flexible and reasonable licensing agreements with the pharmaceutical companies, for either vaccines or antivirals, so that more production facilities can be constructed and put into operation in more places, more quickly. In the current situation, stocks of vaccine or antivirals will be grossly inadequate in the event of a pandemic, with existing supplies likely available only to wealthy developed nations.

No way to prepare for a potential global public health catastrophe.

Rep. Richard Pombo, R-Calif., future science great

Remember this name: Rep. Richard Pombo, R-Calif.

I'll say it again: Rep. Richard Pombo, R-Calif.

Once more: Rep. Richard Pombo, R-Calif.

A panel of House Republicans, chaired by - - Rep. Richard Pombo, R-Calif. -- has concluded that the dangers of mercury pollution have been overstated.

"After an exhaustive review of all the science surrounding the mercury debate, it is clear that some special-interest groups are crying wolf," said the panel's chairman, Rep. Richard Pombo, R-Calif. (SFGate)

How does Rep. Richard Pombo, R-Calif. know? Because if it isn't overstated, then Rep. Richard Pombo, R-Calif. defense of the Bush Administration against charges it is gutting mercury emission rules from power plants (see previous post) is in trouble. The Bush Clear Lies Skies bill comes up for a vote shortly. Hence the importance of the scientific "discovery" by -- Rep. Richard Pombo, R-Calif. -- a discovery that overturns the outmoded theories of the FDA, EPA and numerous state agencies across the country.

Like all great scientific pioneers -- Rep. Richard Pombo, R-Calif. -- will be unfairly vilified by the world of conventional science, until such time as a future generation, despite brain damage by mercury poisoning in the womb, will recognize him for what he truly was -- Rep. Richard Pombo, R-Calif.

Influenza planning at the local level

We have been pretty critical here about the degree to which CDC is getting the ready for a possible influenza pandemic, so it is nice to report something good, although modest. The CDC's Cities Readiness Initiative hands out money to local health departments to figure out ways to get self-administered medicines (like antibiotics or antivirals) quickly to the population. Designed for "bioterrorism" it would work equally well for delivering antivirals like oseltamavir (tradename Tamiflu). Of course that assumes there is Tamiflu to deliver, which at the moment doesn't seem to be the case, so while CDC and the cities are working on a delivery system, if there isn't anything to deliver . . .

Anyway, a story in the Seattle Post Intelligencer has some interesting details on what Seattle is doing with its $830,000 grant (equivalent to how many minutes of Iraq War? Nevermind.) One aspect of the plan is to use lettercarriers to deliver medicine. They know the neighborhoods and the system itself is a distribution system for letters. But Seattle's Health Commissioner, Al Plough, is also considering other possibilities:

"Rather than having a postal worker going to each home, and no one being there, we might have a large number of small neighborhood sites" where people could go to pick up medications from health care providers who could teach them how to properly use them, said Plough.

Such protocols have grown out of local preparation for the possibility of an influenza pandemic, which Plough calls much more likely than a bioterror attack. "If you're ready for that (influenza pandemic), you're ready for anything."

Michael Loehr, Public Health's preparedness manager, said that rather than being completely reliant on the CDC strategic stockpile of medicine, the department would draw on local sources such as hospital pharmacies and regional drug wholesalers in King County.

A couple of things about this deserve mention. First, the recognition that in the event of a national/global influenza pandemic, it will be up to the local communities to deal with it. They will be pretty much on their own and they need to start getting their act together, as Seattle is doing. Second, Plough's statement that if you are ready for the (much more likely) event of an influenza pandemic, you are pretty much ready for anything (including a bioterrorist attack) is right on target. So why, then, does CDC have it backward: preparing for an influenza pandemic by preparing for a bioterrorist attack? They are not the same thing and the resources you use for one are not the same as for the other. In this case there is some overlap, but how much better prepared could we be if we actually set out to prepare for influenza rather than reap any benefits as a biproduct. Third, there is a great deal of ingenuity, resources and desire to help at the local level that could be tapped. Organizing "neighborhood sites" for distribution is one example. Hotels could be used as temporary hospital beds, retired nurses and doctors could be pressed into service, and Visiting Nurses could serve some patients in their houses.

But these things take some advance planning. There is too little of it being done and some of it is being done for the wrong objectives. The CDC public health commanders are still fighting the last war. Of course, consider who the General Staff is.

Bird flu: neurotropic and underestimated?

This week's New England Journal of Medicine reports on two Vietnamese bird flu cases of a year ago. What was unusual was the initial presentation was not fever and respiratory symptoms but gastrointestinal (diarrhea) and coma. The deaths of the two children, a boy and a girl, were first classified as encephalitis. H5N1 was recovered from the boy's feces, giving rise to another route of person-to-person transmission not previously contemplated. As noted in press reports, the authors warned (via Bloomberg):

"Clinical surveillance of influenza H5N1 should focus not only on respiratory illness, but also on clusters of unexplained deaths or severe illnesses of any kind,'' Menno de Jong, a virology researcher who led the study, wrote with colleagues. "These cases have important clinical, scientific and public health implications.''

The NEJM report is also highlighted in a news article from the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota:

"These cases emphasize that avian influenza A(H5N1) should be included in the differential diagnosis of a much wider clinical spectrum of disease than previously considered and that clinical surveillance of influenza H5N1 should focus not only on respiratory illnesses, but also on clusters of unexplained deaths or severe illnesses of any kind," the [NEJM] report states. "Awareness of the full clinical spectrum is essential to appropriate management of the illness, since treatment with antiviral agents is likely to be beneficial only when it is started early in the course of illness."

CIDRAP goes on to give some details from the NEJM report (which is subscription only):

Both children died in hospitals in southern Vietnam in February 2004, the article says. The 9-year-old girl arrived on Feb 1 with a 4-day history of fever, watery diarrhea without blood or mucus, and increasing drowsiness. She had no respiratory symptoms, and her chest radiograph was clear. She became comatose and died the following day; acute encephalitis of unknown origin was listed as the cause. Her body was not autopsied.

The girl's little brother was admitted to the same hospital in Dong Thap province on Feb 12, 2004, having suffered fever, headache, vomiting, and severe diarrhea for 2 days. A chest radiograph was normal.

Within days, his diarrhea and stupor worsened. He was transferred to a hospital in Ho Chi Minh City on Feb 15 but fell into a coma within 12 hours of the transfer. By Feb 16, a chest radiograph showed bilateral infiltrates. He died the next day, with acute encephalitis reported as the cause. No autopsy was performed, but samples were taken for an ongoing study of the causes of acute encephalitis.

When researchers examined those samples at different times over the succeeding months, they ruled out several possible causes before they found the H5N1 virus in the boy's throat, rectal swabs, serum, and cerebrospinal fluid.

It is reported WHO is now in the process of changing its case definition of bird flu to take into account the new findings. The lead researcher in the NEJM paper, Dr. Menno de Jong, said that

"[i]t appears this virus is progressively adapting to an increasing range of mammals in which it can cause infection, and the range of disease in humans is wide and clearly includes encephalitis." [snip]

Dr Jeremy Farrar, director of the Wellcome Trust's Vietnam unit, said [to the BBC]: "This latest work underlines the possibility that avian influenza can present itself in different ways.

"The main focus has been on patients with respiratory illnesses but clearly that's not the only thing we should be looking for.

"Therefore the number of cases of H5N1 may have been underestimated."

This is confirmation of the warnings that Henry Niman at Recombinomics has been sounding for some time, reiterated yesterday here, here and here.

It is also the kind of development we called on WHO to acknowledge with some public information regarding the Philippine meningo-like cases they investigated and the definition of person-to-person transmission in case clusters in our Open Letter of February 16, 2005.

We are still waiting for a response.

Something else for my dossier

As if there's probably not enough in it already, here's something else to put in my personal dossier: a critical post about the commercial company who keeps a dossier on me (and you).

In an earlier set of posts we talked about President Bush's desire for every American to have his or her own electronic medical record. In another piece we noted that the redoubtable Taser International, Inc., about whom we have developed some kind of shocking obsession, was trying to reassure everyone that when it sold its stun guns to the public it would be doing background checks on them to make sure that everyone who bought one was who they said they were ("Here's your package, Mr. Manson. Have a nice day.") and didn't have a criminal background (Bush Administration exclusion applies). How were they gong to do this? Through the Atlanta-based firm, ChoicePoint, Inc.

Now MSNBC reports that the folks with a criminal background have the last laugh, stealing (at least) tens of thousands of personal dossiers from ChoicePoint. Now the criminals have your name, address, Social Security number, credit reports and such other information as is in your personal record, or at least we know they have them for some 30,000 plus Californians whom they have notified, as required by California law. If you live in any other state, there is no such requirement that you be notified, so I guess you weren't notified. Were you.

ChoicePoint reportedly has 19 billion records (yes, billion), covering virtually every US citizen (as reported by SFGate). They sell personal information to 40 percent of the nation's top 1000 companies and have contracts with 35 government agencies, including law enforcement.

It must be heart wrenching for them to have released personal information to people without even the common decency to have paid them for it.

An Open Letter to WHO

The following letter has been sent to WHO via email at the address of the WHO Global Influenza Programme. Their email address is: whoinfluenza@who.int

We suggest readers similarly concerned email WHO at that address.

Open Letter to WHO

Public health is a global enterprise, transcending national and political boundaries. As an international agency WHO has understandably been oriented to its member states and their public health authorities. Now, due primarily to new communications technologies like the internet, the nature and composition of technically competent and concerned individuals and communities has enlarged dramatically. A new kind of virtual public health community exists and needs to be taken into account.

In such a setting, it is important WHO recognize that information can circulate requiring corroboration, disconfirmation or a status report if misunderstandings are to be avoided. To be more concrete, three issues related to the public health aspects of avian influenza A/H5N1 have become the subject of discussion via email or various websites. Each would benefit from a statement by WHO:

i. What are the criteria by which statements regarding possible person-to-person transmission of H5N1 are made in the face of evidence that initial testing produces some false negatives? In particular, what does WHO know about the negative predictive value of the diagnostic tests now in use in Thailand and Vietnam where time-space clusters of cases have been reported?

ii. The Recombinomics website (http://www.recombinomics.com) raised the possibility that in a number of instances certain events could conceivably represent H5N1 infections. These include the meningo-like outbreak in the Philippines and reports of sudden bird deaths in North America. There was no claim these were H5N1 infections, only the reasonable question whether anyone had thought of the possibility and bothered to verify it or not. It was announced that WHO sent a team to the Philippines to investigate the outbreak there. Given the level of concern regarding an H5N1 event, a response from WHO would be useful.

iii. Recently there has been some discussion, both on the Recombinomics site and via email, about influenza A/H1N1/WSN/33 sequences in Korean swine influenza A/H9N2 reported to GenBank in October 2004. There are rumors that WHO has looked into this and resolved the issue. If this is true, a statement to that effect is necessary. Because of the gravity of the implications, we believe some public explanation is required.

We urge WHO to recognize the new setting regarding public health information generation and dissemination and act accordingly. Failure to do so will only create confusion where clarity is desperately needed.

The Editors (phrevere@gmail.com)
Effect Measure
http://effectmeasure.blogspot.com

CNN and the Eason Jordan thing

I don't like to see anyone lose their jobs (OK. There are some exceptions.) But this Eason Jordan thing over at CNN is really too much. I know I'm supposed to defend him because he was the victim of a right-wing vigilante blogger mob. But it is hard to defend someone who won't properly defend himself. So first I'll defend what he had to say, then I'll attack him.

Jordan got in trouble for suggesting (what he actually said is a matter of dispute) during an "off the record" session at the World Economic Forum in Davos that the US military intentionally or perhaps without due care, targeted journalists in Iraq. What a gaffe. Imagine. Except that you can make a pretty good case it's true in some instances (see here and here). What he said had some foundation and he should have pushed it for all it was worth. He didn't. Instead he resigned:

I have decided to resign in an effort to prevent CNN from being unfairly tarnished by the controversy over conflicting accounts of my recent remarks regarding the alarming number of journalists killed in Iraq. I have devoted my professional life to helping make CNN the most trusted and respected news outlet in the world, and I would never do anything to compromise my work or that of the thousands of talented people it is my honor to work alongside.”
– Eason Jordan LINK-ABC News via The American Street.

My main reaction: "Give me a fucking break!" CNN, the most trusted and respected name in news? In their dreams. Everyone else knows this is a bunch of low wattage hacks (think Wolf Blitzer and Kelli Arena). Here's an example of recent CNN "journalism," via CJR:

Last week, The Brad Blog informs us, the good folks at CNN.com posted a photo of a nuclear plant in North Korea. Also last week, CNN.com posted a photo of a nuclear plant in Iran. A Brad Blog tipster with an eagle eye took a good look at the photos and noticed that they seem to depict the same facility. (You can see for yourself here) [EM: Do take a look. It is pretty unbelievable] An exasperated Brad wants to know where the photos came from -- perhaps, he writes, someone who "may have an interest in ginning-up fears over the two so-far unconquered players in Bush's 'Axis of Evil'" was responsible -- and asks: "Are there simply no national media organizations left who know how to do the job of reporting accurately, responsibly and in such a way that doesn't send us to war again due to their utter failure to do their jobs correctly?!"

Hey, CNN. Thanks for that twit Tucker Carlson. Thanks for Bob Novak. We can rely on you, all right. And so can the Bush Administration.

I agree with Eason Jordan about one thing. It's a shame to see CNN unfairly tarnished for something they should have been proud of (but of course, weren't). Let's see some fair tarnishing about all the other stuff they have to answer for.

Bird flu news: bad, good, bad?

Recombinomics (welcome back after a short hiatus) and others are reporting a new suspect human case in Thailand. This is a little boy (6 years old) with a history of recent contact with sick poultry. This follows another suspect case of a 7 year old boy with lung involvement, fever and also a history of recent contact with sick poultry. A test for H5N1 was reportedly negative in that case, but Henry Niman raises again (as he has in the past) the real possibility that false negatives are occurring with some frequency. This is an extremely important question that deserves serious consideration by authorities at WHO, in Thailand and in Vietnam. To date, Niman seems to be the only one to have addressed this. Official silence. Niman also reports further poultry outbreaks in Thailand, many near the suspect cases.

At the same time, Vietnam is implying an impending victory over bird flu in their country. No new cases were reported over the Tet New Year celebrations and the number of provinces battling the disease in poultry has decreased.

"The situation is much better compared to the days before New Year," said Bui Quang Anh, head of the agriculture ministry's animal health department.

Seven of the country's 34 provinces and cities that were fighting the disease had not registered any new cases in poultry for 21 days, he said.

Four people who had been admitted to Hanoi's Bach Mai hospital with the disease had been discharged, he added.

"Thanks to these good results, we will keep doing our best to control the epidemic in February or March by maintaining the strict prevention measures already in force," Anh said.

But WHO is warning against complacency, noting that the disease is now firmly entrenched in southeast asia and will likely recur.

"It is mainly an agricultural issue. Not only it is a matter of getting rid of the virus but also to change the structure of the poultry production," [the WHO representative] said.

"If we don't do it and if we get complacent, I promise you we will see it happening again in six months or one year."

Just what it means "to change the structure of the poultry production" is unclear. We have reported here (and links above it in sidebar) the warnings of Ron Nigh that it may be the very changes in poultry production such a policy would promote that are responsible for the outbreak in the first place. Like a number of issues, the effects of agribusiness on bird flu are going unaddressed or possibly made worse.

It is worth remembering, too, that Vietnam declared victory twice last year. I guess you could say those claims were "premature."

Who needs CNN?

Who needs CNN when you can have Odor Screen, an Olfactory Perception Altering Compound for professionals and private consumers. Odor Screen bills itself as just the ticket to "alter the perception of burnt flesh, decomposing flesh [and] infected wounds."

It can be reapplied as necessary - with no limit. No known side effects.

No known side effects? Wow. That's even better than Wolf Blizter!

Drugs unsafe in Canada are safe here (and vice versa)?

The FDA doesn't want you to buy prescription drugs in Canada because it can't be assured they are safe.

I guess Canada feels the same way about FDA approved drugs sold in this country. Health Canada has suspended the sale of the ADHD drug Adderall XR because of concerns over 14 deaths in children and six deaths in adults.

Health Canada says that it instructed Shire BioChem Inc., the manufacturer of Adderall XR, to withdraw the drug from the Canadian market. Health Canada is advising patients who currently are being treated with Adderall XR to consult their physician immediately about use of the drug and selecting treatment alternatives.

Health Canada's decision came after a thorough review of safety information provided by the manufacturer, which indicated there were 20 international reports of sudden death in patients taking either Adderall (sold in the United States, not in Canada) or Adderall XR (sold in Canada).

These deaths were not associated with overdose, misuse or abuse. Fourteen deaths occurred in children and six deaths in adults. There were 12 reports of stroke, two of which occurred in children. None of the reported deaths or strokes occurred in Canada. (Health Daily)

The US FDA, on the other hand, thinks continued sale is just fine for American consumers. FDA reviewed the same data as Health Canada, but, "based on [its] own knowledge and assessment of the reports. . . felt that no immediate changes were warranted in its labeling or approved use . . . ."

To which, the FDA adds:

Patients using the drug (or parents of children taking it) who have questions should consult their physicians before making any alterations to their therapy . . .

In other words, ask your doctor . . . unless your doctor says it's OK to buy re-imported prescription drugs from Canada.

Is bird flu vaccine for the birds?

In the wake of the post I did on the less-there-than-meets-the-eye Chinese vaccine for bird flu, comes this article from The Star (Singapore):

A BIRD flu vaccine for poultry could help prevent the spread of the disease, much like how firefighters surround a hot spot before moving in to put out the flames, says Singapore’s Agri-Food and Veterinary Authority.

But vaccinated or not, said its deputy chief executive officer Dr Chua Sin Bin, all birds in affected areas must be culled or the vaccine could turn into a double-edged sword – masking the symptoms of infected birds while fanning the flames of infection.

“Vaccinating is a stop-gap measure, when animals cannot be culled fast enough to check the spread of the disease,” he said.

It will not eradicate the disease that is endemic in the region but is “part of a multi-pronged approach that also includes extensive testing and the culling of animals.”

He was responding to queries on an announcement by Chinese scientists this week that they had developed a new vaccine which could protect poultry from bird flu for a longer period of time than existing drugs.

They said their vaccine provided at least 10 months of protection for chickens and ducks.

The current vaccine can offer six months’ protection.

Officials in China said vaccinations will be administered not only to birds at poultry farms but also to water fowl in the country’s key water areas, including rivers and lakes, to prevent the spread of bird flu from China’s neighbours once birds begin migrating north.

Vietnam, which has been hit hard by the virus, has said that it will use the new vaccine on its poultry flocks by the end of the year if tests to prove its viability are successful.

But vaccinations will not be an option in Singapore, Dr Chua said, because vaccinated birds can still catch and spread the disease, although the symptoms may be masked.

“We don’t want to have a situation in which the bird may look healthy but can still spread the disease,” he said.

“Neither do we want farmers here to have a false sense of security and let down their guard.

“It would be dangerous to do this in a country which is free of bird flu,” he added.

All two million chickens in Singapore’s five poultry farms will be slaughtered and their carcasses incinerated if a single case of the flu is detected here. [snip]

Sounds right to me. But then, Dr. Chua adds this:

“It’s not the large commercial farms which are causing the spread of bird flu, it’s the small-scale ones where people breed the animals for their own consumption or trade,” he said.

Hmmm. Not so fast, Dr. Chua. This may be right, but I have been sensitized by the perspective of anthropologist Ron Nigh, writing here, here, here and here. Nigh presents a good argument that it is the large commercial farms that are making the flu happen, if not spreading it.

I have the sinking feeling that the (justified) fear of bird flu is being used to transform agriculture to agribusiness.

Carnival of the godless, #3 is up!

Carnival of the godless, #3, hosted by the inimitable Coturnix at Science and Politics blog is now up. Come one, come all, step right up to see the weird, anomalous, bizarre heathens (including yours truly, Revere) whose posts grace the freakish sideshow of the -- (drumroll) -- godless!

Blogrollin' Friday on Saturday

On Fridays we (try to) obey the wise dictum of Political Site of the Day (PSoTD) who encouraged us to forget about cats, dogs and other significant others and devote a post to another blog, for whatever reason.

But I didn't do Blogrollin' Friday yesterday. Truth is, I forgot. But thanks to a great post over at Bouphonia, I found a great site.

Sorry for the plagiarism Philalethes. Read her post first and then visit WorldChanging: Models, Tools, and Ideas for Building a Bright Green Future.

Bird flu sites: update

Since I last posted on this here, another site covering the bird flu problem has come to my attention: influenzapandemic.blogspot.com. Keeps up-to-date with links. Between this site and the others in the previous post, you will be able to keep current.

On another note, recently I posted my thoughts on Henry Niman's Recombinomics site. Niman has consistently taken positions expressing greater concern about specific avian influenza issues than the official pronouncements. I thought it worthwhile to review those positions and give my own views on them. On balance, I came out much closer to Niman's views, which I believe to be not only scientifically defensible but also more consistent with a public health precautionary perspective than WHO's or CDC's.

Since that assessment there has been no activity on his site. I hope this was not a consequence of my post. The Recombinomics site has been a valuable source of information to all interested in this public health problem and I want to encourage Niman to resume activity at his former level and keep pushing the envelope.