October (selective round-up)

October ends with Thailand seeing its twentieth case of bird flu, a 50 year old woman who lived on the northern outskirts of Bangkok and reportedly had helped her husband clean a chicken coop that had been occupied by infected birds (AP) She is in stable condition and said to be improving. Her husband is asymptomatic but under quarantine (Reuters). Two other cases have also occurred this month in Thailand, a 48 year old male who died after handling his neighbors' sick chickens and the man's 7 year old son, who also was reported to have handled the birds. The boy, who was treated with Tamiflu early on, is recovering. Vietnam also has reported four suspect cases this month, two of whom have died (Reuters). Indonesia also reported several more cases, bringing the confirmed total to seven of whom four have been fatal. However there are many more suspect cases (the exact number is in dispute, so the numer seven is a very conservative lower bound. Finally, The deaths of a 12 year old Chinese girl and her 9 year old brother, while declared negative for H5N1 by Chinese authorities, is still under suspicion by WHO, who has asked for additional information to substantiate the negative result. The suspicious cases occur in the setting of three new outbreaks in bird flocks in China.

Thus the human cases continue to be reported from Asia, South Asia and Southeast Asia. This is also the area where the H5N1 virus has become endemic in birds and where WHO believes a pandemic is most likely to develop. Because of the vast number of viral "bioreactors" (birds, other livestock and humans) living closely together in this region, this is a reasonable (but not necessary) proposition.

But the panzootic (pandemic in animals) also extended itself this month, finally reaching Europe.

Outbreaks of avian influenza H5N1 have now been confirmed in five countries either by the World Organisation for Animal Health (OIE) or national government agencies in the WHO European region: Croatia, Kazakhstan, Romania, the Russian Federation and Turkey. In addition to this, avian influenza H5N1 has been confirmed in an imported parrot in the United Kingdom. There are now numerous further outbreaks of disease in birds under investigation in several European countries.

Since the occurrence of outbreaks of highly pathogenic avian influenza H5N1 virus in migratory birds, the risk of transmission to domestic birds has increased. Surveillance in wild birds has thus become a priority and the European Union has made guidelines available. It is likely that migratory birds are responsible for the introduction of H5N1 in the European region, as the viruses from outbreaks in Kazakhstan, Romania and Turkey are phylogenetically almost identical to the virus that caused the wild bird die-off at Lake Qinghai in China in May 2005. (from WHO, citations omitted)

WHO is at pains to emphasize (correctly) this is not evidence of the start of a human pandemic, although the increased range and number of infections might add to the risk. This is correct, of course. But it does mean that preparations and surveillance need to be ramped up everywhere. The appearance of H5N1 in the parrot in the UK also sparked new import bans in the European Union:

The European Commission has banned the import of live birds into the European Union (EU) from outside countries. The ban covers captive live birds except poultry imported for commercial purposes. No more than five birds will be allowed into the EU with their owners, provided they have undergone a 30 day quarantine, been vaccinated against avian influenza, or have tested negative for avian influenza in a 10 day isolation period before movement. However, birds may be accompanied by their owners between the EU and Norway, Switzerland, Liechtenstein Andorra, Iceland, Greenland, Faeroe Islands and San Marino. Birds may also be moved between approved zoos and similar institutions. (Eurosurveillance Weekly)

All in all, not a good month on the bird flu front. But it could have been worse. And it likely will be.

The plan behind the plan

What are we to make of these two stories? The first says Bush is going to unveil the long-awaited (and unforgiveably tardy) pandemic flu plan tomorrow. The plan includes proposals to beef up stockpiles of vaccines and antivirals and allegedly also a fund to build infrastructure (AP via Yahoo News). Sounds good, if they are serious about it.

Then there's this: "Congress Weighs Big Cuts to Medicaid and Medicare." That's the Republican Congress, folks, Bush's party. I guess they aren't in on the "plan." Or maybe they are another part of the plan, the part that won't be publicized on Tuesday:

Congressional committees have proposed substantial cutbacks in Medicaid and Medicare, the nation's largest health insurance programs, which together cover more than one-fourth of all Americans.

[snip]

The House bill would take all of its savings from Medicaid, the program for low-income people, while leaving Medicare, the program for those 65 and older and the disabled, untouched, as the Bush administration wants. By contrast, the Senate bill would squeeze savings from both programs.

The new cuts are estimated to save $4 billion for the feds and $3 billion for the states in the next five years. $7 billion dollars in five years. We will burn $7 billion in a little over a month in Iraq. The Iraq mistake is already costing almost thirty times the estimated savings from five years of painful cuts to our oldest and most vulnerable citizens. al-Qaeda must be delighted.

Not everyone will suffer, however. Big Pharma doesn't want to get hurt and it's putting on a full court press to see it doesn't happen.

Federal auditors and investigators have repeatedly found that Medicaid overpays pharmacies. The Senate and House bills would reduce those payments. The Senate bill would also require drug manufacturers to give larger discounts to Medicaid, a provision not included in the House bill.

Craig L. Fuller, president of the National Association of Chain Drug Stores, a trade group, said he did not understand how House Republicans could cut payments to pharmacies and increase co-payments for poor people without requiring drug manufacturers to make any contribution to the savings.

But Billy Tauzin, president of the Pharmaceutical Research and Manufacturers of America, a lobbying organization for brand-name drug companies, said the price concessions required by the Senate bill could hurt Medicaid recipients and other patients by forcing drug makers to "reduce research and development of life-saving medicines."

This kind of lobbying from Big Pharma is the height (or depth) of something so rotten, uncaring and immoral it takes your breath away.

So "the pandemic plan" is coming. But what the Republican Congress giveth it taketh away. In multiples. Bush will try to look good with a national announcement but in the back room his party will try to nullify it--and more. Why should anyone take these jokers seriously, other than as criminals?

Public hospitals in Louisiana: getting flushed?

The great sucking noise you hear is Louisiana's public hospital system going down the toilet.

"We're out of money, roughly after Thanksgiving," Donald Smithburg, chief executive of the Louisiana State University Health Care Services Division, told reporters. "We are running out of time."

Smithburg said the system, Louisiana's largest health care provider with 1.2 million patients annually before the storm, will have to furlough 2,900 of its 8,000 employees next week, the first step toward permanent layoffs on Dec. 17. (Yahoo News via DailyKos)

Both Charity and University hospitals in New Orleans are total losses after Hurricane Katrina but so far FEMA has made no decision as to whether they will qualify for federal disaster funding for replacement (estimated $750 million). No hurry, I guess.

As a result of the closures, the other seven hospitals in the system are bearing the brunt and will need $200 million in interim financial support. Because they weren't directly damaged by the storm, however, they may not be eligible. With proposed new cuts in Medicaid and Medicare, the rest of the hospital system will be even more stressed.

The richest nation on earth is showing its face. It ain't pretty.

Leon Kass, living fossil reburied

Leon Kass, as I remember him from decades ago, was always a serious man. Unfortunately he is also a serious joke. Serious as in harmful. Joke as in without serious intellecutal content but entertaining and amusing to the Far Right.

Kass is a bioethicist who until recently headed Bush's Council on Bioethics. As Chris Mooney observed at American Prospect when his appointment was announced four years ago:

It's probably a lucky thing for Leon Kass, the conservative University of Chicago ethics philosopher appointed to head George W. Bush's new Council on Bioethics, that his position doesn't require Senate confirmation. Last April, the neocon Washington Post columnist Charles Krauthammer effused that Kass should be named surgeon general, a post that does require confirmation, but that might have backfired: Kass has a paper trail that would put any quotation-hunting opposition researcher in hack heaven. Virginia Postrel, editor-at-large of Reason magazine, has already bloodied Kass considerably by drawing attention to a passage from his 1985 book Toward a More Natural Science in which Kass complains about "our dissection of cadavers." Writing in the Los Angeles Times, Postrel observed: "This isn't about the 21st century. It's about the 16th."

Kass stepped down as Chair of the President's Council on Bioethics October 1, but remains a member. He was replaced by the 85 year old former president of Catholic University and bioethicist, Edmund Pellegrino (WaPo).

Kass was awarded "wanker of the day" status by Atrios after this devastating critique by Amanda Marcotte at Pandagon , where she puts a stake through the heart of his intellectual pretensions. Not healthy reading if you have a tendency to high blood pressure, but as thorough job of destruction as you are likely to find.

Freethinker Sunday Sermonette: copywrong in the right cause

Sunday, and I'm weary. But pulpits are to preach from, so time for a sermon directed at my most loyal parishoners, scientists. Even they sin.

Case in point. The National Academy of Sciences and the National Science Teachers Association are threatening the benighted Kansas Board of Education with a copyright suit for quoting their materials in Kansas's disgraceful looming new "science" standards. They provide time for "alternatives" to evolution (you can guess what the alternatives are). The two science organizations were supported in a statement by the American Association for the Advancement of Science (AAAS), to which I belong. I also work on NAS committees, so I have a relationship with two of the three associations involved here.

Here is the rationale for the copyright tactic:

"Kansas students will not be well-prepared for the rigors of higher education or the demands of an increasingly complex and technologically-driven world if their science education is based on these standards," Ralph J. Cicerone, president of the National Academy, and Michael J. Padilla, president of the teachers' group, said in a joint written statement today. "Instead, they will put the students of Kansas at a competitive disadvantage as they take their place in the world."

In the statement, as well as in letters to the state board, the groups opposed the standards for singling out evolution as a controversial theory, and also for changing the definition of science itself so that it is not restricted to natural phenomena. (New York Times)

The Board has a six to four anti-science majority and won't be deterred by this tactic. More importantly, however, the NAS and NSTA (with AAAS support) are violating an important principle. I agree strongly with Cory Doctorow at Boingboing:

As much as I support their cause, I deplore their tactics.

The heart of science is publication and refutation. The difference between an alchemist and a scientist is that alchemists don't publish their findings and so for 500 years, every alchemist had to discover for himself that drinking mercury was a bad idea. The publication and review of a scientist's findings -- especially the reviews of his sharpest critics -- is how science progresses. It's how we, as a species, progress.

That's the very heart over the fight for evolution. If scientists start arguing that their detractors are illegal infringers who should be silenced by the courts, they set themselves on a road to ruin.

Science will win this fight, but it can't win it at the expense of the scientific method and free speech.

Copyright is not about endorsement or agreement, and it's not a right to stop criticism, even ill-considered criticism. Quotation can be fair use even in a context the original author abhors -- that's precisely when we need fair use most, we on all sides of a political debate.

The organizations are free to broadcast their loud disapproval of the uses to which their publications are being put, and free to sue for misrepresentation if false statements or positions are put into their mouths, but asserting copyright rights seems a heavy-handed way to win a battle of ideas.

Copyright, whatever its merits (and they are few), is not meant for this purpose.

Sermon over. Go forth and sin no more.

Bird flu tit for tat

This is a small taste of what it will be like.

Columbia notified the international body that oversees global animal health that it had an outbreak of low pathogenic avian influenza. Immediately five countries (Bolivia, Ecuador, Panama, Peru and Venezuela) halted imports of Colombian poultry (AP).

You'd think they would be praised. But no. The argument was that Columbia risked damage to the Latin American poultry industry with its notification, which, although of no public health significance, raised public fears.

Colombia "didn't even have to report this low pathogenic virus," said Dr. Richard Lee, a bird-flu expert and professor at the State University of New York at Buffalo. But the reaction by Colombia's neighbors, he said, was "not justified."

Yanzhong Huang, a bird-flu specialist who heads the Center for Global Health Studies at Seton Hall University in the United States, said the action by Colombia's neighbors might confuse the public if the poultry bans are long-term.

"It could reinforce the misperception that you could catch flu by eating fowl," Huang said. Experts say no one has caught bird flu from eating properly cooked poultry.

Maybe Columbia didn't have to report it, but it was the responsible thing to do. Now they are being punished and will serve as an object lesson to other countries in the region: shut up about your bird flu problems.

But the damage didn't stop there. Columbia retaliated by halting rice imports from Bolivia and Ecuador, ostensibly on the grounds that "migratory birds land in rice fields" (no one has ever suggested you could get flu or transmit it through rice).

A small example of what the bird flu problem can do. Just watch.

Bird flu in Kurdish Iraq?

As if they don't have enough problems, veterinary authorities in Erbil, Iraq (near the border with Turkey) are confirming what they say is H5N1 in domestic chickens. This development was both feared and expected after Turkey confirmed an outbreak on October 8. Samples were sent to a "dedicated bird-flu testing laboratory in Egypt" for confirmation.

Regarding the suspect bird deaths, Butros said. "When we received news of deaths of chickens in a poultry farm near Khabat [30 kilometres west of Erbil] a team of experts visited the property to collect samples, and the preliminary analyses gave a positive result to the [bird flu] virus.

"Given the lack of specific labs for bird flu diagnosis in the region we sent the samples to Cairo for further testing which confirmed definitively the initial results" she added.

The local Kurdish language paper, Aso, on Thursday broke the story of the discovery of the virus in the region.

"Our personnel, along with American hygiene squads, are making every effort to inspect poultry farms in the region" Butros added, "to check out many reported deaths establish the cause and draw up health plans to deal with possible future cases." (AdnkronosInt [Italian news agency])

The US government is aware of the outbreak, apparently, and has personnel on the scene. On Thursday the US supported government in Baghdad announced an import ban on poultry from some 20 countries, but this (not surprisingly) didn't do the job. Migratory birds are notorious scofflaws.

So now avian influenza is poised to become endemic in an area "home" to 150,000 migratory Americans. Lovely.

Cautionary note, 1:11 pm EDST: I feel compelled to point out this is an (as yet) unconfirmed report. Past experience suggests caution. However, it is also a highly plausible one, and if not this time, probably soon.

Addendum, 11 pm EDST, 10/29/05: This report has disappeared from the radar screen. ProMed carried a UPI report and asked for more information early this afternoon, but since then there is no mention anywhere on the newswires I can find. If anyone knows more, leave a note in the Comments.

Update, midnight, 10/29/30: Reuters Alternet is saying it is not H5N1 but some low pathogenic strain. Hat-tip Monotreme. Glad I put a question mark in the title.

Grover gets his wish

This has made the rounds plenty in the blogosphere, but it never hurts to remind everyone (and ourselves) exactly what this means.

So here it is again.

As I was saying . . .

Thursday Reuters reported that the US pandemic plan was being readied. Pardon me but I've heard that before. Or maybe I should say, I've been hearing it for years. Literally. They started working on the (as yet unfinished) plan in 1993. But let's say it's true. Just for fun. What's in it? Why has it taken so long? According to Department of Health and Human Services Secretary Michael Leavitt, the plan includes better disease reporting and stockpiles of vaccines and drugs.

That's it? No wonder ordinary citizens are hoarding Tamiflu. We're on our own.

Leavitt says (correctly, in my view) that at this point the role of the federal government will be limited (see also "The cavalry isn't coming"):

"If a pandemic hits our shores, it will affect almost every sector of our society, not just health care, but transportation systems, workplaces, schools, public safety and more," Leavitt said in a speech at the National Press Club.

He said the federal government was doing what it could, but he said he would detail ways for local authorities to do their share.

"One example: The federal government can deliver stockpiles of medication and supplies to a city in the United States anywhere within a matter of hours," Leavitt said.

"But it's the distribution at the state and local level that ultimately defines victory. In a moment of crisis, if we are not able to deliver pills to people over a wide area in a short time frame, lives will be lost." (Reuters)

The catch here is in (my qualifier) "at this point." We are in the (unprepared) fix we are in because the Bush, Clinton and Reagan Administrations didn't get us ready when they could have and should have. Let me correct that. Because they abandoned us.

To apportion the blame properly, we should start with Reagan, who in his eight catastrophic years in office did tremendous damage by dismantling a large part of the public service structure and its commitment to community well-being. It still takes my breath away how someone so fundamentally (but genially) awful could be considered a hero, but that's another story. The destruction of the federal and societal commitment to each other was engineered by the Reaganites (many now pulling the levers in the Bush Administration), slowed slightly (but continued) by Clinton/Lieberman and their ilk, and then driven right off the cliff by Bush wackos who are bankrupting the country with their murderous recklessness abroad and corrupt cronyism at home.

I know you have heard this here before. A lot. Here is a snippet from one of our earliest posts, "Influenza and leadership," dated November 29, 2004:

This post is ostensibly about avian influenza A (H5N1). It's really about how we are going to cope without effective public health leadership. Avian flu is a freight train coming our way. Whether or not it hits us will just be a matter of dumb luck one way or another and is probably out of our control by now. How badly we are hurt if we are hit isn't. But it isn't just a matter of an effective plan or manufacturing a vaccine, although both are part of it. As much as anything it is about a public health system that is leaderless, uninspired and dispirited.

[snip]

One response is essentially nihilist. In the nuclear freeze movement of blessed memory we used to have a poster giving the steps to take to protect yourself against a nuclear attack. It ended with sitting down, putting your head between your knees and kissing your ass good-bye. That kind of response won't happen because we are hardwired to try to survive. But it would be nice to have some vision other than as a bit part in a post-apocalypse reality show.

I don't see much that our public health officials are doing to plausibly prepare for this. We go through an endless cycle of "needs assessments," contingency plans and appropriations that never find their way to the street level. Most knowledgeable people don't believe we are in much better position to cope with an emergency than we were a few years ago. We have no more surge capacity in our hospitals than before. Even a slightly worse flu season than usual overwhelms them. And there will be a serious shortage of nurses and other care givers, not to mention undertakers. It isn't as if this hasn't happened before. It has. But we aren't really in better shape. There is neither the political will, the political vision, nor the political public health leadership. We are drawing up plans on paper on how to get to the life boats when the ship hits the iceberg. Even if that works in an orderly way (and there isn't enough room for everyone), there is precious little thought what to do when we are set adrift.

So what am I saying? In an earlier post (Vioxx: What would Gandhi do?) I suggested we adopt a "constructive program" and do our own planning, constructing and implementing on a small local scale. We don't need CDC or Tommy Thompson to think about how to use hotels or motels for surge capacity (each room has a bathroom), begin to organize volunteer retired nurses and doctors (our neighbors) in case of an emergency, start talking to the mortuaries about what they will do, inquire again and again at our community hospitals about adequate supplies of respirators (including pediatric sizes since this virus seems to have a predilection for children). I know some of these things are (allegedly) being done by state health departments. But my (up close) observation is that with staffing shortages, turf battles and a stunning narrowness of vision, most of it isn't happening and the plans on paper will be out the window in the first 24 hours after a true emergency is recognized.

So here we are, almost a year later, AND I'M STILL SAYING THE SAME GODDAM THINGS.

Meet the Focker

With our Fitzmas present today there came this. Meet Screwter's replacement as Vice's Hauptgeneral, David Addington (via MyDD):

Where there has been controversy over the past four years, there has often been Addington. He was a principal author of the White House memo justifying torture of terrorism suspects. He was a prime advocate of arguments supporting the holding of terrorism suspects without access to courts.

Addington also led the fight with Congress and environmentalists over access to information about corporations that advised the White House on energy policy. He was instrumental in the series of fights with the Sept. 11 commission and its requests for information.
. . .
Colleagues say Addington stands out for his devotion to secrecy in an administration noted for its confidentiality.
. . .
Even in a White House known for its dedication to conservative philosophy, Addington is known as an ideologue, an adherent of an obscure philosophy called the unitary executive theory that favors an extraordinarily powerful president.
. . .
Addington's influence -- like Cheney's overall -- extends throughout the government in his bid to expand executive power. He goes through every page of the federal budget in search of riders that could restrict executive authority. He meets daily with White House counsel Alberto R. Gonzales and often raises objections to requests for information from Congress or the public, officials say. He also routinely works to defeat proposals from the State Department, where the pervasive internationalist philosophy is at odds with Cheney's neoconservatism. (WaPo)

Torturer heads the Department of Justice, Torturer in Vice's office. I'm guessing the new Supreme Court nominee will be a friend of torture, too.

Walking on egg shells

There is a lot of bird flu stuff in the news, but it's a little like the CIA leak investigation. Lots of miscellaneous facts but not much solid to go on. So instead of trying to meld all these things together without having an organizing principle, I'll just grab a few that interest me. For whatever reason.

ABCasiapacific reported that China had its third outbreak of bird flu. The flu obsessed already knew that. What got my attention in the same report, however, was that Japan was sending "more experts and medical equipment to Indonesia."

The Japanese embassy says three experts in laboratory diagnosis are due to arrive in Indonesia along with the first batch of medical materials. Japan is also preparing to send more experts to help the government in areas such as surveillance, laboratory diagnosis and clinical management.

So this is a clinical team, not a team of poultry experts. There are reportedly more than 80 suspect cases of human bird flu in Indonesia, most of whom have not been confirmed one way or another. It sounds like Japan is going to bring some diagnostic expertise into the country. Interesting.

Meanwhile, in Europe, where dead birds seem to be popping up here and there, the poultry industry is worried about a decline in sales (Xinhuanet). Chicken consumption in Italy fell 40% last month. A number of countries are curtailing free-range chickens, requiring instead the birds be raised indoors to avoid infection from migrating birds.

And the European Food Safety Authority (EFSA) is warning people off raw eggs and advising thorough cooking of chicken:

"Cooking poultry and eggs will protect humans from salmonella or other organisms, and if the avian influenza virus is present, it would also be inactivated through cooking,'' Anne-Laure Gassin, a spokeswoman for the European Food Safety Authority, said in a telephone interview from the body's headquarters in Parma, Italy.

[snip]

The link between humans catching the disease and eating infected poultry products hasn't been proven, the head of the WHO's Western Pacific office, Shigeru Omi, told a conference in Copenhagen yesterday. Contact with an infected animal's feces or respiratory secretions are the most common transmission methods, he said.

"We don't think there's much risk, but we can't say there's no risk, so we give the advice to cook chicken thoroughly,'' Ben Duncan, a spokesman for the European Centre for Disease Prevention and Control, said by phone. The biggest risk from eggs is that the shells may harbor traces of excrement containing the virus, he said. (Bloomberg)

Sounds like prudent, authoritative advice. Unfortunately, there are a lot of authorities out there and they are saying different things. Consider the risks of eating chicken and eggs:

A spokeswoman for the Food Standards Agency said: "Like EFSA, we are not aware of any reports of people getting avian flu from eating poultry or eggs.

"The issue is people having contact with live birds that have the disease.

"EFSA appears to be reiterating long-standing food safety advice about cooking poultry and eggs thoroughly to kill bugs and viruses."

The European Commission said that the consumption of poultry eggs and meat in the EU poses no bird flu risk to humans.

"We don't have avian influenza in commercial poultry in the European Union and we consider that poultry meat and eggs, especially when properly cooked, pose no risk to human health," said spokesman Philip Tod.

Professor Hugh Pennington of the Society for General Microbiology, said: "The virus is transmitted by live birds. It's not in the poultry meat and it's certainly not in eggs." (BBC)

Hmmm. I thought I understood it the first time, but now I'm not so sure. The UK Food Standards Agency says only live birds are risky. EFSA says breathing infected feces and respiratory secretions. Maybe I should read further:

Humans catch avian flu through close contact with live infected birds.

Birds excrete the virus in their faeces, which dry and become pulverised, and are then inhaled.

Therefore, the people thought to be at risk are those involved in the slaughter and preparation of meat that may be infected.

Live birds only. Feces with virus in it. So I'm not sure I get the "therefore" part of "poultry workers only." And then what's this about cooking dead chickens and not eating raw eggs? Maybe the trade press can help:

Processors making products like mayonnaise, mousse and icing will be looking for a consumer reaction to the latest bird flu advice from the EU's food safety regulator, which yesterday called on consumers to avoid eating raw eggs.

EU poultry processors are already seeing big drops in consumer demand from the rising fear that the avian influenza virus will spread throughout the bloc. A panic is building as more and more EU members report incidents of the flu and authorities issue warnings.

The European Food Safety Authority yesterday said that Europeans should avoid eating raw eggs and cook chicken carefully as part of the precautions for ensuring that the virus does not infect humans.

The agency's experts said there was no evidence that the virus could be transmitted through food. However they warned the link could not be ruled out altogether. (Food Production Daily)

Yikes. They're waiting for me to tell them.

It seems the industry is walking on egg shells and the experts don't have the foggiest. Next story.

Democrats, bird flu and "the vision thing"

I'm sorry to keep bashing Democrats. On balance they are so much better than Republicans (or at least not anywhere near as bad). But they are always such a disappointment.

They are now on the bird flu train. Better late than never, but much better not to have been so late. But now that they are on the train it would be nice if they exhibited a little imagination. You know, "the vision thing," as George H. W. once called it.

Senate Democrats proposed $8 billion in new spending on preparedness against avian flu Wednesday, in an attempt to increase funding by more than double over what was passed less than a month ago.

The Democrats used their bill as an occasion to criticize what they said was a slow Bush administration response to the threat of a bird flu pandemic. That angered Republicans, who charged the Democrats with using the threat for political purposes.

The bill, which could reach the Senate floor as early as Wednesday night, calls for the federal government to spend $3.3 billion to stockpile a now-experimental vaccine against the H5N1 avian flu virus strain. The administration approved an initial $100 million deal with vaccine maker Sanofi Pasteur in late August to begin filling government stockpiles.

The package also spends $3.3 billion to increase stocks significantly of anti-viral drugs, such as Roche`s Tamiflu, and devotes other money to increasing both hospital capacity and disease-surveillance capabilities.

The bill more than doubles the $3.9 billion senators had agreed to add to a defense spending bill on Oct. 3. Democrats said the increase was needed to speed preparations. (via Monsters and Critics)

OK. Criticism of the slowness of the Bush administration is warranted. And dollars will be helpful. But a little thought to go with the money toss isn't too much to expect, is it? Instead we have a proposal to use most of the money to stockpile an experimental vaccine (which essentially doesn't exist) and stockpile Tamiflu (which will do little except at the margin). Hospital beds and surveillance. Good ideas, but missing context. The biggest need is to repair a crumbling public health system. Hospital beds don't take care of patients. Staffed hospital beds do. And with cuts being proposed for medicaid and other health care services, beds won't matter much. What the Democrats should be doing now--and should have been doing for the last five years (not to mention the years when they had the Whitehouse) is beating the drum to improve public health infrastructure--all of it. Not the "bioterrorism" components but politically unsexy routine, bread and butter public health: maternal and child health, immunization programs, substance abuse, STDs and AIDS, communicable disease, vital records and vital statistics, routine monitoring and surveillance, outbreak investigations, food safety, water and wastewater, etc., etc. They haven't done it because there wasn't enough (or any) political mileage in it. The old saw, "When public health works, nothing happens," is not a formula for an active constituency. So championing it requires leadership, and leadership requires vision, a vision of the role of government.

In public health we are talking about things people can't do for themselves that make our communities healthier, more satisfying places to live and work. Republicans are fond of saying people know better what to do with their money than the government does. I don't know about that. But I do know that if you give me back $300 in tax cuts, I can't buy better public health with it. I can only do that if I put my $300 together with your $50 and your $1000 and your $3000, etc. The Democrats need to articulate clearly those purposes for which pooling our individual resources make sense. And surely most would agree public health is on that list. With a robust and healthy public health infrastructure we would be much, much better able to cope with a pandemic. As it is, we will be improvising and desperately trying to stick our fingers in the dike.

As lacking in imagination as it is, the Democratic proposal is stillborn anyway. The Republicans will see to that:

The plan incensed at least some key Republicans, who branded it a vehicle for political attacks on a White House already facing criticism for a slow response to Hurricane Katrina.

'It`s political gimmickry,' a visibly angered Sen. Ted Stevens, R-Alaska, told UPI. 'That`s just throwing money at the wall. You can`t spend that kind of money,' Stevens, who chairs the Appropriations Committee, said of the bill`s $8 billion.

A senior GOP Senate aide said Republican leaders were unworried about the large spending increase in Wednesday`s amendment. Even if it gains Senate approval, the increase is unlikely to survive a conference with the House, leaving lawmakers to deal with the $3.9 billion they passed in the military spending bill, the aide said.

Ah, yes. The "visibly angered" Ted Stevens of Alaska. The asshole who would rather spend $200+ million on a bridge in Alaska for fifty people than on hurricane relief for the Gulf. It's his vision we have to live with until a better one comes along. And he convinced all but 15 of his Senate colleagues to see it his way. That included most Democrats.

I'm still waiting for another vision.

The specter 1976

The specter of 1918 is a pervasive and explicit influence on the professional and the public attitude to the current threat of a pandemic from H5N1. That much is clear to everyone. What is less recognized, however, is that for the professional influenza community in the US there is another specter, the Swine Flu episode of 1976. There have been a number of good accounts, so we will only sketch it here, but it is worth acknowledging there are important reasons for ambivalence among experienced public health professionals who went through that traumatic episode.

In highly abbreviated form, this is the gist. During an otherwise routine influenza outbreak at Fort Dix, New Jersey in January of 1976, several new recruits were discovered to have become ill with an influenza virus whose origin was apparently pigs, i.e., instead of the then (and now) circulating A/Victoria/H3N2 a few of the many ill soldiers were infected with H1N1 whose origin was pigs. This raised alarm bells at CDC because it was widely believed that the 1918 virus might have retreated into pigs after the mid 1920s and there was a possibility it was now re-emerging into a world where the only effective the immunity was in those over fifty (those born before the 1920s). Some notable flu experts also believed pandemics were on a regular and predictable cycle and we were "overdue for one." Adding to the alarm was a follow-up seroprevalence survey at Fort Dix which suggested as many as 500 soldiers might have become infected, that is, swine flu had gone "human to human." Outside Fort Dix there was no apparent infection. Not yet. If there were to be a pandemic the following flu season, a decision about making a vaccine had to be made immediately. Moreover, because of the gravity of a repeat of a 1918 pandemic, if a vaccine were to be made, it was thought a full-scale vaccine program should be cranked up to vaccinate the entire population (at that time a little over 200 million people).

You can read accounts of the messy decision making process in a reconstruction of events (with oral histories) done for Department of Health, Education and Welfare Secretary Joseph Califano by Richard Neustadt and Harvey Fineberg. A book by Silverstein came out in the 1980s and shorter accounts can be found in the popular books on influenza by Alfred Crosby and Gina Kolata. Within a short period of time, the highest levels of the nation's health establishment had decided universal vaccination with a yet to be produced swine flu vaccine was needed, President Gerald Ford agreed almost immediately, and he personally announced it on television rather than leaving it to the Director of CDC or Secretary of DHEW. His view was that if everyone were to be asked to take the vaccine, the request should come from the President. It was in fact an act of courage on his part, as it was understood it was a no win situation politically and Ford was locked in a bitter primary campaign against Reagan (it is not easy to imagine the current incumbent taking this route). Ford asked for and received congressional approval for $135 million for the vaccine and associated programs. Four vaccine manufacturers immediately switched their production from A/Victoria to the new swine flu virus. When they balked at the last minute to bottle the preparation because of liability concerns, congress further insured vaccine-associated risks.

I have skipped many details, but the most important facts for our purposes are these. Just as the full scale effort was underway, news media began to publicize hitherto unvoiced strong disagreements with the universal vaccination policy by a few scientists, some within the government, At the same time, epidemiologists pointed out the likelilhood that a wide variety of adverse events would occur in close temporal relationship to vaccinations just because tens of millions of people were involved. Sudden deaths occur with regularity, with or without vaccines, but any that would occur shortly after vaccination would inevitably be associated with it. Indeed that is what happened. Within three weeks, 41 vaccination-associated deaths were counted. The CDC's response that this was within the number "expected" was not persuasive to most people. Even more troublesome was an apparent association with a rare but potentially serious neurological condition, ascending transverse myelitis or Guillain-Barré Syndrome (GBS). To this day there is no agreement as to whether GBS was truly related to the swine flu vaccine or not. There are persuasive arguments on both sides. In any event, there was a definite public and professional perception that GBS was a side-effect of swine flu. As a result, the entire swine flu program was abruptly halted in December 1976 after three months. By then 45 million people had been vaccinated and there was long list of claims of vaccine-associated maladies, including GBS. There were 52 deaths, more than 500 hospitalizations and compensation claims of over $1.7 billion in a wave of litigation.

But not a single case of swine flu. The feared pandemic never happened. An extraordinary national commitment to stave off a disastrous epidemic, for the first time in history, was overshadowed by doubts, recriminations and second guessing. While the public has largely forgotten the episode, the American public health establishment has not. It is still remembered as a monumental fiasco that those involved would not like to repeat. Many of those professionals--people who genuinely were trying to do the right thing, who acted on that impulse boldly, and perhaps did do the right thing--are still around in senior policy making positions.

One can hear the echoes of 1976 in the hesitancy and ambivalence over the correct response to H5N1 today. Because there are many parallels: the specter of 1918; the uncertainty as to whether there will be a pandemic or not, when it will be, how bad it will be; the downside of doing nothing; the risks and costs of doing other things. Nobody wants to guess wrong.

And like 1976 there are numerous other agendas: desire not to distract from other priorities; desire to use the real threat of a pandemic to rebuild public health; numerous politically partisan motives; ideological currents. One of the lessons some have taken from 1976 was that a more prudent course would have been to stockpile the vaccine and only deploy it if a pandemic was getting underway. We see the stockpile theme prominent today, and probably it isn't a bad lesson to learn.

What we don't see, however, is a public commitment to rebuild the kind of social solidarity that will be an essential element in managing the consequences if a pandemic were to materialize. You can say that's my agenda. To promote the power of neighbor helping neighbor. I'm not hiding it.

Bird flu employment issues

An article in Scoop (New Zealand) raises interesting pandemic-related employment law issues. Does an employer have the ability to require employees to stay home? Can an employee refuse to attend work? When is an employer obliged to pay in these circumstances?

Workplaces could be completely disrupted by absences, which the Ministry of Health estimate could reach 50% of staff if and when the pandemic is at its height.

"While many have taken the blasé approach to the "bird flu", putting it in the "the sky is falling" category with Y2K and SARS, the potentially devastating effects of a pandemic in an employment setting cannot be ignored. Regardless of the severity of the pandemic, if it hits, employers will face a number of issues which at the very least could give rise to personal grievances, and at the worst could destroy "the workplace' as we know it", [employment law specialist Scott] Wilson said.

The incentives to force workers to come to work in circumstances where there is severe short staffing may run up against a prudent policy that workers who aren't feeling well or have sick family members should stay home. And what will happen to benefits plans when half the labor force is on sick leave? Will employers be required to provide protective equipment like face masks, gloves, hand antiseptics? If a business closes down during a pandemic, what will happen to existing labor agreements?

These are questions over and above the obvious ones of how the business will manage to keep functioning, during and after a pandemic. Should a pandemic happen, there are going to be a lot of unexpected consequences.

Dark as a dungeon, way down in the mine

Jordan at Confined Space brings us the latest in the Bush appointee least-qualified sweepstakes: Richard Stickler, nominee for Assistant Secretary of Labor for the Mine Safety and Health Administration (MSHA).

The only thing Stickler is a stickler for is mine company profits. When he was appointed to Pennsylvania's Bureau of Deep Mine Safety in 1997, the United Mine Workers of America's Safety Director, Joe Main, wrote a distressed letter to then Governor Tom "Color Code" Ridge detailing Stickler's sorry record as a mine manager for Bethlehem Steel.

Stickler was manager of the company’s Cambria Slope Mine No. 33 near Ebensburg, Pa., from 1989 to mid-1994. He was manager of Bethlehem’s Eagle’s Nest Mine near Van, Boone County, from 1994 through 1996.

Main wrote that the Cambria mine “had a deplorable health and safety record (one of the worst in Pennsylvania) during the time that Stickler managed the mine.”

While Stickler was mine manager at Eagle’s Nest, Main wrote, federal officials targeted the mine for the most serious enforcement action allowed under the nation’s mine safety laws.

He wrote that the two mines had injury and accident rates that were double the national average in six of the eight years that the union reviewed.

Also, Main wrote, both operations were cited for hundreds of mine safety violations in each of the years that Stickler managed them.

He said the figures indicate “a very poor compliance record.”

“These figures would rank Stickler’s operations among the highest cited in the country,” Main wrote. “Collectively over the eight-year period, the federal government issued nearly 3,000 citations and closure orders at mines that Mr. Stickler managed.”

“I found this information on Mr. Stickler’s background very alarming,” Main wrote. “Not only has Stickler’s focus been solely on productivity and cost, but it appears that management at his mines allowed miners to be placed at a very high risk while he worked toward his focused goals.

“How could such a person with this clear pattern of high violations and high accidents even be considered for such an important health and safety position?

Just to be clear. This is Bush's appointment for the man to be in charge of mine safety for the United States. Think about it.

Dis-Orent-ing

It's tiresome, but I guess I'll have to do it. Again.

Freelance journalist Wendy Orent is at it once more, pooh-poohing the threat of avian influenza and, not incidentally, cashing in. Orent gets paid by the word and specializes in being the messenger of "don't worry, be happy," a highly saleable commodity when everyone else is writing about the dangers of bird flu. Since she is one of the few--the very few--hewing to this line, she has a ready made market in newspapers whose idea of "balance" is a version of "on the one hand" paired with "on the other hand." As one of the regulars on PBS's NewsHour with Jim Lehrer once wryly commented about that show's tendency to do the same thing, it's like "And now for another view of the Holocaust . . . " (Disclaimer: I still like the show).

OK, that was snide. But I am irritated by having to waste bandwidth on this lightweight. What's her argument?

News reports make the threat even more ominous. In resurrecting the 1918 pandemic virus, the deadliest flu strain of all time, researchers recently learned that this strain was far deadlier than any other human virus — it killed mice, while normal human flu won't even ruffle a mouse's fur. They also found out that all of its genes came, directly or indirectly, from birds. Unlike the pandemics of 1957 and 1968, the 1918 version didn't arise from a combination of bird and mammal genes. Instead, the bird genes evolved into a human virus that killed as many as 50 million people.

This means, say breathless news reports, that what happened in 1918 could happen again, this time with H5N1. (LA Times)

When last I addressed the Orent story (March 2005) she was making a big deal about the fact that Taubenberger was saying they weren't bird genes. Never mind. There's more. Like the Professor of Aeronautical Engineering at MIT who patiently explains to his class why anything designed like a bumblebee couldn't possibly fly, she impatiently explains to the stupidos at CDC, WHO and the rest of the scientific establishment why she, Wendy Orent, anthropologist, can demonstrate that bird flu couldn't possibly be a problem. In doing so, she doesn't mind lobbing a few misleading rhetorical asides. For example, right after the last sentence quoted above, she goes on to say:

But Peter Palese doesn't think so. He is lab director at Mount Sinai Hospital in New York, where the technique that re-created the 1918 genes — known as reverse genetic engineering — was developed. He and associate Adolfo Garcia-Sastre contend that what the resurrected virus really shows is how supremely adapted it is — how well its parts fit together, how perfectly it works. The sublime malignance of the 1918 virus doesn't lie in one part but rather in how the genes function together. Evolution shaped this virus to be a sleek, effective killing machine.

It so happens I also have talked to Peter Palese about this. He has publicly expressed reservations that the next pandemic will be from H5N1 but not that there will be a next pandemic. He doesn't know if it will be H5, H7 or H9 or something else. He told me his hunch was against H5N1 because of a paper from 1991 that showed 7% seroprevalence against H5N1 in rural China, although not elsewhere. But he also said it was only a hunch and he didn't really know. I disagree with his assessment, but I respect him. What he does not say is that the concern over H5N1 is just hype and misplaced, which is what Orent implies he says.

Orent's main point, however, is that it isn't likely a bird virus can now evolve to be both efficiently transmitted in humans and highly lethal at the same time. The fact it did this in 1918 was a unique outcome of the crowded conditions of soldiers in World War I (citing the speculations of Paul Ewald). Without those conditions, she claims, the virus could never have attained the degree of lethality it did. Her only evidence to this effect is in essence a "thought experiment." If the virus killed quickly and efficiently, there would be insufficient opportunity to be transmitted to another host. This is a simple-minded view that doesn't take account of the complexity of evolutionary dynamics where one has opposing tendencies within the host and between hosts, multigene interactions at different scales and simultaneous polymorphisms within each host. It is known that such dynamical systems often produce counter-intuitive results, so arguing from the crudest level as does Orent can be misleading. But more important than these theoretical issues are the empirical counter-examples.

We know of many diseases that are highly transmissible and also highly lethal in immunologically virgin populations. Smallpox and measles are two examples that wiped out vast numbers of indigenous North Americans when Europeans arrived, and these diseases continued to do so through the last century. More bizarrely for Orent's argument, we have the pneumonic plague (The Black Death) of the 14th century (hardly a time of overcrowding), a disease about which Orent herself has written a book with the scaremongering title, Plague: The Mysterious Past and Terrifying Future of the World's Most Dangerous Disease. Maybe she resents an upstart virus displacing her own favorite doomsday agent.

More to the point, however, is that we don't need H5N1 to be highly and quickly lethal. We only need it to be highly transmissible, which is advantageous in evolutionary terms. The 1918 virus, for example, had a case-fatality estimated to be "only" two or three percent, but when you have infected a significant portion of the world's population (immunologically naive to H5N1), 2% is quite a lot of dead people. Thus if there is a 40% infection rate (perhaps comparable to 1918), we would have 2.4 billion infections, very few (percentage-wise) fatal. But a 2% case-fatality rate (no one's idea of super lethality) is still 50 million deaths. Fifty million deaths is not exactly a tunafish sandwich, I'd say.

In addition, influenza is infectious before symptoms (and hence incapacitation) occur, unlike SARS or Ebola. Orent likes to say that the reason wild ducks are only mildly affected is that dead ducks don't fly. But infectious people do fly--on airplanes. In addition, diseases that don't make animals sick often make people very sick. Thus viruses can continue to circulate in large animal reservoirs like aquatic waterfowl and still sicken incidental hosts like humans or other animals.

I'd go on to address her other arguments except she doesn't have other arguments. Her claim that the jump to virulence requires a long period of adaptation and is unlikely is just plain false. When you have billions of virions experimenting in each host and hundreds of millions of hosts, random mutations of the right kind are not rare. There are several mechanisms to produce this genetic variation, including reassortment, missense mutations and recombination. The latter doesn't even require co-infection, since we know of instances where the influenza virus has changed from Low Pathogenic to High Pathogenic via non-homologous recombination with its own genome. Moreover we now know that the protein changes needed are often extremely small, almost trivial.

But why go on. When you're selling crap by the word, someone's blog post isn't going to stop you. I'm sure we haven't heard the last from Wendy Orent. Too bad for us.

Lugon's challenge

Loyal reader/commenter and Flu Wiki stalwart lugon has issued a challenge that is worth taking up. "Revere," he asked, "please do start a competition among bloggers with the theme: what should be the elements for community preparedness?" Lugon goes on to make a suggestion for a letter to neighbors he has posted over at The Flu Wiki.

There are a lot of possibilities, here, since there are many things that can be done. So I will start us off with the understanding this isn't either the most important or the most urgent idea, just an example.

There are many older citizens who live alone and depend on their children (often in their fifties or sixties themselves) to get them groceries, pick up their prescriptions and make sure they are OK. What if these caregivers get sick and cannot do these things anymore? There may be a lot of clever solutions to this problem. Let me advance a simple-minded one with the hope someone can do better.

A social service agency (Visiting Nurses, Red Cross, charitable/church group or just some enterprising community members) could organize a roster of volunteers and a place to register someone needing care or a number where a caregiver could call in the event they were incapacitated. This would be a well-publicized contact point supported by protocols for doing the most frequent and urgent tasks in the event of need. For this to work it would have to be organized ahead of time and sufficient publicity be given so it could be employed in a timely and efficient way. Nothing fancy, just mobilizing the community to meet a foreseeable need.

Now it's your turn. Use the Comments.

The cavalry isn't coming

The National Journal (much read by congressional staffers) must be reading Effect Measure. Either that, or "the obvious" is stating to be, well, obvious:

If a bird-flu pandemic hits the United States, don't expect to see the federal government riding to the rescue. "Communities, in large part, will be on their own," predicts Pat Libbey, the executive director of the National Association of County and City Health Officials.

By definition, a pandemic affects a vast geographic area and a huge number of people. Avian flu would spread fast and easily from person to person (especially in buses and other confined public spaces), since it is contagious before symptoms develop. By the time the first victims appeared, epidemiologists would have to presume that the flu had already spread far and wide.

Every community in America would go on red alert. At that point, the federal government "can't come in and take over," Libbey said. "The math alone just doesn't work."

The federal role in such a pandemic would be largely policy-oriented and advisory, Libbey and local health officials explain. The Centers for Disease Control and Prevention would issue technical advice to health care workers, such as what symptoms to watch for in the population, how to administer a vaccine or an antiviral, and which groups of patients should receive treatment first. (The National Journal; subscription only, alas)

Besides advice, the feds might also distribute vaccine--except for the minor point that there isn't one.

But beyond all that, the federal government can't provide much tactical help. "It's every community for itself," says Gary Oxman, the health officer for Multnomah County, Ore., which includes Portland. This comes as no surprise to local officials. Ever since the 9/11 attacks and the October 2001 anthrax mailings, communities have been gearing up for a bioterrorist attack, the effects of which could mirror a flu pandemic. In the process, they've taken a hard look at their own limits.

The rest of the National Journal article is about the obvious medical and public health issues of surge capacity (additional hospital beds and equipment). But the more important issues relate to how all parts of the community--public services, businesses, schools, transportation, supply lines, etc.--will cope with a projected 30% prolonged absenteeism. This has the potential to cause a set of cascading problems, such as interruptions with food deliveries, essential drugs like insulin or blood pressure medications, water and power, and more. Many of the problems are foreseeable. Prior planning can greatly lessen the consequences.

So there's no sense waiting for the federal government to tell us how they will respond. They won't. Every community will be on its own. Time to get ready. For ideas, visit The Flu Wiki.

Autoimmune disease in Congress

With bird flu spreading and no vaccine, immunity is the topic of the day. Time for our Congress Things to take action. And they have.

This week they passed legislation providing immunity for gun makers and cheeseburgers.

Gunmakers.

Congress gave the gun lobby its top legislative priority Thursday, passing a bill that would protect the firearms industry from massive lawsuits brought by crime victims. The White House says President Bush will sign it into law.

The House voted 283-144 to send the bill to the president after supporters, led by the National Rifle Association, proclaimed it vital to protect the industry from being bankrupted by huge jury awards. Opponents, waging a tough battle against growing public support for the legislation, called it proof of the gun lobby’s power over the Republican-controlled Congress.

Under the measure, about 20 pending lawsuits by local governments against the industry would be dismissed. The Senate passed the bill in July. (FreeInternetPress)

Maybe NIH's H5N1 vaccine isn't protective, but at least complete protection is possible someplace. Way to go, Congress Things.

Cheeseburgers.

The US House of Representatives easily passed the "Personal Responsibility in Food Consumption Act" - the Cheeseburger Bill - on a bipartisan 306 to 120 vote on Wednesday.

"Food manufacturers, marketers, distributors, advertisers and sellers should not be held liable for injury because a person's consumption of legal, unadulterated food is associated with the person's weight gain or obesity," said the White House in a statement.

As a result, the bill will block in state and federal courts "frivolous lawsuits against the manufacturers, distributors or sellers of food or nonalcoholic beverage products" arising from obesity claims. According to a Gallup Poll, nearly 90 percent of consumers oppose these types of lawsuits. (FoodNavigator)

So if 90% of Americans opposed these suits, it wouldn't seem they would succeed in court, since juries are made up of those same people. Moreover some 18 states already have cheesebuger bills even though they don't have lawsuits:

In Texas for example, House Bill 107 was created to prevent speculative lawsuits against the food industry, which threaten to engulf the sector. The bill's author, Rep. Corbin Van Arsdale, (R-Houston), called it "a preemptive strike on lawsuits against anyone up and down the food chain".

In other words, "Don't even think of suing us. We own the lawmakers."

But this may be a pyrrhic victory because the tactic now is to sue food manufacturers for false and deceptive advertising. This is harder for the fat cats to defend against for two reasons. The first is the obvious one that they do engage in false and deceptive advertising. The second: What are they going to do? Pass a law that says false advertising is OK?

On second thought, they might do exactly that.

Freethinker Sunday Sermonette: Starbuckling

Sunday again. I'll take the pulpit to reflect on god and mammon.

Or god and coffee. Starbuck's is buckling to the godstruck and reportedly will include in its quotes from writers, scientists, musicians, athletes, politicians and cultural critics on cups a quote from Rev. Rick Warren, author of the metaphysical pot-boiler The Purpose-Driven Life (USA Today, 10/19/05). It will put your mind to sleep no matter how much caffeine you've had.

Starbucks was apparently feeling the heat from America's Taliban. Baylor University (University?) pulled Starbucks cups after a quote from Armistead Maupin appeared saying life was too short (actually "too damn short") to hide being gay. Instead we'll get Warren's pitch for god the creator, sent in after he saw a quote on evolution. Jeez. Talk about gutless. My next cup comes from Peets.

Starbucks now joins In-N-Out Burger and the Forever 21 and XXI clothes outlets, all of whom have a tiny little Bible book, chapter and verse notation (John 3:16) on the bottoms of their shopping bags proclaiming: "For God so loved the world, that he gave his only begotten Son, that whosoever believeth in him should not perish, but have everlasting life." Not to mention the Hobby Lobby chain that only plays Christian music on their muzak. Imagine the furor if the godless majority of this country were to launch a campaign to force these stores to put Freethinker quotes on their shopping bags or play Heavy Metal satanism ditties for their customers. I'm not advocating it. The god-addled shouldn't either.

Where will it all end? Someplace like this:

A 26-year-old Missouri woman was refused [Emergency Contraception, the "morning after pill"] when she handed her prescription to a pharmacist at a Target store in Fenton, MO, on September 30. The woman was told by the pharmacist, “I won’t fill it. It’s my right not to fill it.” She was told that she could go to a local Walgreens instead. The woman said, “When the pharmacist told me she wouldn't [fill the prescription], I went from disbelief to shock to anger. I guess I'm still pretty angry. It seems unbelievable to me that a medical professional could/would deny access to a federally approved drug and impose their personal beliefs in a professional setting. I am also grateful that I did not need it filled at that time. I don't know how it would be if I had just been raped or if the condom broke and I was a feeling confusion and panic anyway -- and then was denied access and told to go across the street.”

Starbucks and Target. You're on my shit list. Have a nice Sunday.

Controlling our fears

China says it will shut its borders to keep human bird flu in, while most other countries are making plans to keep bird flu out. Nice ideas. Neither will likely work.

Australia is drawing up plans which include large quarantine stations in airplane hangers to isolate planeloads of people if bird flu appears among them in flight. They are also planning to use thermal sensors to detect fever in incoming passengers. A news report I saw recently (but can't find the link) says the US Senate will ask the Department of Transportation for something similar. This was tried with SARS, a much easier disease to control in this fashion because it isn't at its peak of contagion until late in the disease. Every expert says it didn't work for SARS and it certainly won't work for influenza where people are contagious before the onset of symptoms and signs.

It is inevitable that these kinds of restrictions will come into play if a pandemic is starting. It is just as inevitable they will be costly and will fail. It isn't even sure they will slow things up much. This is apparently an obligatory response that can't be stopped. But it shouldn't also prevent us from beginning the kind of community mobilization that will really make a difference in managing the consequences of a pandemic, should one come.

Pulling up the drawbridge and community mobilization, unfortunately, are polar opposites. One is based on fleeing our neighbor. The other on neighbor helping neighbor. We will just have to get used to the idea that both are basic survival impulses and we will have to manage our instincts as well as manage the consequences of a pandemic.

Visit The Flu Wiki for more.

How far (genetically) to a human H5N1?

An article in press at the journal Virology by Gambaryan and her Russian and CDC colleagues has interesting, and somewhat disquieting data on the evolution of H5N1. As noted in somewhat more detail on our Primer II piece at the Flu Wiki, influenza viruses adapted to birds have a slightly different predilection for binding to cells than those adapted to humans. To infect a cell the virus looks for a "receptor" on the cell's surface, essentially the door it uses to enter. The receptor for influenza viruses is a combination of a fat, sugar and protein tipped by sialic acid. How the sialic acid is connected (what kind of linkage) seems to be one determinant for a preference for bird cells or human cells. Bird viruses prefer the α 2-3 sialic acid linkage while human viruses prefer α 2-6 linkages. The α 2-3 links are characteristic of the intestinal tract of birds, while the α 2-6 linkages are the predominant receptors in the human respiratory tract. However it was recently reported that humans also have a significant number of α 2-3 receptors (on ciliated cells) in the respiratory tract and it is likely through these cells that the H5N1 virus transmitted from chickens grabs on and replicates. We don't know why it doesn't happen more often, however. The human virus seems to prefer to start off in the α 2 -6 linked cells. This is apparently not a problem in the intestinal tract of birds.

This overall picture is even more confused because the pathology of influenza A by human-adapted viruses shows a great deal of replication in the ciliated cells (that is, the ones with the α 2 - 3 linkages) of the human respiratory tract (in the trachea, the large part of the conducting system; see Primer I at the Flu Wiki). Thus human viruses seem to initially infect the non-ciliated cells that have the α 2-6 receptors but then are able to replicate efficiently in the ones with α 2-3 receptors after infection is underway. Exactly what is going on here isn't clear yet.

That's by way of background to the new paper. Gambaryan et al. looked at binding to α 2-3 and α 2-6 receptors of a variety of influenza A/H5 viruses, including those from 2003 - 2004. Most of them, including those isolated from humans in 1997 and 2004, retained their α 2-3 specificity, that is, seemed still to have bird cell preferences. But two isolates from Hong Kong from February 2003 showed decreased binding to the bird α 2-3 receptor and increased binding to the human α 2-3 receptor. Moreover, sequencing revealed that they differed only in a single amino acid in the HA protein, i.e., a single change in the protein switched the virus from a bird preferring one to one with an increased ability to bind to human cells. This is not genetic shift. It is genetic drift, the result of a random mutation. No co-infection or reassortment is needed to bring this about. The paper also presents evidence that H5N1 has been adapting to life in poultry from its previous home in aquatic wildfowl.

The more virus there is out there the more likely it is to happen by chance on the recipe for efficient infection of humans and then efficient transmission. It has already done this for terrestrial birds (poultry). This work shows that the genetic distance the virus needs to travel to find a successful recipe may not be large.

Addendum, 10/23/05: Niman at Recombinomics has a Commentary on this paper as well. He makes the intriguing suggestion that recombination with an H9N2 in the Middle East (on the migratory bird flyway) might result in the HA change that is permissive for α 2 - 6 binding and efforts should be made to shelter birds in this area.

Bird flu economic effects: the future is now

If you are wondering about the many ways bird flu can affect the economy, consider this example.

Soybean futures are down:

Soybean futures ended lower on Thursday. Weakness came from concerns that Asian bird flu may slow demand for soybeans and soybean meal. The disease has spread to Europe and there are some reports that poultry demand has fallen by 30%. Soybean meal a major poultry feed. November ended 4 1/4 cents lower at $5.85 and January was 3 3/4 lower at $5.98. (Ag Professional)

This doesn't just affect futures traders, but the whole chain of production, from suppliers of farmers, farmers, storage, transportation through to the market.

Not amused either

The H5N1 panzootic has resulted in the killing of an estimated 100 million birds in Asia. But if you aren't in Asia and want a piece of the action, you can now buy the choking chicken toy, manufactured by a company in Taiwan and sold in stores across Australia.

A product description on the Web site of Jaycar Electronics, a major Australian importer of toy, says: "Grab him by the neck and he will squawk and cluck like mad, flapping his wings and feet wildly as if he is really being choked." (Boston.com)

For children three years and up.

The Royal Society for the Prevention of Cruelty to Animals (Australia) is not amused:

"What's next? Burn a cat? Shoot a dog?" [the RSPCA spokesman] said. "Children of that age are likely to turn around and try the same thing on their pet bird or even the cat or dog. Then they're going to wonder why the animal fights back."

I'm with the RSPCA on this one. Bad enough I have to write almost daily about the industrial massacre of millions of animals. It's not a giggle.

(Hat tip Kevin, MD via Boingboing)

Hard travelin'

In the wake of alarming press stories always comes the anti-alarming press stories ranting about "scaremongering." Sometimes legit, sometimes suspect. The World Tourism Organisation has provided us their public health expertise, warning governments and media to avoid "unnecessary scaremongering" (as opposed to necessary scaremongering?). Unnecessary scaremongering risks "a sharp drop in international tourism."

"We must ensure that people are not deterred from travelling without good reason," said the Madrid-based agency, which will meet with the World Health Organisation shortly to discuss the looming threat to the industry.

"Unnecessary scaremongering can cause a sharp drop in tourism that squeezes the economies, especially those of developing nations and the incomes of millions of workers in this industry," warned WTO Secretary General Francesco Frangialli in a statement.

[snip]

"We know that the avian flu epidemic is very likely to happen, but not what regions it could hit or for how long. But we do know from our previous experience with SARS that its effect on tourism could be substantial," he added. (AFP)

Um. Sr. Frangialli. Influenza isn't SARS. It won't stay put "in a region." If a pandemic happens, your industry will take a hit. A big hit. Plan for it. If it doesn't happen, you'll be ahead.

But complaining about scaremongering will get you nowhere. And it makes you sound bad.

Frist: next Delay?

Tom Delay is scheduled for his perp walk on Friday (Lindsay at Majikthise will cover it). Maybe Bill Frist is next? (a Republican leadership post seems to be a risk factor). Frist? Well Frist's investigation for possible insider trading has been given a pretty low key treatment by the media, so you might not know the details the way you know Plame-Rove-Scooter. It's not out of the blue, though. It is a public health story, or at least a medical care one.

Here is some of a superb post by Larry Beinart, whose novel Wag the Dog became first a movie and then the Bush Administration:

Bill Frist is a very rich man. At the time of his first Senate race in 1994, he declared his personal holdings as $20 million, and $13 million of that was in HCA stock. HCA is the largest health care company in the country. It was founded by Frist’s father, Thomas, and, later on, run by his brother, Thomas, Jr.

When Frist won, he became the health care industry’s own senator. It’s not that they bought him, he was them. He voted against the “Patient Bill of Rights.” He made it harder for patients to sue their HMOs for not receiving care. He sponsored the bill that protects pharmaceutical companies from liability for their use of thimersol, a mercury-based ingredient in vaccines. He pushed through the mega-bill that makes Medicare pay top dollar to the pharmaceutical industry. He worked for the tobacco interests and against USDA inspections of food suppliers.

Meantime, an investigation of HCA was going on. It turned into the largest medical fraud case in history. HCA had defrauded Medicare, Medicaid and Tricare, the military’s health care program. They kept two sets of books. They paid kick backs. They engaged in “upcoding,” billing for more expensive procedures than what they actually performed. They charged their advertising to the government as “community education.”

HCA consolidated and sold billions in property to pay for the legal fight. But then they settled with the government just two days before Trent Lott stepped down and Frist stepped up to become Majority Leader.

Part of that settlement could be regarded as a sweetheart deal. A plea of guilty to the criminal part of the charges would have disqualified them from government contracts. They were allowed to use subsidiaries to accept the criminal liability and then let those companies go out of business.

Frist’s brother, Thomas, was charged with insider trading in 1997, but survived the allegations.

This was not Bill Frist’s only peculiar financial transaction. In 2000 he took a million dollars in campaign contributions and invested them in the stock market. He lost $710,000 of it. He stood by his decision, saying, "Over time, money that is placed in markets will increase faster than placed in banks."

You can find more on the Frist family shenanigans in Henry Scammell's superb book, Giant Killers.

(hat-tip, Rebecca's Pocket)

Bird flu iceberg

There seems to be a lot of bird flu reports in the last day or two. It is hard to say if these are new occurrences or the general climate is now more permissive to admitting a problem. But it is not just birds.

Vietnam: 400 dead ducks in southern Bac Lieu province, where almost 40% of its estimated 1.1 million fowl were vaccinated in recent months. The government claims to have vaccinated 56 million out of a targeted 156 million poultry already. Maybe.

Vaccination is controversial because there is some concern that while it prevents the animals from getting sick, it may not prevent them from becoming infected and shedding virus and their immune status prevents easy identification of infection. Vietnam has killed an estimated 50 million birds since the resurgence of the virus in 2003.

Malaysia (AFP): A fresh outbreak in Kelantan state, near the Thai border, has been reported. 1200 cickens and ducks within a one km circle of the village of Belian were culled and house-tohouse checks of residents are being conducted. Over 800 people were screened, seven sent to the hospital for checks (all discharged). But a 10 year old boy with fever and cough and a woman from the veterinary department with diarrhea and fever remain hospitalized, according to AFP. Officials are blaming fighting cokcs from Thailand for the outbreak, which is a blow to Malaysia's resurgent poultry industry.

China (AP): 2600 dead birds in northern China's grasslands in Inner Mongolia, according to the government. "The epidemic is under control," Xinhua [News agency] said. Right. And the check is in the mail and I'll respect you in the morning.

Russia: this time just south of Moscow (Tula region), the first (reported) instance in European (west of the Urals) Russia. The EU is concerned that this is a "second front" (on the north), with a long border with Finland, Estonia and Latvia in eastern Europe and the Baltic area.

Indonesia: Forget about the birds and the swine, where the virus is solidly entrenched. It is the humans that keep getting sick here. From Antara News Service:

"We have received a report from the RSPI hospital`s director that the hospital had received two new patients - a father and his son - with symptoms of bird flue," Health Minister Siti Fadillah Supari said after breaking the fast with her ministry officials at her residence.

The two patients had been transferred by the Hajj Hospital in East Jakarta to the RSPI Sulianti Saroso hospital after showing bird flu symptoms such as high fever, breathing problems, headache, and a sore throat.

Today a new family cluster is also being reported, a father and his infant son, admitted to the hospital yesterday. No other details as yet, but person to person spread is suspected.

Thailand, too, is reporting a new death, its 13th. The only information available at the moment is that it was a farmer who had contact with sick chickens.

Then there is India, where the government declares no bird flu at all in south Asia or India in particular. Yeah, right.

More likely this:

British scientists travelling to Asia to inspect the spread of bird flu said the number of cases reported in humans could be only "the tip of the iceberg".

Just 120 cases - which have led to around 60 deaths - have been confirmed since 2003, but as the avian flu spreads from Asia to Europe, the concern about the possible infection of humans has grown.

Sir John Skehel, director of the Medical Research Council (MRC) National Institute for Medical Research, said part of the reason for making the trip was to look at the way the disease was being monitored in other countries.

Speaking at the MRC in central London, he said: "How are people checking in the Far East for people who have recovered from the infection? Are the total number of people who have been infected the tip of the iceberg and, beneath them, are there are a lot of others who have been infected? It is an important question." (The Guardian)

Tip of the iceberg, indeed.

Correction (10/20/05, 9:55 pm EDST): An alert reader has caught a serious error in this post. The reported cases in Malaysia are not recent, but from a year ago. No cases are currently being reported from Malaysia. We apologize for this oversight. We try to be careful, but it was early in the morning (hat tip Jeremy).

You can't stop a wrecking ball in mid-swing

Two readers (hat tip J&PF and Chuck) have called our attention to a piece in Government Health IT, an online newsletter for, well, government health IT, types.

As state and local health departments gear up to battle a possible avian flu outbreak, they face a sharp cut in funding from the Department of Health and Human Services. However, the loss could be fixed through funds intended to cover the costs of controlling a pandemic, added as an amendment to the 2006 Defense Department Appropriations bill.

“Critical funding is shrinking just as public health agencies are being required to expand their work in pandemic influenza preparation and response," said Dr. Rex Archer, health director of Kansas City, Mo., and president of the National Association of County and City Health Officials (NACCHO).

The Bush administration, in its proposed 2006 HHS budget, slashed funding for public health preparedness by $129 million -- from $926 million in 2005 to $797 million. The House version of the 2006 HHS bill appropriates $853 million while the Senate bill sticks with the$797 million requested by the administration.

Donna Brown, government affairs counsel at NACCHO, said those state and local preparedness funds provided by the Centers for Disease Control and Prevention (CDC), an HHS agency, are used for a wide range of activities by local health departments, including information technology and disease surveillance systems.

“We need robust electronic information systems to detect disease outbreaks," Brown said, including surveillance systems that can alert local public health officials to potential flu symptoms. Those would be critical to helping combat a pandemic.

So what's the deal? Bush reads The Great Influenza and then cuts funds for public health?

Yes and no. The cuts are independent of the concern for influenza. They are a consequence of the wrecking-ball policies of the Bush Administration and the Republican-controlled congress (and shame to the democrats who helped). You don't stop a wrecking-ball in mid-swing. It has too much inertia and will continue to destroy critical infrastructure even as bandaids like supplementary avian flu funding try to cover the worst of the damage.

It's not just public health. It's dams, bridges, levees, the shredded safety-net for our most vulnerable neighbors. While pursuing military adventures abroad and obsessed with terrorists at home, the BushCo's left us defenseless and dangerously vulnerable in our own homes, workplaces and communities.

Enough is enough.

Jailbirds

If a flu pandemic comes and there is a lot of absenteeiism, we need to plan to take care of people we don't think about often. Like prisoners. What if a third of the already understaffed guards and a third of a small clinic staff are out and a third or more of the inmates are sick? So I was glad to see this headline in a Chicago area news outlet: Jail Prepares for Avian Flu. About time, I thought.

Until I read the article:

With worldwide fears of avian influenza on the rise, local officials are taking a closer look at McHenry County's highest-risk population.

While the arrival of foreign federal prisoners promises to bring millions of dollars in cell-rental fees to county coffers, local public-health officials want to make sure that illegal immigrants do not also bring the bird flu.

Because the jail hosts a large number of immigration detainees from China, where infected poultry populations have been discovered, jail administrators are increasing vigilance for human cases in McHenry County, Jail Chief Tom Svoboda said. (Northwest Herald via CBS2, Chicago)

Don't get me wrong. It isn't bad to be vigilant about imported infection. But two things about this bother me. The first is the rather obvious xenophobic undercurrent that will only intensify as fears intensify. This is another reason Bush's military quarantine initiative is of worrisome. In times of fear, nativist tendencies seize on whatever weapons are available. Well-off whites will have no trouble evading a quarantine. It will likely fall disproportionately on immigrant groups. The second thing is that there still seems no evidence of planning to manage the consequences of a major community outbreak of influenza that will cripple the routine operations of the jail, possibly resulting in the abandoment of the inmates.

As we know from the Katrina nursing home patients, it happens.

Clustering

Helen Branswell of Canadian Press shows once again why she is the best flu reporter on the planet (hat tip crofsblog). Branswell alerts us abut a paper to be published in the journal Emerging Infectious Diseases about clustering of H5N1 infections. The paper presents evidence for at least 15 instances since the disease reappeared in 2003. Human-to-human transmission is strongly suspected in some or all of them, although data are insufficient to show this beyond doubt. But beyond doubt is an unrealistic and probably inappropriate standard.

The authors combed published reports and consulted regional contacts looking for clusters of cases within families that occurred from January 2004 to July 2005. Since their report was submitted another family cluster occurred in Indonesia involving a woman and her young nephew, both of whom tested positive for H5N1 virus.

[snip]

A cluster was considered two or more cases, where at least one member tested positive for the virus and other members of the cluster experienced severe pneumonia or death from respiratory disease.
Olsen said where human-to-human transmission may have taken place, the dates of onset of illness suggest transmission stopping after one generation. In other words, if a person passed the disease on to someone else, the newly infected individual did not appear to have spread it further.

"It's not to say there weren't tertiary cases, but we're not clearly seeing that in these data," she said from Bangkok.

Most clusters comprised two or three cases, though one stretched to five. The researchers could not determine what happened to the members of that cluster, which occurred in Vietnam in early March.
In one grouping of three family members in Vietnam, two nurses who looked after someone with the virus were subsequently hospitalized with severe pneumonia. But infection with H5N1 was confirmed in only one of the health care workers.

Branswell quotes CIDRAP's Michael Osterholm as saying the start of a pandemic will have multiple clusters (ten or twenty) in a given area and they will be larger. While this is plausible, the evolution to pandemicity may not happen all at once or so suddenly. As suggested by one of our readers last February, it may not be the number of clusters but the average size of each cluster that is the signal. Cluster size is related both to basic reproductive number (R₀) and to network topology. Larger clusters are the more highly connected nodes.

The lead author of the EID paper, Sonja Olsen, is acting director of CDC's International Emerging Infections Program in Bangkok. One suspects her scientific contribution is not entirely welcomed by WHO:

A spokesperson for the World Health Organization said the data, while helpful, are retrospective.

"If transmission from birds to humans had become more efficient, then we would be seeing more cases," Maria Cheng said from Geneva.

"But it's certainly very useful to have this information in terms of tracking the disease in the future."

This is not only faint praise, it is incomprehensible. What does it mean for the data to be "retrospective"? They want her to report clusters before they happen? Unfortunately, WHO's stance seems to be just as expressed. They won't believe it until they see cases filling the hospitals. One wonders if they'll "see" it even then.

We should say that this evidence of clustering has been noted persistently by Henry Niman at Recombinomics. WHO never liked it there, either. But credit where credit is due.