Sunday, April 30, 2006

Scandal now reaches the FDA

It just goes on and on. There are so many Republican scandals going on in parallel it is hard to keep track of them. Since this is a public health blog, let's just do the latest, involving the former head of the US Food and Drug Administration Lester Crawford. He resigned in September, just three months after being confirmed by the Republican Senate. Reason? It was time for someone else to lead the agency. Three months. That's time. He is now (what else?) a lobbyist in Washington.

Commissioner Crawford, you may remember was involved in nixing over the counter (OTC) sales of Plan B, the emergency contraceptive otherwise known as the "morning after" pill (see here and here). Despite recommendations from FDA and independent scientists that the drug was appropriate for ale OTC, the FDA declined to approve it. Virtually everyone involved knew this was a political pay-off to Bush's right wing conservative base. So the FDA is being sued by the Center for Reproductive Rights (CRR). As part of this suit, the CRR's lawyers have been taking depositions (questioning under oath) of FDA officials. On Thursday it was to be Crawford's turn.
[But on] Wednesday Ms. [Barbara] Van Gelder, who is his personal lawyer, asked for a delay, saying she would instruct him to invoke his Fifth Amendment rights. Dr. Crawford previously declined to answer questions from the Government Accountability Office about Plan B.

Ms. Van Gelder told Magistrate Judge Viktor V. Pohorelsky of the District Court for the Eastern District of New York on Thursday that Dr. Crawford had been represented by Justice Department lawyers in the reproductive rights center's suit.

According to the transcript, she said that Dr. Crawford was under criminal investigation and that the issue of his financial disclosures "is within the grand jury." (New York Times via Atrios)
Whoa. What's this all about? It seems financial disclosure forms showed that in 2004, when he was deputy FDA Commissioner and then Acting Commissioner, either Crawford or his wife sold shares in companies also regulated by the FDA (not that Crawford would ever let outside considerations affect his judgment).

Criminal investigation. I guess this is a bit of a fly in the ointment of Crawford's cushy retirement life as a Washington lobbyist. I wonder if he has a Plan B?

Freethinker Sunday Sermonette: Oh, Canada

Sunday. Reading the news.

Polling in the US and Canada in the last year or two provides a snapshot of attitudes of the electorates in each country regarding religion and politics. Since the questions were different in the Canadian and American polls it is hard to compare them directly, but it is interesting to see the effect on Canadians of American views on the subject.

Earlier this month, Kevin Phillips summarized in The Nation results of several national polls in the US. More than 60% of "conservatives" and "republicans" (two separate -- but equal? -- categories) believe that a political leader should rely on religion when making policy decisions (Source: ABC/Washington Post poll, April 2005), with the figure for "democrats" and "liberals" in the low to mid twenties.

Canada just elected an evangelical Christian, Stephen Harper to lead their government, so it's interesting to look at their attitudes. According to a poll by CanWest News Service this month, 63% of respondents said they'd vote for an evangelical Christian "even [sic] if they liked the party and its views." (down from 80% ten years ago) but 68% said they'd vote for a Muslim or atheist candidate as well (down from 74% and 72% ten years ago). These are clearly different questions than posed to Americans, but comparing responses to the same questions within Canada shows slippage for identifying religion and politics. Canadian analysts suspect the US scene has something to do with it:
Mr. [Andrew Grenville, a senior vice-president of the polling firm Ipsos Reid] speculated that nervousness about American politics -- more so than the "Harper factor" -- is responsible for Canadians shying away from politics with religious overtones.

"One part of it is probably the Stephen Harper factor, but I don't think he has been really wearing his religion on his sleeve, nor really embraced strong moral stances that can be traced back to religious belief," Mr. Grenville said. "It's the U.S. example that has really turned people off."

The religious right in the United States is considered to be largely responsible for sending President George W. Bush back to the White House in 2004.

Moreover, the invasion of Iraq, which Canada did not support, was widely regarded to be infused with religious overtones.

"I wonder if we're being reactionary when we hear George Bush spouting off Bible verses along with rhetoric around his war?" said Richard Ascough, a religious scholar at Queen's University in Kingston.


In Canada, there was also a slip in the belief Christians should get into politics to protect their values, with only 39 per cent agreeing with the idea, compared with 46 per cent a decade ago.

There was also a five per cent drop -- to 40 per cent from 45 per cent -- in the number who believe it's essential for Christian values to play a major role.

Mr. Grenville said he believes there's been a bit of a backlash against the divisive political debate in the last couple of years over same-sex marriage.

"To me it suggests a growing divide in Canadian culture where religion can become that wedge that pushes people apart," he said. (Ottawa Citizen)
So the news from Canada isn't all bad, despite electing a religious rightwinger to lead them. And the same Canadian article suggests the backlash is happening in the US as well:
Americans who were surveyed also appear to be less inclined than they were a decade ago to vote for a leader who is an evangelical Christian, even if they liked the party and its views.

Only 64 per cent would do so, compared with 78 per cent 10 years ago. The results also suggest Americans would be more likely to vote for atheists or Muslims as leaders than they would have been in 1996.
Someday future generations will look back on this era as some kind of weird Dark Age that gripped the country before the sun shone again. I hope it doesn't come complete with a modern version of The Plague.

Saturday, April 29, 2006

Shorter road to Tamiflu synthesis

Kudos to the Elias J. Corey laboratory at Harvard University for a chemistry tour de force and for their position on intellectual property rights. Both are important. First, the chemistry.

A serious obstacle to ramping up oseltamivir (Tamiflu) production in anticipation of a possible pandemic of influenza/A has been its long production cycle. Pharma giant Roche initially claimed the drug could not be made in less than 12 months and required more than a dozen steps, some of them involving very hazardous materials. It also required the use of expensive and scarce ingredients, (-)-shikimic or (-)-quinic acids. Shikimic acid is derived from fermentation of Chinese star anise fruit, in limited supply.

Now Corey has devised a way to make oseltamivir without these complex starting materials and without hazardous intermediates. A second alternative route by Japanese researcher, Masakatsu Shibasaki, is also said to have inexpensive starting materials and no hazardous steps, but smaller yield:
"Our synthetic pathway has several advantages over the current Roche production method," Corey says. "It is shorter, doesn't involve any hazardous substances, begins with very cheap starting materials that are pennies per pound, and has excellent overall yield." Corey's overall yield is about 30%—about twice that of the commercial route and significantly higher than the approximately 1% that can be calculated for Shibasaki's.


Although Roche researchers declined to comment on the new synthetic routes, a spokeswoman says the company is in contact with the authors of both papers. Both the technical potential and regulatory impact of any new route still have to be explored, she comments. In his group's paper, Corey, who serves as an adviser to Palo Alto-based Roche Biosciences, thanks Roche researchers in Switzerland for their encouragement. (Chemical and Engineering News)
There is some way to go before either method is in production, but the more important part of the announcement is that Corey has placed his method in the public domain. Shibasaki, by contrast, has applied for a patent, although this wouldn't prevent him from allowing no cost licensing if he wished. However, given the situation, Corey's move is highly significant and should be considered a model for others.
"I hope the work will stimulate others to work on different ways of synthesizing Tamiflu," Corey says. "Although our route is already very efficient, it's conceivable that when you put new developments together, you'll have an even better and cheaper process. I think the Tamiflu supply problem is solved."
Solved, that is, if someone will make the drug with this process. Roche has invested much in production facilities using a process for which they have the license. On the other hand, many independent companies may now use this new process, with or without Roche's permission (Roche still has the license for the drug itself).

In 1990 Corey won the Nobel Prize in Chemistry for his achievements in chemical synthesis. He hasn't lost the touch.

Nor the commitment to the common good.

Friday, April 28, 2006

The doctor will see you now

There's no flu emergency now. No heat wave. Just normal times. What's "normal" in the Emergency Department?

CDC has just reported that 10% of emergent cases (patients who should be seen in less than 15 minutes after arrival in the Emergency Department) and 20% of urgent cases (should be seen in under an hour) had waiting times of more than an hour to see a doctor. These two categories constitute half of all ED visits.

And if you are black or Hispanic you were even more likely to wait:

If this is "normal," what do you think a flu pandemic will be like at your friendly neighborhood Emergency Department?

The mask problem

As noted previously, the "mask question" was kicked over to the Institute of Medicine (part of the National Academies of Science). The report came out yesterday.
If a worldwide flu epidemic strikes, face masks should be considered a defense of last resort since there's little evidence about whether the masks available to the average person or most health care workers can prevent influenza infection, the Institute of Medicine said Thursday.


Health workers use masks — simple surgical masks or better-filtering ones called N95 respirators — mostly to keep from breathing their own germs into open wounds or onto otherwise vulnerable patients. But certain filtering masks also can protect wearers from specific respiratory diseases, such as tuberculosis.

The masks are supposed to be used once and discarded. Anticipating a staggering demand if the bird flu or some other super-strain of influenza sparks the next pandemic, federal health officials asked the IOM to determine whether there are masks that could be reused safely, to conserve supplies. (Lauran Neergaard, AP)
Do masks work for influenza? No one knows:

The first question is whether different masks really block influenza, noted the IOM panel — a question the government didn't ask, but that the scientific advisers said should be studied, urgently.

"Just to double-emphasize: We don't have good data to make a decision about how effective they are or are not," said panel co-chair Dr. Donald Burke of Johns Hopkins University.
It would seem a no-brainer that using a mask is better than not using one. But that depends on whether the mask affects your behavior, for example, encouraging you to do things you wouldn't do without it, like go into crowds. As we have noted here a number of times, we don't understand completely how flu gets around, specifically the relative importance of object to hand to mouth/eye versus large (quickly settling) droplets from coughs or sneezes versus tiny droplets that remains suspended for hours or days.

Filtering masks also have to be professionally fitted to the user's face (forget it if you have a beard). Assuming the mask works for flu (an open question), its outside remains contaminated, so it has to be handled and disposed of carefully. The IOM panel was reluctant to discourage people from wearing a mask because it honestly didn't know their value.

Masks thus join Tamiflu and the current experimental vaccines as methods absorbing a lot of resources but of unproven effectiveness. Better to invest in the harder but proven methods of strengthening the public health system and its social service counterparts. Those work, pandemic or no pandemic.

Better to bite the bullet than to wait for a magic one.

Thursday, April 27, 2006

So you want to be a model

[NB: corrected the date]

The results from yet another computer model of pandemic influenza spread have just been published in the journal Nature. They are being variously interpreted and reported by news sources. CBC News says they show there is no magic bullet to control flu, but HealthDay says fast treatment and isolation of the sick and their households is "key to effective control of any flu outbreak." On the glass-is-half-empty side we have an AP story:
If pandemic influenza hits in the next year or so, the few weapons the United States has to keep it from spreading will do little, a new computer model shows.

A pandemic flu is likely to strike one in three people if nothing is done, according to the results of computer simulation published in Thursday's journal Nature. If the government acts fast enough and has enough antiviral medicine to use as preventive dosings — which the United States does not — that could drop to about 28 percent of the population getting sick, the study found. (Seth Bornstein, AP)
What are we to make of these results, especially compared to a slightly different set announced two weeks ago from another group at Los Alamos National Laboratory? Let's talk about models.

It is a truism among modelers that all models are wrong, but some models are useful. The art of mathematical modeling consists in stripping down to its bare logical skeleton the part of the real world you are interested in. If you have included enough of what is important and discarded enough of what isn't you may be able to see things that are useful when you turn the mathematical crank. (I'm simplifying, but then that's what modelers do. Call this meta-modeling.)

One of the oldest and simplest mathematical models of infectious disease dynamics is called an SIR model: S stands for susceptibles, I stands for infectives, R stands for recovered or removed (possibly by death or immunity). The game consists in modeling what happens when you introduce a certain number of infectives into a susceptible population. If you assume that every susceptible has the same chance of coming in contact with an infective that a certain fixed proportion of those contacts result in new infections in each time interval, that the disease lasts a certain length of time with a fixed proportion of those infected recovering and another fixed proportion dying, then you can make some statements about what will happen given various starting points of initial infectives and susceptibles, and contact, transmission, recovery and mortality rates.

I teach students to do this using the techniques of ordinary differential equations but it can also be done by simulating the whole thing with a computer. You start out with the infectives. On day one they come in contact with the designated number of infectives, a proportion of those cause disease, etc. That gives you the number of new infectives and susceptibles at the end of day one. The computer moves on to day two. And so on.

This is a pretty simple model and some of the assumptions are highly questionable. Mixing isn't random in the population, not everyone is alike in his or her susceptibility or ability to transmit, infection and mortality rates differ with age, etc. With some ingenuity and a couple of supercomputers working in parallel you can incorporate a lot of complexity and do it for very large populations, whole nation-sized populations even.

A lot of the hard work consists in trying to figure out the parameters of the model. The parameters are the numbers like contact rates in different age groups and subpopulations, transmission rates, etc. Inevitably important elements aren't included. In the recent Nature paper, no account was taken of any resistance developing to the drug Tamiflu. You hope that the omitted factors are only important on the margin, not centrally. Anyway, you'll get a grant to stick them in the model next go around.

The Los Alamos modelers and the modelers who just published in Nature know what they are doing. They are among the best infectious disease modelers we have and these papers as well as those from some other groups are tours de force. But of course they are wrong. All models are wrong. The question is whether they are useful. This question needs to be made a bit sharper: useful for what?

If you know a lot about the mechanism and are sure of the parameters, mathematical models can be highly accurate and predictive. We use them to put spacecraft into orbit or figure out the efficiency of engines. That's because we have Newton's mechanics and thermodynamics to help us. We aren't so lucky in modeling infectious disease dynamics. But even if there is a lot of uncertainty about mechanisms and parameters the models can still be useful for some things.

We might be able to get some qualitative idea of disease dynamics, say, without being able to make exact quantitative predictions. For example, does the disease spread, involving more and more of the population with time until all are infected? Or does the number of diseased bounce around, going up and down, perhaps chaotically or regularly? Or does the disease sputter and peter out? Often this kind of qualitative description is extremely useful because the same general behavior occurs over large ranges of parameter values, for example, uncontrolled spread occurs over large ranges of transmission rates, contact rates and initial numbers of infectives. This means you don't have to get all these factors exactly right, but it might also mean that there are some things, like rate or pattern of spread you can't predict. As you make your models more and more "realistic" (meaning you think you have included more and more important things that will allow you to come up with more specified predictions), your model can also become more sensitive to the actual choices of parameters. You may test how sensitive your model is to the guesses so that you can get an idea of how far off it might be.

Back to the influenza models. You will find that they differ in how parameters are estimated, which elements of the real world are included (and how finely), how transmission and contact rate are modeled -- and in lots of other ways as well. All the choices are quite defensible and you hope the ones that were made don't screw things up by leaving out something important or including something unimportant that obscures what you want to see. Modeling is a process of successive approximations. You hope you are getting closer and closer to the real world. Unfortunately, most of the time we can't test them. There is a heavy dose of faith needed (this is not a religious statement!).

So here's where I am with the models. I think they are valuable for suggesting in broad outline general behaviors, such as closing borders doesn't seem to affect spread and peak case loads much. That's not conclusive that closing borders won't work, but it lends weight to what many experts believe on the basis of inference from experience and there is always something about saying it came from a computer that is persuasive to policy makers.

But we still have to use these models carefully. Take the quote from the AP article. Use of antivirals and isolation might reduce peak rates from 33% to 28% according to the model. What this really says is that even unrealistically widespread use of antiviral therapy and isolation doesn't do much. The "not much" of 5% suggested by the model shouldn't be taken too seriously because relatively small alteration in model assumptions could change the numbers somewhat even though the "not much" would still be true. On the other hand, there are cases where abrupt changes in qualitative outcome (for example uncontrolled spread versus containment) are very close to practically attainable parameter values (such as 50% effective antiviral use). We shouldn't believe that 50% works but 45% doesn't, even if the model says so. The models are being made to bear more weight than they can handle in that case.

To sum up: All models are wrong, but some models are useful. And many models are used wrongly. They are valuable if used wisely and understood properly but can be misleading if used blindly.

Not that that would ever happen.

Wednesday, April 26, 2006

Greenhammer does King County

Another flu blog. They seem to be replicating. Many are really excellent, although I can't say I keep up with most of them. Too busy with this one.

However I did get notice of a fledgling I'll keep my eye on, the blog Greenhammer. It interests me because it is dedicated to news of pandemic preparedness in King County, Washington (Seattle and environs). The King County Health Department is one of the most forward looking in the nation on preparedness issues and I am looking forward to hearing more about what is going on there. I hope the new blogger, David Baum, will tell us, and do it in detail.

We need to learn from each other and there is much we can all learn from King County.

Welcome to the blogosphere, Greenhammer.

Your travel plans are not just your business

If you mess around with people's privacy, the result is that there is resistance to every new measure that involves wholesale collection of personal information. CDC wants to collect personal information on all domestic and international travelers, they say to help track an epidemic.
"What we're asking for is the authority to collect the information in the context of modern travel on airlines," Dr. Marty Cetron, the Center for Disease Control and Prevention's director of global migration and quarantine, said Tuesday in a telephone interview with The Associated Press.

"There's just a number of conditions where acting quickly with electronic access to passenger information is going to make a lot of difference," Cetron said.

The CDC wants to be able to easily find, notify and recommend treatment to airline passengers who have been exposed to bird flu as well as such diseases as plague, dengue fever or SARS -- even if the travelers' symptoms don't appear while they're traveling. (Boston Globe)
The financially fragile airlines industry hates the idea, saying it will cost billions of dollars to get full name and address, emergency contact numbers and detailed flight information on every passenger and keep it for 60 days in a form ready for instant retrieval should CDC ask for it. One impulse for the measure is the difficulty public health authorities had tracking down SARS cases in the 2003 outbreak. CDC got information from paper customs declarations but much was inaccurate or useless.

But this isn't the only effort to get personal information of travelers. The Transportation Security Agency (TSA) has been trying to get airlines to share their electronic domestic manifests so names can be checked against the notoriously inaccurate terror suspect watch lists. International flights already give names to the Department of Homeland Security who has agreed to give them to CDC, in violation of an agreement with the European Union that such information can't be shared. Clearly this Administration doesn't care about international agreements and probably wouldn't care about any agreements they made about CDC data.

And therein lies the problem. This wouldn't stop a bird flu epidemic, although it is conceivable it could be useful in some cases, like SARS. But no one trusts the Bush Administration to use private information solely to protect public health. The Bushies are notorious violators of civil liberties, not to mention international law, which they flagrantly ignore, making this a rogue nation in every way but name.

Here is the expected (and rational) reaction to these proposals:
Infectious disease experts and the American Civil Liberties Union raised concerns on Friday [April 22, 2006] about an agreement that would allow U.S. Centers for Disease Control and Prevention and customs agents to detain anyone who looked sick with bird flu.

The memorandum of understanding, a copy of which was provided to Reuters, also provides for Customs and Border Protection agents to give personal details of airline passengers to the CDC.

It was signed in October by Health and Human Services Secretary Michael Leavitt and Homeland Security Secretary Michael Chertoff. HHS spokeswoman Christina Pearson denied it was secret or sinister.


"CDC is authorized to isolate and/or quarantine arriving persons reasonably believed to be infected with or exposed to specified quarantinable diseases and to detain carriers and cargo infected with a communicable disease," it reads.

It also provides for Customs or Border Patrol agents to forcibly detain, if necessary, anyone coming in who appears to be sick while the CDC is contacted. (Maggie Fox, Reuters)
Not surprisingly, the threat of a bird flu pandemic is being used as a lever to get this unpalatable measure accepted, although the idea it would stop flu is just plain stupid, or, as Dr. D.A. Henderson said more kindly, "silly."
But Dr. Donald Henderson, an expert on influenza, smallpox and other infectious diseases who has advised the administration of President George W. Bush on such issues, calls it "silly."

"I was absolutely astonished when I saw that proposed federal regulation," Henderson said in an interview.

"It's so silly," added Henderson, who now works at the Baltimore-based Center for Biosecurity at the University of Pittsburgh Medical Center.

Henderson noted that people can be infectious with influenza and other diseases long before they begin to feel sick or show any symptoms.

"You are spending huge amounts of money and have we got any evidence that this is going to do anything? Is it worth all the energy we are going to be putting into it?" he said. (Reuters)
This comes as many suspect the core of the Bush administration's "plan" for doing something about bird flu is forced quarantine:
The ACLU [American Civil Liberties Union] believes that protecting the public is not the motivation.
"The tracking of data on airline passengers, which can amount to building lifetime dossiers on Americans, has been a hotly debated issue for many years -- and now we find out that two government agencies may have agreed, behind the public's back, to share data," said Barry Steinhardt, director of the ACLU's Technology and Liberty Project.

ACLU legislative counsel Tim Sparapani said: "Once again, we are seeing that DHS cannot be trusted to exhibit restraint in the handling of personal information.

"They collect information, say they'll use it for one purpose, and then they turn around and use it for another."

The Center for Biosecurity's Penny Hitchcock, a former National Institutes of Health infectious disease specialist, said the CDC risks losing the public's trust.

"The information that will be collected by CDC/HHS is part of this quarantine effort -- sharing information collected for disease prevention could be harmful," she said.

"The harm being that it will create suspicion and encourage people to regard the public health service as 'disease cops.' Why would people want to cooperate under those circumstances?" (Reuters)
Fear of disease brings every crooked quack out of the shadows to prey on people. It also gives license to crooked governments to do things they couldn't do otherwise. So it's not enough to "just" worry about a truly worrying disease, avian influenza. We also have to watch our backs for a truly worrying government, the dishonest and malevolent Bush administration.

Maybe on balance it doesn't bother you that much. If you trust them, then I've got a used car you might be interested in. You can drive it across the bridge in Brooklyn I'll give you a 99 year lease on as you head for the beachfront lot I'll sell you in the Everglades.

That's where the WMDs are.

Tuesday, April 25, 2006

Timing is everything

Who needs OSHA, anyway? We know the Bush administration and its patrons don't. We know the right wing nutcases at Cato Insititute and the Heritage Foundation don't. We know the Republican congress doesn't. Who does?

This via (Koufax Award winning blog) Confined Space:
Medina Township - Building inspectors say they got there just in time.

They had just shut down construction of a new building for the Goddard School for Early Childhood Development, moving the work crews out from under the newly raised roof.
No more than 10 minutes later, the roof fell in and part of the walls collapsed. An OSHA investigator was on the scene, as were county inspectors. OSHA is investigating.

County Building Inspector Art Verdoorn said local contractors had their eyes on the Georgia company that was erecting the preschool on Normandy Park Road because the trusses for the roof were bowing.

Someone made an anonymous call to the Occupational Safety & Health Administration office in Cleveland and someone called Verdoorn. By coincidence, both agencies made a surprise visit to the work site a week ago Monday, just in time to issue a stop-work order before the collapse.

Verdoorn said the exterior walls were up and half the roof was on but the structure wasn't braced correctly. Verdoorn estimated a crew of six was pulled off the structure, some on the high beams and some inside, minutes before the collapse.

Standard Building Co. of Atlanta requested the building permit, Verdoorn said. OSHA records list it as a non-union company.

An OSHA spokesman in Washington said three complaints have been filed against Standard Building, two in 2005 and one in March on a job in Elyria.

The company was fined $1,200 for failing to provide a safe work environment for employees after a worker was struck by a forklift on a Georgia job. The two other complaints were unfounded, an OSHA spokesman said. (Cleveland Plain Dealer)
This "just in time" is great but doesn't quite balance out all the other "not in times." Like this one (regular type, Jordan at Confined Space, small type news clips. See link for sources.):
Jose Rodriguez Garcia of Mission, Texas, was killed yesterday when a 10-foot deep trench collapsed on top of him. But hey, what are you going to do? Accidents happen.

Santa Cruz Irrigation District Manager Roy Garza described Rodriguez as “a good worker. A very good worker; dedicated to his job; always on time. Just a good darn worker.”

Garza says his workers always practice safety. “They're careful. They don't horse around. They don't play around during the job. It just happened we had an accident,” he said.

The reporter, in this case, thought to ask a few more questions:

But some rescue workers say the accident could have been prevented. Edinburg firefighter Ubaldo Perez said, “If there would've been safety measures before it occurred. Prevention would've been the best scenario.”

Firefighters say a 10-foot trench requires safety measures. They believe there should have been reinforcements so the dirt would not cave in.
But that would have been hard work, according to Garza.

Garza tells us why reinforcements weren’t used. “Okay, it is hard to provide in this particular job. You have telephone lines. They go this way. You have to get a back hoe. This job would've taken an hour to do and maybe they didn't put the right protection they needed,” he said. When asked if they should have, he replied, “I believe so.”

Yeah, didn't want to spend another hour. Oh well, maybe next time. (Confined Space)
Mid-term elections, November 2006. As they say, timing is everything.

Playing chicken with imports

In a month (starting May 24) processed poultry from China can be imported to the US despite widespread outbreaks of avian influenza there. This isn't Chinese poultry, according to authorities. It is US poultry (or poultry from countries the US accepts for import), sent to China for processing. Live poultry from China cannot be imported. The request to allow this came from China. One wonders what the quid pro quo was. According to the US government, here's what it wasn't:
Chinese President Hu Jintao visited President George W. Bush on Thursday at the White House. In advance of his visit, China made several commitments, including an agreement to drop a mad cow disease-related ban on imports of U.S. beef. Raymond said the deal is unrelated to poultry imports and has been in the works since 2004. (Canadian Press)
The US Department of Agriculture (USDA) says not to fear. The meat will be "fully cooked and perfectly safe."
"It will have been processed," said Richard Raymond, the department's undersecretary for food safety.
"Cooking will kill the virus, if there is any virus, in poultry meat."
That's a relief. I'm sure the processing facilities in China are regulated with the utmost strictness. Just like in the US. So we don't have to worry about cross contamination of the same machinery used for batches of Chinese poultry. They'll clean it throughly for the small batches of US chicken. Won't they?

Still, I wonder. In 2005 the journal Virology reported on H5N1 contaminated processed duck meat imported from China to Japan:
This duck meat isolate was highly pathogenic to chickens upon intravenous or intranasal inoculation, replicated well in the lungs of mice and spread to the brain, but was not as pathogenic in mice as H5N1 human isolates (with a dose lethal to 50% of mice (MLD50)=5x10(6) 50% egg infectious doses [EID50]). However, viruses isolated from the brain of mice previously infected with the virus were substantially more pathogenic (MLD50=approximately 10(2) EID50) and possessed some amino acid substitutions relative to the original virus. These results show that poultry products contaminated with influenza viruses of high pathogenic potential to mammals are a threat to public health even in countries where the virus is not enzootic and represent a possible source of influenza outbreaks in poultry. (Mase et al., Virology. 2005 Aug 15;339(1):101-9)
But don't worry. USDA and the Bush administration have this all figured out so that there's a net benefit.

For someone.

Monday, April 24, 2006

Et tu, pigeons?

Don't worry about pigeons and bird flu, we're told. Well I wasn't, since there is so much else to worry about, but now that they've brought it up, let's take a look.

In an AP story that is all over the bird flu news today, we find the following:
City folks, don't worry. Nobody expects pigeons, more common than manhole covers, will bring the deadly bird flu virus.

Pigeons are not immune from the virus. But tests indicate the birds pick it up only when they are exposed to very high doses, do not always become infected under those conditions and are carriers only briefly.

"Pigeons aren't a big worry," said Rex Sohn, a wildlife disease specialist at the U.S. Geological Survey's National Wildlife Health Center in Madison, Wis. "But to make absolute predictions that pigeons won't be susceptible to this virus, in whatever form it arises in North America, is not something you want to say." (AP)
I guess you don't want to say them because we know some pigeons are susceptible to the virus, as the very same story lays out in detail. The Agriculture Department's Southeast Poultry Research Laboratory in Athens, Ga. has been studying it since 1997 or so and the results were said to have produced more questions than answers. Hmmm.

Using the virus that surfaced in Hong Kong (the story doesn't say from a bird or a human), USDA researchers couldn't infect pigeons, even with direct instillation into their mouths with doses orders of magnitude higher than would be encountered in the wild (they say; I'm not sure what this is based on). But in 2004, using high doses of isolates from a pigeon and a crow in Thailand, seven out of 12 pigeons were infected, with one death. This year, a 14 year old Iraqi pigeon seller contracted bird flu and died. So pigeons can be infected, although at this point they are not as susceptible as chickens or ducks, and while they carry the virus for more than a week, they are said not to be infective for more than a day or two. Maybe. The virus is changing and finding new hosts. Why not pigeons?

We can agree with the bottom line, summed up in the AP story:
"The experimental data is not very strong that pigeons are going to be spreading this virus around," [Southeast Poultry Research Laboratory Director David] Swayne said. "At this point they have not been implicated in spreading it to humans and to farms."
So it's true that pigeons aren't a big worry now. "At this point."

The wise man of Jamaica

The Jamaica Observer has a terrific columnist by the name of John Maxwell. His most recent column dealt with a variety of issues, including bird flu. It is so good I am having a hard time selecting just pieces of it. Here is an extended excerpt:
Egypt is in the throes of a bird flu epidemic. Apparently, the Egyptian poultry industry has been destroyed but backyard rearing of chickens is making the pandemic impossible to control. Galal Nassar, writing in Al Ahram, says an unpublished study suggests that "the avian flu virus is now endemic in Egypt and will remain so for years because of the bungling of health authorities at every step of the way".

It is suspected that the virus entered Egypt by the illegal importation of infected birds, which implies, according to Nassar "on top of gross negligence, gross corruption motivated by a greed so voracious that it had no compunction at letting the interest of immediate gain override the dangers to which it was exposing society".

Nassar points out that the Egyptian pandemic has occurred despite sensible precautions taken early on; a state of emergency had been declared, there was wholesale slaughter of industrial poultry, but little attention was paid to backyard poultry rearing or to the possibility that unscrupulous people might import infected poultry into the country. So, despite enormous early sacrifice, Egypt is again threatened by a pandemic to which the government's response is to blame the backyard chicken rearers.


In Jamaica, we need to realise that if bird flu becomes endemic here, as it has in Egypt, despite the fact that only a few people have died, it will mean the end of the tourism industry and wholesale unemployment. At that point we will have not only a public health emergency but a public security emergency. Before we are very much older we need to begin, and urgently, to devise a food security programme, diverting some of the millions we are spending on highways to nowhere to importing and planting food.

We really need to begin turning some of our sugar land over to peas and beans, to begin programmes to promote backyard gardening and to develop new strategies to guarantee reliable supplies of protein foods for the population. I believe it would make sense for us to begin to convert some of the enormous craters left by bauxite mining into fish ponds. It may make sense right now to forbid bauxite companies to mine out all the bauxite and instead to leave a lining of bauxite clay in the ground so that we can seal the ponds without too much expense.

It may also make sense to begin developing cottage industries around these ponds for the salting/pickling of freshwater fish, because if the pandemic really gets a grip even our electricity supplies will be in danger. We may not be able to import the oil to drive the generators to provide power for refrigerators and freezers. We need to begin a completely new look at our survival techniques and a completely new understanding of what it means to be civilised.

We can be certain of only one thing: we have no idea how desperate our situation may become.

But even if it does not become desperate we need to begin to understand the meaning of sustainable development and to prepare for future threats.
Wow. This guy is good.

Sunday, April 23, 2006

Flu Wiki gets on its feet again

Flu Wiki2 is now open for business. Pogge, Dem and Melanie (with the Reveres gesticulating offstage) have gotten the Forum back up on a new server. It still runs on the PmWikie platform, which is a problem for the discussion format, so in the near to mid term we will be moving to a different platform that can handle that kind of traffic. We are hoping that by splitting the Wiki side proper from the Forum we will buy time and get back decent responsiveness on both parts, now running on different servers.

The new arrangement should be relatively transparent to the user since the Main Page remains the same on each and there are direct links to the respective servers from there. The original Wiki URL remains the same and the Forum is now on Flu Wiki2. If you use the Forum primarily or the Wiki side primarily you can set your bookmarks appropriately, or just go to the other server from the sidebar.

The Forum is no longer Read Only and is wide open. We're hoping by the time it gets bogged down with files again (since each thread is a separate file on PmWiki) we'll be on a more appropriate platform.

Thanks to my Wiki partners for the gargantuan effort, and to you, our community for your patience, good humor and participation. We're still pursuing the plan we announced over at the Wiki last week, and this is the first installment, as promised and on schedule.

Business -- as usual

The guy who won his spurs by designing the EPA's policy allowing power plants to keep emitting mercury will soon be out of that position, at least if the Bush Administration has anything to say about it. That's because they want to promote him to be Assistant Administrator for EPA's Office of Air & Radiation. That doesn't sit so well with more than a dozen public health groups, including Physicians for Social Responsibility (PSR). Here's what they said in a letter to Senate Environment and Public Works (EPW) Committee who is set to vote shortly on the appointment:
Mr. Wehrum was an architect of EPAís approach allowing power plants to continue emitting toxic mercury emissions at excessively harmful levels for nearly two decades longer than the Clean Air Act allows. Last year, EPA revoked its prior determination that it was necessary and appropriate to regulate power plant mercury emissions as a hazardous air pollutant. This step purported to eliminate the agencyís legal obligation to adopt plant-specific pollution controls requiring deep reductions in mercury and other hazardous pollutants by 2008. Instead, EPA adopted a weaker and delayed cap-and-trade approach that dispenses with plant-specific control obligations and fails to require mercury-specific reductions until 2018. In fact, EPAís own analysis projects that the utility industry will not achieve the agency's required reduction level until sometime after 2025. This approach also abandons regulation of other hazardous air pollutants from power plants altogether. On September 13, 2005, 47 senators voted in favor of a Congressional resolution disapproving this regulation.

EPA’s Inspector General found that the mercury rulemaking process was “compromised,” in large measure because EPA senior management told agency staff what result they wanted (34 tons annual mercury emissions) and directed staff to work backwards to achieve the combination of standards for different types of power plants that would yield this pre-determined result. Even when staff analysis projected achievable emission levels lower than senior management’s chosen outcome, EPA failed to make this analysis public until the Inspector General’s highly critical report disclosed it. EPA also refused to conduct analysis of more protective mercury control levels requested by the Federal Advisory Committee that EPA created to receive advice on the mercury rule. According to the Los Angeles Times, at a meeting when EPA staff expected to be discussing how to conduct the comparative studies requested by the advisory committee,

William Wehrum, a senior advisor to [then Assistant Administrator] Holmstead who also represented industry clients before joining the Bush administration, told the dozen or so staffers that comparative studies would be postponed indefinitely.” The agency never conducted the studies. (full .pdf of PSR letter to EPW here)
That's just for starters. It takes PSR three pages of densely packed particulars just to hit the highlights. PSR wants Senators to vote against Wehrum, but this is a Republican dream appointment, so it's not likely. He's proved his worth to the power industry so that's all the qualifications he needs in this Administration.

There are some really stinker faux Democrats out there (Joe Lieberman in the Senate and Jane Harmon in the House come to mind), but come 2006 if the Republicans lose one or both houses, we are much less likely to see this kind of thing : just Business -- as usual.

Freethinker Sunday Sermonette: the road to Hell

It's a pity there's no Heaven and no Hell. Heaven, because it sounds like a nice place to hang out in, although maybe a little boring. At my age, boring doesn't sound that bad, although I remember the physicist Richard Feynman was alleged to have said on his deathbed as he was lapsing into a coma, "I'm glad I only have to die once. It's so boring."

But Hell, now that's something to really regret doesn't exist. Just think of the bastards who aren't going to have to go roast in agony there, like Kissinger, Cheney, Rumsfeld and Bush.

And this guy.
An American evangelical franchise is plastering posters around the poorest areas of Lesotho, promising "miraculous" cures for AIDS. Headed by Ohio-based preacher Ernest Angley, the flyers effectively equate "salvation" with medical treatment, which is much harder to come by for Africa's poor. (Boingboing)
The cornu copia of AIDS misinformation spews forth from the Reverend Ernest Angley of Ohio. If you go to his site, contribute some money, because he has a lot of expenses:
Angley owns a huge complex in his home base of Cuyahoga Falls, Ohio, a complex formerly owned by another television evangelist, Rex Humbard, and formerly known as the Cathedral of Tomorrow.

This complex now includes the Grace Cathedral, the Cathedral Buffet restaurant, WBNX as well as other companies which lease space.

Outside of Angley's evening talk show, WBNX operates as a secular TV station, and is currently affiliated with The WB Network. It is consistently one of the top 15 WB affiliates in the country. It will be affiliated with the CW Network in the fall of 2006. (Wikipedia entry)
So what's the good Rev like? Here is a personal account from someone who survived one of his marathon revival meetings in 1991. From the blog, Truly Bad Films:
I went to see the televangelist Ernest Angley at the Convention Center Auditorium in Greensboro. The man fascinated me. His fake-sounding name, his god-awful toupee, and his faith healings combined to promise a show I could not miss. And it was free!

Many people seriously claim that they have been healed at Reverend Angley's Crusades, and I'm not in a position to dispute or confirm that. I was attracted to the event as pure theater, so I looked over the audience when I got there. Elderly folks in wheelchairs were on the front row. The rest seemed to be a generous cross-section of young, old, black and white. I saw a few bad perms and I spotted one woman with her head covered in Muslim fashion. That surprised me.


The first 15 minutes was a pitch for the new book on Lucifer. "Lots of people paid $20 for it," he assured us. "Some paid $15. But today I'm gonna give it to you for a real bargain. I'll let you have it for $5.00. Get 2 copies. One for your married children."

Ernest led a sing-along during which his Lucifer book was sold around the auditorium. He sang, "I'll Fly Away," and "At the Cross," in an odd falsetto that hit every note on the scale before it found the right ones. He checked his watch during the sing-along.

"Kuwait was the last big war before Armageddon," he told us, because "Gorbachev brought the peace of the anti-christ to earth. In seven years the Rapture will take place. The anti-christ was born about 1967 or 1968. Our nation changed then. Did you know that?" Lots of uh-huhs and yes, lords were offered up from the crowd.

"If it hadn't been for God intervening, Saddam would have gotten Israel. God intervened for Israel's sake. And we lost Vietnam because we forgot God. I've been smuggling my literature into Saudi Arabia for years. You know it's a miserable situation over there!"

Then he led the room in chanting, "One flight out!" I had no idea what that meant, and I'm sure no one else did either, but they chanted it vigorously.


Then Ernest began asking for donations to his television tower fund. He had lots of stories to tell to encourage generous offerings. He started with asking for $1000.00 donations and about 50 people went up to pledge that amount. Then the donation requests worked down until he was asking the people who would give $5.00 to come forward.

He prepared to do his healings. Three ushers stood by to catch each person who passed out from the healing bolt. As he paused before each person, he motioned for them to raise their arms, he performed the healing and then blessed them with a palm to the forehead. The blessing is what caused them to fall backwards, as it concluded with a short shove backwards.

He prepared to heal a deaf man, whose arms were lifted. Ernest put a finger into each of the man's ears and vibrated his hands, saying "Thou foul deaf spirits, COME OUT!" Ernest yanked his hands away from the man's head. Then he placed his right palm on the man's forehead and gave him the blessing blast that knocked him backwards. He was caught by the ushers and lowered to the floor. Like him, many others had to be gently lowered to the floor, where they rested for awhile after their healings. Eventually they would be helped up and they returned to their seats.

One woman in a wheelchair could not stand up after her healing. Ernest advised her to, "sit and let the power work." After healing a busload of deaf people from Danville, Ernest encouraged some of them to demonstrate their healing.

"Ah!" Ernest led off.

"Ah!" said the newly healed man.

"Men!" said Ernest.

"Baby!" said the man.

"Ah!" Ernest tried again.

"Ah!" said the newly healed man.

"Men!" said Ernest.

"Buh!" said the man.

"Baby!" Ernest tried.

"Kubep!" said the newly healed.

"Ah!" said Ernest.

"Ah!" said the healed.



This went on for a long time.

At last Ernest said he saw 117 people in the audience who had a blood condition. He wanted them to stand to receive healing. Then he spied 56 who suffered from stomach aliment. They were to stand for a healing. Apparently 17 people were suffering from a "head condition." Ten people had a severe throat condition and 3 of those had cancer, Ernest said.

The he had all 27 people who were deaf in one ear, who had not yet come forward, hold up a finger. Ernest was going to empower the finger by God. He blessed the fingers and had them all insert the fingers into their ears. "Evil spirits of the ear, COME OUT!" he bellowed. I wish you could have been there to see 27 people yanking their fingers out of their own ears.

At this point, Ernest had been talking non-stop for 3 hours. He looked like he could go another three, but I was exhausted.
The good Reverend also predicted The Rapture would be about seven years from that date (somewhere in 1998 or 1999). He's still around, if you consider conning poor people in Lesotho as being around. So he didn't go to Heaven on schedule, although I'm sure he cheered George W. Bush's attempt to hasten The Day.

But then he didn't go to Hell either. As far as I'm concerned, he can.

Saturday, April 22, 2006

Flu denier two-fer

A new AP-Ipsos poll says half of Americans aren't too confident that its government can handle the situation if bird flu gets into birds in North America.
In the poll, 52% said they were not confident the government would handle an outbreak properly; 48% were confident. Almost two-thirds expect U.S. birds to become infected.

Fear is likely to spread if the virus is detected in the United States: Half of the people questioned said they thought the bird flu would kill them if they got it.

The survey found strong majorities in favor of these steps to contain any outbreak among humans: quarantining those who have been exposed to the bird flu, closing the borders to visitors from countries that have experienced the flu, closing schools, offering experimental vaccines or drugs, and encouraging people to work from home.

The poll of 1,001 adults was conducted Tuesday to Thursday with a margin of sampling error of plus or minus three percentage points. (USA Today)
The public has no particular reason to believe in the competence of the government, since all it has seen from this Administration is a surfeit of incompetence. I won't bother with the whole list (Katrina, Iraq, etc.) It's too long.

But does it mean the public health system can't handle bird flu? Unfortunately, it probably does. Because one aspect of the incompetence has been to starve public services that would be needed in the event of a pandemic, including health care and public health but also the social services what we would all depend on.

To make matters worse, everyone, ourselves included, are learning on the job about this virus. There are confusing and mixed messages coming from Washington, from academia, from state officials, from the private sector, because we are all more than a little confused by this virus and there are more than the usual mixed opinions. This bug is presenting surprise after surprise. But it is an unusually nasty virus, of a type that periodically sweeps the globe in pandemic form. What most people agree on is there is serious public health potential here and recognizing this and preparing for it quickly would be, to understate the case, prudent.

Most people.

There are still a few contrarians who are making a living (literally) by muddying the waters further. The two most prominent flu deniers are Wendy Orent and Marc Siegel. Despite errors in fact and atrocious judgment they continue to peddle their shoddy wares wherever and whenever they can get a hearing. Since the press loves man-bites-dog stories, they are often successful. Here's a sample:
But a small group of skeptics say the bird flu hype is overblown and ultimately harmful to the public’s health.

There’s no guarantee bird flu will become a pandemic, and if it does there’s no guarantee it will kill millions of people. The real trouble, these skeptics say, is that bird flu hysteria is sapping money and attention away from more important health threats.

“I have a bunch of patients coming in here who are more worried about bird flu than they are about heart disease,” said Dr. Marc Siegel, an internist and associate professor of medicine at the New York University School of Medicine. “The fear is out of proportion to the current risk.”


“Ridiculous,” scoffed Wendy Orent, an anthropologist and author of "Plague: The Mysterious Past and Terrifying Future of the World's Most Dangerous Disease." [NB: her own fear-mongering book about the Black Death]

She said public health officials have vastly exaggerated the potential danger of bird flu.

Several factors make it unlikely that bird flu will become a dangerous pandemic, Orent said: the virus, H5N1, is still several mutations away from being able to spread easily between people; and the virus generally attaches to the deepest part of the lungs, making it harder to transmit by coughing or breathing.

“We don’t have anything that makes us think this bug will go pandemic,” Orent said. “Yes, it’s virtually certain in human history there will be another pandemic strain … but there’s no reason for it to happen now, or 10 years from now or 20 years from now.”


But skeptics like Siegel and Orent say you’re better off guarding against more realistic dangers — heart attacks, for example, or even gum disease.

“I’d worry more about flossing my teeth than I’d worry about avian flu,” Orent said. “I want people to see what the real dangers are.” (MSNBC)
Orent is an anthropologist who sets herself up as an expert in epidemic infectious disease and the pandemic potential of a virus neither she nor real virologists understand well enough to be able to say what will happen, although they understand all too well what might happen. Siegel is a primary care doctor who writes books about how other people are scaring us. He is a fear-monger of fear. He is also careless about his science and when it is pointed out to him he doesn't care enough to correct his errors (Example: "This bird flu appears to be better absorbed by the deep pockets of bird lungs, whereas human flu is absorbed by the cells of our upper airways." This is an intestinal disease of birds. The paper he refers to was about human lungs, not bird lungs).

Orent and Siegel know perfectly well that the public health and health care systems aren't up to coping with an epidemic of infectious disease that affects a sizable proportion of the population. It doesn't matter if it's an H5 or H9 influenza subtype or some other virus altogether. Proper preparation for an H5N1 pandemic is an investment for all sorts of other problems, extraordinary and ordinary, against which our long-term disinvestments have rendered us defenseless. The claim that a "laser-like" focus on H5N1 must impede more general preparations is a straw man. Bush has been glad to shovel money to Big Pharma for antivirals, which are mainly aimed at influenza. That's short-sighted, I agree, but I don't hear Orent or Siegel criticizing it. Instead they attack others trying to defend public health. They misleadingly assert the conservative line that public health is a zero sum game. It isn't, at least not in the sense they are implying. When Bush wanted to wage war in Afghanistan and Iraq (to the current tune of $10 billion a month), he just allocated money. He also simultaneously shrunk the size of the pie by cutting taxes.

Those were social decisions "The Decider" made. If we had another Decider we would have other decisions.

Let's hear more about this from Orent and Siegel, not the kind of know-nothing scepticism that does little to advance public understanding and makes the work of those worried about people as much as birds less difficult.

Friday, April 21, 2006

Cambodian village seroprevalence study

A paper now being reviewed at The Lancet is reporting that the prevalence of antibodies against H5N1 is zero in 351 villagers in a Cambodian town that suffered a bird flu death in March of last year. This is surprising on several levels. First, the assumption many had (including us) that there was likely quite a lot of mild inapparent and undetected infection with this virus, thus artificially inflating the case fatality rate (CFR, which is technically not a rate but a proportion). The good side of this is that it implies the virus has very little transmissibility, either from bird to humans or human to human. The bad side is that it implies this is one of the most dangerous viruses known, with a CFR exceeding 50%.

The second surprise is that there seemed to be nothing unusual about the exposure of the 28 year old farmer who did become infected and died.
Dead birds were reported in the village in Cambodia’s southern Kampot province and the H5N1 virus was detected in poultry there. Many villagers surveyed said they had very close, daily contact with the birds – collecting dead or sick poultry, feeding them, cleaning up faeces, plucking and eating them.

“That supports data from all over the region suggesting that it’s actually very inefficient to transfer from birds to humans,” said Benjamin Coghlan, a WHO epidemiologist from Australia who participated in the study.

“So, what does (the transfer) require? Well, we’re not sure,” he said. “Certainly, this case in the village wasn’t doing anything unusual that everyone else in the village wasn’t doing.” (Ireland Online)
Host factors we don't understand are involved. It is not just the virus. We know that age is a significant host factor, because the virus seems to prefer the younger age group (see the age distribution of reported cases here and here). In addition we know that the environment is a factor, since there is a marked (but unexplained) seasonality to influenza, including H5N1.

This is a reminder of an important point. An infectious disease is a function of the host, the agent and the environment acting together in a particular combination. Virulence is not a property of a virus but of the combination of the virus and the host, modulated by the environment. So the talk of "mutation to a virulent" form is really a shorthand for a more complicated idea. It is also important to remember that transmissibility (the ability to pass on infection), and virulence (the ability of infection to cause serious disease), are separate things. At this point we have little or no idea of the genetic, host or environmental factors affecting either in human beings.

So far these data have not been published but only presented at a conference. We look forward to seeing the published paper with the supporting tables and description of methods. Since the prevalence was zero, this isn't a statistical issue, because while the results don't rule out a small probability of infection that couldn't be detected because of sample size, that in itself is a statement about transmissibility. More importantly, it doesn't rule out some kind of bias, for example a problem with the measurement or selection of subjects. Therefore it is important to see the published paper.

We can't assume too much about this virus. There is always the hope that the transition to transmissibility is more difficult for the virus than is a reversion to less virulence. This virus is continually changing and the result could go in either direction. We don't know the biology well enough to hazard a guess which. It is currently a very dangerous bug that is constantly evolving. It continually uses hosts to make copies of itself and if chance happens on a good recipe for a human host cases will come faster and more abundantly.

If that happens it won't matter whether you believe in evolution or not, nor does that kind of virus believe in abstinence.

Prostitutes, drug pushers and Congress

Lots of bad news these days, but some people are pretty happy.
After years of pumping millions of dollars into election campaigns, the pharmaceutical industry is reaping the benefits of a vastly improved political climate on Capitol Hill.

The increases in donations have moderated since the last decade as the industry has won passage of long-cherished legislative objectives or fended off challenges that it deemed a threat to its way of doing business.

In the last year, drug companies have won protection from lawsuits involving production of a pandemic flu vaccine. They have been invited to join President Bush in mapping a government strategy to fight a pandemic and have been sought out to assist in producing vaccines against flu and bioterrorism.

At the same time, legislative measures aimed at the industry - notably, bills that would permit importing cheaper prescription drugs from abroad - appear stalled, with little likelihood they will come up soon. (Philadelphia Inquirer)
So bird flu has ben a mixed blessing. A deadly threat to most of us, responsible for much wheel spinning "preparation" on the part of the feds, but a boon to Big Pharma. I'm so glad someone gets something out of it. And now that they've gotten it, they aren't spending as much dough in the Congressional Whorehouse. The reasoning, as given by former Republican CongressThing Billy Tauzin, is breathtakingly blatant:
Billy Tauzin, president of the Pharmaceutical Research and Manufacturers of America, the drugmakers' lobbying arm, said one reason for the decline [in contributions] was passage of the Medicare prescription-drug plan in 2003, an important legislative hurdle.

The measure was a major victory for the industry, not only because it committed the government to spending an average of $67 billion a year over 10 years on their products but also because proposals requiring the government to negotiate for the lowest price were defeated. Drugmakers feared that provision would have cut deeply into profits and opened the door to price controls on other drug spending.
Tauzin helped write the prescription drug plan and then left Congress to become Big Pharma's chief pimp.

But don't despair if you are one of the Congressional prostitutes. If the Democrats win one of the houses of Congress in 2006 the money spigot for Republicans (and some Democrats like Joe Lieberman -- should be win his primary) will open again as the atmosphere becomes less congenial to the drug pushers.

Prostitution never goes out of business as long as there are addicted johns who live to screw somebody.

Thursday, April 20, 2006

A hospital bottom line

It's beginning to sink in. The federal government is telling hospitals to get ready in case a pandemic arrives and the hospitals are looking at the bill and saying, "No way."
The U.S. government may be urging local officials and hospitals to get ready for a bird flu pandemic, but top hospital executives said on Tuesday they cannot do everything that is being called for.

"If the federal government doesn't help run this, it really isn't going to go well," Dr. Frank Peacock, who heads emergency preparedness at the Cleveland Clinic in Ohio, told a conference. (Maggie Fox, Reuters)
Department of Health and Human Services Michael Leavitt is doing yeoman's duty traveling to all 50 states, trying to get them to get ready. He is also telling them not to expect much help from the federal government. That's realistic, at this point. But how did we get to this point? You can't tell hospitals to do things they don't have the resources to do. And one reason they don't have those resources is a Republican Congress that has repeatedly slashed funding for essential services and starved the public health sector. After abandoning states and local communities, the message that they are "on their own" is a maddening one, made more so by Leavitt's comment that maybe they should be buying ventilators rather than renovating swimming pools.
"I think it is a good thing for the Secretary to say we have to stockpile ventilators. But I think a lot of us know we don't have the resources to buy another two, three, four hundred ventilators," he said.

Preparedness could come down to more than having the medical equipment.

"We may not have the staff needed to run those ventilators adequately," said Vicki Running, who heads disaster planning at Stanford University Medical Center in California.

Day-to-day business is already overwhelming hospitals, according to Running. "We are operating at capacity," she said.
So it is a matter of the bottom line. And if you want The Real Bottom Line, here it is:
Peacock said much of the response to a pandemic will involve very basic medical care -- including triage, or sorting out which patients cannot be helped except through heroic measures.

"Those patients are going to get some morphine and get sat in a corner. That is the definition of a disaster -- need exceeds resources," Peacock said.

Then health workers will turn to patients who are more easily helped, and the very sickest may have to be allowed to die as comfortably as possible, he said.

Indonesian bird flu joke

What do you say about a country that has had 31 cases of bird flu and 24 deaths, making it second in the world on that tally (all since last July): just had a family of five admitted to the hospital, a family who had three other children diagnosed earlier; and has diseased birds all over a huge, sprawling archipelago, much of it remote and without veterinary services?

Here's one thing I would be very unlikely to say about it:
Indonesia is winning its fight against bird flu and expects to be free of the killer virus by 2008, the country’s agriculture minister said today.

“During the rainy season, bird flu cases did increase, but in general, cases both in humans and animals are declining in Indonesia,” Anton Apriyantono said in Jakarta. “This is because we have gained experience and are capable of fighting bird flu in better ways.” (Ireland Online) (h/t Coming Influenza Pandemic)
Indonesia is an unfamiliar culture for many Americans, so this kind of statement needs to be translated into language more familiar to us:
"I picked up a newspaper today and I couldn't believe it," he said. "I read eight headlines that talked about chaos, violence, unrest. And it just was Henny Penny - 'The sky is falling'. I've never seen anything like it! And here is a country that's being liberated, here are people who are going from being repressed and held under the thumb of a vicious dictator, and they're free. And all this newspaper could do, with eight or 10 headlines, they showed a man bleeding, a civilian, who they claimed we had shot - one thing after another. It's just unbelievable ..." (US Defense Secretary Donald Rumsfeld, three years ago, responding to news that the situation in Iraq was detiorating only a month after the invasion)

Over the past year, the coalition has pursued a strategy of building up Iraqi institutions and strengthening the Iraqi people's capacity for self-government and self-reliance. The progress that's taken place in governance, security, and in essential services all represent a threat to the goals of the terrorists and the regime remnants, which is very likely why as the transfer of sovereignty approaches those folks have stepped up their efforts to sow violence. (Secretary Rumsfeld, two years ago, explaining why he was extending the term duty of 20,000 US troops in Iraq)

Gen. George W. Casey said that despite continued lethal attacks by insurgents, the security situation in Iraq had improved. He reiterated a position he had taken earlier this year on the possible decrease in the U.S. military presence during a one-day visit by Defense Secretary Donald H. Rumsfeld for meetings with Prime Minister Ibrahim Jafari. (General Casey, one year ago)

The terrorists seem to recognize that they are losing in Iraq. I believe that history will show that to be the case. (Donald Rumsfeld, last month)
That makes it clear. Now I am just as certain Indonesia is making progress against bird flu as I am that US forces are making progress in Iraq.

Maybe even more certain.

Wednesday, April 19, 2006

If you're reading this . . .

If you're reading this, you are part of an extraordinary phenomenon. The blogosphere. However skeptical you may or may not be about blogs and blogging, you have to be impressed by its sheer size. David Sifry at Technorati, the service that tracks blogs and blog traffic, has issued another of his quarterly reports on the state of the blogosphere. It is mind boggling.

The blogosphere has been doubling in size roughly every six months, (literally) exponential growth. Obviously it cannot continue to do this for long, but it has done it long enough to produce astonishing numbers, growing sixty times in three years. In the time it has taken to read this, another twenty or thirty have been created -- roughly one a second. Many are transient, temporary or some kind of spam or robot pingers but amazingly, over half of all bloggers-- 19.4 million of them -- are still posting 3 months after their blog was created. Almost four million of them update at least weekly, and many -- including this site -- daily, seven days a week. This produces 1.2 million posts a day, about 50,000 an hour.

Our corner of the blogosphere -- public health -- is extremely tiny in this big picture. I''m guessing there are not more than a couple of dozen worldwide, of which Effect Measure is one of the most widely read. That's not to say our audience is huge -- a couple of thousand unique visits a day. Small, yet influential in public health, as I have cause to know.

Most of us don't have the immediate sensation of participating in anything extraordinary, and only time will allow us or future chroniclers to evaluate its significance. Some future graduate student in the history of public health, medicine or political science may write a dissertation on the role of the blogosphere in shaping (or failing to shape) the social and technical response to a pandemic. As with most things, time will tell.

And time may be growing short, so we'll get back to blogging about public health instead of blogging about blogging.

Who will show up for work?

It made the wires. A small study in Maryland suggests almost half of public health workers assume they wouldn't be needed in a pandemic and would stay home. I don't take it seriously.

The study was done a year ago, before there was much talk about the meaning of a pandemic. The major determinant seems not to be a concern for personal safety but a mistaken impression that people not involved in infectious disease wouldn't be needed. This is partly a reflection of poor education in state and local health departments about the consequences of having a third or more absenteeism across all sectors of society. It also reflects the poor state of preparedness of the Maryland personnel at that point. Whether it is much better now is unknown but it would be incorrect to generalize on the basis of a non-random sample from a couple of local departments at a (now) remote time in the development of awareness of pandemic flu. The authors themselves question how representative the respondents were of public health workers. But that's not my main point.

Continuity of operations plans are now on the agenda in many departments (although not all). They usually call for role shifting as dictated by need. So if this study were to be repeated today we might see a much better response. But the problem is not limited to health departments or even the health sector. Many people provide services essential to keep things running smoothly. For example, in many small businesses only a few people are involved in getting people paid or keeping the computer system running. Sometimes only one person knows how to unjam the fax or copy machines, a small but potentially vital task.

One of the most important jobs of civic leaders is to mobilize the community to prepare for this kind of problem. There will be no shortage of willing volunteers once people understand the stakes and understand that together we will get through a pandemic much better than if we hide from each other, hunkered down in our houses, trying to avoid a virus that may be difficult or impossible to avoid. Most people won't get sick, and most people who do get sick will recover. This is not doomsday. But the disruption in society can have its own painful, sometimes lethal, effects if we don't get ready for it. And there's no reason not to get ready. What it takes to prepare has lasting benefits beyond a flu outbreak.

Will there be those who are too fearful for themselves or their families to help out? Certainly. They will need our help, too, whether they help us or not. But the overwhelming majority of people will do what they can -- if we make it possible for them and we promote the idea it is for our common good. I don't worry that health care or public health or police or fire will abandon their posts if we are prepared.

The idea we are all in this together is an ideological notion, of course. It opposes the equally ideological one that says it's every person for themselves. There are good reasons to believe we are better off as a society if we work cooperatively, but no one can guarantee for any individual person they are better off. If you hold as a moral position that a person's only concern should be to look after him or herself, then you should also be prepared to forfeit the help of others when you need it.

Your choice.

Tuesday, April 18, 2006

Eighteen holes of extra wetlands

Many experts and the US federal government expect H5N1 to come to North America soon on migratory birds. Without entering into the contentious area of whether they are important vectors of spread, let's assume it for the moment. The big fear among the poultry industry is that it will then get into terrestrial birds (poultry) and devastate the poultry industry. It's not just a North American problem. Every continent has countries with poultry industries of some kind. Now that the virus is in Africa, there is fear it will endanger an important source of protein and also find a new environmental niche where it can evolve in unpredictable ways.

So people have been thinking of ways to prevent mixing of wild birds with domesticated ones, and, not incidentally, acknowledging that some human actions have increased it. Consider wetlands.
NAIROBI - Restoring wetlands and clearing poultry farms from migratory flyways could help curb the spread of bird flu by stopping wild birds from mixing with domestic fowl, a U.N.-commissioned report said on Tuesday.

The clearance of wetlands due to drainage for agriculture or hydroelectric projects is forcing some wild birds on to alternative sites such as farm ponds and paddy fields, bringing them into direct contact with domestic poultry, the report said.

This increases the spread of the virus, which has jumped from Asia to Europe, the Middle East and Africa.

"There's a contraction for the habitat for wild birds and a natural situation arising which promotes the inter-mixing of wild birds and domestic poultry," said David Rapport, a Canadian professor and lead author of the report.

"So should a pathogen arise in domestic poultry, it becomes more likely to be spread into wild birds... because the health of those ecosystems has been compromised," he told a news conference in Nairobi. (Reuters)
If you know that US Interior Secretary Gale Norton has just declared victory over wetland loss you might think we are moving in the right direction. You'd be wrong. Much of the gain that offsets continuing losses is from areas not usually considered wetland by normal people: artificially created ponds, such as golf course water hazards and farm impoundments. Maybe you didn't notice this little piece of sleight-of-hand, but the sporting community did. And they didn't like it. From Field&Stream:
Thursday (March 30), Interior Secretary Gale Norton called a press conference to claim our long nightmare of wetlands loss had finally come to an end due to unprecedented gains since 1997 (click here [.pdf] to read the report she cites). However, she then admitted much of that gain has been in artificially created ponds, such as golf course water hazards and farm impoundments.

The sporting community--from Ducks Unlimited to the Theodore Roosevelt Conservation Partnership--reacted quickly, and not favorably. Researchers long ago established that natural wetlands such as marshes, swamps and prairie potholes are far more productive than even the best-designed artificial wetlands. And sharp-edged water bodies like water hazards, farm ponds, and even reservoirs offer very little for wildlife. Putting man-made ponds in the same class as natural wetlands is like ranking pen-raised quail with wild coveys. [NB: Vice President Cheney was "hunting" pen-raised quail when he shot the elderly lawyer in the face].

The boldness of Norton's claim was particularly galling given the Bush Administration's record on wetlands. President Bush, like other presidents before him, promised a policy of “no net loss” of wetlands, but his administration has consistently supported rollbacks of the Clean Water Act to satisfy industry and development.

In fact, at the same press conference, the Fish and Wildlife Service reported a continued loss of 523,500 acres of natural wetlands during the same time period. So how could the nation have come out ahead if it lost more than half a million acres? Norton didn't try to hide the truth: The 715,300-acre “gain” was mainly artificial ponds. (Field&Stream)
If you think this is tough language, there's more:
While saying the nation's wetlands picture remains “precarious,” Norton added that "even ponds that are not a high quality of wetlands are better than not having wetlands." Now there's ringing endorsement of the president's program.

Norton's announcement was likely an act of setting the table for more administration assaults on wetlands protections. It was probably no coincidence that three days earlier, the Army Corps of Engineers and Environmental Protection Agency proposed new regulations that encourage development of companies that build artificial wetlands used by industries that destroy the vital natural habitats. It's part of the wetlands mitigation banking concept--which gives companies permits to drain wetlands, as long as they produce “new” wetlands somewhere else.

Norton may think a water hazard is better than no wetlands but for fish, wildlife and sportsmen, but it may be even worse. That type of public policy provides an excuse for more permits to drain more natural and productive wetlands to be replaced by non-productive water hazards. Those might be good for real estate values along the 18th fairway, but for fish and wildlife that rely on wetlands ecosystems to survive, it's terrible.
Not to mention bad news for the poultry industry.

I'm not a hunter, but I grew up where hunting is considered a normal activity. The start of deer hunting season is an event. If you're a Republican and you've pissed these folks off, your political troubles are deep indeed.

That's the good news.

Monday, April 17, 2006

BioShield is BS

Last week the Center for Infectious Disease Research and Policy at the University of Minnesota (CIDRAP) reminded us about another Bush administration and Republican boondoggle, BioShield. In fairness, faux Democrat Joe Lieberman had a hand in this one, too, and he is compounding the crime by pushing an even bigger boondoggle, BioShield II (other posts here, here, here and here).

BioShield is the $5 billion plus failed program that begs patriotic Big Pharma to defend the country by making bioterror countermeasures at a guaranteeing a reasonable profit. (BioShield II corrects the error by offering obscene profits.)
The Bush administration acknowledged last week that its $5.6 billion program to build a supply of medical countermeasures against biological weapons and other threats is struggling and needs help, according to a newspaper report.

Alex M. Azar II, a deputy secretary in the Department of Health and Human Services (HHS), acknowledged that Project BioShield has problems and promised increased efforts to make it work, according to an Apr 7 report in the Washington Post.

Speaking to the health subcommittee of the House Committee on Energy and Commerce, Azar "conceded that the lack of a strategic plan has left industry guessing about the government's priorities," the Post reported.

The story said corporate executives warned that they need clearer direction from the program to help them decide what kind of research to launch. Executives also complained of delays, bureaucratic inertia, and other problems with the program.

Rep. Anna G. Eschoo, D-Calif., was quoted as saying, "I think what's lacking in all this is a real sense of urgency. I can't help but think we are not prepared if, God forbid, any of these catastrophes were to be visited upon the United States." (CIDRAP News)
Maybe there's no sense of urgency because there isn't any urgency to sense. The bioterrorist threat is a joke, at least compared to avian influenza.

So far almost the only thing BioShield has done is let a huge $877 million contract for 75 million doses of an anthrax vaccine to VaxGen, a company whose only other product failed and who had no expertise in making recombinant vaccines. The company admits they are already at least a year behind schedule. I'll be surprised if we see any vaccine from these guys, ever. Which is not as bad as it sounds, because it is almost impossible to imagine what we would do with 75 million doses (enough for 25 million people) of a vaccine for a non-contagious disease that you wouldn't use pre-exposure.

The whole thing has a bad odor to it. Time for an investigation of the whole BioShield program. Its initials say it all.

Wherein I don a tinfoil hat

I was unfair to Dr. Julie Gerberding, the CDC Director when I said some almost-nice things about her the other day. So let me correct it by taking it back.

I said then I at least gave her high marks for being a good, relatively spin-free communicator, even if she is a Katrina-sized management disaster at CDC. But then she went ahead and made a lier out of me in an appearance last week in Tacoma, Washington:
Federal health officials at a meeting Friday in Tacoma downplayed the risk bird flu poses to humans, contrasting earlier warnings from the federal government. “There is no evidence it will be the next pandemic,” Dr. Julie Gerberding, head of the Centers for Disease Control and Prevention in Atlanta, said of avian flu. There is “no evidence it is evolving in a direction that is becoming more transmissible to people.”

Gerberding spoke at the Greater Tacoma Convention & Trade Center at a pandemic flu conference that drew 1,200 people from across the state, mostly health department officials and others involved in emergency planning.


Audience questions Friday about buying surgical masks and stockpiling food showed the concern Bush’s comments and others have raised.

But Gerberding noted that, though the disease has killed “gazillions of birds,” it has killed about 100 people out of about 200 sickened worldwide. The victims were in intense, daily contact with sick flocks, often sharing the same living space. Two people have become infected from person-to-person contact.

She did not say what had changed the thinking of health care officials about bird flu, but said that, at this point, there is “no reason to think it ever will” pass easily between people.

Given those facts, bird flu, like SARS, swine flu and other once widely publicized health threats, might never become a significant human illness.


She and other federal officials said H5N1 bird flu likely will reach the United States, because bird flu and its many strains occur naturally in migratory birds.

When that happens, “it does not signal the start of a pandemic” or a threat to the food supply, said Richard Raymond, an undersecretary at the U.S. Department of Agriculture.

Cooking meat to 160 degrees will destroy the virus, he said – in addition to destroying salmonella, “which sickens more people than H5N1 ever will even if there is a pandemic.”

Gerberding cautioned that when H5N1 is detected in the United States, “there will be temptation for the press to make this into something it is not. We will need responsible journalism” to prevent irrational panic. (Tacoma News Tribune)
There's no reason to think it ever will become easily transmissible? On the contrary, there are many reasons. Good, sound, plausible, scientific reasons. No conclusive reasons, perhaps. But comparing "gazillions of birds" to 100 human deaths has only one function here, to trivialize the issue. Responsible journalism? Irrational panic?

This is now the second Administration spokesperson to start to ratchet back on bird flu. I reported the other day that Tony Fauci had granted an interview to AP in which he did the same thing, although not so flagrantly and irresponsibly as Gerberding. One reader pointed out to me there was no news hook in the Fauci interview. It seemed to come out of the blue. Meanwhile rumors are circulating that Gerberding is reorganizing again at CDC and the Flu Branch is going to be shifted around. It is now part of the National Center for Infectious Disease (NCID) but may move to the National Immunization Program. Last year the Flu branch lost some of its key personnel. Look for more with this reorganization. No one knows from day to day what their new job is going to be in the Alice in Wonderland of the New CDC. As one state epidemiologist said to me recently, "It's like a Repertory Company. Everybody you deal with now at CDC is Acting Something or Other."

This is a ridiculous time to be screwing around with CDC organization, especially considering the enormous upset and morale plunge Gerberding's previous management mishaps caused. By every account she doesn't listen, is arrogant toward the professional scientists, and is an Administration toady. Heck of a job, Julie.

Carrying water for the Bushies also made her extremely tardy in alerting the states to the bird flu problem, preferring instead to parrot Administration messages about bioterrorism (talk about unreal threats!). She never strayed from the "message," which was terrorism and the Iraq debacle. Given the new vibes coming out of Washington about plans to bomb Iran, it makes me wonder whether there is no room in that message for bird flu, once again . . .

Oh, oh. Please hand me my tinfoil hat.