A Visitation of the Influenza

DefoeIn seeping through the world’s every nook and cranny, pandemics have a way of forcing themselves into our lives as a lurking presence. Even the most insular of functionaries, who typically makes his living solving problems by ignoring them, straightens up and takes notice.

As an epidemic wave arrives, each of us faces intimate decisions we may have thought a concern only for someone somewhere else far, far away. Should my family flee, vaccinate, wear masks, scrub regularly, shun crowds, isolate itself, drink brandy-infused elderberry, or, for the jittery among us, just crawl into bed until 2011? Others, on the other hand, may ask whether we should even bother worrying.

The answers are as variable as the people who arrive at them. Over the past two weeks I’ve heard friends and family heatedly talk through their positions online and in the real world. I’ve overheard strangers in cafes, on buses, and on the street wrestle with what were months ago only abstract possibilities better left to the eggheads.

Daniel Defoe wrote of a similar spectrum that emerged during the Great Plague of 1665, an account he claimed for any generation confronted with something similar some terrible year in the future,

I now began to consider seriously with myself concerning my own case, and how I should dispose of myself; that is to say, whether I should resolve to stay in London or shut up my house and flee, as many of my neighbours did. I have set this particular down so fully, because I know not but it may be of moment to those who come after me, if they come to be brought to the same distress, and to the same manner of making their choice; and therefore I desire this account may pass with them rather for a direction to themselves to act by than a history of my acting, seeing it may not be of one farthing value to them to note what became of me.

The rich and their servants largely fled Defoe’s London. In their flight some, carrying Certificates of Health from the Very Worthy Lord Mayor, &tc., helped spread the pathogen to other towns along the way. The tradesmen, Defoe included, agonized over saving themselves or their businesses. Did obeying God mean trusting Him to save one’s life (and so stay) or trusting Him to save one’s shop (and so leave)? The working poor and destitute had little recourse save their choice in superstition. Opportunistic prophets of doom and peddlers of dubious fetishes ran up a bubble market.

Three hundred and fifty years later, we can still see the twists and turns the human mind takes in assimilating an outbreak, this one very much of our own making. Given their scope, pandemics hold up a mirror to humanity in all its deep and dark complexity. Deciding on the right path, then, is not an easy matter, even as choices have to be made in the face of an urgent, and potentially catastrophic, situation.

Here I take on some of the characterizations about swine flu H1N1 (2009), from more to less flippant, with an eye that such a review might help us—myself included—think through the personal and political choices that must be made.

“What’s the problem? Swine flu is no more virulent than a seasonal influenza, maybe even less so.”

Not true. Data rolling in from a variety of levels of analysis show the virus, while no 1918, to be more dangerous than seasonal influenza:

  • At the molecular level, the virus is capable of bonding with lung receptors as well as those in the throat in ways unlike seasonal influenza.
  • At the clinical level, the virus induces a nastier infection across mammalian models, a result we discussed in some detail in an earlier post.
  • The World Health Organization reports a severe form of the infection in circulation that targets the lungs, causing severe illness in otherwise healthy adults. Some countries are reporting as many as 15 percent of hospitalized patients require intensive care.
  • At the population level, the virus has caused 100 times greater mortality in some human populations, with greater mortality for people in their prime, again largely unlike seasonal influenza.

“I got swine flu. Didn’t get very sick. It’s no big deal.”

A scientist commits an ecological fallacy when he or she concludes that a characteristic of the population can be applied to every individual in the population. The converse fallacy, committed here, involves sweeping declarations about the nature of a phenomenon based on personal experience alone.

What may be mild for one person may be deadly for another. Infections manifest the variation central to Charles Darwin’s population thinking, rather than its typological predecessor. That is, variation, and not some singularly idealized expectation, is what’s real.

Other testimonials refute the typecast. Here’s a description of the swine flu infection one blogger’s husband suffered this spring,

Now while H1N1 hit me quick and hard and then moved on, it doesn’t always play that way. When I first started on this blogpost, I had been living for seven weeks at the intensive care unit of one of the best hospitals in town. While our daughter and myself recovered quickly enough, H1N1 almost killed my husband…
You see, a certain number – and it’s currently impossible to know how many – of those non-deadly H1N1 cases are much like my husband’s: people in whom the virus does not follow its relatively benign trajectory, but in whom it provokes severe damage to the lungs and other organs. In my husband’s case, by the time we got to the ICU (after 72 hours in the ER) the flu had triggered septic shock – a failure of the circulatory system – and Acute Respiratory Distress Syndrome, an oftentimes deadly devastation of the lungs caused when toxins spill into them from the blood system. ARDS is thought to be the cause of most of the deaths in Mexico in March.
Even the worst influenza humanity remembers was characterized by great variation in the pathogen’s effects: Some during the 1918 pandemic were exposed but not infected. Others were infected but suffered only a seasonal-like flu. Then there were those whose innards melted from the inside out. A case fatality proportion clocking in at only 2-3% managed to kill 50-100 million people worldwide. A small mortality rate for a large number of infected still produces a large number of deaths.

The variation is more than descriptive, however. It’s causative. Those of us who, unvaccinated, manage to avoid the worst of an infection can still act as carriers, infecting others not so lucky. A pandemic operationalizes the critical principle that health is a communal obligation. We are plugged into a network of neighbors and coworkers that, like a Russian doll, extends out to the rest of the world.

The mutual integration renders unsubstantiated claims in the other direction, that this flu is milder than or at worse similar to a seasonal flu, nigh on sociopathic. Blasé dismissals for what will be for many a fight for their very lives should be held to account, if only by calling them out.

“Vaccines are unsafe.”

For a more exhaustive refutation, try this blow-by-blow post on the junk science underlying the anti-vax movement. For instance,

For some vaccines, substances called adjuvants are added to increase immune system response & spread a smaller quantity of antigen over more doses.

For one thing, the H1N1 vaccine doesn’t have any. Secondly, even if there were aluminum salts or squalene in the bloody thing, that wouldn’t be a reason to fear it. There is no evidence aluminum-containing vaccines are a serious health risk or justify changes to immunization practice. Aluminum salts have been used as adjuvants for about 80 years, and there’s much more aluminum in breast milk & infant formula than there is in the vaccines.

For our purposes, we’ll note that

  • Vaccines have had an excellent track record, with fundamental impact on global public health across multiple diseases.
  • Given the scale of production, the adverse effects of influenza vaccines are miniscule in incidence (see here, here and here).
  • The preliminary results–albeit largely from the vaccine industry (although peer-reviewed nonetheless)–indicate the vaccines for swine flu H1N1 are safe, with minimal discomfort (see here and here).

For most years, the public health fallout from vaccine denialism or just plain absenteeism is largely minimal. There exists enough partial immunity at the individual level and herd immunity at the population level to slow down a seasonal infection.

But during a pandemic year, a new strain’s emergence, outpacing vaccine production, is in a fundamental way as important as the state of its virulence. Even if swine flu clocks in with the same virulence as a seasonal strain, and continues to in the coming years, a contention no health official in their right mind would make, orders more people are going to be infected than between pandemics. Without partial immunity and herd immunity brought about by previous infection or timely vaccination, many more people infected will likely lead to more deaths.

Forgoing vaccination, then, is a much more consequential course of action this year. And with 30% of parents polled declaring they won’t vaccinate their children against swine flu, even as the CDC reports more children already killed so far this season than last year’s grand total, skeptics need to own up to the gravity of their decision. Unless, in their own minds, in an expression of a particularly American contradiction, they expect medicine will somehow rescue them from the pandemic they chose to ignore until it turned nasty.

“Vaccines are ineffective.”

Shannon Brownlee and Jeanne Lenzer recently weighed in on the effectiveness of the influenza vaccines (as opposed to their safety). They argue that the vaccine doesn’t work for the elderly (and seems effective only to the extent that the healthiest elderly are the ones to get vaccinated in the first place). The pair also argues vaccines are largely effective for most other diseases, but for influenza, which evolves season-to-season, questions vaccination as a long-term strategy.

Brownlee and Lenzer claim the medical establishment refuses the placebo-controlled trials needed to confirm the bias of healthy participants by hiding behind an ethical quandary,

Lone Simonsen explains the prevailing view: “It is considered unethical to do trials in populations that are recommended to have vaccine,” a stance that is shared by everybody from the CDC’s Nancy Cox to Anthony Fauci at the NIH. They feel strongly that vaccine has been shown to be effective and that a sham vaccine would put test subjects at unnecessary risk of getting a serious case of the flu.

As applied to humans, Brownlee and Lenzer’s view of vaccines is a minority opinion. The efficaciousness at the population level is, however, under debate for multiple host species, including livestock. Influenza is an evolution machine and requires new vaccines every year. The approach works, but, with influenza’s relentless reemergence year-to-year, by definition represents no panacea. Some years the vaccine misses the mark or a new influenza emerges, including this year’s swine flu, for which we have no vaccine until later in the season.

There are other issues. The scientific literature describes a number of examples in which livestock vaccination has selected for new influenza strains or kept outbreaks from burning out by generating reservoirs of subclinical infection.

Vaccines, antivirals, and other reductionist interventions are problematic if only because the pathogen refuses to obey the epistemological model under which much biomedicine operates, a key point in our recent book. Such pathogens instead live and evolve in response to multiple levels of biocultural organization over large swaths of geographic space.

So influenza remains a very difficult problem and requires interventions at all of the levels at which it operates, a full-court press as yet unpursued. The disease’s difficulties , however, don’t mean we can wash our hands of our responsibilities to do something about it this year. The answer certainly isn’t to shelve vaccination. In fact, vaccines are essential. For the long term, however, we’ll need to expand the scope of the interventions we partake. Not only non-pharmaceutical interventions now encouraged by public health authorities–regular washing, social distancing, self-quarantine, paid pandemic sick and family leave, among others–but into more contentious territory, including, like an ancient river, to the pathogen’s source.

A burgeoning variety of new influenza subtypes capable of infecting humans, swine flu H1N1 (2009) included, appears the result of a concomitant globalization of the industrial model of poultry and pig production. Since the 1970s vertically integrated stockbreeding has spread out from its origins in the southeastern United States across the globe. Our world is encircled by growing cities of millions of pig and poultry pressed alongside each other, an ecology well-suited for the evolution of multiple virulent strains of influenza.

An onslaught of new influenza recombinants raises the stakes. It increases the chance a truly virulent influenza evolves. It increases the range of strains vaccines must potentially cover. As a result, it also increases the unpredictability of any one year’s crop of human influenzas further complicating vaccine production.

“Vaccination may work, but why should I trust an industry in such a condition?”

As there has been very little money to be made from influenza vaccines, production, largely privatized since the Reagan administration, has suffered over the past two decades in both output and regulation.

In 2003, for instance, the FDA discovered bacterial contamination at a Chiron Corp vaccine plant in England, one of only two supplying the U.S. at that time, but did nothing but suggest voluntary changes. It wasn’t until 16 months later that British regulators finally shut down production, causing a gap in vaccine coverage here that flu season.

The last five years have seen something of a reversal in production at least in industrial countries. Governments, however, are ramping up production for this pandemic in part by indemnifying pharm companies from litigation should safety problems emerge. That kind of interference, or lack of it, speaks to a structural—as opposed to a nefarious–corruption. That doesn’t mean that this year’s vaccines are unsafe, but that we are flying with less of a net than we might.

With the caveats about their long-term sustainability discussed above, well-produced vaccines work year-to-year. This year the likelihood of getting a serious influenza infection by far outweighs the chance of getting a bad shot, no matter how distasteful the economics on which their production is presently based may be. The public’s confidence in vaccines, however, requires the industry be subjected to the strictest of regulation.

“Donald Rumseld owns Tamiflu stock” and “Swine flu will be Obama’s rationale for justifying a dictatorship.”

There’s plenty to call out for swine flu: agribusiness, Big Pharma, neoliberalism, foot-dragging governmental agencies, WHO, among others. But there is a fine line between a healthy skepticism about the pharmaceutical-government complex and sociopathic tendencies. Just because Roche–and Donald Rumsfeld and whatever bête noire the left or right can think of–profits off antivirals doesn’t mean swine flu isn’t capable of killing people.

There remains a material reality for which any political framework must still account, other than getting the drop on one’s talk show opponent. Given the potential danger at hand, it may serve us all better if for once we avoided confounding the politicians we despise with the pathogens that might kill us.

That isn’t to say that we shouldn’t demand clarification about and accountability for swine flu policy from politicians, scientists, and health officials alike, often a difficult expectation given the fluid nature of a pandemic. The expectation, however, comes at a price. Contrary to a prevalent ethos, particularly online, a free fire zone of anonymous flaming with few personal consequences for its practitioners, accountability also flows in the other direction. Public health requires public participation, including getting vaccinated.

Following in Defoe’s footsteps, a pandemic is a bad situation that forces us into a corner where we are able to exercise only limited options. That’s an ideological no-no in a land that over the past thirty years traded in the social safety net for the dream of a billion cheap commodities. To protect this Homeland of the Mind one can try to rationalize the danger away. In something of an orthogonal direction, one can try to confound what we should do about the pandemic in the immediate term with the long list of institutions which deserve the blame for bringing about the crisis (and which even now may be mishandling it).

But in the end it’s about duct-taping together the best response under bad conditions that, yes, the present system brought about. Swine flu H1N1 is the real deal and our neighbors’ health is intertwined with our own. That’s why I champion vaccination. It’s also why I believe it necessary to force the issue whether vaccination and antivirals can continue to be the sole means of controlling influenza.

For now, surviving the year is an important stop on the road to a new model of public and animal health, one we can make ourselves proud passing on 350 years later.

2 Responses to “A Visitation of the Influenza”

  1. I’m of similar mind regarding vaccination in general, of course, but there’s one argument that Brownlee and Lenzer reference which I’m curious about. I agree with the argument about the ecological fallacy in pointing to a steady or increasing secular trend in death rates among the elderly as an argument about the ineffectiveness of vaccination. But what about the point they make about the years 1968 and 1997 in which there was apparently a mismatch between the vaccination and the circulating virus. They claim there was no excursion in death rates above the overall trend. This is obviously not a journal article, so they don’t provide detailed numbers that the reader can examine, but I’m wondering if you have thoughts about that point.

  2. rgwallace Says:

    Allow me a quick and dirty answer, as I am no expert in vaccine minutia. On a fly-by through the scientific literature I found

    1) Simenson et al.’s (1) influential 2005 paper on the overestimation of the effectiveness of influenza vaccines in the elderly.

    But also 2) Nichol et al. (2)’s sensitivity analysis measuring the effects of an unnamed confounder on elderly survivorship. Confounders might include race, income, or–Brownlee and Lenzer’s bugaboo–functional status.

    Nichol et al. concluded that even in the face of a healthy-vaccinee effect, vaccines remained significantly protective across the 18 cohorts of community-dwelling elderly and across the year-to-year variation of their 10-season study. For the record, the study did not include nursing homes, in which the frailest, with less responsive immune systems, live.

    For the two seasons in which the vaccine provided a poor match, vaccination still offered a significant reduction in hospitalization and death, although less so than seasons with a better match. In other words, mismatched vaccines may still provide protection at the population level (although this may play out differently from person-to-person). I’d like to add the hypothesis–perhaps already offered elsewhere–that herd and partial immunity have a longer expiration date than over a single season. Is the protection accumulative?

    Other countries (3) have shown declines in elderly mortality upon introduction of a nationwide vaccine program. As the immune response is in part social in origin (4), one wonders if vaccines’ coverage-response surface is structured by the state of an area’s socioeconomics. Do vaccines fail more across seasons in which, and in regions where, the elderly population–and the institutions that support them–are in severe fiscal stress or social crisis?

    Consider this, Eric O., a heartfelt invitation to cull the literature too. And the more the merrier (and the faster we’ll all learn).

    (1) http://origem.info/FIC/pdf/Simonson%20et%20al%20Impact%20of%20Influ_Arch%20Intern%20Med%2005.pdf
    (2) http://www.preventinfluenza.org/newsletters/nejm.pdf
    (3) http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TD4-4T890SX-2&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ffac9428733c9d2ffb78e98f733e0c98
    (4) http://www.ncbi.nlm.nih.gov/pubmed/11932203

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