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A pandemic waiting in the wings

By David Oshinsky
Sunday, December 6, 2009

THE FATAL STRAIN

On the Trail of Avian Flu and the Coming Pandemic

By Alan Sipress

Viking. 386 pp. $27.95

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Americans know little about lethal infectious diseases. With the exception of AIDS, which targets specific population groups, we haven't experienced a nationwide epidemic since the 1960s, when the so-called Hong Kong Flu sickened millions of children and older adults, though killing relatively few. In 1900, infectious disease was the leading cause of death in the United States; today, with life-saving vaccines and antibiotics, this is no longer the case. When health officials talk about current "epidemics," they more likely are referring to chronic illnesses like cancer and heart disease. Aside from the post-9/11 threat of bioterrorism, infectious disease is more of a seasonal annoyance to most Americans than a major threat to their lives.

Until now, that is. Almost overnight we are discovering that microbes can be deadly and that the current influenza virus known as H1N1, or something uncomfortably close, has visited us before. In the fall of 1918, a strain of the swine flu triggered the worst seasonal pandemic in world history. Estimates range as high as 100 million deaths, and the United States was hardly immune. Indeed, 10 times as many Americans died in that year of influenza as were killed on the battlefields of World War I. The good news is that the current H1N1 strain has proved far less lethal than the one that circulated in 1918. The bad news, says Alan Sipress in his superb and sobering book about the shadowy progression of a virulent avian flu now moving across Asia, is that the worst is yet to come.

Sipress, a deputy business editor at The Washington Post, is uniquely positioned to tell this story. He's intimately familiar with the region, having served as a correspondent in South Asia during the devastating recent tsunami. And his grasp of virology, as well as of the ins and outs of the world health bureaucracy, serves him well in explaining why medical practices that appear so obvious to Western experts in containing a deadly epidemic are largely irrelevant to "the backyard chicken farmers, cockfighters, witch doctors, political bosses, and poultry smugglers" who control the terrain where this battle must be fought. We may be "closer to a global epidemic than [we've] been in a generation," says Sipress, who adds: "The pandemic [is] coming."

The culprit will not be H1N1, Sipress notes, but rather H5N1, an avian influenza that has killed millions of birds throughout East Asia since the 1990s and has now turned up in places as distant as Egypt and Azerbaijan. Flu viruses are defined by two types of protein: hemagglutinin, which the virus uses to break into the victim's host cells; and neuraminidase, which the virus needs to break out again in search of new cells to infect. What makes H5N1 so virulent is its ability to penetrate deep into lung tissue, unlike seasonal influenza, which targets the nose, throat and upper respiratory system. Particularly troubling is the fact that it has already jumped the species barrier from animals to humans. Though few people have been infected so far -- all in Asia and the vast majority in close contact with diseased poultry -- the mortality rate has been a staggering 60 percent.

Sipress sees H5N1 as the product of numerous factors, including a livestock revolution gone wild. Countries like Indonesia and Vietnam have become world leaders in poultry production without changing the primitive ways they go about tending their flocks. Chickens and ducks are rarely segregated from other farm animals, allowing all sorts of viruses to mix and spread. The birds are packed together in astonishing density; slaughtering takes place in open markets or private homes. Epidemics are ignored or covered up by public officials. Why risk the sort of publicity that could cost hundred of millions of dollars in poultry sales and tourism? "The fatal strain's progress across East Asia," writes Sipress, "had been a journey veiled in secrecy and blessed with neglect."

The blame does not rest solely in this part of the world, however. Western governments have been slow to grasp the resentments of Asian nations, which are both starved for antiviral drugs like Tamiflu and reluctant to provide influenza strains without receiving compensation from the pharmaceutical giants that will profit from them. This "fracture between haves and have-nots," as Sipress calls it, may well derail the coordinated effort needed to battle a pandemic.

It must be noted that many infectious disease experts are skeptical of H5N1's catastrophic potential. They note that this influenza strain, which jumped from animals to humans more than a decade ago, has still shown almost no ability to move from one human to another -- the key factor in triggering a pandemic. If it hasn't happened by now, they argue, the potential for person-to-person transmission appears low. What does worry these experts, however, is the sort of mutation, common to influenza viruses, that could produce an H5N1 variant that is transmissible and to which there is no current human immunity. That, indeed, may be the next fatal strain.

David Oshinsky, the Jacob K. Javits visiting professor at New York University, won the Pulitzer Prize for History in 2006 for his book "Polio: An American Story."

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