PBS Wide Angle: 'H5N1: Killer Flu'
Wednesday, September 21, 2005; 11:00 AM
The next global human flu epidemic may begin with a sick duck in Vietnam's Mekong River Delta, now the epicenter of a deadly bird flu outbreak. The World Health Organization estimates that the H5N1 virus - which already has jumped species from birds to humans - could kill tens of millions of people worldwide.
Wide Angle travels to Vietnam to investigate the threat of a global pandemic, portraying Vietnam's response to outbreaks in its cities, provinces and villages, where doctors, epidemiologists and veterinarians are battling the virus. As the government tries to contain the disease and educate its people, there is growing evidence that the virus is evolving and already may have begun to spread via human-to-human contact for the first time, dramatically increasing the risk of a worldwide catastrophe.
Producer Micah Fink and director Steven Silver were online Wednesday, Sept. 21, at 11 a.m. ET to discuss the PBS Wide Angle film "H5N1: Killer Flu."
H5N1: Killer Flu producer Micah Fink is an award-winning journalist who has developed and produced a variety of documentary programming for Thirteen/WNET, PBS's Frontline, National Geographic Television, and ABC News. Director Steven Silver has won numerous awards, including the Audience Award at both the Double Take and Hot Docs film festivals, and the Gold Plaque at the Chicago International Television Competition for his documentary, The Last Just Man, about U.N. force commander General Romallaire during the 1994 Rwandan genocide. He also directed Wide Angle's 2002 The Soul of India.
The transcript follows.
Philadelphia, Pa.: Some of the worst case scenarios come from an interesting source: Foreign Affairs magazine, which almost read like a horror novel. It almost seems as if the mainstream press is downplaying the potential affects of a major flu outbreak while the professional journals are warning of potential disaster. I hate to use this analogy, but are we potentially repeating what happened in New Orleans: we are aware of a disaster, but because the costs of preventing the disaster are high and the odds of disaster low, we prefer to look away and go with the odds and just hope the disaster never happens?
Dear Philly, Pa,
I think your sense is right. The professional journals and Web sites (like promed) have been keeping a very close watch on the avian flu virus for the last few years, but the main stream media -- perhaps because the evolution of the virus seems like such a technically complex issue -- have until recently really avoided the issue. Also, to be fair, terrorism and the war in Iraq have dominated much of our foreign coverage and the news hole, never large for international affairs, has been filled. That said I agree that this is a pressing and important issue (or else would not have proposed the program) and I think we should be doing much more than we are doing now. Antiviral supplies are very small (and the patents are held by just a few corporations) and even in the best case scenario, will not be available on a large scale if a pandemic strikes. Not even in the US -- if ever there was a time for patent sharing, it would seem like now is a good moment -- to allow the world to prepare. Also most of the federal money in the US these days seems be getting spent on terrorism related issues -- which may very short sighted.
Washington, D.C.: From what you have learned, is there evidence that avian flu is spreading between humans and if not, what do experts consider the likelihood that this will happen?
Steven Silver: It is difficult to confirm cases of human to human transmission because there is no difference in the virus's makeup once a person has been infected. In other words, you have to exclude any other source of infection to confirm a case of human to human transmission. Nonetheless, there is strong evidence that we are seeing the first examples of human to human transmission. Our film documents one such case. He was a nurse who cared for an H5N1 patient who had no contact with poultry, infected or otherwise. The cases of human to human to transmission are rare at the moment. So we might say that the virus is capable of inefficient transmission between humans in certain rare instances. The danger is that the virus has become markedly unstable and is hopping from one species to another. What everyone fears is that the virus will develop the capacity for efficient human to human transmission.
Lawrence, Kan.: It has been my understanding that the human-to-human transmission of Avian flu could be precipitated by a mixing of the H5N1 virus with a regular flu virus. But in your documentary, it was suggested that this mixing of viruses was not the only way human-to-human transmission could be precipitated. I believe the speaker on the film mentioned something like a mutation of H5N1 could also trigger human-to-human transmission. Which of these scenarios is the more likely? Please elaborate on this. Thank you.
Micah Fink: Dear Lawrence, Kansas.
I'm not a scientist, but my understanding is that there are two main scenarios in which the virus can evolve. In one scenario U.N. lands in a body that is also infected by another human flu virus (an avian virus that has already adapted to people) and the two viruses combine to create a new virus. Apparently the various components of the virus -- the NH's and the MN's -- are easily interchangeable between viruses and this has been seen happening in the laboratory. The second scenario is a mutation scenario. The H5N1 virus is a RNA virus-- and it is typical that when RNA viruses replicate in a cell that they often make mistakes (has something to do with the fact that RNA viruses have only one strand of genetic material). These mistakes can give rise to new versions of the virus -- some will die and other will survive and a few will thrive. Of course, the more replicating that takes place, statistically speaking, the more likelihood that a nasty new version will arise. That's the reason that the wide spread of the virus through the region is so concerning. The more birds infected; the more virus; the more virus; the more the chance of human infection; the more human infection, the greater the likelihood that the virus will mutate and create a new and nastier version...
Both pathways are scientific possibilities -- and the mutation pathway is what scientists now believe happened in 1918. So what we are seeing now -- which is the mutation scenario -- is particularly concerning.
Wheaton, Md.: Are villagers compensated for the destruction of their fowl? How do they balance getting sick with a need for food and a livelihood?
Micah Fink: Dear Wheaton,Md,
Villages are supposed to be compensated when their birds are destroyed; but there are a number of practical problems. The compensation often less than half the market value of the bird -- and so people are reluctant to kill their birds -- also since water birds -- like ducks -- don't show signs of being infected many people are unwilling to destroy their flocks. Also, the government is fairly poor, and simply doesn't have enough money to pay for all the birds in Vietnam -- even if they did want to wipe out the whole flock and start over again (like Hong Kong did). And there is a fair amount of evidence that with the virus now so wide spread in 11 or 12 countries in the region -- that killing all the birds , even if feasible, would be ineffective.
Maryland: My wife and I will visit Saigon in November. Are there any current vaccines that we can take or is everything still experimental?
Steven Silver: Scientists recently confirmed that they had successfully tested a vaccine for humans but this is not freely available yet. The anti-viral Tamiflu is an effective treatment for H5N1 if taken in the first 48 hours. One can take Tamiflu preventatively but this is really only necessary if you are in a high risk area - an area which has had outbreaks in the avian population. If you are going to a high risk area, I would try and get a course of Tamiflu for the visit and hang on to it.
Duluth, Ga.: I participated as one of 103 citizen advisors in a Public Engagement Pilot Project on Pandemic Influenza held in Atlanta, Georgia on Saturday, August 27, 2005. The primary sponsor of the symposium was the Centers for Disease Control. This was the first time that ordinary citizens were asked to be involved for their perspectives and input in planning for how to respond to a potential public health crisis.
Prior to the symposium we were given materials to study about Avian (bird flu) and about influenza in general. That Saturday we had presenters from the scientific community to address us and then we had very focused discussions on deciding who should have priority in receiving vaccine, if and when a major "drift" occurs with A (H5N1).
Although, the discussion was a hypothetical discussion, it was nonetheless very emotionally taxing deciding who should get the scarce vaccine, should a pandemic occur. It was as if we were playing "God" with who should live and who may die.
The vaccine cannot be made until it is identified that there appears to be a major change in the virus and then it takes minimally four to six months to prepare the vaccine and then it must be determined if one or two doses of vaccine are needed to cause immunity.
Should there be a bird flu epidemic it would probably last about 12 weeks and because you cannot predict how to make the vaccine in advance it is inevitable that vaccine would be scarce. Only one percent of the American population would be able to receive the vaccine on a rolling basis, once it was ready. If two doses of vaccine are required then even less people could receive vaccinations.
Ironically, just days after the symposium Hurricane Katrina hit and we saw just how disorganized and delayed the federal government was in adequately responding to the disaster of the gulf coast region.
Hopefully, the department of Health and Human Services, which is the parent agency of the CDC and FEMA who would be running the show if a bird flu pandemic occurs has learned something about how to prepare and respond to domestic crisis and in meeting human needs. If not, and a pandemic bird flu should come about, the suffering, death, and economic losses that have occurred with Hurricane Katrina and its aftermath will be minuscule in comparison to the loss of life and the economic consequences that will result from a poor response to a pandemic bird flu outbreak.
The threat of an Avian bird flu epidemic is a real threat to our nation: and should be viewed with the same importance as in addressing terrorism. Otherwise, we are doomed.
Citizen Advisor~Atlanta 100
Avian Pandemic Influenza Symposium
Micah Fink: Dear Duluth, Ga,
Thanks for your remarks. I think that the issues you are raising are very real and very disturbing. It shows how very unprepared we are for a pandemic. The parallel to Katrina is apt, I think, because this would be a public crisis of the highest order.
Olney, Md.: Does the fact that Vietnam is run by Communists hinder research or flu tracking and prevention?
Steven Silver: Our experience in Vietnam was that the government was quite open about their outbreaks both avian and human. In fact, they are ahead of the game at the moment in tracking the virus and in the development of effective treatments. We were among the first journalists to be given this level of access to the country's hospitals, health authorities, patients etc which is a sign that Vietnam is taking the virus very seriously.
Alexandria, Va.: I am planning to travel to Beijing and Shanghai in November. Should I be concerned about contracting the bird flu? How do I protect myself?
Steven Silver: No, I would not avoid travel to East Asia. The danger presented by avian flu does not lie in its current activity in that region, it is in the fact that the virus is volatile and might mutate, become easily transferable from one human to another and cause a pandemic.
If you want, you might carry a course of Tamiflu with you as a precaution. But I would only do this if I was in a high risk area or meeting H5N1 patients.
Alexandria, Va. : As an epidemiologist, I am getting a little sick of calling this a "bird flu." It isn't. There isn't any such thing, at least not literally.
This is a "factory farm" flu.
Animals, particularly birds and pigs, are kept in feeding, transport, pre-slaughter and slaughter conditions so unnaturally cramped and filthy that the animals are administered huge doses of antibiotics to prevent flock- and herd-killing diseases. (This, of course, is before the animals are butchered alive and fully conscious, as the USDA permits). The animals then become antibiotic-resistant. These "bird flu" events don't really happen in a comparable way in nature.
Every time a consumer buys a McBurger or a Mc Chicken, that consumer is paying to re-re-reintroduce factory farming diseases into the cycle, causing agony to the animals and disease to humans. The only long-term solution is a perfectly healthy non-meat diet.
Micah Fink: Dear Alexandria, Va,
Bird flu, avian flu, avian influenza, H5N1 -- these are all the names that we see in the scientific and popular media. It is a bird flu, technically, because the virus naturally exists in wild birds.
I agree with your basic point -- that factory farming has increased the likelihood that the virus can spread among large flocks, increasing the statistical risks of mutation, and thus making a pandemic more likely. The poultry population of Asia has risen enormously in the last two decades -- as the region grows wealthier, more people want to eat meat. The cruel reality, however, is that in Vietnam, most of the birds are being raised on family farms, free-ranging, in rather idyllic environments (for the ducks, geese and chickens, at least) and that this is where most of the infections are taking place. This free range environment means exposure to wild birds -- who can transport the virus to new regions (this is what seems to be happening now in Russia and Tibet).
But before recommending vegetarianism to all Asia, I would remind you that Flu pandemics are natural phenomena, and were probably occurring long before the onset of factory farming -- and will probably continue to occur long after this method of raising meat is obsolete.
York, Pa.: The evidence of the possibility of a pandemic is growing. At what point would it become necessary for people to wear face masks and gloves as a precaution?
Micah Fink: Dear York, Pa,
I can only offer you my own personal thoughts on the matter.
Its important to say that a pandemic has NOT begun.
That said, I think that once we start reading about large scale outbreaks -- village clusters and the like, we might all want to start wearing face masks. This is what they did in 1918, and short of antivirals for all, I think basic hygenic precautions (masks, hand washing, avoiding public spaces) are still the best way to way to try to protect yourself.
Check out my producer's note on the Wide Angle web site for details about what kinds of masks we wore and what sorts of medications we brought along with us to protect the crew.
Washington, D.C.: What countries have the most flu related deaths? What are their budgets for flu tracking?
Micah Fink: Dear Washington, DC,
Check out the WHO's web site for specific details, but my sense is that Vietnam has the largest number of human cases, followed by Thailand and Cambodia. (Cambodia doesn't have much of a public health infrastructure and so the real number of flu cases is hard to know. Also, countries like Laos, share borders with Vietnam and China and a very similar way of rural life -- so we can expect cases there as well. Currently, Indonesia is also reporting an increase in human cases...
I don't know what their budgets are for tracking the diseases, but can say that the Vietnamese are taking this issue very seriously and are watching their provinces carefully.
"Otherwise, we are doomed": While I don't disagree that bird flu is a threat to humans, isn't it true that the virus would have to mutate before it became transmittable between humans? It seems to me that the media tends to overdramatize the threat of exotic viruses because it makes for a good story. I wonder if people in the United States are much more susceptible to the regular flu.
Steven Silver: You are correct. The virus would have to mutate or reassort with the human flu to become widespread or cause a pandemic. What scares scientists at the moment is not simply that the virus might be capable of limited human to human transmission (which it is now) but that the virus has become unstable. In this sense it is behaving how they think the Spanish flu (also an avian flu) behaved just before 1918. That pandemic killed about 40 million people and had a mortality rate of about 1 to 2 %. Right now H5N1 is following a similar pattern. It jumped from wild birds to chickens and then to ducks. It is now lethal in chickens but asymptomatic in ducks. It has infected pigs in Indonesia and 2 tigers died in Thailand. Its morality rate is dropping in humans which ironically is a bad thing - it allows for greater transmissibility. I don't think the media is being alarmist. I think Katrina has demonstrated the state of preparedness in one of the world's most advanced countries. I don't think is there is enough noise about H5N1 yet. The WHO's position is that a pandemic will happen at some point. That might be in a year, in five years or maybe only in twenty years. Nobody knows. What is clear is that if our current state of preparedness does not change before that moment, the results could be disastrous. So we need to be prepared. And, the preparedness will be useful not just for an H5N1 pandemic but is also applicable to other disaster or emergency situations.
Fairfax, Va.: Today's Post reports possible transmission between humans of the virus in Indonesia. Does this guarantee a pandemic?
Micah Fink: Dear Fairfax, Va.
Increased reports of human to human transmission is worrisome, but no guarantee of a pandemic. Right now the world's scientific community is waiting and hoping that we can dodge this viral bullet. That the virus will take a wrong turn and transform into a harmless agent unable to spread or harm people. But it may also mutate into something worse. We really don't know. The basic point of our program, I think, that that we need to be prepared for the worst case scenario. At the very worst, this would be a expense of money that will probably reap other benefits as health infrastructures are improved and surveillance is increased. I think the lesson here is that we in the US are just as vulnerable to diseases like the flu as any impoverished third world person -- and that our fates are linked, even if large continents and oceans and languages and customs seem to separate us.
Maryland: On the grand scale of things to worry about, is avian flu more of a threat than a known quantity like malaria, West Nile or various tropical diseases or parasites?
Steven Silver: Right now Avian Flu is not more of a threat than other diseases like malaria, TB etc. Countries like Vietnam can easily cope with its human cases and have enough anti-virals to treats its patients. But an Avian Flu pandemic would be far more of a worry. In a reasonably bad case scenario, we would be talking about millions of deaths, hundreds of millions of infected people needing medical attention and dramatic knock-on effects to international trade and the global economy. We need to take steps to head off a pandemic and preparedness steps that assume it is impossible to prevent.
Washington, D.C.: Would you avoid a trip to the Mekong Delta region?
Steven Silver: No, I would be happy to travel to the Mekong as we did to make this film. It is very beautiful.
Steven Silver: Thanks to everyone for participating.
Micah Fink: Thanks to everyone for their thoughtful remarks. I hope that our program helps to raise the issues we've been discussing to a higher level. For more information about the nature of the virus, patterns of human trafficking and wild bird flight paths, and more about the program -- please visit the PBS Web site about our program at
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