Predictable as clockwork, no sooner does the Director General of the World Organization for Animal Health (OIE), M. Bernard Vallat tell us that things are looking up for bird flu then we have a massive outbreak threatening to devastate the poultry industry of India. So the poultry problem is neither stable nor under control, whatever M. Vallat says (and I daresay he probably regrets saying it). The Indian problem is a big deal, with reports of villagers eating birds that died of the virus and violent resistance to culling efforts. Clearly India was unprepared for this poultry outbreak, despite ample warning and plenty of examples elsewhere.
Nor is their health care system -- even their best hospitals -- prepared. Last year India dumped its plans to train health professionals midway through last year:
There are three vital training aspects -- clinical, preventive-medicine and microbiology -- to handle avian influenza outbreak. The team, last year, held clinical training sessions for health professionals. However, it could not complete its work, as it was 'abandoned' apparently for no good reason.Effectively, the health professionals, including paramedics, lab technicians, professors and assistant professors do not have any idea about preventive and microbiology aspects, in case there is an outbreak. Three experts from clinical, microbiology and preventive medicine from city teaching hospitals were appointed for the rapid response team. The three members were sent to National Institute of Communicable Diseases (NICD), New Delhi, to get trained by avian influenza researchers. The members of the team were given a mandate to set-up a response team in the State, which could be deployed at a short notice in the event of an outbreak. (The Hindu)
So the only rapid response in India is panic.
Meanwhile, yet another conference of bird flu scientists is taking place, this time in Bangkok, Thailand. Meetings where scientists come face to face are still a major means of disseminating scientific information. The usual scientific sessions may provide the news but the work gets done in the corridors, lunch tables and other informal venues. No Power Point presentations there. Just scientists discussing their problems and often disagreeing and arguing about them.
And make no mistake. There is much to discuss and argue about. One school of thought says H5N1 is poised to become a pandemic strain, where and when no one knows. Robert Webster from St. Jude's in Memphis, the dean of flu virologists is in that camp. He is matched on the other side by Peter Palese, an equally eminent flu virus scientist from Mt. Sinai. Palese is by no means complacent about H5N1, but has wondered for a long time if there is some biological barrier to this subtype assuming pandemic features:
"I'm not convinced H5 really has the ability to jump into humans and cause the next pandemic," Peter Palese, a professor at the Mount Sinai School of Medicine in New York, told Reuters.
"Most of the human cases are the result of a large dose infection," he said, such as victims who come into close contact with sick birds.
"If you are a chicken it's a serious problem, but I'm not so sure it's the next pandemic strain," he said. (Reuters)
I don't know if Peter is right about this or not (and neither does he). It's not impossible. But I do believe we should act as if Rob Webster is right. There's too much we don't know, including the essential elements:
"We don't really know what it takes to be transmissible and we don't know where it's coming from. Where is it hiding out?" Webster told Reuters.
But how we act as if H5N1 could become a pandemic agent is also a matter that requires thought. My view, often expressed here, is that we are best served by investing in strengthening the public health and social service infrastructures of our communities (something we are not doing; on the contrary, we are weakening them with budget cuts). That way it doesn't matter who is right, Webster or Palese, because we will be acting in a way that covers them both.
I've said that before. Often. Just following the old adage, "The secret to marketing is repetition. The secret to marketing is repetition. The secret to marketing is repetition . . . "
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"The secret to marketing is repetition. The secret to marketing is repetition. The secret to marketing is repetition . . . "
Yep, Yep, Yep! Keep saying it until they finally start believing, and then keep saying it ... LOL!
Dave Briggs :~)
I think you should add another group to your list of needed professionals-psychiatrists. Mental health should be a critical part of marketing the message. Without them we are going to see death counts increasing because of preventable situations. Suicide, risky behavior, and panic spring to mind. We have seen all of these in the last few days in India. How to say the message so consumers actually participate in preparedness, is as important as repetition. Focusing on positive ways to address the possibility of pandemic is critical to its success.
To me the big question is why the major media outlets aren't showing the same level of concern for this issue as, say, this blog is. I can only think of three reasons. One is that they are being influenced by the government and/or poultry and tourism industries to protect the poultry and tourism industries. Two is that they do not want to start a panic and three is that they do not want to be criticized for fear-mongering. Whatever the reason is, I think they are failing badly in reporting important developing news considering how quickly a pandemic can develop if the virus changes.
Perhaps the problem is WHO's threat-level system. How long is WHO assuming that Levels 4 and 5 would last before Level 6 is attained? Is that assumption based on proven science? If their upping the threat level is what it will take for the media to increase coverage, then that's how long people will have to prepare, both psychologically and ration-wise. From some reports I've seen, that could be a fairly short period of time.
Something is rotten in Denmark, but it's hard to say just where.
Another plausible reason is that this has kind-of dropped off the radar screen, and there are a lot more interesting and photogenic stories around that will fill the airwaves. And there seems to be a large and creepy element of randomness in what becomes front-page news, with feedback loops guaranteeing that once some story becomes front-page news in one place, it often expands to take over all kinds of news time, and self-sustains for awhile, and then just drops off the map and is never heard from again. Think Anna Nicole, OJ, the Menendez brothers' early inheritance scheme, the latest cute blonde girl raped and murdered in the tropics (if she'd been ugly, we would never have heard of the story), etc.
I imagine some kind of TV newsroom discussion about the bird flu story, which goes like this:
"So, what kind of pictures can we get?"
"Lots of dead poultry, angry third-world farmers, and old men and women in lab coats talking in technical language about viruses and mutations and pandemics and antivirals."
"I see. Well, how's that cute blonde chick raped and murdered in the tropics story coming along, again?"
I think the biggest obstacle to real reporting on this matter is that the media, for the most part, don't think the US is unprepared or in poor condition in terms of infrastructure and health care. Quite the opposite. The pundits and bloviaters all think it's just silly to talk about socialized medicine because we've got the best healthcare in the world, people! The only problem, according to them, is that everyone isn't covered. Yakkers like Tucker Carlson and others consistently make the claim that health care in 'socialized medicine' countries costs more than it does here and 'you wait longer'. They say these things all the time and people, among them reporters for big papers, believe them.
So I suppose I'm just proving Revere's point...with which I agree, obviously.
I'm dumbfounded by Palese's comment. There has to be more to his statement - more context not presented here. As it stands, he's talking about humans contracting a bird virus. While that's not good, that's not the pandemic concern. As I understand it, we don't know why a relatively few people (351) have contracted the disease. Whether it was exposure to a large "dose," as Palese mentions, or some genetic peculiarity about cells in these individuals' respiratory tracts, or some other factor, we don't know. But, in any case, we're talking about a bird virus. The issue/worry is that the bird virus will develop a human virus - a human-transmissible strain of H5N1. For many/most of us, a tiny "dose" of that would cause sickness.
Relatively speaking, what does it matter if it takes a "large dose" of this bird virus to cause human sickness? What relationship does that have on whether this bird virus ever spawns a human variant - i.e., ever causes a human flu pandemic?
I don't follow Palese's logic. Revere, do you?
Chirp: I talked to him about it a couple of years ago (when he felt the same way). His view was that there might be some biological reason why the H5 subtype wasn't becoming easily transmissible. He is a very, very experienced flu virologist and this was his hunch, based on the fact that the subtype had been around humans for some time but didn't seem to care much for humans as a host. You and I (and Rob Webster) may disagree, but his is not an opinion I dismiss lightly. But it is an opinion (like ours is an opinion). I don't think it is "logic" but more a gut feeling. While we don't know why it has infected so few people, this is precisely his point. Maybe there is a reason that prevents it from infecting more. If it swaps H5 for something else and becomes a monster it is still not H5.
I seem to remember Indian ministers (representatives?) saying not so long ago that avian flu could never happen in India. H5N1 doesn't respect political borders; it doesn't matter what you say--it will come or not depending on the spreading mechanisms in your part of the world. Dumb of India to think arrogantly that bird flu can't happen here.
History-SARS-China. History-H5N1-China. It starts with being totally open and not having someone sitting around in a pissing match over the name of a new bug. Next is when you got a problem you let the rest of the world know. China bears a big load of responsibility for the people that died and have died in both outbreaks and that in particular counts on this one. Outright denial in SARS until it broke in Boxun.com. Same with H5N1 and the outbreak finally being acknowledged as being in country and in humans for a full two years longer than what was first stated. Somehow the lefties laid the responsibility for AIDS at Reagans feet because the conservatives wouldnt fund research into it until it started affecting the hetero's. Okay that is a political issue and thats what we have here... A political issue. Not a health issue.... political.
Off we go to Geneva and the great political pump is the WHO itself. Politics and doctors dont mix except in promotions. There has been a near total failure of this organization to effectively manage bugs of any kind. Its like our CDC during SARS. They didnt do squat and arguably even though it was on a Clinton watch they should have. They literally did nothing except put six doctors onto a plane and sent them to Canada. 8000 got it, 800 died worldwide. Both organizations showed their ineptness and neither have power to enforce and that means unfortunately agreeing to be subservient to their wishes if a bug comes. This would entail giving up resources from one country or a couple to another that is going down the toilet. Said resources being paid for by someone else and just given/taken (terminology is open for discussion) to the other. I dont like that idea and anyone who is POLITICAL can see they wont be in their seat for more than five minutes after it arrived into the country that now has no supplies.
The socialist nature of the WHO organization has lead to the butting of heads over samples and data. Well boys and girls even during the height of the Cold War weather information was passed with absolute timeliness to our Red opponents and them to us. Same with Cuba. Start there.... you might see a change in heart about delivering some vaccines to Indon if it starts, but by my count at least 2/3rds of the country would be gone by then anyway if the current CFR holds.
We also have because of the socialist nature of the beast come to find that our other little children on the planet want another socialist handout to give up their samples. The capitalists have said no way. Cheery situation we are in. We have a politician as DG, we have direct and indirect Pandemic Level 4 activities going on in at least two countries maybe three. We have a regional outbreak of bird pandemic flu (that means birds ARE in a pandemic of the stuff) and no one wants to take responsibility to do as Revere says and that is to prepare as if it is coming. We might differ on how that is achieved but the message is clear - pandemic of somekind is coming and for the first time really in human history we CAN do something about it. The NPFP was a good start but there has to be some nuts and bolts rather than suggestions. Some of this will have to be tossed ten minutes into a pandemic because the bug and the people will not react the way we want them to.
But its a pandemic. If we were so smart we wouldnt be having one would we?
"Most of the human cases are the result of a large dose infection," he said (Palese), such as victims who come into close contact with sick birds."
What about the others?
I might allow myself to consider Palese's position to be an objectively valid assessment, rather than a "gut feeling," if we had a more comprehensive understanding of the trajectory of the 1918 H1N1 virus. If one "fully" avian virus could successfully manage the transition to a completely efficient, highly transmissible human virus, as it evidently did, then I am very reluctant to assume that there is "something" that prohibits H5N1 from overcoming this hurdle. Is there "something" fundamentally different about H1N1 -- which was not subject to any antigenic shift -- which allowed it to transition into a human-adapted pathogen; some sort of mechanism that is biologically denied to H5N1? Maybe. But it will take a lot of very compelling persuasion, on that point, to successfully engineer me from my present position, into a position where I would feel comfortable in the Palese camp.
Show me the biology.
Dylan: Of course you are right, which is why I am not in Peter's camp. Even if someone gave me a biological reason (that's part of the receptor narrative) I don't think I would feel confident enough to say, "OK. No problem." I think Peter is talking as a scientist to the press the way he would talk over the lunch table (or in the case where I spoke to him, over the dinner table) and that isn't appropriate. He is a good guy, though and a good scientist but I don't think he appreciates the consequences of saying these things.
Revere, there has been significant commentary about Dr. Vallat's opinion of the virus' stability. In your comment here you suggest that he was referring to its spread in birds (you reference India as proof against the virus being stable). Others suggest he was wrong about the virus being stable since it mutates frequently. I, on the otherhand, feel that his comment was about the virus not becoming more human friendly.
Which is it?
Before we continue to attack what he said, we need to understand the context/intent of his statement. If his opinion was as I interpreted it, I feel that he is exactly right and the data (human infections over the past few years) backs this up.
Stan: If I didn't know Revere better, I'd have to swear that he planted you, here. Just so that he could swat this one right out of the ballpark. But I do think that I know him better than that; so your question has to be a legitimate one.
Now, I'm just going to have to sit, back and watch this one sail right over the fence. Whack!!!
Stan: Someone who talks to the press in ways that can be interpreted three different ways is not exactly a world class communicator. For the record, I don't know what was in his head (there is a hidden assumption here but I won't go there) but it is clear, or should have been clear, how it would be interpreted, and frankly, I think that's how it was meant as well: that this virus is stable with respect to whether it would become a pandemic strain, since neither of the other two interpretations make any sense.
Now if the first two don't make any sense -- that is that the virus remains out of control in the bird population AND that it continues to mutate, as is the natural behavior of negative sense RNA viruses (no proofreading), then the third makes no sense either. Moreover the man is a veterinarian and if he got the animals stuff all wrong, then why would anyone listen him about the human stuff?
If you are exposed to asbestos (latencies of 20 to 50 years) and you feel fine through year 25 does that mean you have nothing to worry about? Maybe you are fine. Maybe there's a cancer growing in your left main stem bronchus. Would you say your health was stable? Stable means it isn't going to change. The obvious point here is that since we don't know what makes this virus easily transmissible (or not) we don't know if it is stable with respect to transmissibility or a bunch of other things. Suppose it takes five changes, on average, but the changes can be of many different kinds or combinations. Not only possible but plausible. If you have flipped four of the switches nothing happens. Is that situation stable?
I agree with you about one thing. You interpreted him correctly. Where I disagree is what he said was wise or warranted. He's not just some poor asshole who couldn't dump shit out of a boot if he had it by the heel. He is the Director Fucking General of the OIE.
Thanks revere.
Note to Dylan, your smartass and ignorant comment aside, I'd say this one is "still in the park".
"Note to Dylan, your smartass and ignorant comment aside, I'd say this one is "still in the park". - Stan
Not quite.
Sorry. Not the case. And I'm not at all as kind as Revere is. To paraphrase Ronald Dumsfeld, "He (Vallat) knows that he does not know some things (at least he should; since that's his job). And that is what those who are doing the direct research on the evolution of this virus do not know, either; because they do not have sufficient access to all known isolates to draw any definitive conclusions about its current status. Period. They don't know? Then he doesn't know.
We are working almost exclusively in the dark, here. Therefore, it necessarily follows that he, also, is in no position to draw any intelligent, informed conclusions in this regard, either. You cannot conduct research on material that you do not have. Simple enough?
He also knows that he does not know what he does not know. There are entire geographical areas out there -- countries, and possibly even continents -- that are nothing more than informational black holes. And they are increasing in number. What is the significance of that, with respect to Vallat? That ought to be self-evident.
He is either:
Innocently mistaken? (I think that we can dispense with that one.)
Stupid?
Blind?
Venal?
Incompetent?
Or all of the above?
If any, or a "cluster," or all of these things are true, then it follows that he should not be in the position that he currently occupies. Period.
And yes, that does directly address the issue that you raised.
Dr. Vallat voiced an opinion based on the data that he has been provided. I would hazard a guess that this data is more complete that the data that either you or revere has been privy to. His opinion is that the virus is "stable", meaning that it is not becoming more human flu like. The hard data we have available substantiates that as well (ie the number of human cases has not been going up the past few years even with an increased geographical spread and increased surveillance). Experts voice opinions all the time. You can disagree with his decision to voice his opinion but if you look at the data one would have a hard time saying he is wrong. The virus is not increasing it's affinity toward humans. That does not mean that it couldn't change at some point and he even said that.
Oh and one more thing Dylan, you are an idiot!
Yes, Stan. M. Vallat knows the secret stuff the rest of us aren't privy to. Just like George Bush knew about the WMDs. The fact is -- and it is a fact -- we don't know what makes this virus transmissible or not. So he doesn't know either. No one knows. And if they did and didn't tell the scientific community, they ought to be jailed for a crime against humanity.
Tell me what's going to happen to the stock market. There's data. What does it say? I don't have a hard time saying he's wrong about the human data. I'm an epidemiologist and he isn't. He's a vet. I do this for a living. I deal with "hard epidemiologic data" all the time. There is nothing very "hard" about our bird flu data, as Dylan has pointed out, quite accurately, even though you don't like what he is saying.
Revere, you continue to misrepresent what Dr. Vallat (and I for that matter) have said. He did NOT predict that the virus COULD NOT become a pandemic strain. He said that the virus is stable NOW in terms of becoming human panflu. All of this other crap that you and Dylan are trowing out is meaningless noise.
Furthermore you seem to be quite critical of Dr. Vallat's interpretation of the virus as it relates to humans since he's only a vet and not an epidemiologist. If you are going to use that logic then Dr. Palese's opinion of the virus and it' apparent inability to become a human flu virus must trump what you or nearly anyone else thinks. Aferall, he is a virologist and making commentary on influenza viruses what he does "for a living".
One more thing I'd like to point out since you seem to assign great importance to the fact that Dr. Vallat is only a vet while voicing his opinions. Would it have made a difference if he were an epidemiologist instead?
Michael Perdue is an epidemiologist with the WHO and used similar language to describe the virus back in 2006 when he said: "It also appears that the virus is relatively stable."