Access to medicines has become the test above all others by which the rich world will be judged in its dealings with the poor.285
Scientific agreement about the imminent danger of an avian flu pandemic is almost as broad and all-encompassing as the consensus that humans are largely responsible for global warming. All the summit organizations responsible for world health, including the WHO and the CDC, have warned that the coming viral hurricane might be even more deadly than the 1918 pandemic. The major dissenter to this view is Amherst biologist Paul Ewald, a controversial advocate of “evolutionary medicine.” In his view, the leading influenza experts have failed to grasp elementary principles of viral evolution, especially “the selective processes that favor increased or decreased virulence of virus strains.” The 1918 pandemic, in his view, was a unique historical event whose catastrophic outcome depended upon the evolution of influenza virulence in the extraordinary conditions of the Western Front. “Both theory and the evidence,” he claims, “implicate the Western Front as the source of the epidemic.” Ewald doubts that environmental conditions so favorable to the emergence of hypervirulence in influenza A will ever reappear. “We will fail to see,” he predicts, “a recurrence of a pandemic influenza with the kind of lethality that characterized the 1918 pandemic.”286
Some scholars, of course, would dispute that the virulent second wave of the 1918 virus originated in France at all: Kansas, in fact, seems a better bet. Ewald also skirts over the geography of the great pandemic, whose deadly epicenter was India, not the Western Front; nor does he engage theories about how malnutrition and malaria amplified influenza mortality. Still, Ewald may be correct that crowded Army training camps, hospitals, and ships, as well as the trenches themselves, were the bellows that turned outbreak into conflagration. The 1918 pandemic dramatically grew in virulence between its initial spring outbreak and the deadly second wave in the early fall, so the key variables must have been crowded, often unsanitary conditions with large concentrations of sick victims able to transmit an evolving virus quickly to distant locations. Ewald calls such an environment a “disease factory.”287 He might also have called it a slum.
The Western Front of the world’s first industrialized war recapitulated much of the disease ecology of the classic Victorian slum—the locus classicus of most discourse about infectious disease. In the nineteenth century, the great slums of Europe, America, and Asia had a total population of perhaps 25 million; today, according to UN-Habitat, there are 1 billion slum-dwellers: a number expected to double by 2020. Is there any reason to assume that today’s bustees, colonias, and shantytowns are any less efficient “disease factories” than Victorian slums or crowded 1918 army camps? If, according to Ewald, the sine qua non of a deadly airborne pandemic is “host density” in poor sanitary conditions, then—as Table 12.1 shows—today’s megaslums are just as fetid and overcrowded as any of their notorious Victorian predecessors. With population densities as high as 200,000 residents per square kilometer, they offer perfect environments for the evolution of flu virulence. By such criteria, pandemic influenza and other deadly infections have a brilliant future.
While the combustible role of Asia’s thousands of slums in the development of a future pandemic has been oddly neglected in the research literature, the great concentrations of urban poverty in Dhaka, Kolkata, Mumbai, and Karachi are presumably like so many lakes of gasoline waiting for the spark of H5N1. Moreover, the contemporary megaslum may be a crucial link in a new global disease ecology. In 1976 the historian William McNeill proposed that there had been three “historic transitions” in the co-evolution of humans and microbes: the Neolithic (agro-urban) revolution; the creation of an Eurasian Ecumene in classical times; and the rise of the modern world system in the sixteenth century. Each transition was a stage in the biological “reunification” of the human race as well as a corresponding exchange of microbial parasites. Some epidemiologists now argue that neoliberal globalization represents a fourth transition or “reshaping of relations between humans and microbes.”288 Clearly, the crucial environmental conditions favoring the rise of a new pandemic flu offer a partial model of this larger transitional dynamic.
To recapitulate from earlier chapters, the two global changes that have most favored the accelerated cross-species evolution of novel influenza subtypes and their global transmission have been the Livestock Revolution of the 1980–90s (part of the larger world conquest of agriculture by large-scale agro-capitalism) and the industrial revolution in South China (the historical crucible of human influenzas) which has exponentially increased the region’s commercial and human intercourse with the rest of the world. The emergence of Third World “supercities” and their slums, then, would constitute a third global condition tantamount to Ewald’s Western Front as a human medium for potential pandemic spread and virulence evolution.
Table 12.1.
Urban Density (1000s per km2)
(Slums in Italics)
| Dharavi (Mumbai—densest streets) | 571.0 |
| Delhi (densest slum) | 300.0 |
| Kibera (Nairobi) | 200.0 |
| Cite-Soleil (Port-au-Prince) | 180.0 |
| Lower East Side (1910) | 145.0 |
| City of Dead (Cairo) | 116.0 |
| Les Halles (Paris, 1850s) | 100.0 |
| Imbaba (Cairo) | 84.0 |
| Dhaka (old town) | 80.0 |
| Five Points (New York, 1850) | 77.0 |
| Nairobi slums (average) | 63.0 |
| Orangi (Karachi) | 50.0 |
| Manhattan (1910) | 32.0 |
| Cairo (greater) & Caracas barrios | 25.0 |
| Mumbai & Lagos | 20.0 |
| Colonias populares (Mex. City) | 19.0 |
| Shanghai | 16.4 |
| Manhattan & central Tokyo | 13.4 |
| Mexico City | 11.7 |
| World urban average | 6.6 |
| London | 4.5 |
| Los Angeles | 2.4 |
(One of Ewald’s signal theoretical contributions to the study of pandemics, by the way, has been to show that pathogens do not always become less virulent and more well-behaved over time, as some textbooks still claim. Offered the unprecedented menu of huge slum populations, a new pandemic influenza might not be as easily tamed as some of its ancestors. As Ewald explains, “If predator-like variants of a pathogen population out-produce and out-transmit benign pathogens, then peaceful coexistence and long-term stability may be precluded much as it is often precluded in predator-prey systems.”)289
But there is also a fourth, negative element that closes the ominous circle of influenza ecology: the absence of an international public health system corresponding to the scale and impact of economic globalization. Such a system, as Laurie Garrett emphasizes in her much-praised book, Betrayal of Trust: The Collapse of Global Public Health, “would have to embrace not just the essential elements of disease prevention and surveillance that were present in wealthy pockets of the planet during the twentieth century, but also new strategies and tactics capable of addressing global challenges.” Nothing like this, of course, now exists, and Garrett paints a dark, almost despairing portrait of how the worldwide HMO revolution (which, in addition its effect into the United States, has also had a surprisingly broad impact on developing countries) has promoted cost-containment at the expense of saving lives. The WHO, “once the conscience of global health,” Garrett adds “lost its way in the 1990s. Demoralized, rife with rumors of corruption, and lacking in leadership, the WHO floundered.”290
Richard Horton, the editor of The Lancet, the premier British medical journal, offers an equally bleak view of world public health. “UNICEF and WHO have largely abandoned the world’s children to die in poverty. For example, spending on immunization by UNICEF totaled $180 million in 1990. By 1998, the figure had fallen to around $50 million.” Some 11 million children under the age of five die each year, and “99 per cent of these deaths occur in setting of acute poverty.” Horton accuses the WHO, even under the supposedly enlightened tenure of Director-General Gro Harlem Brundtland, both of being subservient to corporate elites and “of censorship when criticism was made of the pharmaceutical industry.” He also damns the Bush administration’s sordid crusade to defend Big Pharma’s monopoly over drugs treating chronic conditions. “Once again,” he wrote after a 2002 U.S. veto of Third World efforts to obtain cheaper generic pharmaceuticals, “access to vital drugs to treat health emergencies among those living in poverty will be restricted solely to protect profit. And WHO has nothing to say on this issue.” Many of the most effective artemisinin-based antimalarial drugs, for example, are priced out of reach of the poor people whose infants and small children die in such shocking numbers every year in sub-Saharan Africa.291
Many Third World governments, meanwhile, are disinclined to spend much on public health when the alternative is feeding their generals’ bottomless appetites for new weapons. Delhi, for instance, spends 16 percent of its budget on defense, but only 2 percent ($4 per capita per annum) on health.292 Other poor countries are too shackled by structural adjustment and debt to have any choice. “Kenya,” Alex de Waal complains, “finds itself unable to offer jobs to several thousand unemployed nurses because of a cap on public-sector employment, while Zambia is in the extraordinary position of being required to lay off health-sector employees, even while many districts have no health professionals at all.”293 In sub-Saharan Africa, where 100,000 trained medical workers were lost during the 1990s to AIDS or emigration, it is estimated that the region desperately needs at least 1 million more personnel, especially nurses and assistants, to ensure even the most rudimentary public-health coverage to the entire population.294
In the face of the peril of avian influenza, as with HIV/AIDS earlier, world public health resources are organized rather like the lifeboats were on the Titanic: many of the first-class passengers and even some of the crew will drown because of the company’s skinflint lack of foresight; the poor Paddies in steerage, however, do not even have a single lifeboat between them, and thus, they are all doomed to swim in the icy waters. In September 2004, with H5N1 resuming its murderous course in Vietnam, local authorities and the WHO were desperate to vaccinate exposed populations to prevent a possible reassortment of avian and human influenzas. But as WHO influenza chief Klaus Stohr bitterly complained to the New Scientist, “There is no excess. There is no vaccine available for Vietnam.” Thailand, although much wealthier than Vietnam, faced the same problem. “We do not have sufficient vaccine to prevent co-circulation,” complained Prasert Thongcharoen, a prominent representative to the WHO. What little surplus was available in Europe and Canada had been bought up by New York City and other local U.S. health authorities in the wake of the Chiron fiasco.295
Only twelve drug companies make influenza vaccines, and fully 95 percent of their output (about 260 million doses) is consumed in the world’s wealthiest countries. Current production is limited by the supply of fertile eggs, and even a switch to cell culture—as all experts advocate—would face the problem that “there are surprisingly few suitable accredited cell lines and cell banks available, and many of those are the property of pharmaceutical companies.”296 Despite the WHO’s urgent Geneva summit in October to lobby governments to finance (and drug companies to produce) a so-called “world vaccine,” little progress has been made. “Of the world’s major flu vaccine manufacturers,” Science reported during the summit, “so far only two are willing to tackle the financial, regulatory and patent issues involved in making a new pandemic vaccine, mainly for the U.S. market.”297 Previous test vaccines, as we have seen, failed to keep pace with the evolving virulence of H5N1, and even if current clinical trials are successful, Washington has ordered only 2 million doses from Aventis-Pasteur. With the exception of Canada (which has contracted with a Quebec-based firm to gear up production for 6 million doses per month), most wealthy countries are buying just a few “lifeboats” now in the dubious belief that they will have time to order more when the crisis arrives. (A recent Johns Hopkins study shows that, unlike the 1968 pandemic, which took a year to circle the world, air travel would now spread a pandemic much faster than pharmaceutical factories could be geared up to produce vaccine.)298
With so little investment in expanded manufacturing capacity, the WHO came up with a desperate scheme to stretch the vaccine supply by adding a cheap adjuvant like alum. (Unfortunately, some researchers believe that even with adjuvants, two doses may be needed to make an H5N1 vaccine effective, a possibility that would double the problem.)299 Stohr urged EU leaders to take the initiative in testing a low-dose pandemic H5N1 vaccine containing an adjuvant. While he argued that this was the only possible way to ensure that some vaccine would be available to the Third World, Europe could not find the money. “The EU,” Stohr caustically observed, “has not the flexibility or the political will.”300 Nature echoed Stohr in rebuking the EU for failing to support pandemic planning and accelerated vaccine development.301
Without vaccines, as we have seen, there will be a mad global scramble over Tamiflu: according to Science “the world’s only initial defense against a pandemic that could kill millions.”302 Back in 1999, René Snacken, the chair of the European Scientific Working Group on Influenza, warned that “waiting until a pandemic strikes to determine access to prophylactic materials inevitably contributes to inequities in supply for countries to produce antiviral agents or vaccines or lacking resources to competitively purchase supplies at a time of scarcity.”303 The WHO, of course, has stressed the “need for international solidarity”; arguing that the only way to contain an initial pandemic outbreak will be to douse it with powerful antivirals. It has urged the pooling of Tamiflu for use in Southeast Asia. “But whether countries will voluntarily ship their own precious stockpiles overseas to fight a faraway plague remains to be seen.”304 Even if some antivirals are made available, there is little guarantee they will actually reach people in the hot spots. In 2004, for example, all the foreign donations of Tamiflu to Vietnam were confiscated by its army, which refused to share even with veterinarians working directly with infected flocks.305
But this appalling lack of vaccine and antivirals is not the only problem faced by the global “steerage class.” The death tolls during the 1957 and 1968 pandemics were dramatically reduced by the widespread availability of new, effective antibiotics to treat secondary bacterial pneumonias—but the major bacterial pathogens, including the pneumococci and H. influenzae, have evolved resistance to penicillins erythromycin and other antibiotics usually employed in hospitals. Such a cycle of resistance is the inevitable result of natural selection, and the only solution is the constant development of new antimicrobial therapies, but the pharmaceutical industry has largely abandoned antibiotic research (although it sells huge quantities of antibiotics to the livestock industry and thus contributes to the accelerated obsolescence of the current generation of antibiotics). In the event of a pandemic, there is a great risk that mortality from bacterial pneumonia, especially in poor countries with limited supplies of older antibiotics, might return to pre–World War II levels. In July 2004 the Infectious Diseases Society of America issued a major white paper on the antibiotic crisis whose succinct punch line was “Bad bugs, no drugs.”306
How would almost defenseless Third World cities respond to a pandemic? The precedent that scares many public-health experts was the September 1994 outbreak of pneumonic plague in Surat, India’s twelfth largest city. Laurie Garrett and, at greater length, Ghanshyam Shah have both discussed the Surat experience “as a warning of epidemics to come.” A city of textile and diamond-cutting sweatshops and slums with one toilet for every 150 people, Surat epitomized the polarized condition of urban health care in most of the Third World: a small modern sector existed for the affluent, and a wretched mixture of inadequate public medicine and sheer quacksterism sufficed for the rest of the population.
Shah describes a “public health system [that] has not only gone downhill in its delivery system but also lost credibility. Even the poor do not trust it.” Although Surat had no shortage of doctors, most of them were in private practice, “motivated by a quick profit. Ethical values among medical professionals are disappearing very fast.”307 As patients began to present plague symptoms, the doctors were the first to flee the plague. “They were totally unprepared for what followed. The private doctors panicked. Eighty percent of them fled the city, closing their clinics and hospitals and abandoning their patients. The fear in those physicians’ eyes did not go unnoticed by the populace, and rumors of a great impending disaster spread swiftly among the largely illiterate masses. Surat’s middle class discreetly packed their bags and slipped out of town.”308
Within days, wild rumors had overrun India, antibiotic stocks had been depleted, and Delhi had been forced to send the elite Army Rapid Action Force to quarantine Surat’s slum dwellers from fleeing in the footsteps of the middle classes. The outside world, meanwhile, began to quarantine India, screening Indian jets or banning flights altogether; the Gulf states even stopped postal communications with the subcontinent. “WHO,” Garrett writes, “did little to slow the [international] stampede toward hysteria or to stifle the opportunistic shouts of boycott.” India appealed for international assistance, but few countries had inventories of plague vaccine, and new production would take six months.309
Fortunately the plague was contained in a week: “For many . . . a miracle,” writes Shah. Experts debate whether the massive application of antibiotics (tetracycline and chloramphenicol) was decisive or whether the plague bacterium simply became less virulent through evolutionary modification. Nonetheless, the immediate explosion of panic, the desertion of private doctors, the hoarding of antibiotics, the absolute lack of confidence in government, the use of force to quarantine the poor, the silence of WHO Director-General Dr. Hiroshi Nakajima, and the hysterical stigmatization of India by its other countries—all confirmed experts’ worse fears about the vicious circle of epidemic disease, slum poverty, and neoliberal politics.310 An influenza pandemic would magnify the Surat experience perhaps a hundredfold.
The WHO is most worried about Africa. “Without a doubt, the virus will get there,” Klaus Stohr told Science in October 2004. “The situation will be much, much worse than anywhere else. Access to vaccines will not be an option, let alone antivirals.”311 The 27 million or more Africans who are HIV positive, of course, would be the human bull’s-eye of a H5N1 pandemic. “People with HIV/AIDS,” says a CDC fact sheet, “are considered at increased risk from serious influenza-related complications. Studies have shown an increased risk for heart-and lung-related hospitalizations in people infected with HIV during influenza season . . . and a higher risk of influenza-related death.”312 AIDS, in other words, might become influenza’s deadly dancing partner like malnutrition in India or malaria in Iran in 1918; as a result, the potential death toll could be a full order of magnitude higher than the estimated 2 million Africans killed by the 1918 pandemic. Yet, apart from some public notice taken in South Africa, the continent is wholly unprepared to address a pandemic; many countries do not even return influenza questionnaires to the WHO. (In many cases, public-health systems have simply collapsed under the relentless weight of AIDS and civil war.) World indifference towards the AIDS holocaust in Africa, moreover, provides a lamentable template for current global inaction in the face of the avian influenza threat.