Black Death: The Coming Influenza Pandemic

I've been meaning to write something on the swine flu scare, but the news cycle's been WAY busy with other stories, and that's not to mention (threats to) my day job.

In any case, the kids' doctor's office called the other to notify us that our swine flu shots had come in. We asked about this a couple of months back, when folks were in a panic about getting vaccinations, and shots weren't available. Both my boys received nasal vaccinations for the flu, but now that the doctor's called, my wife and I are thinking twice. It's always seemed like a bit of government hysteria to me, especially with this administration. Besides, it's almost Christmas now, and the urgency has been winding down.

So, despite reports of overreaction to the threat, federal officials are calling for universal vaccinations "to prevent another wave of illnesses after the holidays." See the Wall Street Journal, "U.S. Health Officials Urge H1N1 Shots for All Groups."

I wrote previously, "Swine Flu Hysteria: Perfect Timing for Democrats' National Health Emergency."

But folks should really spend a some time with Robin Cook's spectacular essay at Foreign Policy, "Plague: A New Thriller of the Coming Pandemic." Here's an excerpt:

BeforeI reveal the infectious agent of this putative coming plague, I would like to refer the reader to my 17th book, Contagion, published in 1995. A cautionary tale about the hazards of bioterrorism, the story involves a microbiology technician who is bent on starting an epidemic but who has to learn on the job, so to speak, about the critical importance of both virulence and transmissibility. He starts with Y. pestis, but his intended plague quickly fizzles with only a few victims because the necessary perpetrators of the scourge, rats and their disease-transmitting fleas, are not available. Undeterred, he finally comes to recognize that for a really scary epidemic to occur, it needs three things: the availability of a self-sustaining reservoir (usually an animal as an asymptomatic carrier), easy human-to-human transmissibility, and impressive virulence. By the end of the book he finds his agent: the influenza A subspecies H1N1 that caused the 1918-1919 Spanish flu, which he obtains from digging up in Alaska the frozen corpse of a victim of that dreadful pandemic.

Influenza A is perfect not only for my villain in Contagion but also as the infectious agent in Plague. It has a normal reservoir in the guts of birds, spreads via aerosols (the easiest and most efficient method of disease transmission), and can be amazingly virulent. By some estimates, as many people died from the Spanish flu as from the Black Death. Contemporary anecdotes of the Spanish flu describe asymptomatic people boarding the subway in Brooklyn and being dead by Manhattan. Such a death is hardly the torture of bubonic plague, but singularly impressive for its rapidity nonetheless. With today's medical knowledge, such an event would be explained as a "cytokine storm," in which the stricken individual's immune system reacts against the invading virus with such ferocity and such inflammation in the victim's lungs that death results from drowning in one's own secretions..

I personally developed great respect for influenza as a 17-year-old when I contracted the avian H2N2 subspecies during the 1957 Asian flu pandemic -- along with most everyone else at my high school. I suffered through an unpleasant illness that forever gave me a keen appreciation of the benign-sounding term "general malaise." My respect for influenza was further reinforced by the 1968 Hong Kong flu pandemic, caused by H3N2. At the time, I was a surgical resident, confronting seriously ill patients in the intensive care unit struggling to breathe. So when a new and highly virulent subspecies of influenza, designated avian H5N1 flu, appeared in Southeast Asia in 2006 and quickly began to spread globally, I felt compelled to do something for myself and my family. Despite this new subspecies's low human-to-human transmissibility, I stocked my isolated ski cottage with Tamiflu, antibiotics, ibuprofen, and N95 face masks. In the back of my mind was Isaac Newton's flight to the countryside from plague-infested London in 1665.

All this begs the question: Could an influenza pandemic as bad as the one that struck in 1918 occur again? In our current state of world complacency and unpreparedness, I'd have to say absolutely yes, which is why my supplies are still in my ski cottage.

In fact, such an outbreak could be worse than the Spanish flu, even with the antiviral drugs we now have, the antibiotics that are today available for secondary infections, and the modern equipment in our intensive care units. For though medical science has learned a lot about viruses in general and influenza in particular since the World War I era, there is a long way to go. What we do know is that viruses are highly evolutionarily developed, quintessential parasites. To reproduce, they end up stealthily slipping inside and then hijacking the biomolecular machinery of other life forms, such as bacteria or mammalian cells, as they don't have this machinery themselves. The problem, of course, is that the invaded entity is often killed in the process; for us humans, an attack from the influenza virus means that the cells lining our respiratory tract begin to die, as it is these cells that are selectively chosen. The flu is primarily a respiratory disease.

The fact that viruses such as influenza do their dirty work within cells is what makes treating them so much more difficult than treating bacterial diseases such as bubonic plague, which, in contrast, does most of its dirty work outside cells. In some respects the situation is akin to the difficulties of dealing with cancer in that killing infected cells can put normal cells in jeopardy, too. Modern medicine does have some antivirals in its armamentarium, but the highly evolved, wily viruses are quick to mount resistance. What it comes down to is that the best way to deal with influenza is to prevent it.

Don't miss the whole thing.