H5N1

How climate change has plagued the health of nations for centuries

The Tyee has published my review of Anthony J. McMichael's important book Climate Change and the Health of Nations: How Climate Change Has Plagued the Health of Nations for Centuries. Excerpt:

The past 10 thousand years should have taught us two things: When climate changes, people move, and when states can’t feed their people, they fall. As McMichael describes it, too little rain, or too much, leads to malnutrition and famine. Malnourished peoples succumb to new epidemics, or rise up against their rulers, or invade their neighbours. 

As the Sahara dried eight thousand years ago, farmers and pastoralists migrated to the Nile Valley and founded Egypt. Twelve hundred years before Christ, a prosperous Bronze Age Mediterranean civilization collapsed into wars and anarchy as climate refugees tried to find land and water.  

The “barbarians” didn’t invade Rome just for the hell of it. They were technologically about as advanced as the Romans, but climate change drove them across Rome’s frontiers against their will — often pursued by still more climate refugees. 

Rome, of course, tried to keep them out, or to recruit them into its legions. But climate change also enabled the “plague of Justinian” to kill millions of Romans in the first European incursion of bubonic plague. The empire just didn’t have the bureaucrats and farmers and soldiers left to stop unwanted immigrants.  

Volcanoes + fleas = pandemic 

Even when a major state like Rome seems to have established a strong society, climate can undo it all. The plague of Justinian, McMichael suggests, was thanks to a volcanic eruption in New Guinea that cooled the planet and enabled infected fleas to survive on the rats in grain shipments from Ethiopia to the Mediterranean. Similarly, climate enabled rats to stow away on caravans in central Asia, spreading bubonic plague to both Europe and China.

After this epic tour of human history, McMichael makes it easy to see how climate change continues to affect modern societies. He argues that we are less susceptible to climate change — but not immune. Even heat waves, as they grow longer and hotter, can kill thousands in days. Over 70,000 died in the 2003 European heat wave, and 55,000 in Russia in 2010. 

Moreover, we’re not as robust and resilient as our ancestors were: we eat ourselves into obesity, we suffer high blood pressure, we don’t exercise enough, and many of us live with chronic stress. Not only do these put us at risk in the next heat wave or pandemic, but our infrastructure can break down: electricity can fail, reservoirs and snowpacks can dry out, bridges and highways can wash out, and farmland is degraded.

McMichael argues, “Societies with coherent and stable structure, mutual trust, shared and well-applied knowledge, efficient information dissemination, good government, and community-level capacities are better placed to cope with climatic threats or crises.”

A war we should all support — but probably won’t

The Tyee has published my review of Deadliest Enemy: Our War Against Killer Germs, by Dr. Michael T. Osterholm and Mark Olshaker: A War We Should All Support — But Probably Won’t. Excerpt:

The people who work in global health tend to think of it as a war, and I understand why. On a visit to the European Centre for Disease Control and Prevention in Stockholm, I talked to doctors who referred to “the pandemic” of swine flu in 2009 just as veterans refer to “the war” — whatever war they’d fought in.  

So I can understand why Dr. Michael Osterholm believes that we’re all in a war, against a literally existential threat: viruses and bacteria that do not negotiate. With his co-author Mark Olshaker, he gives us a briefing on the chief theatres of conflict across the whole planet. 

Osterholm has earned his nickname “Bad News Mike.” In 1980 he was among the researchers studying fatal toxic shock syndrome in young women — which was found to be triggered by a particular kind of tampon that actually fed the growth of Staphyloccocus aureus bacteria in the vagina. Before that was fully understood, politics and corporate money complicated the research.  

He was also involved in trying to understand HIV/AIDS in the 1980s, even before it had a name. Ever since, he’s been engaged in the fight against infectious diseases and other health threats. As the director of CIDRAP, the Center for Infectious Disease Research and Policy at the University of Minnesota, Osterholm is a key authority on global health. If he says it’s bad news, it’s really bad news.

In ‘The Politics of Fear,’ Mèdecins Sans Frontiéres reflects on response to Ebola crisis

The Tyee has published my review: In ‘The Politics of Fear,’ Mèdecins Sans Frontiéres Reflects on Response to Ebola Crisis. Excerpt:

This book should be a required text in every school of public health in the world, and in the training program of every health-related nongovernmental organization. Health bureaucrats and journalists should have it on their phones and tablets, where they can consult it when new outbreaks occur.  

That’s because it throws a new kind of light on a serious disease outbreak — and especially on how we respond to such outbreaks. Here, the real story is the failure of the global health community to understand its own considerable role in the spread of Ebola and other diseases.  

After any bad outbreak, governments and nongovernmental agencies usually do private post-mortems and then issue bland “lessons learned” reports that may or may not be applied in the next outbreak. This post-mortem by Médecins Sans Frontières is neither private nor bland. It is a tough look at itself, involving both its own people who fought Ebola in West Africa and outsiders given access to MSF internal documents about the outbreak. 

Then, rather than keep the findings in-house, MSF brought out this book. Of its many lessons, one stands out: health workers’ culture and politics are as much a part of an outbreak as those of the people they help, and fear drives both culture and politics.

A heads-up on The Politics of Fear: Médecins sans Frontières and the West African Ebola Epidemic

A couple of days ago I learned that MSF had just published a book on the Ebola outbreak and its own response to that outbreak. I downloaded the book and I'm just a couple of chapters into it. Look for my review in The Tyee in a week or two.

But don't wait for my review. If you live in the US, here's the Amazon.com link: The Politics of Fear: Médecins sans Frontières and the West African Ebola Epidemic. If you work in public health, or you're just an interested bystander like me, you need to read this book.

 

It's not a puff piece on how MSF rode to the rescue; it's a savage criticism of MSF, by both its own people and outsiders given access to MSF's archives. But it has plenty of blame to go around, not just to WHO and the governments involved, but to us as well. We looked down on the West Africans for their culture-driven response to Ebola, but our own response was equally culture-driven. 

 

I have my complaints about the book, especially about the jargon clogging its early chapters, but they don't matter. Buy the book, plow through the jargon (and the horror), and consider how we might not just respond to the next outbreak, but prevent it from even happening.

MSF publishes book on Ebola outbreak

Via MSF.org: The Politics of Fear. Excerpt:

In a new book released this week, Médecins Sans Frontières (MSF) argues that the response to the West African Ebola epidemic of 2014–2015 was led by fear rather than medical priorities. The Politics of Fear highlights how patients and their care were not sufficiently prioritised, as security and containment not solidarity became the biggest prerogative of governments and organisations supporting the response.  

While misinformation, panic and isolation featured heavily in the initial Ebola response, it is unclear how the epidemics of tomorrow will be better addressed.  

Written by both MSF and non-MSF authors, the book collects critical and comprehensive impressions of the outbreak's rapid appearance, uncontrollable spread and the challenges faced by the global health community in its response.  

It provides an intimate account, told through various disciplinary lenses (political science, anthropology, clinical medicine, bioethics and history), of one of the most devastating health emergencies in recent times. Complex issues such as controlling fear, ethical questions on quarantine, experimental drugs and the tension between quality and quantity of care colour a thorough and thought-provoking account of a dark chapter in history.    

In all, 28,646 cases were confirmed during the outbreak alone and 11,308 patients died across Liberia, Sierra Leone and Guinea. With over 59 million euros spent on its response in 2014, MSF oversaw the recovery of 2,329 Ebola patients in its centres across the affected countries.  

The book exposes how countless deaths could have been avoided if the global health community had acted sooner and with greater strength. Ebola exposed the fragility of the global health community – MSF included – that leaves everybody with a share of the blame.  The Politics of Fear is a step towards greater understanding of epidemics of the past in order to better address the outbreaks of tomorrow.

I've just bought and downloaded a copy.

Cholera in Haiti: The CDC on Deadly River

Via Emerging Infectious Diseases: Ahead of Print -Deadly River: Cholera and Cover-Up in Post-Earthquake Haiti. The review concludes:

As long as the reader is aware that there are other, well-supported, points of view from scientists with an equal dedication to control of cholera in Haiti, the book is of value in recording the events of this massive epidemic and the factors that led to its occurrence, from the vantage point of one of the major scientific investigators in Haiti at the time. 

However, the tone of the book and its tendency to see all events (and science) from the viewpoint of a single investigator/investigative group is not ideal and detracts from the impact that the work might otherwise have had. Science does have its controversies and infighting, and intermingling of scientific and political issues is inevitable; however, one might hope that our goal, as scientists, would be to resolve controversies with better science, while minimizing acrimony. 

Unfortunately, this book, with its focus on possible cover-ups and “suspect theories,” does not move us in this direction.

As a supporter of Dr. Piarroux, I find the review somewhat defensive in tone. If the reviewer had made an effort to demolish the idea of "cover-ups," and found serious flaws in Frerichs and Piarroux's rejection of the "cholera paradigm," the review would be more persuasive. My own Tyee review of Deadly River is here.

Peter Piot on two recent Ebola books

Via Nature News & Comment, a long, must-read review by Peter Piot: Public health: Beating Ebola. Excerpt:

Ebola: How a People's Science Helped End an Epidemic, by Paul Richards

Ebola's Message: Public Health and Medicine in the Twenty-First Century, ed. Nicholas G. Evans, Tara C. Smith, and Maia Majumder

The Ebola epidemic in West Africa was an unprecedented health crisis, causing more than 11,000 deaths and destabilizing three countries. It eventually mobilized a coalition of countries from the United States to China, as well as the African and European unions. 

Neither the nations most affected nor the international community were prepared for an epidemic of a highly lethal virus on such a scale. They had to learn on the fly: hands-on experience of Ebola outbreaks and patient care was scant. We now have a much larger body of experts and knowledge, which will be invaluable for preventing and controlling future outbreaks.  

Two very different books on the epidemic have now emerged. Anthropologist Paul Richards' Ebola is an original account of how Sierra Leone in general, and 26 villages there in particular, interpreted the epidemic and wider responses to it, and acted on it at its peak. 

Ebola's Message has a broad interdisciplinary focus on West Africa's outbreak. Covering aspects from media response to bioethics, it is edited by philosopher Nicholas Evans, molecular epidemiologist Tara Smith and computational epidemiologist Maimuna Majumder.  

Ebola's focus on the comparatively poorly documented role of local responses to the epidemic makes it a must-read for all involved in epidemics, epidemiology and public health. It is an important counterweight to analyses by international panels, including one convened by the London School of Hygiene and Tropical Medicine and the Harvard Global Health Initiative, which I chaired. These have focused on institutional aspects and global governance. As the ongoing outbreaks of Zika in the Americas and yellow fever in central Africa show, concerted action — local as well as global — is crucial. 

Richards wisely nods to the key role of national and international epidemic control. But his central thesis is that rapid local adaptation and common sense led to the Ebola epidemic's downturn. He terms this community action a “people's science” of Ebola control. The book abounds with real-life examples from his long-term research in Sierra Leone.  

Richards bases his analysis of how villagers coped on two concepts. Sociologist Émile Durkheim's social-paradigm theory posits that belief is shaped by social action — in this case, collective emergency response. Durkheim held that it is not enough to “pump knowledge into the heads of affected populations” to prompt behaviour change. (That classic public-health approach has failed repeatedly, from HIV prevention to overcoming immunization refusal and controlling obesity.) The second concept is sociologist Marcel Mauss's “techniques of the body” — the idea that our physical actions, such as hygiene practices, are culturally determined. 

Burials during the epidemic revealed how these theories played out. Funerals carry great meaning in West Africa: they are moments for honouring the dead, remembering that life is finite or resolving disputes. They also involve rituals such as washing the deceased — one of Mauss's techniques of the body. Locals unaware of the risks from infected corpses unwittingly helped to spread the disease. 

As Richards notes, such circumstances require urgent community dialogue at the start of an outbreak to find a way to control the risk but retain social meaning; training in safe burial techniques is also needed. But he also found that, as in Durkheim's theory, some villagers formed their own evidence-based appraisals of the risks of infection, and demanded to be trained in safe procedures. That approach became a model for rapid action within complex community structures and traditions.

Garrett reviews Zika: The Emerging Epidemic

I missed Laurie Garrett's July 28 New York Times review, but here it is: Review: ‘Zika’ Tracks the Trajectory of an Epidemic. Excerpt:

If a publisher had come to me four months ago and asked me to write a book about the Zika crisis in just 30 days, I’m not sure I would have had the courage to say yes, as Donald G. McNeil Jr. did. So many assumptions written in March or April could prove wrong by June or August that the challenge of quickly producing a book on Zika would seem too risky — given that there will also be sleep deprivation, speed writing, high-velocity editing and rewrite ahead.  

And so it is with considerable amazement that I find much to applaud in Mr. McNeil’s “Zika: The Emerging Epidemic.” Though slim, with just 174 pages of text and an 11-page question-and-answer section, “Zika” is dense with information. How Mr. McNeil, a science and health reporter for The New York Times, managed to accomplish this so fast I cannot fathom.

The best book yet on cholera in Haiti

The Tyee has published my review of Dr. Ralph R. Frerichs's great book Deadly River: Cholera and Cover-Up in Post-Earthquake Haiti: Cholera in Haiti: A True-Crime Medical Thriller. Frerichs tells the remarkable story of how Dr. Renaud Piarroux found the evidence of the UN's importation of the disease. Excerpt:

As of mid-May 2016, cholera has sickened over 780,000 Haitians while killing over 9,000 of them. According to PAHO, between Jan. 1 and April 30 of 2016, 13,859 have fallen ill with cholera and 150 have died -- more than the same periods in 2014 and 2015.  

Early in the outbreak, Piarroux was contacted by Dr. Ralph R. Frerichs, professor emeritus of epidemiology at UCLA. Frerichs was also alarmed at the official response to Haiti's cholera. Their online communications grew into face-to-face contact, and eventually into a years-long debriefing in which Piarroux detailed his experiences in Haiti. That in turn led to this book, the best yet written on Haiti's cholera. It is also a medical thriller, a crash course in basic epidemiology and a primer on the politics of global health. 

Frerichs writes brilliantly, letting facts and events speak for themselves. The result is a damning indictment of the national and international health agencies -- and the cynical governments that rule them. 

The coverup organized by the CDC, the World Health Organization and other UN agencies was a violation of medical ethics on an international scale. They sacrificed Haiti simply to escape political embarrassment.  

In fairness, though, none of the great health agencies is a free agent. As science writer Sonia Shah recently noted, "private interests have commandeered the public-health agenda." WHO has been on an ever-dwindling budget for decades. CDC isn't allowed to do research into firearm deaths as a public health issue. Both rely on "donations" from corporate benefactors, not solely on public tax dollars. And the benefactors too often dictate the agenda.  

So we get as much public health as our political and corporate masters find convenient. In the case of Haiti, that is very little public health indeed.

I've added Deadly River to the Books on Infectious Diseases list, in the middle column, with a link to Amazon.com.

Sonia Shah's Pandemic gets a great review

Via The New York Review of Books, Dr. Annie Sparrow reviews Sonia Shah's Pandemic: Tracking Contagions from Cholera to Ebola and Beyond: The Awful Diseases on the Way by Annie Sparrow. It's a wonderful review by a knowledgeable writer. Excerpt:

Shah’s thesis is that pandemics are the product of complex human behavior. In her view, development, urbanization, and population growth transform harmless animal microbes into human pathogens. Empire-building takes humans into animal habitats, while climate change caused by human activity and deforestation forces animals into urban areas; industrial poultry, cattle, and pig farms also bring humans into greater contact with animals. 

The “cholera paradigm” is a term coined by the microbiologist Rita Colwell. It means that the environment—biological, social, political, and economic—is both the source and driver of today’s emerging diseases in ways resembling the spread of cholera.

And as long as we're on the subject, here's my Tyee review of the book—equally positive, but not as well informed as Dr. Sparrow's.