The hyperbolic response to the recent bout with swine flu reveals how much our antiquated public health policy motivates fear. Neither the number of deaths attributed to the H1N1 virus nor the geographic distribution of cases makes this a worrisome epidemic. But with flu policy guided by a horror vision of a return of the “Spanish flu,” which caused tens of millions of deaths worldwide in 1918, even the present mild outbreak looks like a fearsome challenge.
Despite a wealth of knowledge not available in 1918, we still deal with each new outbreak of flu as if the virus were an invading army and the US population its target. We meet each year’s flu with immunization, “stockpiles” of Tamiflu and a command and control center at the CDC. A few programs normally held in reserve, like school closings and airport screenings, are brought up to the front lines when we’re feeling particularly menaced. Each year, we win a Pyrrhic victory–there are piles of casualties on our side, but the enemy deserts the field. Then, when flu returns the following year, we do the same thing all over again.
The traditional armamentarium works against flu only in the limited sense of reducing casualties in developed countries. It doesn’t work if we recognize that our policy of arming ourselves against communicable diseases allows us to ignore them when they devastate the world’s poor. It doesn’t work if we consider the costs to poor farmers’ economic welfare and physical health when flocks or herds are slaughtered to protect rich-country livestock from flu. And it fails utterly if we count the long-term costs of letting flu viruses infest herds and flocks, recombine and start the cycle again.
In order to break out of this cycle and invigorate a broader approach to public health, we must dispense with the naïve notion that fighting flu is an annual battle and begin to think in terms of management. Whether we want to change this situation because it threatens us or out of a deeper sense of obligation to the world’s welfare, we have to regard flu as a resident of an ecosystem humans share with animals. We have to equip ourselves to understand not only how flu crosses species barriers but how the many interactions in a complex system of agriculture, climate, land use, food production, commerce and human behavior influence the development of new flu strains.
Flu viruses drift in a wide web of connections among their many hosts: humans, swine, birds and some wild animals (waterfowl, ferrets, feral cats and others). The links in the web are sometimes intimate and direct–farmers breathe the same air as their pigs, for instance. Often, though, viral connections are mediated by subtle forces in the environment: shifts in climate alter species balances and bring once-separated animal populations into contact; the endless competition between strains of microbes (bacteria, notably) affects the health of animals and humans, and that microscopic struggle responds to minuscule changes in social ties within or between species.
The dimensions and connectivity of this wide web are further affected by economic and political factors that normally receive short shrift in discussions of (and research on) human disease. Wealth disparities can force poor farmers to raise more stock on less land. When farmers live close to the animals they raise and slaughter, microbial dynamics shift and create opportunities for viral movement. When the poor are displaced altogether, a globally mobilized proletariat offers a vehicle for the spread of contagion far more worrisome than flu-infected travelers on airplanes.
We monitor our industrialized food production facilities in the hopes that it will protect us from flu and other pathogens at home. But we can no longer imagine that there is any clear distinction between “home” and “away.” Indeed, we’re learning that the worldwide reach of the food industry enables the transmission of viruses, flu in particular. When transport routes are farther flung and more people and goods traffic between rural habitats and cities, human populations become less isolated. The SARS outbreak reminded us that the most modern parts of our most modern cities are no longer very far away from wild-animal markets in rural villages–and thus to the diseases the animals in those markets carry.
But the outbreak of swine flu is not a near-miss doomsday scenario. We should not succumb to anxieties about modern life that make us think that our attempts to control nature have invited catastrophe. It is not the imaginary danger of infectious apocalypse that should drive us to change; it’s the futility and shortsightedness of merely defending America against “pandemics.” We do not need to go back to subsistence farming to protect ourselves from the next outbreak of disease. But we must rethink our outmoded assumptions about public health.
Paradoxically, to make a great gain against flu, we have to stop battling it and start managing it. We are already making the metaphoric shift from threat defense to multifaceted management with regard to the environment. To do the same with disease will require international conventions that protect the interests of farmers, particularly in poor countries; tougher regulation of land use, water access and food production and distribution; and consideration of virus management in the development of trade and environmental policies. Pharmaceutical companies and agribusiness shouldn’t set hygienic and trade standards; we’ll need to find a more positive role for governments in regulation. We might stop depending on Tamiflu as a weapon, although we aren’t going to stop needing doctors and nurses–the medical and veterinary professions should help craft a more comprehensive approach to the environment, agriculture and health.
President Obama took a step in the right direction on May 5 when he announced a $63 billion commitment to international health. “The world is interconnected, and that demands an integrated approach to global health,” he said. The strategy, in part a response to the swine flu scare, will fund efforts to deal with AIDS, malaria and TB and add financing for maternal and child health and other programs. The details remain to be seen, though, especially in regard to how flu will be handled. Turning the global plan into real programs will mean knitting together the complex strands of economics, agriculture and health.
If the new global health plan means that pragmatism and internationalism will enter the public health arena worldwide, this is the time to jump from the defense-minded dogma of twentieth-century public health to a twenty-first-century conceptualization. In order to stop the hysteria about flu and limit its many costs, we have to manage the natural web within which it lives, not just skirmish with it.