Table of Contents:

Foreword

Introduction

I. Storm Gathering

1. 1918

2. Master of Metamorphosis

3. H5N1

4. Playing Chicken

5. Worse Than 1918?

6. When, Not If

II. When Animal Viruses Attack

1. The Third Age

2. Man Made

3. Livestock Revolution

4. Tracing the Flight Path

5. One Flu Over the Chicken's Nest

6. Coming Home to Roost

7. Guarding the Henhouse

III. Pandemic Preparedness

1. Cooping Up Bird Flu

2. Race Against Time

3. Tamiflu

IV. Surviving the Pandemic

1. Don't Wing It

2. Our Health in Our Hands

3. Be Prepared

V. Preventing Future Pandemics

1. Tinderbox

2. Reining in the Pale Horse

Topics

References 1-3,199

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—Frederick C. Tilney, on the 1916 polio epidemic in New York2801

It may be too late to soften the disease impact of the pandemic, but it is not too late to prepare. “We need to take steps so that people who are spared by the pandemic influenza virus aren’t done in by starvation, cold, chronic diseases, or contaminated water,” writes one prominent risk management specialist.2802 “We don’t want people who are spared by the virus done in by riots either.”

Civil society is expected to disintegrate, triggering violent social disturbances as populations attempt to flee contaminated areas or engage in mass looting.2803 After Katrina hit, it took only 48 hours for 20% of New Orleans’ police force to disappear and drug addicts in withdrawal to claim the streets with gunfire.2804 FEMA director Brown said his agency was forced to work “under conditions of urban warfare.”2805 And that’s only one city in crisis.

Experts fear that civil unrest could be a tipping point for instability in a number of governments around the world “as their economies implode.”2806 There is a concern that even early on in unaffected countries, panic and chaos could erupt as the world media reports the daily advance of the pandemic.2807 One CDC economist was asked to predict the social fallout. That was outside his realm, he replied, “Go ask the fiction writers what could happen.”2808

Nature commissioned its senior reporter in Paris to write a fictional yet realistic account of how an influenza pandemic could be expected to unfold. It can be read in full at tinyurl.com/h5ylq. It is fiction, but not fantasy.

In 1918, orderly life in America began to collapse. Families stopped taking care of each other. In its 1919 An Account of the Influenza Epidemic, the Red Cross reported that “people [were] starving to death not from lack of food but because the well were panic stricken and would not go near the sick.”2809 Social services begged neighbors to take in children whose parents lay dying or dead. A historian reported, “The response was almost nil.”2810 Victor Vaughn, Surgeon General of the U.S. Army, described as “a careful man, a measured man, a man who did not overstate to make a point,” warned, “Civilization could have disappeared within a few more weeks.”2811

In 1918, the social order broke down. The chief diagnostician in the New York City Health department summarized the impact of the pandemic on the mental state of its victims: “Intense and protracted prostration led to hysteria, melancholia, and insanity with suicidal intent.”2812 Violence broke out. In San Francisco, a Health Department inspector shot a man for refusing to wear a mask. In Chicago, a worker shouted, “I’ll cure them my own way!” and then proceeded to cut the throats of his wife and four children.2813

Riots broke out. The War Department, overwhelmed by the pandemic, was unable to assist in controlling the civic disorder at home.2814 All levels of government were severely crippled, affecting public services across the board.2815 Undertakers had to hire private armed guards around their valuable coffins.2816

The official U.S. pandemic preparedness plan predicts much the same scenarios developing today.2817 This doesn’t surprise researchers in the field.
What happens when people in South Side Chicago or Compton or the Bronx see people dying of this, while others get the care they need? What happens if the hospitals which traditionally serve the needs of the inner city begin to run out of beds? Do we think that people will sit pat in the projects and poor neighborhoods of our country and watch as their family and friends, their very communities, die? I don’t see why there wouldn’t be civil unrest.2818
When Chinese villagers realized that information had been withheld by provincial leaders during the SARS outbreak, they rioted against proposed quarantine centers that were being prepared to isolate outsiders. Asked why information had been withheld from the villagers, one bureaucrat told a news correspondent, “They just won’t understand.”2819 Open communication is considered vital to maintaining trust. As former senator Sam Nunn said, playing the U.S. President in Dark Winter, a smallpox bioterrorist exercise,2820 “The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300 million people to take steps they don’t want to take.”2821

This means starting the national debate now. Who’s going to get the antivirals, the vaccine, the hospital bed—the 70-year-old grandparent, the 30-year-old mother of two children, or the children themselves? “People in America are not used to that kind of rationing,” a CDC economist told Science.2822 The chief of clinical bioethics at the U.S. National Institutes of Health recently published a suggestion that proved controversial with those in the medical field.2823 He proposed that children should be given precedence, even if just prioritizing doctors might save more lives, based on what’s been called the “fair innings” principle2824 that “each person should have an opportunity to live through all the stages of life….”2825 The time for this discussion is now, before the pandemic has begun.2826

Social psychologists describe a chilling effect on human nature, values, and motivations visited upon us by plagues throughout history. A chronicler of the Black Death wrote in 1348, “Father abandoned child, wife husband, one brother another…. And no one could be found to bury the dead for money or friendship.” He himself was forced to bury his five children with his own hands.2827 According to a distinguished medical historian, the general attitude can be summed up by a line from Ben Johnson’s The Alchemist in which, during a plague outbreak, one character tells another, “Breathe less, and farther off!”2828

This base human tendency, born of fear and distrust, can fester into a Lord of the Flies social pathology of hate.2829 The bubonic plague led to violent attacks upon minorities such as Jews, especially after one Jew famously “confessed” (under torture) to poisoning wells across Europe.2830 More Jews may have been murdered by their countrymen than by the Black Death.3170 Such attacks led to further spread of the disease as persecuted peoples fled affected areas en masse. Dominant social groups seized the situation to further socially conservative agendas, under the flag of “God’s punishment for sin.”2831

Scapegoating is endemic throughout medical history. Since the early 16th century, for example, syphilis has been called morbus gallicus (the “French pox”) in Italy, le mal de Naples (the “disease of Naples”) in France, the “Polish disease” in Russia, the “Russian disease” in Siberia, the “Portuguese disease” in India, the “Castilian disease” in Portugal, and the “British disease” in Tahiti.2832

In 1918, the rich blamed the poor and the poor blamed the rich for the emergence of the “Spanish Lady”—itself a xenophobic, misogynistic label for the flu. Swedish socialists staged a general strike proclaiming, “Flu Avenges the Workers.” The poor areas of the world did suffer disproportionately, but in some cities such as London, the death rate was “as high in prosperous Chelsea and Westminster as in the slums of Bermondsey and Bethnal Green” for the first time in the history of public health records.2833 As one expert noted, “[I]nfluenza’s very very democratic.”2834

The 1918 pandemic was fodder for racists and anti-Semites. In Baltimore under Jim Crow segregation, the hospitals were closed to blacks at their moment of greatest need. Once the pandemic passed, Baltimore officials then defended the city’s poor public health performance by attributing the city’s elevated mortality rate to its proportion of black residents.2835 The Poles blamed the Jews, whom they called “a particular enemy to order and cleanliness.”2836 As reviewed in the New England Journal of Medicine, this is “sadly neither the first nor the last, of the social scapegoating that is one of the most common, ugly, and unproductive features of epidemics in human society.”2837

Victims of infectious disease are blamed and shunned to this day. During the SARS epidemic, artists of Chinese descent were denied access to a middle school in New Jersey.2838 Some of the employees of the company that fell prey to the first anthrax case were doubly victimized. Family physicians refused to see them, and their kids were turned away from schools.2839

The religious intolerance and victim blame of 1918 was repeated in 2005 following Hurricane Katrina.2840 Founder of the Christian Coalition of America and former presidential candidate Pat Robertson linked both Katrina and terrorist attacks to legalized abortion.2841 The director of the fundamentalist Christian organization Repent America prayed, “May this act of God cause us all to think about what we tolerate in our city limits, and bring us trembling before the throne of Almighty God.”2842 A Christian leader within New Orleans agreed that it was God’s mercy that purged New Orleans. “New Orleans now is abortion free,” he said. “New Orleans now is Mardi Gras free.”2843

1918 brought out the worst in people, but it also brought out the best. “White and colored worked side by side then,” recalls one survivor from Louisiana. “Had we the cooperation between races today that we had during that epidemic it would be a blessing.”2844 The U.S. Homeland Security Council National Strategy for Pandemic Influenza is relying on this goodwill: “Institutions in danger of becoming overwhelmed will rely on the voluntarism and sense of civic and humanitarian duty of ordinary Americans.”2845 A month after the World War I armistice, the German bacteriologist famous for inventing the test for syphilis wrote from Berlin: “For me there are no Germans, no Englishmen—only men who suffer and must be helped.” As the fateful year wound down, a Greek daily summed up the evolving spirit of the times with the line: “Today all nations sneeze as one.”2846