People's Democracy

Wither H1N1 Pandemic?

Amit Sen Gupta

THERE was a palpable sense of relief in the corridors of Nirman Bhawan � seat of the country�s ministry of health � as the new year was being ushered in. For much of 2009, the biggest �story� on health � going by column centimetres that newspapers used up and television bytes on news channels � was the swine flu epidemic. The jury is now almost set to pronounce its verdict � the worst of the H1N1 pandemic is over.

REASON FOR

SELF-ADULATION?

We would, in the coming weeks and months, expect a series of self adulatory reactions from the health ministry regarding how the country managed to stave off the worst effects of the pandemic. We shall not be alone in this exercise � health agencies across the world, led by the WHO, have already started the self congratulatory exercise. By all accounts, in almost all countries, the pandemic has peaked and is set to start declining. Recent government data suggests that the pandemic has affected about 26,000 people in India and has been responsible for less than a 1,000 deaths. Given that surveillance systems in India are notoriously weak, the actual figures could well be significantly � perhaps 3-10 times the official figures. But still, nowhere approaching the 33 per cent of the Indian population (i.e. almost 350,000,000) that Gulam Nabi Azad had predicted, would be affected, in August 2009.   

The picture is similar to what is unfolding in most countries across the world. In mid-2009, the department of health in UK had warned of 65,000 deaths, set up a special advice line and website, suspended normal rules so anti-flu drugs could be given out without prescription and told health and local authorities to prepare for a major pandemic. Planners were told to get morgues ready for the sheer scale of deaths and there were warnings that the Army could be called in to prevent riots as people fought to obtain drugs. But just 251 deaths have been reported in the UK since the beginning of the pandemic alert. Researchers from the UK Medical Research Council and the US government�s Centre for Disease Control (CDC) predict that by the time the winter wave of swine flu infection peters out, it will have been no more severe than an average flu season. Remember that these predictions come at a time when the first mass vaccination programme is yet to start anywhere in the world.

In the United States about 10,000 people are estimated to have died of the infection by mid-November, much less than even the lower end of a forecast of 30,000 to 90,000 deaths made in August by the Barack Obama�s council of advisers on science and technology. Death estimates in the US have to be seen differently from that reported in Europe (and hence are much higher), as they estimate not just deaths directly related to the infection but also excess deaths that would have occurred because of the infection compounding existing illnesses.

So, did a Herculean effort in public health lead to such a dramatic turnabout? Unfortunately, the major reasons for the pandemic not creating the predicted bang lies somewhere else. It is now becoming clear that this is the least lethal modern pandemic of influenza. Present estimates indicate that the H1N1 virus is killing between 1 in 2,000 to 1 in 4,000 people. Contrast this with the Spanish Flu pandemic in 1918 that killed 1 in 40 people who contracted the infection. Even the �less virulent� pandemics of 1957 and 1968 killed about 1 out of every 500 people affected. In other words, the present pandemic is almost 100 times less lethal than the 1918 pandemic. Research now shows that the swine flu is not easily spread from person to person as first thought. Researchers followed more than 200 families and found that the flu only spread to 13 per cent of potential contacts.

Celebrations may still be premature as we are still not sure if the virus will mutate into a more virulent form, but the chances of that happening recede as the pandemic starts entering its second year.

PATHETIC CONDITIONS OF

PUBLIC HEALTH EXPOSED

Are there, then, any lessons to be drawn? The first lesson is of course that we still know very little about how new viruses will behave. The H1N1 virus has proved to be unusually co-operative � its infection rates are low, it rarely affects older populations, it is still susceptible to anti-viral medicines, and it has stubbornly refused to mutate and transform into a more lethal avatar. But precisely because we know so little about why this virus has proved to be so relatively benign, we know next to nothing about when the next truly lethal cousin will strike.

What if the pandemic had been of the predicted scale and virulence, or if the presence one suddenly starts living up to its early �promise�. Are the global and national efforts in the last nine months or so cause for comfort? Unfortunately, the answer would have to be an emphatic no. At the global level efforts have been singularly lacking in purpose and coherence. The US authorities dithered for weeks, while knowing about the outbreak in Mexico, before instituting any measures. There was very little evidence of any co-operative spirit as the rich countries rushed to reserve a lion�s share of available vaccine manufacturing facilities. No global efforts were instituted to rein in drug companies who held patents on oseltamivir (tamiflu), the principal drug found to be effective against the H1N1 virus.

At the national level, response by the government ranged from the comic to the tragic. Pronouncements ranged from sporadic show of bravado to pessimistic hand wringing in the face of an impending catastrophe (that mercifully did not unfold). Just one statistic should suffice to show how ill-prepared we really were. If Azad�s initial projection of 350,000,000 cases were to be taken at face value, and the initial estimates of 1 per cent of them requiring hospitalisation are factored in, we would have needed to hospitalise 3,500,000 swine flu cases over a period of six months. Calculating that each would have needed about a week�s stay in hospital, it would have meant that an excess of 1,00,000 people would have needed to be hospitalised at any given point of time. Not just hospitalised, they would have to have had access to modern facilities, including facilities to be put on a ventilator. Contrast this with a few hundred beds that have been kept aside to treat swine flu patients, and the gross mismatch between demand and supply would become clear.

The issue that we need to understand is that you cannot plan for a response to an epidemic, after it has been set in motion. Epidemics can be tackled only if public health facilities exist when a pandemic hits a population. The pandemic that almost never was, has shown up the utter lack of public facilities for health care in the country. If it had caused the destruction that was earlier predicted, we would perhaps had had no other option but to hide our heads, ostrich like in the sand, waiting for it to pass.

WAS THE PANDEMIC ALERT

DELIBERATELY ENGINEERED?

As evidence about the �failed� pandemic starts mounting globally, there is now concern being expressed that the World Health Organisation was too hasty in announcing that the globe was actually in the midst of a new influenza pandemic. Pandemic, by definition, is a global epidemic that affects a significant number of people and the infection is sustained in local communities. Dr Margaret Chan, Director-General of the World Health Organisation (WHO), gave a statement on 11 June 2009 confirming that the H1N1 strain was indeed a pandemic. There are some who have started expressing the possibility that the false alarm and scare mongering about the pandemic was deliberately engineered.

A major salvo, that recently captured headlines across the world, was fired by Wolfgang Wodarg, the chair of the health committee in the European Council. The German parliamentarian is also an epidemiologist and former health director in Flensburg. Wodarg commented recently that: �we have had a mild flu � and a false pandemic�. Wodarg accuses the WHO of succumbing to pressures by the pharmaceutical industry by announcing a global pandemic in June, 2009. On the basis of these accusations an emergency debate in the European Council, about the influence of the pharmaceutical industry on the WHO, is being organised in January this year.

Wodarg has also held the �scare mongering� by the WHO responsible for huge contracts entered into by many European countries with vaccine manufacturers. He says: "The governments have sealed contracts with vaccine producers where they secure orders in advance and take upon themselves almost all the responsibility. In this way the producers of vaccines are sure of enormous gains without having any financial risks. So they just wait, until WHO says "pandemic� and activate the contracts."

Further, he makes the serious accusation that WHO deliberately changed its definition of �pandemic� so as to make it easier to declare the H1N1 infection as a pandemic. He claims that earlier, to be declared a pandemic, an infection had to be shown to be responsible for �high mortality and morbidity� i.e. cause severe illness and a large number of deaths in those affected. As the H1N1 did not qualify in this regard, Wodarg claims that the reference to mortality and morbidity was dropped in the definition of pandemic on WHO�s homepage.

This is not the first time that a senior epidemiologist has held the WHO responsible for keeping the definition of pandemic �too loose� and thereby open to the possibility of alarm bells being set to ring without sufficient cause. Last year, Peter Gross, infectious disease specialist with the Hackensack University Medical Center in New Jersey, in an editorial for the British Medical Journal suggested that the WHO's loose definition of a pandemic could lead to false alarms.

PHARMACEUTICAL COMPANIES

SET TO MAKE A KILLING

At the core of this controversy is the huge amounts of money that pharmaceutical companies are poised to make, riding the crest of the declared pandemic. It is estimated that over two billion Euros have been spent, in Europe alone, on the pandemic emergency. An even larger amount has been spent to tie up contracts with vaccine manufacturers. Now the British government is trying to offload up to �1billion of swine flu vaccine, ordered at the height of the scare. Recently, Germany and France announced that they would scale back orders or sell excess H1N1 drug supplies. Shares in the manufacturer GlaxoSmithKline (GSK) have fallen as orders are cancelled. The company had previously estimated total sales of its pandemic flu vaccine across more than 70 countries at �2bn, over 2009 and 2010.

There are also concerns that the drug for swine flu, Tamiflu, was aggressively pushed without adequate medical reasons for its widespread prescription. Britain's Health Protection Agency (HPA) now says that only one in five people who were diagnosed with swine flu actually had the disease and that four fifths were instructed to take Tamiflu unnecessarily. The agency reported that around one million packets of Tamiflu have been prescribed so far, but more than 800,000 of these were not necessary.

Further, the nexus between the pharmaceutical industry, is not a matter of mere speculation. Last year, the Daily Mail carried reports about Sir Roy Anderson, a scientist who advises the government on swine flu, who also held a �116,000-a-year post on the board of GlaxoSmithKline. GSK makes anti-flu drugs and vaccines and is predicted to be one of the biggest beneficiaries of the pandemic.

The real story may take months to unravel, and the entire truth may still remain unknown. But the H1N1 pandemic has raised many issues regarding global preparedness in dealing with pandemics and the global dependence on pharmaceutical companies in situations of a potential crisis. It is hoped that proper lessons will be drawn by the global health community.