Dr. Margaret Chan -- swine flu ain't her first pandemic rodeo, folks.
Scott McPherson
in Politics and government, influenza and infectious diseases
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13 Comments
This afternoon, I challenged and questioned the World Health Organization's decision to move its pandemic doomsday clock from Phase 4 to Phase 5.
Then, on my drive home, I heard a familiar voice on my radio. I immediately recognized it as Dr. Margaret Chan, the head of the WHO. Later, I found out that it was Chan who personally made the decision -- and takes the responsibility -- for moving the world to One Stroke from Midnight.
I absolutely support Dr. Chan, because she is getting to be an old hand at these things.
A history lesson is in order for the newbies who are coming to this Website. Dr. Chan is a dual Canadian and Chinese citizen. I am confident that distinction has literally saved her life at least once.
In June of 1997, Dr. Chan was the public health secretary of the City of Hong Kong when the city was handed over to the Communist Chinese by the British government. Barely six months later, Hong Kong citizens began dying from a sudden outbreak of a new and novel strain of influenza. At first, Chan was told -- ordered -- by the Communist handlers to ignore the situation and to downplay it however possible. At first, she did this. But it was soon apparent that this novel virus was moving with devastating efficiency from person to person.
This virus was then typed. It was an avian flu that jumped the species barrier and began infecting humans directly. It was moving quickly and she recognized that drastic action was necessary. So, in direct conflict with her new Communist bosses, she disclosed the existence of H5N1 -- H5N1 -- and ordered the culling -- the destruction -- of all commercial poultry in the city.
Amazingly, her handlers stood down, the Hong Kong government moved quickly, and an H5N1 avian flu pandemic was averted. That original human strain of H5N1 was moving person-to-person and she stopped it in its tracks with her actions.
Next came the beginning of 2003. In neighboring Guangdong province on the mainland, and an area under direct Communist control, people were getting sick and dropping dead of a strange and deadly virus that moved far more quickly than influenza. Initially, she was unable to even inquire into the affairs of a neighboring province. The Communists had settled in, and they had established a ridiculous and centralized reporting infrastructure that meant everything went through Beijing. Eventually, she felt compelled to act, again risking dismissal, imprisonment (or worse) from her bosses.
The virus would eventually be known as Sudden Acute Resipratory Syndrome, or SARS. Her actions help save lives and she helped beat back the disease.
Some have been critical of Dr. Chan's handling of the SARS crisis. Those criticisms usually revolve around the delayed quarantine of E block of the Amoy Gardens apartment complex within the city.
Let me set the record straight on this. Hong Kong's residents were and are very independent. Amoy Gardens block E was a 33-story, 8-units per floor apartment complex. It took Dr. Chan several days before it was decided by the authorities that she even had the authority to quarantine an entire apartment building. Then, many residents attempted to break quarantine. Eventually, the government was able to convince the residents to evacuate the building and move to different accommodations, because reinfection with SARS was possible via the sewage system of the building. Once the residents were moved, the outbreak ended.
One only needs to read former Time editor Karl Taro Greenfield's superb - and I mean superb - chronicle of the SARS epidemic, titled "China Syndrome - the True Story of the 21st Century's First Great Epidemic" to appreciate both the restrictions placed upon Dr. Chan by the Communist bureaucracy and her resourcefulness in overcoming those obstacles.
Decisions made in these situations are similar to battlefield decisions, and events move very, very rapidly. I am sure some decisions hang heavily on her to this day. But she has never shirked away from her duty.
In 2003, the WHO brought in Dr. Chan to become director of the Department for Protection of the Human Environment. She rose to the position of Director General in November 2006, following the sudden and tragic death of her predecessor, South Korea's Lee Jong-wook, who died in late May, 2006 after he underwent surgery to remove a blood clot on his brain. Her direct experience with H5N1 and SARS got her the assignment.
So as far as pandemics go, this ain't her first rodeo. She has stared down two pandemic candidates and helped beat them back. She has seen both diseases up close and personal. So if Dr. Chan felt compelled to make the call and push the button and take us to Phase 5, I am not qualified to question her decision. I am with her all the way.
No one alive has the experience she does to make that call. No one else has the blend of medical, scientific and political knowledge necessary to make that call. She is unique among her peers and the world is fortunate to have her where she is.
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Reader Comments (13)
As always, appreciate the informative insight you bring to the discussion.
Chan rocks. Glad she's on the job.
Scott - I have been an avid regular reader of your blogs for several years now. In fact, I consider your posts and insights to be my favorite source on all epidemic concerns. I do not believe that I've posted commentary here before now, but I just wanted to weigh in on the discussion of moving from Phase 4 to 5. Having followed the situation in great detail as well, I too was extremely puzzled to find the WHO making this move, based on the information and spread of the virus as we know it at this moment - particularly with some evidence that Mexico's infection & death rate may have hit their plateau in this cycle and remaining cases throughout the world remain fairly mild as a whole.
Although I still feel that likely trend lines in the spread of the virus have a high probability of invoking Phase 5 justification, it still feels quite premature, based on the data to date.
I thank you for providing the information and background on Chan to help explain the motivations and qualifications behind the person responsible for making this decision. However, even experts can leap to conclusions too quickly at times. Although I (unfortunately) believe that a Phase 5 justification will be borne out within the next week or so, I still feel that she jumped the gun too prematurely on making that call. I am concerned with the ramifications of such a hasty leap in publicly escalating the scale of risk without a substansive body of evidence on the ground to match such a designation. It is too easy for the public & media to either over-react or worse - perceive the disconnect and view this as "overblown concern". It is dangerous to both current and future efforts to appropriately monitor, address and mitigate epidemic concerns if the public's perception is that the WHO and governments are "crying wolf" or making "mountains of of molehills". Measured vigilance and appropriate preparedness and action is vital now and in the future on these types of situations. It is bad enough that so many people out there have already been scoffing that this is another "1976 swine flu scare". We all hope that this remains fairly mild and dissipates over time and does not come back roaring with a vengeance in the fall. We all share concern that this could become a full blown pandemic either soon or during the next flu season cycle. Therefore, it is essential that governing bodies, such as WHO and the CDC get their calls right and do not "jump the gun".
Thank you as always for your blogging and thank you as well for listening.
-G
Thanks for your commentary on Chan's decision to raise the Pandemic Level. Of course many are asking the obvious question: 'is it warranted?'.
Its comforting to know that the 'experts in charge' are courageous enough to make a decision such as the one that has been made by Chan, because as she would no doubt know, the ramifications are enormous.
Having said that, it begs the question: what is it that we in the outside world ' do not know'? and which is not apparent. All I can say - 'there must be alot more to the scenario!
Also I would like to ask the question as many are comparing this incident to 1918.
Although from a disease perspective there may be similarities, one glaringly obvious difference is that the world is not suffering from the devastating deprivation experienced in the aftermath of WW1 ie nutrition, mass dislocation of troops etc and advances in medicine, hygiene etc.
One would hope the preparation for H5N1 will make a difference in the early implementation of prevention strategies... including the increasing of the Pandemic alert level as one of those.
What is it that we don't know?
A TON. I've been following these flu blogs for 3 years now and finally I GET it. But how do I explain pandemic epidemiology in one short post? Argh! Read postings here, read Effect Measure and all the other ones. Here's a virologist blog: http://www.virology.ws/ Maybe if you read enough, you'll start to understand.
The mild nature (so far) of this flu is making people think it's not a problem. It isn't...until lots and lots of people have it all at once all around the world. It's disruptive. The fact that it continues to infect people and the fact that we have no immunity to it b/c it's new suggests that it isn't going to stop until the herd has acquired a certain level of immunity.
It's hard to not sound panicky when you know people need time to get a 1 month supply of food, top off the gas in cars, call relatives, get prepared and know how to treat flu at home (b/c hospitals are going to have their hands full). It's a huge task. It takes time. YOU have to get prepared b/c everyone else is going to be busy. Denial is so sweet though...
Scott, Dr. Chan is certainly has deep experience dealing with pandemics up close and personal. But isn't it a possibility that she has simply reverted to the action that happened to work well for her in the previous two cases?
I for one would like to know what evidence warranted jumping two threat levels in just a few days.
I hate to comment from an iPhone, but this is an important discussion. So far yes, the virus seems much more of a disruption than a mass death event. But what a disruption! It has virtually shut down Mexico, a nation of 100 million! What gets me worried is why shut down so much of the Mexican economy, government set ices, etc. all for only (though tragic) 160 or so deaths. This is hardly a blip for Mexico City where I am sure more routine causes totally swamp out swine flu. It doesn't seem like hospitals are filled or overwhelmed, and for that matter bodies don't seem to be piling up. Given all the media attention on Mexico, I don't believe massive coverups could work. So what gives? Why all the disruption over what seems to be a run-of-the-mill pandemic, like ones that seem to recurr ever couple decades?
Scott,
I've only recently found your blog and have enjoyed reading your informative posts. There is one thing I'd like you to look at regarding the H5N1 infection rates and the statement regarding Dr. Chan taking independent actions in 1997 when people in Hong Kong began to die.
According to the CDC: "Since November 2003, nearly 400 cases of human infection with highly pathogenic avian influenza A (H5N1) viruses have been reported by more than a dozen countries in Asia, Africa, the Pacific, Europe and the Near East." http://www.cdc.gov/flu/avian/gen-info/avian-flu-humans.htm
Nearly 400 human cases is less than 400 cases reported anywhere in the world. Add into this total the ones recorded since 1997 and the number increases very little. Please also note on the CDC's page I've linked to that the disease in humans is quite rare and there are very few cases where human-human transmission is suspected. The possibility of H5N1 combining with human flu virus is where the concern appears.
Here are a few facts I've gleaned from the page. Note not all cases are H5N1:
H5N1, Hong Kong, Special Administrative Region, 1997: Highly pathogenic avian influenza A (H5N1) virus infections occurred in both poultry and humans. This was the first time an avian influenza A virus transmission directly from birds to humans had been found to cause respiratory illness. During this outbreak, 18 people were hospitalized and six of them died. To control the outbreak, authorities culled about 1.5 million chickens to remove the source of the virus. The most significant risk factor for human H5N1 illness was visiting a live poultry market in the week before illness onset.
H9N2, China and Hong Kong, Special Administrative Region, 1999: Low pathogenic avian influenza A (H9N2) virus infection was confirmed in two hospitalized children and resulted in uncomplicated influenza-like illness. Both patients recovered, and no additional cases were confirmed. The source is unknown. Several additional human H9N2 virus infections were reported from China in 1998-99.
H7N2, Virginia, 2002: Following an outbreak of low pathogenic avian influenza A (H7N2) among poultry in the Shenandoah Valley poultry production area, one person developed uncomplicated influenza-like illness and had serologic evidence of infection with H7N2 virus.
H5N1, China and Hong Kong, Special Administrative Region, 2003: Two cases of highly pathogenic avian influenza A (H5N1) virus infection occurred among members of a Hong Kong family that had traveled to China. One person recovered, the other died. How or where these two family members were infected was not determined. Another family member died of a respiratory illness in China, but no testing was done.
H9N2, Hong Kong, Special Administrative Region, 2003: Low pathogenic avian influenza A (H9N2) virus infection was confirmed in a child in Hong Kong. The child was hospitalized with influenza-like illness and recovered.
I'm not downplaying the importance of any of these lives lost or the seriousness of the current flu, however, I'm not sure what prompted Dr. Chan to consider six deaths an epidemic or that H5N1 was spreading by human-to-human contact. There does not seem to be data to support this. In fact, there's no hard data that H5N1 spreads by human-to-human contact still. Dr. Chan may well have done the right thing in destroying poultry flocks, but people weren't exactly dying right and left.
Thanks for the information you post. Good job.
All,
I am working on a blog regarding previous H1 epidemics since 1908. regrettably, my day job is getting in the way!
So it may not happen until tomorrow.
Stay tuned,
Scott
Interested R: It's the traits of this H1N1 virus, not the number of deaths that makes it potentially dangerous.
New virus = no human immunity = fast transmissibility
People with no immunity + health conditions (i.e., asthma) = higher risk of dying if infected
To parents whose children have compromised immune systems, this flu should be worrisome. If the virus keeps branching out (no signs of it slowing down and why would it?), this increases the possibility of their child catching it. Children and elders are most at risk of dying from the seasonal flu. That this flu is contagious raises the possibility we'll have many deaths, just because its so transmissible.
People everywhere have to work together to keep this thing from passing on and on.
WHO and CDC still don't understand the deaths of previously healthy people in Mexico or why this virus seems mild in other countries. But we don't have enough documented cases yet.
The H2H transmission of bird flu H5N1 has been documented (is called clusters). It's controversial. But good risk management practice suggests you don't wait for a double-blind study to make decisions.
Hope that was helpful. Try searching this blog in the search box above for topics you are asking about.
Very good article explaining where this virus might have come from.
Swine flu: The predictable pandemic?
http://www.newscientist.com/article/mg20227063.800-swine-flu-the-predictable-pandemic.html
Great article phytosleuth! Thanks for sharing.
http://apnews.myway.com/article/20090501/D97TCOO00.html
I could not agree more. This says it all. Sorry Scott. I know you probably have posters of Chan on your bedroom wall, but you need to know that not everyone agrees with how the WHO handled this, and I am one of them.