From Field to Plate...

THE COMING PLAGUE by Laurie Garrett

Thursday, November 20, 2014 @ 05:11 AM
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How could we even be thinking of 30% to 40% HIV seropositivity?
Physically Subhash Hira had changed little over the years. But inwardly he was a very different man. Keeping track of Zambia’s horrific AIDS epidemic had taken away a bit of his soul, left scars on his spirit. “People said to me when AIDS started in Zambia, ‘You are looking at the bubonic plague in the Middle Ages, and ten years down the line you will see the same kinds of mass deaths.’ And I thought it was an exaggeration. How could we even be thinking of 30% to 40% HIV seropositivity? Six years ago, in 1985, it was only 3% in pregnant women in Lusaka.”

100,000 female prostitutes in his city were infected
“AIDS has come to India. I must do everything in my power to ensure that what I have witnessed this last decade in Lusaka does not occur in Bombay or Calcutta or Delhi or Madras. HIV is emerging all over India. It may even be too late already.” It was. Dr. I. S. Gilada, secretary-general of the Bombay based Indian Health Organization, estimated that 100,000 female prostitutes in his city were infected, 2 million nationwide, with the highest rates – up to 70% – seen among India’s Tamil women who worked as prostitutes in Bombay. Wherever poverty was high, HIV seemed to have made its entry into Asia well before 1991.

The infection rate among Chiang Mai prostitutes had soared to more than 70%
After touring India, Thailand, and the Philippines at the request of Speaker Tom Foley, Representative Jim McDermott, a physician and Democrat from the state of Washington, released the results of an AIDS investigation he conducted for the House of Representatives, reaching the conclusion that “Asia is the sleeping giant of a worldwide AIDS epidemic”, and predicting that Asia’s epidemic would, within perhaps just five years’ time, outstrip that of Africa. With all the prior warnings and clear evidence of the devastation AIDS was inflicting upon Africa, how could the microbe so overwhelm Asia? Why hadn’t humanity succeeded in preventing HIV’s emergence on the continent? As late as the fall of 1989 valid surveys of Thai drug users and prostitutes revealed infection rates below 0.04%. Yet within a mere twenty months the infection rate among Chiang Mai prostitutes had soared to more than 70%.

Lesson went unlearned
How could this have happened? In retracing the virus’s pathway across Asia, scientists and public health experts gained greater evidence supporting the GPA’s earlier theories that human rights violations, poverty, and the behavior of Homo sapiens played crucial roles in the emergence of disease. Indeed, the only way to comprehend Thailand’s astonishingly rapid HIV emergence was to recognize the intimate coupling of social, political, biological, and economic factors. African history, tragically, repeated itself in Asia. Lessons went unlearned. When officials at WHO plotted India’s AIDS growth rate the slope of Africa’s pandemic arched upward at a gentle angle for the 1990s, India’s forecast was a sharp line soaring up at a 60-degree angle. If India’s epidemic was racing, Thailand’s was moving at supersonic speed.

Thailand had two separate AIDS epidemics
Something strange and troublesome happened in Thailand: two separate lineage HIV-1 emerged, each exploiting entirely different population groups. Among Bangkok’s heroin injectors there appeared a B-class virus that looked genetically like a typical American HIV. But a very different HIV emerged in Thailand’s prostitute and heterosexual populations, one that closely resembled a virulent virus in Uganda. The two strains moved on separate paths in Thailand, and as of 1993 there was no evidence of cross-mixing of their genetic material. So Thailand, biologically speaking, had two separate epidemics, both of which grew at unprecedented rates.

HIV was handed a social gift: human chaos
At the most crucial moment in its emergence into Thai society, HIV was handed a social gift: human chaos. In February 1991 there was a coup in Thailand, bringing a military junta to power. AIDS programs came to a grinding halt; the flow of nearly all foreign aid, including monies earmarked for HIV control, stopped abruptly. There was little change in the sexual appetite of male customers and foreign sex tourists continued to flock into Thailand from all over the world, particularly Japan and Germany. Brothel owners began actively recruiting virgins and young girls, allowing them to market safety for their male clientele. The average ages of prostitutes plummeted and the number of Burmese women working in the brothels soared, topping 40% by 1993. Nearly all the Burmese female prostitutes were slaves. In September 1988 the Burmese government was overthrown in a coup that brought the most corrupt elements of the country’s business and military communities to power. The country sank into chaos. Like Africa, much of Asia was simultaneously undergoing other disease emergencies that could be expected to compound or synergize with HIV/AIDS, including dengue, hepatitis, drug-resistant malaria, tuberculosis, drug-resistant cholera, and virtually every known sexually transmissible microbe.

The U.S. Census Bureau issued dire forecasts
The U.S. Census Bureau issued dire forecasts for Thailand, based on HIV-prevalence rates as of early 1994: population growth down to -0.8%; 25 million fewer people in the country than in the absence of AIDS; a dive in life expectancy from 75 years to 45 years; child mortality rates would triple; and crude death rates would soar from 6 per 1,000 to 22 per 1,000.

THE COING PLAGUE by Laurie Garrett

Wednesday, November 19, 2014 @ 07:11 AM
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The global AIDS pandemic might well make the world’s poorest nations much, much poorer
By 1988 Western economists and African leaders were asking “Will this epidemic slow, or even destroy, African development? Is it possible that AIDS will destroy all the development programs we have spent the last three decades building?” It seemed too horrible to contemplate, yet inescapably apparent, that the global AIDS pandemic might well make the world’s poorest nations much, much poorer. The African nations entered the AIDS era already severely impoverished. The 1987 GNP per capita in the United States was $16,690. In Tanzania it was $290, in Zaire a mere $170.

Familial destruction led to the economic collapse of whole villages
Research identified several key factors. Since the 1970s a host of new microbes had successfully emerged and swept across the continent: drug-resistant malaria, drug-resistant tuberculosis, urbanized yellow fever, Rift Valley fever, and waves of measles epidemics, to name a few. That meant that the health care systems of African nations were already stretched to their limits. Given scarce resources for health care – averaging $1 to $10 per capita annually – any additional burden seriously endangered the viability of entire national medical systems. Compounding the problem was the seeming synergy between microbial epidemics. Wherever AIDS became endemic, tuberculosis followed closely. One epidemic sparked another. Studies all over the continent showed that among the hardest-hit social groups was the well-educated urban elite who could navigate their countries out of postcolonial stagnation into prosperity. Whole families seemed to die off. In some devastated areas familial destruction led to the economic collapse of whole villages that could have a ripple effect through all tiers of the regional economy.

AIDS was creating “a global underclass,”
HIV infection rates in some groups were already staggering by 1988 and would reach positively horrendous proportions by 1993, when some studies would find that upward of 40% of women of reproductive age in key African cities carried the virus. As early as January 1988 economists were predicting financial hard times for the continent. They warned that AIDS was creating “a global underclass,” over and above the previously existent world community of impoverished individuals. The World Bank predicted two immediate consequences of AIDS in hard-hit African areas: a radical slowdown of national GDPs and tremendous competition for scarce health care resources.

THE COMING PLAGUE by Laurie Garrett

Tuesday, November 18, 2014 @ 06:11 AM
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Representatives of 148 nations
“We are entering a new era,” Mann had assured an international press corps. “We will make 1988 the year we turn the tide against the AIDS virus.” He looked over the largest gathering of Ministers of Health ever assembled. Of the representatives of 148 nations who now sat before him in the vast Queen Elizabeth II Conference Center in London, 117 were Ministers of Health or their country’s equivalent. Every key nation, save one, was represented by the most politically powerful health official in their land: Mann was ashamed to say that the exception was his own country. Still not wishing to give AIDS a priority status, the Reagan administration sent Dr. Robert Windom, who ranked two notches down the power ladder from the Secretary of Health and Human Services. Never in history had the majority of the world’s top health officials gathered to discuss an epidemic. Some 700 delegates and 400 journalists were also present in the London hall on this January morning in 1988 to witness the World Summit of Ministers of Health on Programs for AIDS Prevention. Mann felt that it was a coup for his program, for WHO, and for millions of powerless people with AIDS.

If it hasn’t yet emerged in your country, it will
Mann urgently hoped to drive home a message to the world’s health leadership: AIDS is spreading; if it hasn’t yet emerged in your country, it will, unless you plan now, follow our recommendations, educate your populations, and embrace condom-based programs as a prevention strategy. As of January 26, 1988, some 75,392 cases of AIDS had officially been reported to the World Health Organization. But this figure was a gross understatement of the true dimensions of the pandemic: most nations lacked genuine systems for amassing and recording such health statistics. Many nations were deliberately covering up their epidemic for political or economic reasons.

Silence, exclusion, and isolation creates a danger for us all
It was Pattern III nations that most concerned Mann. Asia, the communist bloc, the largely Muslim Middle East, and much of the Pacific region had only tiny outbreaks of AIDS. Some of these countries were truthfully reporting no cases of the disease, and several more were accurately stating that the handful of cases in their countries all involved foreigners or citizens who had acquired HIV while living overseas. In those Pattern III countries, the relative handfuls of cases were equally likely to have resulted from heterosexual, homosexual, needle, or blood exposure. Pattern III, in other words, represented the potential future of the world-wide AIDS epidemic. There was still a window of opportunity for public health action that might successfully prevent HIV from emerging in the majority of the world’s populations. “The global AIDS problem speaks eloquently of the need for communication, for sharing of information and experience, and for mutual support; AIDS shows us once again that silence, exclusion, and isolation – of individuals, groups, or nations – creates a danger for us all.” Though his words were received with thunderous applause and a standing ovation, Mann knew that many were, back home, promoting policies of mandatory quarantine of HIV-positive individuals, escalated repression against homosexuals, even public execution of AIDS sufferers. Mann knew their modi operandi were less those of the laboratory or hospital than those of the maneuvering, backstabbing, and power plays seen in parliaments and presidential circles.

Denial was all too easy a response to AIDS
HIV surfaced almost simultaneously on three continents and was quickly a feature on the health horizons of at least twenty different nations. Not only was there no sign that AIDS might burn out on its own; scientists could see no evidence of the famous bell-shaped curve of infection and disease. Far from causing immediate disease and death, HIV was a slow burner that hid deep inside people’s lymph nodes, often for over a decade, before producing detectable infections. As a result, a society could already have thousands of infected citizens before any sound of alarm was rung, and even when the first AIDS cases appeared, their numbers were small enough to allow governments to feel comfortable about ignoring the seemingly trifling problem. Denial was all too easy a response to AIDS. Further more, no facile measures could be taken by a government to bring AIDS to a halt. Unlike Ebola, Marburg, drug resistant cerebral malaria, or Lassa, HIV hit specific social targets. It was a sexual disease. It was associated with homosexuality, promiscuity, and drug abuse. It pitted public health against organized religion and the moral pillars of society. “Discrimination simply drives AIDS underground. If you drive it underground, you guarantee its spread.”

Marginalization could be a risk factor every bit as crucial as a contaminated syringe
In the 1960s, René Dubos wrote extensively about the special vulnerability to the microbes among people who lived lives of poverty. History demonstrated repeatedly that, with rare exceptions, the microbes exploited the weak points of economically bereft lives: chronic malnutrition, prostitution, alcoholism, dense housing, poor hygiene, and egregious working conditions. Carballo and his colleagues recognized that there was more to microbial vulnerability than the social-class arguments put forward by Dubos. When information was the key to self-protection, there were gradations of Homo sapiens vulnerability that could be rooted in economic class, but could also stem from social alienation. People who were treated as outcasts from the dominant culture in which they lived could be denied vital life-protecting information or public health tools. If the larger society reviled a particular subgroup, its marginalization could be a risk factor every bit as crucial as a contaminated syringe. Carballo saw a confluence of social factors at play in the emergence of HIV in societies: marginalization, social alienation, poverty, and discrimination. In his mind, they united to form a social bridge across which HIV traveled into one society after another.

The pandemic spread relentlessly
On January 28, 1988, the London Summit endorsed the GPA’s fifteen point declaration that called for openness and candor between governments and scientists, opposed AIDS-related discrimination, gave primacy to national education programs as a means to limit the spread of AIDS, and reaffirmed the GPA’s role in international leadership. But even as they smiled for the cameras and signed the declaration, the seeds of failure were being sown. Despite the efforts of the GPA, the pandemic spread relentlessly, always emerging first in communities that were on the outer periphery of societies’ margins.

THE COMING PLAGUE by Laurie Garrett

Monday, November 17, 2014 @ 05:11 AM
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The first penalty that capitalistic society had to pay for the ruthless exploitation of labor
The Alma-Ata Declaration called for “the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to a socially and economically productive life.” In his 1976 Plagues and Peoples, University of Chicago historian William H. McNeil created a sensation in academic circles because it argued with the force of centuries of historical evidence that human beings had always had a dramatic reciprocal relationship with microbes. Waterborne parasitic diseases dominated the human ecology when people invented irrigation farming. Global trade routes facilitated the spread of bacterial diseases, such as plague. The creation of cities led to an enormous increase in human-to-human contact, allowing for the spread of sexually transmitted diseases and respiratory viruses. After centuries of doing battle with one another, humans and most parasites had settled into a coexistence that was rarely a cause of mass destruction. In René Dubos’ view, most contagious diseases grew out of conditions of social despair inflicted by one class of human beings upon another. Tuberculosis arose from the social conditions of the poor during Europe’s Industrial Revolution: urban crowding, undernutrition, long work hours, child labor, and lack of fresh air and sunshine. “Tuberculosis was, in effect, the social disease of the 19th century, perhaps the first penalty that capitalistic society had to pay for the ruthless exploitation of labor,” Dubos argued.

By 1979 McCormick had reached a conclusion
Joe McCormick had heard it all, but all the hand-wringing and theorizing wasn’t going to provide the resources needed to get rid of Lassa. By 1979 McCormick had reached the conclusion that Lassa was an entrenched endemic disease, causing thousands of cases of illness of varying degrees of severity each year. The only way to rid Sierra Leone of human Lassa cases would be to eliminate contact between the rats and humans – an option he considered doable if millions of dollars were spent improving the country’s rural housing and hospitals. The alternative was mass education about rat avoidance and ribavirin therapy for those who suffered Lassa fever. That prospect was also orders of magnitude too expensive for the impoverished state.

A suspect epidemic in Sudan
In late June 1979, McCormick returned to CDC headquarters to take over Karl Johnson’s job as chief of the Special Pathogens Branch leaving Web in charge of the Sierra Leone laboratory. The World Health Organization called to formally request McCormick’s assistance in investigating a suspect epidemic in Sudan. It was believed that Ebola was the culprit. McCormick hastily gathered supplies and the first assistant he could get his hands on – a new EIS officer, Dr. Roy Baron. McCormick showed Baron the only available maps of the region, made in 1955. He described the difficulty of finding villages, which were deliberately hidden in the ten-foot-tall Sudan grass and swamps. He gave a quick sketch of the political and social situation. Since McCormick’s last visit to the region during the 1976 Ebola outbreak, the relationship between Sudan’s north and south had grown more strained; the country was on the brink of civil war.

A vision from hell
The translator led McCormick through the hamlet of mud-and-wattle structures to a round hut on the periphery, to see what he would later describe as a vision from hell. Twenty men and women lay upon grass mats, crammed one against another in a small dark atmosphere of overpowering heat and stench. Most were in agonizing pain, horribly ill, groaning aloud or crying out in demented visions. Some, their skin in excruciating pain, had torn off their clothing and lay in naked terror. All night long McCormick, wearing only latex gloves and constantly steamed-up respirator for protection, knelt beside the Ebola victims, giving them thorough physical examinations, painstakingly noting all information on a pad, and taking blood samples. The instant the needle hit her vein, the woman thrashed wildly, the syringe popped out and landed in McCormick’s thumb. Shoving aside all thoughts of being struck by the needle, McCormick completed his rounds, prepared all samples for shipment, putting them inside a small tank of liquid nitrogen and placing that in a case of dry ice. He injected himself with Ebola antiserum collected from Yambuku three years earlier.

It was clear that Ebola had struck again
It was clear that Ebola had struck again and that he had been exposed to the virus that would take from five to seven days before he got sick, leaving him time to get to the bottom of this epidemic. One afternoon, he spotted an old woman from the death hut strolling through N’zara, a jug of water on her head, clearly full of energy. McCormick was ecstatic. CDC blood tests results cables from Atlanta shortly thereafter indicated that she alone among those in the death hut was uninfected. Whatever her ailment, it wasn’t Ebola. And Joe McCormick had never been infected with the deadly virus.

Poorly run hospitals were the amplifiers of microbial invasions
When the team reconstructed the events of the summer of 1979, they discovered many parallels with the 1976 outbreak, but were still unable to say where the virus came from. Once again, the first case involved a man who worked in the run-down colonial-era cotton factory that was filled with huge swarms of bats and a vast array of insects. He fell ill on August 2, 1979 and died of the disease in N’zara Hospital three days later. All infections could be tied to some direct blood or fluid contact between an ailing Ebola victim and another individual. The team was able to find fifty-six Ebola cases, many hidden in the tall grasses. 65% of those who got infected died. Their inability to pinpoint the reservoir for Ebola would bother McCormick for years. As was the case with Lassa, poorly run hospitals operating under conditions of extreme deprivation were the amplifiers of microbial invasions. Once again, elimination of a disease threat seemed inextricably bound to economics and development. McCormick felt certain that Ebola and other dangerous diseases would continue to haunt the most impoverished communities on earth, constantly threatening to explode into epidemics, some of which might one day lap at the shores of the planet’s richest nations. Out of such poverty, from the African Serengeti to the burned-out tenements of the Bronx, would soon come microbial invasions that would bear out McCormick’s prophecy.

THE COING PLAGUE by Laurie Garrett

Sunday, November 16, 2014 @ 08:11 PM
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A startling increase in their incidence over the last decade
Similar dam-related epidemics of Rift Valley fever would occur during the 1980s in Mauritania, Senegal, and Madagascar, and in the 1990s the disease would revisit Aswan, causing a severe epidemic. By the mid-1980s major donor groups, particularly the World Bank, instructed applicants for major water project funding to submit disease impact studies as part of their project proposal. By 1980 the World Bank would conclude that the worldwide malaria eradication campaign had failed, noting that cases of the disease had increased an astonishing 230% on the Indian subcontinent during the period 1972-76. Most other vector-borne diseases, just a decade earlier considered easy to eliminate, had experienced a “startling increase in their incidence over the last decade.” Sleeping sickness, bilharzia, river blindness, and Chagas’ disease were all increasing in frequency, often in the very countries that had been recipients over the period of billions of donated and loaned U.S. dollars.

Spend more on primary health care and disease prevention
By the end of the 1970s the World Bank’s solution was to urge poor nations to spend more on primary health care and disease prevention. Reaching U.S. health care expenditure levels, even as a function of per capita annual spending, would, however, represent an extraordinary feat for most of the world’s poor nations. In 1976 in the United States there was a 1:600 ratio of physicians to the general population; virtually 100% of drinking water supplies were considered free from infectious disease; people consumed, on average, 133% of their minimum caloric need every day; 99% of adults were literate; 3.3% of the federal GNP was directed toward health care spending for a per capita spending rate of $259. Tanzania had one physician for every 18,490 citizens; safe drinking water was available to less than 40% of the population; the average citizen consumed only 86% of the minimum caloric need; 34% of the population was illiterate; and the government spent 1.9% of its GNP on health care for a total of $3 annually per capita. Between 1967 and 1976, the Tanzanian village health care campaigns increased the numbers of maternal/child health clinics by 610%, rural paramedics by 470%, and built 110 new medical facilities (for a total of 152 clinic structures nationwide by 1976. Life expectancy over that time increased seven years, reaching 47 (compared to 70 in Europe in 1976). Infant mortality also showed modest improvement, decreasing to 152:1,000 babies, compared to a 1967 level of 161:1,000 (with 1976 European infant mortality at 20:1,000).

Problems were particularly acute in Africa because of its severe political and military instability
Though problems plagued all the poor nations on the planet, they were particularly acute in Africa because of its severe political and military instability. Nowhere else in the world were governments so recently freed from centuries of European colonialism. The Portuguese colonies of Guinea-Bissau, Angola, Mozambique, and Cape Verde only gained independence in the mid-1970’s, after more than a decade of bloody civil war. In the southern part of the continent, warfare and instability would persist until the fates of Rhodesia, South Africa, Angola, and Southwest Africa were decided. Mobutu brutally smashed all dissent within Zaire. Self-appointed Emperor Bokassa ruled the Central African Republic with such brutality that he would be overthrown by French paratroopers. Junior elements of the military violently seized power in Ghana. Civil unrest due to religious and tribal disputes raged through Sudan, Morocco, Ethiopia, Mauritania, Angola, and Rwanda. Much of the warfare stemmed from the artificial national boundaries created by colonial powers in the 17th and 18th centuries, dividing ancient tribal lands, extended families, and traditional power structures.

Hoping to align African governments with either the United States, the U.S.S.R., or China
The superpowers, as well as the People’s Republic of China, sought to manipulate these seemingly endless battles, hoping to align African governments with either the United States, the U.S.S.R., or China. As a result, obscene amounts of money were spent on the military and police forces of impoverished countries, squandered by dictators who made ‘gifts’ to their nation’s power elites in exchange for support, wired to the bank accounts of arms dealers worldwide.

Microbes exploited the war-ravaged ecologies, surging into periodic epidemics
Between 1975 and 1980, Uganda, its entire health infrastructure devastated, experienced epidemics of malaria, leprosy, tuberculosis, cholera, visceral leishmaniasis (kala-azar), and virtually every vector-borne ailment known to the continent. A French team found evidence of more exotic diseases as well, when they took blood surveys of villagers in western Uganda. Ebola, Marburg, Lassa, West Nile fever, Crimean-Congo hemorrhagic fever, and Chikungunya were among the viruses found in the blood of the region’s populace. Between 1971 and 1977, Uganda had its worst measles epidemic in over forty years, with high death rates among children. So great was the country’s chaos that no agency kept count of the death toll. Routine vaccination for such diseases as whooping cough and tetanus came to a halt, and the incidence of these diseases rose dramatically. Starving, sick refugees poured by the tens of thousands across borders to Zaire and Sudan, taking their diseases with them. Makerere University, which had been the primary medical training center for East Africa’s doctors, was looted right down to its electrical sockets and bathroom tiles. Rumors of strange disease outbreaks were rampant, but there was nobody left to investigate these claims. Such tragic events, with the resultant epidemics and health crises, were mirrored all over the world. And the microbes exploited the war-ravaged ecologies, surging into periodic epidemics. The World Health Organization, with a staff of only 1,300 people and a budget smaller than that spent on street cleaning by the city of New York, tried to combat such seemingly intractable public health problems with donated vaccines, technical assistance, and policy statements.