Preparing for the Pandemic

Is this the Big One?

Unless you’ve been living under a rock the past few days, you will know the world is facing a possible swine flu pandemic originating from Mexico. As I write this, on the evening of April 27 California time, there are 2,500+ possible cases worldwide and up to 149 deaths in Mexico that can be attributed to the virus. Though this is far from my area of specialty, I’ll contribute what I consider to be the most important things to know about this, namely, just how SERIOUS this may become, advice on how to maximize your chances of survival in points 3 – 5 and speculation about the possible economic and geopolitical fall-out, especially in the US and Russia.

1. This is serious. A “public health emergency of international concern”, according to the World Health Organization. Today they raised the alert levels from Phase 3 (human infections with a new subtype but no or almost no human-to-human spread) to Phase 4 (localized, limited human to human transmission), which would call for instituting strict quarantines and blanketing infected areas with antivirals. I expect to see this in the next few days. I strongly suspect we are fast approaching Phase 6 – a self-sustaining pandemic.

Global growth in new cases of infections and in deaths seem to have followed an exponential trend in the past few days since these figures have become widely available. According to a Google Pandemic Map, there are many confirmed cases in the major US population centers, Spain, the UK, Canada, Australia and New Zealand. This almost certainly means that many more cases remain undetected – and considering the speed of its spread, this virus seems very contagious.

2. We know little about it. One worrying thing about the A(H1N1) swine flu is that, much like the 1918 Spanish Flu which killed 50mn people, mortality is concentrated amongst those aged from 15-45 years. Ironically, this was because their immune systems were too strong. In response to a new, highly pathogenic invader, the body overreacts and unleashes a cytokine storm, killing off too many infected cells and drowning sufferers in their own fluids.

The current estimates put the case fatality ratio (CFR) at a worryingly high 6%, which is significantly higher than for the Spanish Flu. This is higher than the 2.5% CFR of the Spanish Flu, or the 0.5% CFR of lesser pandemics in 1957 and 1968. A quarter of the US population getting infected with such a virus will result in 4.5mn excess deaths.

That said, this does not necessarily mean we are facing a sickness apocalypse straight from the pages of Stephen King’s The Stand. First, up till now all deaths are concentrated in Mexico, so the situation there might – or might not – be qualitatively different from that in the US and elsewhere. We’ll see in the next few days. Second, not all cases would have been registered, which means that less people died relative to those infected – if there were ten people who were “invisibly” infected for every one that made it into the limelight, then the true mortality rate would be closer to 0.5%. Third, the virus may become less lethal as it moves away from the epicenter, which perhaps explains the relative mildness of cases outside Mexico. Fourth, we should bear in mind that Mexico is a developing nation with a poorer health system and lower hygienic standards.

3. Preparing for the pandemic. The best defense…is not to catch it. Though his prediction of Russian GDP growth of -2.5% in 2009 was an epic fail, much like my own crystal ball gazing , Eric Kraus may have been very prescient in his recommendation to stock up on canned food, guns and land in New Zealand.

Much as I respect Kraus' advice, perhaps settling in Madagascar is an even better idea?

If like most of us you are not financially independent and don’t have a doomsday bunker in the Idaho mountains, start practicing social distancing. Refrain from physical contact with people and try to keep away from crowded and confined venues like movie theaters, cafeterias and lecture halls. If possible stock up on non-perishable food, clean water and all the other stuff survivalists harp on about. It will minimize trips to the supermarket and can prove invaluable in the unlikely but not impossible scenario in which utilities and public security break down – don’t forget we’re also mired in the greatest economic downturn since the Great Depression.

Keep stringent attention to personal hygiene and remember to keep your hands well away from your face. Those eerie masks you see people wearing in Mexico City offer negligible protection. Their main purpose is to prevent you from infecting others, not the other way round. They should be worn as a matter of social responsibiliy, but don’t think they’re an impenetrable suit of armor. Practice strict respiratory hygiene.

4. Try to get Tamiflu (oseltamivir) and take two tables for five consecutive days, two days after the onset of symptoms. Relenza (zanamivir) is cheaper and just as effective, but requires a special inhaler. Indications show that swine flu is susceptible to these treatments so far, although it may yet develop resistance.

The difficult thing is in getting Tamiflu. I’ve been concerned about avian flu for a long time, but kept putting it off and ended up missing the boat. I went to my clinic today and requested a Tamiflu prescription. No sorry, its unethical. Why? Because central stockpiling is more equitable than private hoarding. How many courses are there in the US national stockpile? I don’t know. Whatever. I know from acquaintances that before SHTF getting a prescription for Tamiflu was pretty easy, so its obvious that the order to restrict it to folks a) showing symptoms and b) those who can prove they were exposed to a high risk of contracting it, came recently and from above.

But you can still buy Tamiflu from foreign pharmacies (1st-US-Pharmacy.com) or generic versions (US-pharm.com). In the latter case, yesterday 30 pills cost $79, now they’ve jacked up the prices to $179, who knows what they’ll cost tomorrow – assuming they’re still available? I recommend getting them soon. It’s true that buying on-line is risky, because of fakes, but I think its still worth it – even in the worst case scenario, at least you’ll have a placebo you can believe in.

SPEAKING OF FAKES: I welcome comments on reputable on-line drug vendors. Let’s try and make this post into a portal for those who want to take personal responsibility for their health instead of relying on the nanny government.

Admittedly, the government has adequate Tamiflu stockpiles, with 44.0mn courses in a central stockpile and 22.8mn (of a planned 31.0mn) in state stockpiles, giving a total of 66.8mn courses for a population of 303.8mn, or 22% coverage. If the feds were 100% efficient, there’d be no problem – but we know perfectly well that that’s not the case. You need to start treatment within two days of showing swine flu symptons. But since you’ll first have to apply for a prescription before collecting your Tamiflu, that could be a delay that costs you your life.

And should the unthinkable happen and society collapses, no one will be interested in sharing anything with a loser like you.

EDIT April 28 – just spoke with folks in Russia, apparently pharmacies are well stocked with Tamiflu, getting a prescription for it is easy and a pure formality and it costs about three times less than in the US (or about as much as foreign generic versions).

5. Stay informed. The Wikipedia article on swine flu and the info on pandemics from Global Security are extremely informative. Keep an eye on developments at the CDC (Centers of Disease Control) and the WHO (World Health Organization). Searching for swine flu on Google is the most effective way of filtering the barrage of news and the Google Pandemic Map shows up its latest world conquests. However, the news stream is at best hours behind real life and there are suspicions that they are artificially suppressing information on hints from above. I propose a more charitable explanation – as journalists, they have to validate their stories before putting them to print, so information will be late and heavily edited.

However, whatever the real story, if you want to to keep up with the flu news minute by minute, to be exposed to remote cases  hours or even days in advance, you have to get the pulse of the Internet. A Twitter search for #birdflu produces interesting results, but there’s a high noise to signal ratio. A better idea would be to take tweets from specialists like CDCemergency or FluTrackers.

I recommend the Sing to Me Oh Muse forum, the MERGED All Swine Flu Topics Go Here thread at The Survival Podcast and the FluTrackers Swine Influenza Outbreak forum, as well as subscribing to the blog Effect Measure.

EDIT – new sources of info I find will go here: UK Times live updates on swine flu – Global Disease Alert Map – to be continued…

6. What’s gonna happen? As I said, from the current evidence I believe we are going to see a full-fledged pandemic – hopefully something as mild as or milder than the 1968 Hong Kong Flu, but possibly a full-blooded descendant of the 1918 Spanish Flu. However, we are unlikely to see a replication of the mortality profiles of 1918. Practically all nations today have much better healthcare systems now than they did a century ago. Their populations are healthier, cleaner and better fed. The prevalence of tuberculosis, a big risk factor for death from pandemic flu, has plummeted.

The secondary infections that often kill flu sufferers can now be combated with cheap antibiotics, unlike in 1918. In most developed nations there are enough doses of antivirals to treat from 10%-50% of the population, though the figures are much worse in the developing world. Nonetheless, we are much better prepared now for a pandemic than even in 2006, the year when national governments began accumulating antiviral stockpiles.

Furthermore, there are typically several “waves” to a pandemic, with the first one usually being relatively mild. Using the Spanish Flu as a historical analogy, this April outbreak could end up being fairly mild but return with a vengeance in the coming winter. But three to six months is precisely the amount of time currently needed to develop a vaccine against a new form of influenza and initiate mass production.

My main concern is not mass mortality, which I think is very unlikely to surpass the tens of thousands in the developed world and the hundreds of thousands in the developing world even in a worst case scenario. Instead, the real threat comes from social destabilization. We live in a globalized world of instant communications, jet travel and just-in-time consumer culture. Ours is a complex, metastable society, which can moderate small shocks to the system, but is prone to catastrophic breakdown and collapse to a lower state if the disturbance is large enough. Consider this from Andrew Marshall:

In modern society, if key nodes are taken out by disease, the impact could be magnified exponentially. The “nodes” could be people essential to the functioning of society and the economy — doctors, truck drivers, engineers, port workers. And just as with financial crisis, herd behaviour, panic and the spread of inaccurate or incomplete information could provide negative feedback loops, making the catastrophe even worse. “Economic disruptions on the supply side would come directly from high absenteeism… There may also be disruptions to transportation, trade, payment systems and major utilities,” the IMF said in a 2006 report on the impact of a global flu pandemic.

And beyond the immediate catastrophe, an overriding risk from both the financial crisis and any pandemic is that it causes a worldwide retreat from globalisation, with profound long-term consequences for the world economy. In its 2007 report on global risks, the World Economic Forum imagined the consequences of a simultaneous pandemic and global liquidity crisis — a scenario that was purely speculative then but which now seems eerily prescient. The result, it said, would be “a backlash against globalisation, which in turn compounds the hit on global demand”. Across the world, it said, increased militarism and authoritarian tendencies would reshape global geopolitics.

No wonder that Obama spends the day playing golf, the US-Mexican borders remains open and the media is trying to maintain its cool – as this screenshot so poignantly proves.

Russia banned pork imports from Mexico and the US and started checking the body temperature of new arrivals at its ports of entry in an effort to identify people infected with swine flu. These measures will do little to check the spread of the disease – that would require a full-scale quarantine of the country. The real aim is to make an appearance that the government is doing something to reassure the public. It might be cynical populism, but Russia is far from alone in this internationally.

In this simulation from the Los Alamos National Laboratory, vaccination and targeted antiviral prophylaxis were actually sufficient to halt the epidemic within the US by themselves, given certain assumptions about the contagiousness of the virus. I suspect many governments are now waiting for more information about the virus before resorting to extreme measures like shutting down schools, imposing quarantines and making work and travel restrictions.

(They are in a real bind. If they react and the flu peters out by itself, they’d be accused of crying wolf and further damaging the economy. If they don’t react and this blows up into a replay of the Spanish Flu, then the survivors would be angry with them.)

Interestingly enough, a World Economic Forum pandemic simulation from 2006 predicted the world’s initial response:

The [German] Government Team’s first priority was to keep the public calm while limiting travel to contain the disease. But the Government Team did not shut down airports or borders, unlike in most recent pandemic exercises, when the natural reaction was to close borders or quarantine. The Government believed that continuity of transportation and logistics were critical to maintain essential operations.

I highly recommend reading that report in full, as well as a related one. If the softer measures currently being activated behind the scenes fail to check the spread of swine flu, then some of the things we can expect include: prioritization of essential services like healthcare and security to ensure their continuity; the “hibernation” of non-essential services; possible collapse of telecommunication networks and the Internet; extensive government cooperation with business and media outlets; work and travel restrictions; nationalization of strategic infrastructure and martial law; conscription of the “recovered” to fill vacant positions in critical areas, etc. I will write more on this if SHTF in the next few days…

This will have very disruptive effects on the international system, as pointed out by Marshall above. Global tourism and commodity prices will hit rock bottom. The recently heralded “green shoots” of recovery will wither away and die for at least another year – assuming this doesn’t precipitate a full-scale systematic collapse to a lower equilibrium level.

Though the US is well prepared compared to most countries in the world, I am concerned that should the government increase its role as envisioned in the WEF scenario, this will further enrage the simmering constitutionalist, patriot, tea party, etc, movements. Ideological polarization could increase, resulting in political instability and even a radical turn towards Huey Longism or McCarthyism in a fulfilment of already incipient trends.

Oil will probably hit $10-20 in this scenario, wrecking Russia’s financial system and precipitating an economic crisis far deeper than the one it’s currently in – expect to see a GDP decline of 15%-20%? That said, the social effects will not be as bad as implied by the numbers. I think more Russians will take to the vegetable plots on their dachas than to the streets. Although dilapidated, its epidemiological system is extensive and apparently Russia stockpiled 150mn courses of Tamiflu, more than sufficient to treat its own population of 142mn while throwing some scraps the way of Ukraine or Belarus to buy influence.

So there you have it. Five scenarios for the future, and I suspect we’ll know which is the more realistic one within just a few weeks:

1. False Alarm – it just fizzles out.

2. Successful Containment – government intervention remains low key; no more than a few hundred excess deaths in the US; life carries on much as before.

3. Mild Pandemic – control not successful; mortality in the hundreds or at most thousands; localized, moderate government measures focusing on showering hot-spots with antivirals, fabric of life remains whole.

4. Moderate Pandemic – control not successful; mortality in the tens of thousands; widespread intrusive government measures;  significant across the board disruptions to life.

3. Severe Pandemic – large-scale government intrusion; high mortality with hundreds of thousands of deaths; martial law, nationalization, conscription of community militias, threat of social breakdown.

I’m currently leaning to 2 or 3, but all we can do now is wait and hold on tight.

7. Should we dust off the tinfoil? There are folks on teh internets claiming this is all a big government conspiracy, or some kind of bizarre plot involving Mexican drug cartels, al-Qaeda and the KGB. Whatever.

First, their main arguments. Swine flu kills young, healthy people – normal flu doesn’t do it! Well, that’s kind of like the whole point – it’s not a normal flu! It is a new virus that provokes a strong immune reaction, which results in lethal cytokine storms in precisely the youngest and healthiest people. But there’s like avian flu in there, as well as human flu and swine flu, they must have been mixed together by a biowarrior! Again, its the rareness with which they mix (or rather, “reassort”) which is what makes them so special. Pigs are traditional mixing vessels for influenzas from many branches of the animal kingdom.

Second, cui bono? Why would they release it in Mexico? Who has a quarrel with Mexico? Sure it will reach the Great Satan, but it won’t stop there until it reaches al-Qaeda or the Taleban and bites them in the ass. Feel free to throw more at me, but the best the tinfoil men have produced so far in terms of “evidence” go along the lines of bio-security lapses in companies with government contracts. Boo to them, but that’s careless, not genocidal.

Many experts were telling us we are overdue for a pandemic, though granted most were staring up the wrong tree, or rather, chicken coop – N5H1. Thus far the most plausible explanation for the outbreak I’ve come across is rather banal – unsanitary conditions at the Mexican pig farms of the Smithfield food company. It is mostly likely that or something equally mundane.

EDIT: May 2, 2009 – I might have been ill and paranoid, but that didn’t stop me trying to profit from it. I quickly knocked out this thing on April 30 and tried to get it published, unsuccessfully. All the factual stuff was true at the time, though as of this moment I’m no longer concerned (what a difference a day makes!) – lots of people are getting infected, but very few are dying. Just ignore its sensationalism…until the next pandemic, that is.

It’s one thing checking up on Google News for “swine flu”, tracking its new conquests on a world map and reading World Bank reports it will cause a 5% drop in global GDP – the last thing we need for full happiness. It’s quite another thing when it hits you and everyone around you.

Or rather, recombine – and you get a contagious, super-virulent chimera virus, a microbial avatar of the first horseman of the Apocalypse.

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