The Virulence of Poverty - The Monster at Our Door: The Global Threat of Avian Flu - page 8

As difficult as it is to estimate flu mortality in this country, global influenza mortality is mere conjec-
ture. “There is,” writes one research team, “an under-appreciation and an underestimation of the impact of
influenza in the developing world.” 30 It is sometimes said that flu kills 1 million people worldwide each
year, but the toll could be considerably higher because annual influenza is the least recognized of all so-
called “captains of death.” Neither China nor India, for instance, reports flu statistics to the World Health
Organization. 31 In tropical countries, moreover, the absence of well-defined seasonality in the incidence
of influenza makes estimation of excess mortality difficult. This dearth of data, in turn, has reinforced the
stereotype that there is no significant influenza burden in Asia or Africa.
While high death rates from acute respiratory infections in the tropics are often attributed to tuber-
culosis, recent research has established that a majority of acute respiratory deaths are caused by viruses,
and that tropical countries have influenza mortality rates at least equivalent to those in the mid-latitudes.
Indeed, “infection probably has an even greater relative impact on the health of persons from developing
countries who are already susceptible to complications because of underlying malnutrition, tropical dis-
eases and HIV.” 32 As studies in Southeast Asia have shown, “overall influenza-associated mortality in a
region with a warm climate, such as Hong Kong, is comparable with that documented in temperate re-
gions.” Moreover, infant mortality from influenza is probably considerably higher in low-income tropical
countries. 33
Influenza is most of all a mystery disease in sub-Saharan Africa. The region is the weakest link in
the global influenza-surveillance network coordinated by the WHO: in recent years Côte d'Ivoire, Zam-
bia, and Zimbabwe have closed down their national flu surveillance systems after pleading debt and
bankruptcy; currently only South Africa and Senegal actively track flu cases and have the laboratory re-
sources to isolate and characterize subtypes. In the rest of Africa, serious flu cases are commonly con-
flated with malaria or just added to the “acute respiratory infection” (ARI) grab bag. Yet annual influenza
in Africa does often produce explosive local outbreaks, such as the 2002 epidemic in Madagascar which
overwhelmed the country's healthcare system, or the massive irruption six months later in the Equateur
Province of the Democratic Republic of the Congo which yielded shocking rates of secondary pneumo-
nia. 34
Third World influenza is also largely invisible or poorly studied in the historical record. The apoca-
lyptic pandemic of 1918-19—according to the WHO, “the most deadly disease event in the history of
humanity”—is the template for the public-health community's worst fears about the imminent threat of
avian influenza. 35 After two generations of cultural amnesia, popular interest in the history and legacy of
the “Spanish flu” (so called because uncensored newspapers in neutral Spain were the first to report its
arrival) has undergone a dramatic revival in recent years. Since 1974, when Richard Collier published an
anecdotal history based on interviews with hundreds of survivors, an impressive succession of historians
and science journalists—including Alfred Crosby, Gina Kolata, Pete Davies, and, most recently, John M.
Barry—has focused on the far-reaching impacts of the pandemic on American life, medical research, and
the outcome of World War I. Several writers have also chronicled the recent expeditions to Alaska and
Spitzbergen in the Arctic to try to retrieve the 1918 virus from the frozen cadavers of its victims, as well
as the dramatic successes of U.S. Army scientists, led by Jeffrey Taubenberger, in reconstructing much of
the 1918 virus's genome.
The threat of a new pandemic, meanwhile, spurs continuing research into many aspects of the 1918
virus's molecular structure; the enigmatic circumstances of its emergence (reassortment or recombina-
tion?), its geographical origin (a Kansas army base, the trenches in France, and southern China are all pro-
posed epicenters), 36 and its distinctive mode of attack (which produced singularly high mortality among
young adults). Despite renewed scholarly investigation into the 1918 pandemic, however, shockingly little
attention has been paid to the disease's ecology in its major theater of mortality in 1918-19: British In-