The Titanic Paradigm - The Monster at Our Door: The Global Threat of Avian Flu - page 68

ity”; arguing that the only way to contain an initial pandemic outbreak will be to douse it with power-
ful antivirals. It has urged the pooling of Tamiflu for use in Southeast Asia. “But whether countries will
voluntarily ship their own precious stockpiles overseas to fight a faraway plague remains to be seen.” 304
Even if some antivirals are made available, there is little guarantee they will actually reach people in the
hot spots. In 2004, for example, all the foreign donations of Tamiflu to Vietnam were confiscated by its
army, which refused to share even with veterinarians working directly with infected flocks. 305
But this appalling lack of vaccine and antivirals is not the only problem faced by the global “steerage
class.” The death tolls during the 1957 and 1968 pandemics were dramatically reduced by the widespread
availability of new, effective antibiotics to treat secondary bacterial pneumonias—but the major bacterial
pathogens, including the pneumococci and H. influenzae, have evolved resistance to penicillins erythro-
mycin and other antibiotics usually employed in hospitals. Such a cycle of resistance is the inevitable
result of natural selection, and the only solution is the constant development of new antimicrobial ther-
apies, but the pharmaceutical industry has largely abandoned antibiotic research (although it sells huge
quantities of antibiotics to the livestock industry and thus contributes to the accelerated obsolescence of
the current generation of antibiotics). In the event of a pandemic, there is a great risk that mortality from
bacterial pneumonia, especially in poor countries with limited supplies of older antibiotics, might return
to pre-World War II levels. In July 2004 the Infectious Diseases Society of America issued a major white
paper on the antibiotic crisis whose succinct punch line was “Bad bugs, no drugs.” 306
How would almost defenseless Third World cities respond to a pandemic? The precedent that scares
many public-health experts was the September 1994 outbreak of pneumonic plague in Surat, India's
twelfth largest city. Laurie Garrett and, at greater length, Ghanshyam Shah have both discussed the Surat
experience “as a warning of epidemics to come.” A city of textile and diamond-cutting sweatshops and
slums with one toilet for every 150 people, Surat epitomized the polarized condition of urban health care
in most of the Third World: a small modern sector existed for the affluent, and a wretched mixture of in-
adequate public medicine and sheer quacksterism sufficed for the rest of the population.
Shah describes a “public health system [that] has not only gone downhill in its delivery system but
also lost credibility. Even the poor do not trust it.” Although Surat had no shortage of doctors, most of
them were in private practice, “motivated by a quick profit. Ethical values among medical professionals
are disappearing very fast.” 307 As patients began to present plague symptoms, the doctors were the first
to flee the plague. “They were totally unprepared for what followed. The private doctors panicked. Eighty
percent of them fled the city, closing their clinics and hospitals and abandoning their patients. The fear
in those physicians' eyes did not go unnoticed by the populace, and rumors of a great impending disaster
spread swiftly among the largely illiterate masses. Surat's middle class discreetly packed their bags and
slipped out of town.” 308
Within days, wild rumors had overrun India, antibiotic stocks had been depleted, and Delhi had been
forced to send the elite Army Rapid Action Force to quarantine Surat's slum dwellers from fleeing in the
footsteps of the middle classes. The outside world, meanwhile, began to quarantine India, screening In-
dian jets or banning flights altogether; the Gulf states even stopped postal communications with the sub-
continent. “WHO,” Garrett writes, “did little to slow the [international] stampede toward hysteria or to
stifle the opportunistic shouts of boycott.” India appealed for international assistance, but few countries
had inventories of plague vaccine, and new production would take six months. 309
Fortunately the plague was contained in a week: “For many . . . a miracle,” writes Shah. Experts debate
whether the massive application of antibiotics (tetracycline and chloramphenicol) was decisive or whether
the plague bacterium simply became less virulent through evolutionary modification. Nonetheless, the im-
mediate explosion of panic, the desertion of private doctors, the hoarding of antibiotics, the absolute lack
of confidence in government, the use of force to quarantine the poor, the silence of WHO Director-Gen-