Influenza, or "the flu", is a moniker that has come, in the modern vernacular, to represent anything more severe then a cold but less severe than pneumonia. The reality is that a true influenza infection can be extremely debilitating. The influenza virus comes in many forms that continue to circulate in populations of animals, mainly waterfowl such as ducks or geese. The virus readily mutates, and if it mutates in just the right way, it can jump from one species of animal to another. These new hosts, confronted with a virus like none they have seen before, will either survive and develop life-long immunity or succumb to the virus and lose the race to reproduce. This biological dance has occurred throughout recorded history at relatively predictable intervals, when the promiscuous influenza virus has made its way around the world in epidemic waves.

Most recently, a specific strain of the virus, H5N1, has become disturbingly common in poultry populations in Asia. The first recorded appearance of this strain was in the bird flu epidemic that erupted in Hong Kong in 1997, killing six people and resulting in the destruction of almost every chicken on the island, about 1.5 million in all. Efforts to control that epidemic were successful, and the virus is thought to have retreated to its natural host, aquatic waterfowl, in the Guangdong, Hunan and Yunnan provinces in China, where it awaited an opportunity to return.

And return it did in 2001 and 2003, with major outbreaks in Chinese domestic birds that went officially undeclared to the international community but were unlikely to have been missed by Chinese officials. It was probably during the first of these epidemics that Chinese farmers, seeing their livelihood imperiled and with no government system of compensation for ill animals, began to use the antiviral medication amantadine in bird feed. Preventative use of human medications in otherwise healthy poultry is a common animal husbandry practice that is known to render the drug ineffective over time--and possibly useless for treatment of the human populations for which it was intended. When viral samples of the epidemics were finally obtained, it was determined that the H5N1 strain of influenza circulating in the Asian bird population was amantadine resistant, removing one arrow from a relatively small quiver of defenses against the human form of the disease. By early 2004 the virus had infected flocks in Thailand and Vietnam, resulting in tremendous losses to the Asian poultry sector--$15 billion by early 2005--and 108 human cases and 55 deaths in the region from December 2003 to July 2005. Each of these human cases, while tragic, can be looked at as a dodged bullet. Most of these individuals became infected from direct contact with poultry, but the virus did not mutate into a form capable of easy human-to-human transmission, a critical element to seeding a human epidemic. In April 2005 it was confirmed that the virus had crossed from poultry into pigs, long considered influenza's middle ground on its way to a sustained human host. This progression, scientifically unsurprising, offers many ominous signs of a brewing epidemic that could quickly escalate.

This round of influenza is not the first disease to jump out of the Chinese cauldron, nor will it be the last. Conditions in provinces such as Guangdong are the perfect milieu for disease. A dense human population living in close contact with a diverse range of wild and domestic animals creates an ideal opportunity for pathogens to form and propagate. Year-round hot, humid weather and the absence of rigorous hygiene standards further exacerbate the situation. Well-ingrained cultural preferences, such as purchasing food animals live, aggravate these environmental conditions, resulting in a veritable laboratory rife with infectious disease. In 2003 the world learned a painful lesson from the emergence of the Severe Acute Respiratory Syndrome, or SARS, virus that--aided by delayed disclosure by Chinese officials--migrated around the globe before being held at bay. It is with this hindsight that the world is now looking intently at how China deals with the current avian influenza challenge.

Looking the Other Way

To what extent would a growing influenza epidemic in China be reported swiftly to the international health community? Many postulate that a country with a history of strict information control and refusal of international access to known outbreaks--even threatening harm for deviation from the condoned message--would easily deny the first sign of an erupting influenza epidemic. This assumption was borne out during the SARS outbreak, resulting in tremendous international backlash and, ultimately, the resignation of high-level Chinese officials. However, when dealing with infectious diseases, a delay in disease detection is not always done purposefully, for infrastructural factors can complicate timely and accurate recognition of emerging disease. As such, there are two clear potential impediments to the discovery of an avian influenza outbreak in China: the intentional suppression of information and China's inability or unwillingness to identify and investigate suspicious situations in the first place.

Detection and identification of a disease outbreak require significant effort, especially in a country as large as China. There are costs associated with testing dead animals for disease, culling flocks or quarantining areas may be difficult to justify in a country with high levels of underlying disease. Influenza in particular can be transmitted between wild migratory waterfowl--often not showing ill effect from harboring the disease--to domestic flocks. Emerging illness in this environment requires an astute farmer to notice and report an increase in symptoms among his flock. Notification of this nature could easily lead to the destruction of all animals in the vicinity, a heady disincentive to quick notification of suspicious circumstances. The widespread use of the antiviral medication amantadine to treat and prevent avian influenza was probably a desperate attempt by farmers to protect their livelihoods rather than a practice mandated by government officials, although it likely would not have occurred without government knowledge. In the absence of a reimbursement system for culled animals, the cost of reporting the outbreak will be borne solely by the farmers, creating a significant challenge to detection of avian influenza for even the most transparent of political regimes.¹

In the post-SARS period, China has indicated a desire to improve disease detection and healthcare infrastructure. Health and disease data are purportedly flowing from medical practitioners and provincial governments upward through fewer political filters to the central government. Focus has been placed on inter-hospital communication in the more densely populated areas along the east coast to increase efficiency in identifying illness trends. On the agricultural front, increased surveillance and disease prevention in animals has been heralded, and improving circumstances surrounding the storage and marketing of live animals has been identified as a critical component of the fight against emerging infectious diseases. While these interventions are not sufficient to address the full scope of the problem, they are indications that some lessons were learned from the SARS epidemic.

Unfortunately, it is unclear in the short term the extent to which improvements are being implemented, or can be implemented, in the most vulnerable areas. Compliance with promulgated regulations affecting long-standing traditions of animal husbandry and cultural etiquette has proven less than complete. The most effective regulations on paper are useless if not actually put into practice, as appears to be the case with some Chinese food-handling practices. Further, the intellectual capacity and infrastructure necessary to build up epidemiological capabilities is difficult to scale up under the best of circumstances, let alone on the eve of an epidemic and under the watchful eye of the international community. Expanding hospital capabilities and infrastructure is a long-term project. Some necessary changes to agricultural policy can be made overnight, such as providing compensation for flocks culled in the line of disease prevention, but convincing an agrarian community to disclose diseased animals will likely take further reassurances. Time will tell the extent to which the trumpeted changes have materialized on the ground. In the meantime, China should be held politically accountable for not pushing further changes to remedy weaknesses of policy and practice; however, the dynamic nature of public health interventions must also be taken into consideration before attributing political malice.

In the absence of the ability to immediately plug the public health holes, China needs to be willing to engage the international health community for advice without the fear of losing face. A government announcement in mid-June stated that samples of avian influenza-related material couldn't be shipped overseas without prior approval from the Ministry of Agriculture. While not surprising, this effort to stem the dissemination of biological information directly impedes international efforts to understand and prepare for a growing problem. With a virus as feared and potentially costly as avian influenza, there will always be a desire to control the global perception of disease burden. However, effectively shutting down the Chinese scientific community's access to international engagement will greatly hinder their ability to understand and control the problem before it forces itself onto the world stage.

Inextricably Linked

While the international medical community and who will be key to Asia's ability to contain avian influenza, the effects of such an epidemic go beyond simple health threats. Globalization has led to increased interconnectedness of society in many areas--economy, media, travel--resulting in significant structural changes that would have a tremendous impact in the event of a large outbreak of avian influenza. Increased pressure on idle inventories has developed a global economy that hinges on just-in-time delivery of products assembled on far-off shores. The ease of importing components of manufactured goods, either for assembly or repair, has created a world that takes for granted the great degree of global interdependence required for the functioning of even the most mundane of products. Further, the availability of parts is critically dependent on the free movement of cargo and would be severely affected by any global restriction of the movement of goods. If assembly lines were forced to stop production for lack of inputs, breaking the just-in-time delivery chain, the economic impact would be tremendously magnified.