"Communicable diseases know no borders, and the global village is the biological scale on which all people and populations are connected. While emerging infections are inextricable from global interdependence in all versions of these accounts, however, the threat they pose requires a national response. The community to be protected is therefore configured in cultural and political as well as biological terms: the nation as immunological ecosystem."
Typically, says Wald, this involves stories of threats to national health security that are personalized as irresponsible 'bad guys' (e.g. carriers that are coded as 'superspreaders' and 'pestilent foreigners') as well as stories of national health security 'good guys' (normally national doctors or soldiers who battle the disease and protect the homeland). Most significantly, the outbreak narrative also always involves some sort of externalizing and projecting move that depicts the origins of a disease as located outside of the nation-state in a usually exoticized 'hot zone'. In this regard, her account is similar to that of Paul Farmer in his acclaimed book Aids and Accusation.
The subtitle of Farmer's book says it all: "Haiti and the Geography of Blame". In this particular text the geography of blame in question is the one that - wrongly - imagines and/or depicts Haiti as the 'ground zero' or launching pad from where HIV first entered the US. Farmers shows how erroneous and tendentious this geography of blame is, but also makes clear how it has worked nonetheless to serve hegemonic interests. He explains thus how it is caught up in other 'blame the victim' discourses that have allowed US health experts to tolerate or legitimate sub-standard care for Haitians.
Today the writings of Wald and Farmer serve as important reminders that we need to be alert for the ways in which outbreak narratives about swine flu may be used simply to blame Mexicans and Mexico (Wald has also reminded readers in an op-ed that they distract us from underlying problems of global poverty too). Examples of swine flu geographies of blame are proliferating fast and have already attracted critical commentary, including Michael Calderon-Zaks' useful review of how they relate to older examples of anti-Mexican public health racism in the US. Have you seen any geographies of blame? What do they look like? Are there any that complicate the sorts of examples discussed by Wald and Farmer? For instance, what about stories and activist campaigns linking the swine flu outbreak to the US pork producer Smithfield and its operations in Mexico. To be sure, such accounts still identify an external hot zone outside the U.S., and yet they also clearly implicate a US corporation, and, by extension, US consumers and the NAFTA-enabled transnationalization of industrial agriculture, in the creation of viral breeding grounds in the first place. For more on this see the post on Wallace and Davis.
Today the writings of Wald and Farmer serve as important reminders that we need to be alert for the ways in which outbreak narratives about swine flu may be used simply to blame Mexicans and Mexico (Wald has also reminded readers in an op-ed that they distract us from underlying problems of global poverty too). Examples of swine flu geographies of blame are proliferating fast and have already attracted critical commentary, including Michael Calderon-Zaks' useful review of how they relate to older examples of anti-Mexican public health racism in the US. Have you seen any geographies of blame? What do they look like? Are there any that complicate the sorts of examples discussed by Wald and Farmer? For instance, what about stories and activist campaigns linking the swine flu outbreak to the US pork producer Smithfield and its operations in Mexico. To be sure, such accounts still identify an external hot zone outside the U.S., and yet they also clearly implicate a US corporation, and, by extension, US consumers and the NAFTA-enabled transnationalization of industrial agriculture, in the creation of viral breeding grounds in the first place. For more on this see the post on Wallace and Davis.
There is no ultimate lesson yet from this epidemic since it is probably in its infancy. We do not know its transmission dynamics, we do not know its origins, and one can only deduce something about genetic recombination based upon prior experience. Frequently, these reassortments occur in the portions of China near Hong Kong--but the definitive statement that "this is how it happens" is only tentative. All that we know is that the RNA genome of this virus includes segments from "avian influenza," "human influenza," and swine influenza. None of these are specific to these species though.
ReplyDeleteTransmission dynamics include: 1) the R(0). How many people may be infected from a single case, on average, and at the population level? 2) How does this vary based upon location and setting? These are just two such "dynamics." What is the case fatality ratio ("rate") for this influenza subtype? In other words, what percentage of people who contract the infection and become symptomatic actually die from it? So far, there is no clear explanation for the vast disparity of the Mexican scenario, and the early epidemic in the US. At this point, the CFR in the US appears to be no greater than during any seasonal ("regular") epidemic due to genetic drift. Annually, between 25,000 and 35,000 people die of this virus in the US. Put another way, there are approximately 100 deaths per day (although very concentrated in late fall to early spring) in the US alone. Is this strain of influenza any worse than any other, either in terms of infectivity, or virulence, or case fatality? We do not know yet. Whatever happens, there will be, in retrospect, overreaction and underreaction, depending upon the action, the context, and the ultimate descriptive epidemiology of this outbreak.
Many large-scale health interventions by WHO and by other actors have failed because of lack of knowledge of local culture, cultural norms, behaviors, and conditions. This is not the time to let this happen again. I think that this epidemic will manifest itself very differently in the slums of Accra, Ghana, where I work, than in Health Sciences complex at the University of Washington, where I also work. Actual reporting lags days to weeks behind actual conditions, so we do not even know what is currently happening, especially in the more economically impoverished parts of the world, where there is no accurate reporting because passive surveillance is such a poor indicator of a dynamic situation.
Finally, we need to realize that the WHO has far less power to act than we think. It is agency of the UN, with a huge and unwieldy bureaucracy (there have been series on this in the last 5 years or so in the BMJ, Lancet, and other places. It is not a health agency charged with action.
Jonathan Mayer
Epidemiology/Geography/Global Health/Medicine
Univ of Washington
President, Health Improvement and Promotion Alliance