Be very afraid

In "The Monster at Our Door," "City of Quartz" author Mike Davis warns that urban poverty has created the perfect conditions for bird flu to kill millions of people.

Published December 13, 2005 12:37PM (EST)

It's kind of difficult to identify Mike Davis' precise profession. A Google search turns up many descriptions: public intellectual, iconoclast, American social commentator, sociographer, scientist historian, old-time Commie, one-time big-rig driver. Whatever it may be, the defining characteristic of Davis is that he stays in no single discipline, preferring to combine them all, from urban theory to economic history to paleoseismology, to build a fresh perspective on whatever subject he has chosen for scrutiny. His first book, "City of Quartz" -- originally rejected as his history thesis -- lifted the veil on the Los Angeles power structure to reveal that racism, elitism and class struggle were embedded into the social architecture for preserving the ruling-class status quo, which is perhaps an overly simplistic way of describing a very complex book. The book, which came out in 1990, was well timed. "City of Quartz" also presaged the social unrest that erupted in 1992, earning Davis a strange status of modern-day prophet and making the book required reading in classrooms nationwide.

In 1998, "Ecology of Fear" continued Davis' critique of Los Angeles but added a new component: natural disaster. The book described the doom-laden geography of the city itself -- the flood plains, the fire zones, the earthquake faults -- and described the dangers those disasters represent, both on their own and when amplified by the worst disaster of them all: suburbanization. But he was not content to stay in Los Angeles.

Davis used part of his MacArthur Award funding to take one of his children to Greenland to see the melting Arctic with his own eyes. His books "Under the Perfect Sun," "Late Victorian Holocausts" and "Dead Cities" widen the geography and range of topics of Davis' interdisciplinary investigation. His latest book goes global. "The Monster at Our Door: The Global Threat of Avian Flu" looks at the potential for an avian flu pandemic, but goes beyond the usual "killer bug" narrative by focusing on the intersection of epidemiology, globalization and the chronic poverty of the developing world.

What follows is my recent conversation with Davis, a man who named one of his own daughters Cassandra, after the one skeptic who said, "Maybe we shouldn't bring that wooden horse inside the walls of Troy."

Your latest book, about the avian flu, is very topical these days. So let's start there. We'll get everybody good and scared. Let's start with the basics. You were working on the topic a few years ago, before it was a big news story. How did you get interested in epidemiology?

This little book, "The Monster at Our Door," is a spinoff of another project called "Planet of Slums," and a chapter in it called "Slum Ecology." I was doing some research on population densities in the slums of very large, very poor cities like Mumbai [India], Kinshasa [Congo] and so on. As I accumulated data and compared it with the major slums of the 19th century -- the Lower East Side of New York, the East End of London -- it became clear that today's third-world slums are an order of magnitude larger than 19th century slums and even denser than the Lower East Side of our great-grandparents' time, and so I had to ask a question: What does this mean for the transmission of disease?

It's a Victorian relapse.

Well, we have a billion people on Earth by the official reckoning of the United Nations, living under dense, sprawled conditions in swamps with appalling conditions of sanitation. And in so many countries the public health infrastructure has been damaged by the International Monetary Fund and structural adjustment policies from the 1980s that forced hundreds of thousands of health workers in Africa and Latin America to immigrate. Now, so many urban people have no access to even elementary healthcare. In other words, it is indeed the Victorian world, writ large.

How does the avian flu fit in?

I decided, then, to take a contagious disease -- an emerging disease -- and think a little bit about what that would mean in terms of today's megaslums as incubators of disease. Avian flu was my choice, and I was somewhat stunned to discover that slums haven't really been factored in. Because, quite honestly, 98 percent of the debate that's occurring about avian flu and other possible epidemics and pandemics is simply richer people in the richer countries selfishly worrying about their own health. No one had thought about how global poverty creates a perfect medium to spread the disease.

Meaning, we're only worried about whether it will show up on our shores.

The sudden concern about avian flu is because Americans are finally realizing that it is a disease that won't respect borders or the barriers that separate the lives of the rich from the poor. According to estimates by the Bush administration, up to 2 million or more Americans could die of avian flu. And Americans, of course, have been left naked and largely unprotected by the brilliant policies of this administration, which, for example, immediately after its election put "abstinence education" on a much higher priority than influenza -- despite the fact that influenza, even in its normal, seasonal form, kills 35,000 or 40,000 Americans every year, a disproportionate number of those being elderly African-American people.

After September 11th, the defense agenda also got sidetracked by a lot of protection against biological weapons that are a much more distant danger than an avian flu pandemic.

When the administration decided that biowarfare was the great priority, they spent billions protecting us from Ebola fever and anthrax and smallpox. That was partly because of Washington's new emphasis on bioterrorism and the idea that Saddam Hussein had bioweapons, all of which was part of the pretext for invading Iraq. It was only late in the day that the administration suddenly embraced what the World Health Organization and others have been saying since the avian flu first leapt from birds to humans in 1997 in Hong Kong -- that this virus represents a real risk of being as deadly as the 1918 pandemic.

Which was extremely deadly.

It was the most single deadly event in human history, killing somewhere between 40 and 100 million people.

Avian flu is a big news story now, and there's been a lot of reporting on it, but still little context. Your approach to thinking about the deep ecology of disease is unique. You describe the social conditions that provide tinder for a pandemic spark: the livestock revolution, the agro-industrial poultry production and so on. How is the stage set for a potential pandemic?

I'll start with an anecdote. A few years ago I took my son to East Greenland. The East Greenlanders were the last population in the Northern Hemisphere to meet Europeans. In fact, two Danish naval lieutenants who finally managed to get up the treacherous coast of East Greenland were really expecting to meet Vikings, not Inuit. This was at a time when the germ theory of disease already existed in embryonic form, thanks to Koch and Pasteur. And so the East Greenlanders were intensely studied. At point of contact, they were a lean people, eating 98-99 percent seal meat. They had no infectious disease apart from the cold. Their health condition was probably the primordial condition of humans in the 90 percent of our history when we were hunter-gatherers. Then, there were no large concentrations of human beings -- or, more importantly, large enough concentrations of human beings living side by side with large enough concentrations of animals to allow animal viruses or bacteria to jump to humans and assume a chronic or epidemic form.

It was as if the Danish scientists in the 1890s studying East Greenlanders looked back through 10,000 years of human history, before the era infectious diseases -- because most infectious diseases came through the domestication of mammals and birds. That kind of disease is a product of dense populations or urbanization or large-scale agricultural society.

That's what creates "disease transitions"?

Yes. It seems that diseases have emerged in fairly abrupt fashion, in what historians of disease call disease transitions. When the Mongols created their wonderful Eurasian world empire and made commerce between the Yellow Sea and the Atlantic possible, they also created a pathway for diseases like the Black Death to reach Europe. Every major step in the biological unification of the human race brings a massacre of populations. The European arrival in the New World led to the deaths of 90 percent of the population there. Those were disease transitions. And there's broad agreement amongst historians of disease that we're living through a fourth disease transition.

Resulting from economic and social globalization.

Fifteen years ago, an anthology of infectious disease studies was published warning that globalization would bring back old diseases in more virulent forms and lead to the emergence of novel, new diseases. There are various reasons: changing barriers between human and wild animal populations, integrated commerce and the absence of a counterpart investment in global public health. A few years later, Laurie Garrett wrote a Pulitzer Prize-winning book, "The Coming Plague," much to the same effect.

Why is China the geographic origin of these coming plagues?

In the past, it was believed that almost all influenza originates in South China, where there's this highly successful, extraordinarily productive agriculture that mixes domestic birds with pigs and fish and human beings. It's an ideal crucible for bird diseases passing to mammals and ultimately to humans.

A widening crucible, as China expands, urbanizes, industrializes its agriculture --

A little footnote here: Since the 1980s, 200 million people have left the Chinese countryside for Chinese cities. In less than a decade, China has added more people to its cities than did all of Europe in the 19th century, the so-called age of industrial revolution and city building. These people in the cities are demanding more protein, and that demand is being met with chicken. Chicken is now the second major protein after pork, which it will soon replace -- if Avian flu doesn't scare everybody off chicken, that is.

This has created unprecedented concentrations of poultry. In Southeast Asia, a lot of the chicken is manufactured by a huge company based in Thailand called CP, which has created an enormous, multinational factory-farming poultry operation. CP, incidentally, was involved in covering up the outbreak of avian flu in Thailand, and it even shipped sick chickens to Europe for sale. So you have these factors: an integrated, industrialized system of poultry production that looks more like the continuous flow of an oil plant than anything looking like animal husbandry; the fantastic rise in demand for animal protein; the increasing concentrations of people in larger and larger cities, many of them poor. Across Southeast Asia, the huge poultry farms sit side by side with small poultry farms, wild birds and human populations.

It seems like these factors clear a wide open path for new disease. Massive industrialized poultry provides a medium for the flu to move from a rare disease among wild migrating birds to the chronic, recurring bird epidemic that it has become. Since the disease mutates so adeptly, it then jumped species. And then it's a matter of time before a few more mutations or a combination with human influenza makes it communicative between people.

It is an unprecedented phenomenon. This is happening not only in Asia. Two years ago, a different strain of avian flu jumped to people in Holland, killing a veterinarian with very similar symptoms as those in Southeast Asia. Last year, the same thing happened in British Columbia. People got sick but nobody died. What's happening, essentially, is that we have changed the ecology of influenza. We provide food for its survival and evolution. Each time it moves into a new niche, H5N1 jumps another species barrier that was believed to be insuperable. Cats didn't get influenza. They do now: This thing killed most of the tigers in the Bangkok zoo. And every time it moves geographically or crosses species, it diversifies the opportunities to change itself into a form that would spread in the same way ordinary flu does.

And unlike SARS, which caused a huge world scare in 2003, avian flu would be very difficult to quarantine. Because a person with SARS is contagious while also symptomatic, whereas with the flu, you're contagious before you actually get sick.

And this means that flu can, because it spreads easily as a respiratory infection, avoid almost any barrier put in its path. It's already on the move. Avian flu is in Russia, and arriving at the gates of Europe. More disturbing, the disease has almost certainly migrated with infected wild birds to the great lakes of East Africa. There, it essentially goes off the radar screen because there is no surveillance system. Countries like Ethiopia won't even discuss the issue with the World Health Organization. Countries like Uganda and Tanzania would love to be able to monitor avian flu, but they don't have the means to do it whatsoever. So right now, this disease with its vast potential to become the second great plague of globalization after AIDS/HIV just submerged, and when it reappears, it may be too late.

So in addition to the lack of defensive medicine, the missing public health defenses in the Third World represent a breach in the walls.

No one in Washington has proposed funding resources that would allow East Africans to match the level of surveillance that Southeast Asia has. And while all this has been happening, the basic work of defending humanity against infectious disease, which involves continual development of new antibiotics, vaccines and antivirals, has been totally abdicated by the pharmaceutical giants. Those companies have no interest in making antibiotics or vaccines or antivirals because they are unprofitable. Infectious diseases don't create lifelong, expensive demand for medicines the way that chronic conditions like diabetes or heart disease do. Nor are they as profitable as culturally defined illnesses like erectile dysfunction, the darling of the pharmaceutical industry. There is one drug for diabetes that earns more than the revenue from all vaccines and antivirals put together.

Should the government be stepping in? Bush's recently announced plan earmarks money for this kind of research -- not enough, and it's about time, but is that a step in the right direction?

There's a few of us old enough to remember that, for instance, the influenza vaccine was originally developed by Jonas Salk for the U.S. Army in the Second World War. It was manufactured by the federal government, which used to actually make drugs, but no more. The Bush administration has now offered billions of dollars in subsidies to [Big] Pharma, which strikes me as inherently ridiculous. The most that any politician in Washington, Democrat or Republican, can think of doing apparently is to lay billions of dollars in guaranteed profits at the feet of the pharmaceutical companies, to waive all questions of liability for the vaccines and products, and then beg them to produce these vaccines and antivirals. The old-fashioned socialist in me wonders, Why shouldn't the federal government, in association with the public universities that produce most of the raw research that gets turned into these products, not produce lifelong medicines for free -- as a human right?

Some people ask why we should worry about a disease for which we know of fewer than 200 human cases. When we live in a world where millions of children die each year of diarrhea, malaria and even a lack of clean water, isn't this a fantastically rare disease?

And some people ask whether Bush's invocation of the avian flu wasn't just a plot to give money to the drug companies and divert attention from other issues. It is a reasonable question. The reason there should be real alarm is simply the experience of 1918. That was an influenza almost entirely novel to the human immune system, and it killed about 2 percent of humanity. Likewise, H5N1 is entirely new. And, more startling, researchers recently reconstructed the genome of the 1918 influenza and brought the virus itself to life for study, and they discovered that it was also a bird flu that jumped species, just like the emergence of the H5N1 avian flu of 1997.

Let's talk a bit about the public health issue. The public health infrastructure in the United States is suffering. We've seen the HMO revolution reduce the number of beds, and it's very clear, as we saw in Toronto with SARS, that in the case of even a small, localized outbreak, our public health system would be overwhelmed instantly. As a policy matter, massive public health revitalization ought to be at the top of the agenda. One of the things I kept wondering last year when I was covering the presidential campaign was why the Democratic side never equated all the resources spent on Iraq with the missed opportunities to make a sort of national security preparedness effort. The $200 billion thrown at Iraq could have been so much more efficiently spent on the public health infrastructure. As politics, it seems to be a no-brainer, a twofer: Invest at home, and address national security at the same time.

You talk about this a little bit in the book -- how the amount spent on these kinds of public health preparedness in the last three years was a just couple of billion dollars, less than we spend in 10 days in Iraq. Even before September 11th, everybody in the security sector was talking about how the biggest single thing we could do defensive-wise was to rebuild the public health infrastructure. But people really balked at the price tag: $40 billion. Now we've spent hundreds of billions in Iraq. With that kind of money, we could rebuild the entire public health system from the ground up. We could make the whole country like Switzerland, with transformer mountains that turn into hospitals, robots dispensing vaccines, everyone equipped and trained with lifesaving techniques. So I'm asking you to address the clear politics of the avian flu.

That's true, and more. The politics of public health anywhere begin with nutrition, and even right here in California we have a shockingly large number of children who go to bed hungry every night. We have malnourished children and malnourished adults. Fifteen percent of the children in Los Angeles have suffered from malnutrition. If the first level of public health is nutrition, the second level is basic immunization. Immunizations and vaccines should be an absolute human right in this country, freely available to everybody. The third level is our local health facilities, which have been closed by the thousands across the United States in the recent years. The fourth level is hospitals and, above all, intensive-care facilities. Think about what would happen in the case of pandemic influenza, where you need to hospitalize an enormous number of people in intensive care and some degree of isolation. Los Angeles has lost something like 17 percent of its hospital beds since the year 2000, largely due to HMOs, which operate on the "just in time" system of closing hospitals, getting rid of hospital beds and raising the profit margins -- as if epidemics, and surges in intensive-care cases, will never occur.

Wasn't there a spike in normal influenza a few years ago that swamped the capacity of hospitals, private and public, in Los Angeles County?

That case is used now in textbooks. It's a real crisis. In San Diego, just after Katrina, they wanted to bring in 150 people from Louisiana with serious health conditions and offer them beds as a kind of gesture. Then they discovered those hospital beds didn't exist in San Diego County! In many ways, we're worse off than we were in 1918, when the country had a greater surge capacity and more hospital beds per capita than now.

It's absolutely incredible that the first-responder capabilities haven't been totally refurbished since September 11th.

Another dimension is that you need a community response, and what's most effective is giving people actual roles. As in the natural disaster planning in Japan, where there's an equivalent of the citizens alert. In San Francisco, the city identifies block by block anybody who has medical, engineering or law enforcement skills -- anything that would be useful in a disaster. This is because San Francisco has counted on being isolated by another earthquake for a matter of days with no outside aid. They've dealt with this by trying to create a grass-roots network, so everybody who has a skill is prepositioned and knows how to use it. That seems to make more sense than hoarding toilet paper and water and waiting to be dug out of the rubble, as we're told now.

The greatest danger, of course, in any pandemic is fear. Even if it wasn't that deadly we'd all be so scared that society would disintegrate. It's surprising how thin the veneer of civilization is.

That's what happens when you're left in a passive role -- when you're told you have no civic responsibilities; you know, it's each person for themselves, run to the hills, try and get some Tamiflu and hide it, keep it for your family. There's an atomization of society. That's what we have instead of the kind of civic solidarity that would exist if people had roles and if resources were available in communities on an equal basis.

Why, if this is all so obvious, and if you have so many medical professionals and good people trying to shout about this at the top of their lungs, why hasn't it improved? Why has this not translated into any kind of effective political protest or political action?

This brings us back to the absence in the country of a real opposition party. There's no political force capable of mounting serious battles on behalf of most of the basic issues for people in this country and abroad. John Kerry had every opportunity during the election to tack George Bush to the wall over the question of his failure to prepare for a pandemic influenza. It's an absolutely logical thing to do, particularly because the election was taking place in the middle of a flu crisis -- one of the two major vaccine suppliers collapsed in the fall of 2004.

When the Democrats do make noises, it seems the terms are framed by the Republicans.

That's why no one questions, for instance, the need to give away billions of dollars to the drug companies to get antivirals.

Let me try to end my endless riff with this. Roche is the pharmaceutical company with the patent, and therefore monopoly, on producing the antiviral medicine Tamiflu. It can save your life, and it's all made in a single plant in Switzerland. If you line up to buy it from Roche, like the Bush administration's doing, you stand in line for two or three years to get it. And then there won't be enough anyway. The administration is ordering 2 million courses. That's less than 1 percent of the population. This extremely limited supply sets up a "Sophie's choice" -- who will get this in an emergency?

Why are we waiting around? There's absolutely nothing to prevent the president of the United States from saying that the health of Americans overrides everything else, and we're going to start making Tamiflu and we'll have supplies in six months. It can be done, but it will never happen. And there's not, as far as I know, a single Democrat who is talking about this. Where is everybody? This is millions of people we're talking about. Wouldn't real leadership do something?

By Joshuah Bearman

Joshuah Bearman writes for LA Weekly, McSweeney's and The Believer.

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