This article was first published on the Stratfor website.
The author, George Friedman, is chairman and CEO of Stratfor, the
world’s leading online publisher of geopolitical intelligence. 

Word began to flow out of Mexico the weekend before last of well
over 150 deaths suspected to have been caused by a new strain of
influenza commonly referred to as swine flu. Scientists who examined
the flu announced that this was a new strain of Influenza A (H1N1)
derived partly from swine flu,
partly from human flu and partly from avian flu strains (although there
is some question as to whether this remains true). The two bits of
information released in succession created a global panic.

This panic had three elements. The first related to the global nature of this disease, given that flus spread easily and modern transportation flows mean containment is impossible. Second, there were concerns (including our own) that this flu would have a high mortality rate. And third, the panic centered on the mere fact that this disease was the flu.

News of this new strain triggered memories of the 1918-1919 flu
pandemic, sparking fears that the “Spanish flu” that struck at the end
of World War I would be repeated. In addition, the scare over avian flu
created a sense of foreboding about influenza — a sense that a
catastrophic outbreak was imminent.

By midweek, the disease was being reported around the world.
It became clear that the disease was spreading, and the World Health
Organization (WHO) declared a Phase 5 pandemic alert. A Phase 5 alert
(the last step before a pandemic is actually, officially declared, a
step that may be taken within the next couple of days) means that a
global pandemic is imminent, and that the virus has proved capable of
sustained human-to-human transmission and infecting geographically
disparate populations. But this is not a measure of lethality, only
communicability, and pandemics are not limited to the deadliest
diseases.

‘Pandemic,’ not ‘Duck and Cover’

To the medical mind, the word “pandemic” denotes a disease occurring
over a wide geographic area and affecting an exceptionally high
proportion of the population. The term in no way addresses the
underlying seriousness of the disease in the sense of its wider impact
on society. The problem is that most people are not physicians. When
the WHO convenes a press conference carried by every network in the
world, the declaration of a level 5 pandemic connotes global calamity,
even as statements from experts — and governments around the world —
attempt to walk the line between calming public fears and preparing for
the worst.

The reason to prepare for the worst was because this was a pandemic with an extremely unclear prognosis,
and about which reliable information was in short supply. Indeed, the
new strain could mutate into a more lethal form and re-emerge in the
fall for the 2009-2010 flu season. There are also concerns about how
its victims disproportionately are healthy young adults under 45 years
of age — which was reported in the initial information out of Mexico,
and has been reported as an observed factor in the cases that have
popped up in the United States. This was part of the 1918 flu pandemic
pattern as well. (In contrast, seasonal influenza is most deadly among
the elderly and young children with weaker immune systems.)

But as the days wore on last week, the swine flu began to look like little more than ordinary flu. Toward the end of the week, a startling fact began to emerge: While there were more than a hundred deaths in Mexico suspected of being caused by the new strain, only about 20 (a number that has
increased slightly after being revised downward earlier last week) have
been confirmed as being linked to the new virus. And there has not been
a single death from the disease reported anywhere else in the world,
save that of a Mexican child transported to the United States for
better care. Indeed, even in Mexico, the country’s health minister
declared the disease to be past its peak May 3. STRATFOR sources
involved in examining the strain have also suggested that the initial
analysis of the swine flu was in fact in error, and that the swine flu
may have originated during a 1998 outbreak in a pig farm in North
Carolina. This information reopens the question of what killed the
individuals whose deaths were attributed to swine flu.

While little is understood about the specifics of this new strain,
influenza in general has a definitive pattern. It is a virus that
affects the respiratory system, and particularly the lungs. At its
deadliest it can cause secondary infections — typically bacterial
rather than viral — leading to pneumonia. In the most virulent forms of
influenza, it is the speed with which complications strike that drives
death rates higher. Additionally, substantively new strains (as swine
flu is suspected of being) can be distinct enough from other strains of
flu that pre-existing immunity gained from flus of years past does not
help fend off the latest variation.

Influenza is not a disease that lingers and then kills people — save
the sick, old and very young, whose immune systems are more easily
compromised. Roughly half a million people (largely from these groups)
die annually worldwide from more common strains of influenza, with the
Centers for Disease Control and Prevention (CDC) pegging average
American deaths at roughly 36,000 per year.

Swine flu deaths have not risen as would be expected at this point
for a highly contagious and lethal new strain of influenza. In most
cases, victims have experienced little more than a bad cold, from which
they are recovering. And infections outside Mexico so far have not been
severe. This distinction of clear cases of death in Mexico and none
elsewhere (again, save the one U.S. case) is stark.

Much of what has occurred in the last week regarding the new virus
reminds us of the bird flu scare of 2005. Then as now, the commonly
held belief was that a deadly strain was about to be let loose on
humanity. Then as now, many governments were heightening concerns
rather than quelling them. Then as now, STRATFOR saw only a very small chance of the situation becoming problematic.

Ultimately, by the end of last week it had become clear to the
global public that “pandemic” could refer to bad colds as well as to
plagues wiping out millions.

The recent swine flu experience raises the question of how one would
attempt to grapple with a genuine high-mortality pandemic with major
consequences. The answer divides into two parts: how to control the
spread, and how to deploy treatments.

Communicability

The flu virus is widely present in two species other than humans,
namely, birds and pigs. The history of the disease is the history of
its transmission within and across these three species. It is
comparatively easy for the disease to transmit from swine to birds and
from swine to humans; the bird-to-human barrier is the most difficult
to cross.

Cross-species influenza is of particular concern. In the simplest
terms, viruses are able to recombine (e.g., human flu and avian flu can
merge into a hybrid flu strain). What comes out can be a flu
transmissible to humans, but with a physical form that is distinctly
avian — meaning it fails to alert human immune systems to the
intrusion. This can rob the human immune system of the ability to
quickly recognize the disease and put up a fight.

New humanly transmissible influenza strains often have been found to
originate in places where humans, pigs and/or fowl live in close
proximity to each other — particularly in agricultural areas where
animal and human habitation is shared or in which constant, close
physical contact takes place.

Agricultural areas of Asia with dense populations, relatively small farms and therefore frequent and prolonged contact between species traditionally have been the areas in which influenza strains have
transferred from animals to humans and then mutated into diseases
transmissible by casual human contact. Indeed, these areas have been
the focus of concern over a potential outbreak of bird flu. This time
around, the outbreak began in Mexico (though it is not yet clear where
the virus itself originated).

And this is key to understanding this flu. Because it appears
relatively mild, it might well have been around for quite awhile —
giving people mild influenza, but not standing out as a new variety
until it hit Mexico. The simultaneous discovery of the strain amid a
series of deaths (and what may now be in hindsight inflated concerns
about its lethality) led to the recent crisis footing.

Any time such threats are recognized, they already are beyond
containment. Given travel patterns in the world today, viruses move
easily to new locations well before they are identified in the first
place they strike. The current virus is a case in point. It appears,
although it is far from certain, that it originated in the Veracruz
area of Mexico. Within two days of the Mexican government having issued
a health alert, it already had spread as far afield as New Zealand. One
week on, cases completely unrelated to Mexico have already been
confirmed on five continents.

In all probability, this “spread” was less the discovery of new
areas of infection than the random discovery of areas that might have
been infected for weeks or even months (though the obvious first people
to test were those who had recently returned from Mexico with flu
symptoms). Given the apparent mildness of the infection, most people
would not go to the doctor. And if they did, the doctor would call it
generic flu and not even concern himself with its type. What happened
last week appears to have been less the spread of a new influenza virus
than the “discovery” of places to which it had spread awhile ago.

The problem with the new variety was not that it was so deadly; had
it actually been as uniquely deadly as it first appeared to be, there
would have been no mistaking its arrival, because hospitals would be
overflowing. It was precisely its mildness that sparked the search. But
because of expectations established in the wake of the Mexico deaths,
the discovery of new cases was disassociated from its impact. Its
presence alone caused panic, with schools closing and border closings discussed.

The virus traveled faster than news of the virus. When the news of
the virus finally caught up with the virus, the global perception was
shaped by a series of deaths suddenly recognized in Mexico (as
mentioned, deaths so far not seen elsewhere). But even as the Mexican
Health Ministry begins to consider the virus beyond its peak, the
potential for mutation and a more virulent strain in the next flu
season looms.

Mortality

As mentioned, viruses that spread through casual human contact can
be globally established before anyone knows of it. The first sign of a
really significant influenza pandemic will not come from the medical
community or the WHO; it will come from the fact that people are
catching influenza and dying, and are doing so all over the world at the same time.
The system established for detecting spreading diseases is hardwired to
be behind the curve. This is not because it is inefficient, but because
no matter how efficient, it cannot block casual contact — which, given
modern air transportation, spreads diseases globally in a matter of
days or even hours.

Therefore, the problem is not the detection of deadly pandemics,
simply because they cannot be missed. Rather, the problem is reacting
medically to deadly pandemics. One danger is overreacting to every
pandemic and thereby breaking the system. (As of this writing, the CDC
remained deeply concerned about swine flu, though calm seems to be
returning.)

The other danger is not reacting rapidly enough. In the case of
influenza, medical steps can be taken. First, there are anti-viral
medicines found to be effective against the new strain, and if
sufficient stockpiles exist — which is hardly universally the case,
especially in the developing world — and those stockpiles can be
administered early enough, the course of the disease can be mitigated.
Second, since most people die from secondary infection in the lungs,
antibiotics can be administered. Unlike with the 1918 pandemic, the
mortality rate can be dramatically reduced.

The problem here is logistical: The distribution and effective
administration of medications is a challenge. Producing enough of the
medication is one problem; it takes months to craft, grow and produce a
new vaccine, and the flu vaccine is tailored every year to deal with
the three most dangerous strains of flu. Another problem is moving the
medication to areas where it is needed in an environment that maintains
its effectiveness. Equally important is the existence of infrastructure
and medical staff capable of diagnosing, administering and supporting
patients — and doing so on a scale never before attempted.

These things will not be done effectively on a global basis. That is
inevitable. But influenza, even at the highest death rates ever
recorded for the disease, does not threaten human existence as we know
it. At its worst, flu will kill a lot of people, but the human race and
the international order will survive.

The true threat to humanity, if it ever comes, will not come from
influenza. Rather, it will come from a disease spread through casual
human contact, but with a higher mortality rate than flu and no clear
treatment. While HIV/AIDS boasts an extraordinarily high mortality rate
and no cure exists, it at least does not spread through casual contact
as influenza does, and so the pace at which it can spread is limited.

Humanity will survive the worst that influenza can throw at it even
without intervention. With modern intervention, its effect declines
dramatically. But the key problem of pandemics was revealed in this
case: The virus spread well before information on it spread. Detection
and communication lagged. That did not matter in this case, and it did
not matter in the case of HIV/AIDS, because the latter was a disease
that did not spread through casual contact. However, should a disease
arise that is as deadly as HIV, that spreads through casual contact,
about which there is little knowledge and for which there is no cure,
the medical capabilities of humanity would be virtually useless.

There are problems to which there are no solutions. Fortunately,
these problems may not arise. But if they do, no amount of helpful
public service announcements from the CDC and the WHO will make the
slightest bit of difference.