Canadians Face an Epidemic of Fear.
GREGORY FIELDS is a pharmaceutical maverick. He calls his company, Canadian Drug Delivery, based in Nanaimo, B.C., an "online pharmacy intermediary," which means, if you're looking for the best price on medication - anything from Amoxicillan to Zoloft - Fields will comb the globe to find it and have it shipped to your home. In some cases, you won't even need a prescription. Suddenly, business has exploded, and it's all thanks to one pill - an antiviral called Tamiflu that's selling like candy.
Tamiflu was recently found to be the only drug effective in treating H5N1, the deadly strain of avian INFLUENZA that has been spreading fear throughout Southeast Asia since late 2003, and may be heading west. The virus has already infected 115 humans, killing 59 - with 16 more people under observation in a Jakarta hospital - and ravaged commercial poultry flocks in China, Vietnam, Cambodia, Indonesia, Laos, Thailand, Hong Kong and Russia. The world's leading flu experts, including the World Health Organization, are warning that this could be the Big One, an apocalyptic nightmare to rival the most overwrought Bruce Willis movie. This month, Ottawa will host a major international conference to discuss preparations. "We're on a collision course to panic," said Dr. Michael Osterholm, director for the Center of Infectious Disease Research and Policy at the University of Minnesota, who prophesies a death toll upwards of 360 million, making the Spanish flu epidemic of 1918 look like a nasty sniffle. In a recent issue of Foreign Policy journal, he outlined the major plot points: "The reality of a coming pandemic cannot be avoided. If an influenza pandemic struck today, borders would close, the global economy would shut down, international vaccine supplies and health care systems would be overwhelmed-and panic would reign."
IT'S A tremendous amount of hysteria for something that hasn't even happened - and may never happen, if past experience is any indication. For almost a decade, North Americans have been bracing for one cataclysmic threat after another - superbugs, bioterrorist attacks, apocalyptic plagues. There have been real threats (Y2K, West Nile, mad cow, SARS, anthrax), but in each case, the amount of paranoia surrounding the threat has been exponentially larger than the threat itself.
So fear has become the EPIDEMIC - and safety, or our perceived lack of it, an obsession. Perhaps what's most unsettling is that the definition of what it means to be safe keeps changing. Six years ago, being safe meant building a subterranean bunker and stocking up on bottled water and duct tape in the event the Y2K bug should destroy the world's computers and bring about global anarchy. More recently, safety has meant slathering oneself with DEET to ward off West Nile-infected mosquitoes; swearing off burgers, those purveyors of mad cow disease; donning paper masks on subways to avoid contracting SARS; and stocking up on Cipro, on the off chance some maniac should unleash anthrax in our midst.
This minute, it means having an ample supply of Tamiflu. Experts are saying that when - not if - an outbreak occurs, there will be a critical global shortage of the drug. Governments and multinational corporations are frantically stockpiling it. Ordinary North Americans and Europeans, fearing there won't be enough left for them and theirs at the crucial moment - and lacking faith in public institutions to protect them - have taken to creating survivalist flu blogs and building their own anticipatory stashes.
For Fields, who sells Tamiflu prescription-free, it's meant filling orders, 10 per cent of which are coming from Canadians, at a rate of 13,000 boxes (or US$877,500 worth) per week. "It's unbelievable," he says. "Most people buy it for their whole family. Consumers, doctors, professionals - anyone, you name it." In his office, he's set aside about 80 boxes for personal use since, rumour has it, one course might not be enough. "Better safe than sorry."
THERE'S NO denying that avian flu is genuinely scary. As the latest end-of-days hypothetical, the virus has all the makings of a media blockbuster. It's strange and new and it can mutate quickly into unpredictable, ever-more-threatening forms. Thanks to migratory birds and global travellers, it has the potential to blanket the world quickly. Worst of all, there is no known vaccine for the virus, which accompanies a horrifying list of symptoms including a high fever, serious respiratory complications, extreme body aches, multiple organ failure and often death in 72 hours or less.
Eight years ago, the H5N1 strain infected its first 18 people in Hong Kong, six of whom died. This was the first time the virus was found to have been transmitted directly from bird to human. Later, it resurfaced in Cambodia, Thailand, Vietnam and Indonesia, resulting in more human deaths and the destruction of millions of chickens. Scientists have been debating ever since the likelihood that it will mutate into a form that is readily transmittable between humans - a scenario that would produce one of the most deadly viruses humanity has ever seen. Flu epidemics operate in cycles, experts say, and we're well overdue for the next one. In the U.S., scientists are working on developing a preventative vaccine, but since no one can predict what a mutated virus would look like, no surefire vaccine can be developed until an outbreak actually occurs. London-based virologist John Oxford, one of the world's leading flu experts, has likened it to "a tsunami rushing toward us."
FOR NOW, though, it all remains hypothetical. In his new book, The Politics of Fear, U.K. sociologist Frank Furedi suggests that the more secure a society is - in terms of health, wealth and political stability - the more likely it is to fixate on theoretical menaces. In turn, the more obsessed we become with keeping safe, "the more insecure we become," he says, "because safety becomes this elusive quest you never achieve. Even if you never leave the house, you can always slip in the bathtub."
In life, there is much to fear (even fear itself!), and a certain amount of paranoia is necessary for survival since it compels us to implement reasonable precautions, like condoms and bicycle helmets. But what Furedi is describing is a culture plagued by free-floating anxiety, exacerbated by the dramatic and devastating news events of our time: tsunamis, hurricanes, 9/11. It's not that we're more afraid now than we used to be; it's that the things we fear are less tangible, and the fear itself more diffuse and promiscuous. It will affix itself to global terrorism or earthquakes one day, killer bees the next. And when people feel a sense of general insecurity, says York University sociology professor Donald Carveth, their natural response is to try to identify the source, to give the enemy a face and a name, and exert whatever measures of control they can over it. "To feel threatened by vague, abstract forces - that's terrifying," he says. "When you've got an enemy, no matter how powerful he is, once he's been identified, you can get him in the sights of your guns."
Hence avian flu - the latest menace we can take precautions against in our efforts to feel protected.
HELPING to accelerate bird flu mania is a growing band of flu bloggers - techno-agitators and armchair epidemiologists who see each new flu report or update as a call to arms, and use their blogs as a medium to inform and scare the daylights out of each other. "I got on the pandemic flu beat in 1997 when H5N1 was first identified," says Virginia-based Melanie Mattson, a 51-year-old writer and the proprietor of the flu blog Just a Bump on the Beltway. Mattson feels the mainstream media isn't doing enough to warn the masses. She and others say we can't trust our public institutions to save us. (Just look at what happened in New Orleans!) "What we're trying to do," Mattson declares, "is save lives."
The amount of effort that goes into flu blogging is astronomical: one of Mattson's regular posters is a woman named CanadaSue, a nurse from Kingston, Ont., who has constructed a 23-part scenario that details what her city of 112,000 would look like during a pandemic. "Flu bloggers have developed a kind of online community," says Crawford Kilian, a 64-year-old communications teacher from Vancouver who started out blogging about SARS, but has since switched his focus to H5N1. "But now, after watching what's happened in New Orleans, I began biting my lip about 'what if' and 'what's more,' " he says. "What if we get something like a hurricane and we get avian flu? How do we cope with it then?"
WHETHER people realize it or not, fear also serves a real, practical function - it mobilizes us and informs our political and consumer decisions in all sorts of ways. (Y2K, for instance, generated $100 billion for the global economy - a boon for computer nerds everywhere.) But the more powerful fear becomes as a public currency, the more advocacy groups, politicians, charities, media and companies like Canadian Drug Delivery - "fear entrepreneurs," as Furedi calls them - try to manipulate it to produce a desired outcome. "There are great scientific experts saying that avian flu is a problem, but there always are," says Furedi. "If you look at the research that's published, it's always 'Research says that such-and-such will happen if you suntan,' and attached to that is usually a demand for more research money. That's how the fear market is created."
Tamiflu, or oseltamivir, the magic balm on offer for treating avian flu, is produced by the Swiss pharmaceutical firm F. Hoffmann-La Roche Ltd. and belongs to a group of medicines called neuraminidase inhibitors, which attack the flu virus and prevent it from spreading inside the body. The problem is, it's a complex drug and a single dose takes 12 months to produce. Currently, it's only manufactured in a single plant in Switzerland, but the company has plans to expand its facilities. "We've doubled our capacity this year," says Paul Brown of Roche Canada, "and as we go into next year, it will increase again. We'll have more production sites coming on stream. But the problem is, whether we talk about vaccines or Tamiflu, none of those will be available in supply to meet the surge of demand that one would see in a pandemic situation."
Scarcity breeds an every-man-for-himself ethos - and all Canadian notions of equity and not jumping the queue go flying out the window. Not surprisingly, Roche takes the official position that people would be wise to get themselves a stash. "We think it makes good sense for people," says Brown. "If they want to have a few packs of Tamiflu in their cabinet for themselves in the event of a pandemic, then there's a very solid logic for doing so."
In Canada, however, people can't rely on their doctors to give it to them for pre-emptive use because Tamiflu is only licensed by Health Canada for use as a treatment of flu infections that have actually set in. So, in recent months, dozens of websites like Canadian Drug Delivery have sprung up to offer Tamiflu by circuitous means. ("What happens when thousands contract the virus at the same time?" the website asks. "Will you be able to visit the doctor in time? Will there be enough Tamiflu in stock?")
Customers place their orders on Fields' website. He and his team then have one of their licensed affiliate pharmacies - dotted around the globe where prescriptions for Tamiflu aren't required for international export - fill the orders and ship them directly to the customers. "We've had clinics order it," he says. "They were starting a new clinic in the States and they needed a gimmick to get people in, so they ordered 100 boxes to give out as freebies."
Because Fields never actually touches the merchandise, he doesn't need to be certified by any professional board. Technically, what he's doing doesn't violate any laws - he's simply exploiting a loophole. "It's not illegal," says Andy Troszok, president of the Canadian International Pharmacy Association. "But in my mind, this is completely unethical. It's breaking all the laws of pharmacy and medicine."
Still, demand is so strong that only one of Canadian Drug Delivery's three distributors - this one out of Switzerland - has any stock left. "It's a chase game," says Fields. "We have enough stock for the next two to three months, but we're running around the world trying to find more suppliers." A few months ago, the company was selling Tamiflu with a 2009 expiry date, but that's all sold out. Now they're down to 2008.
Bioethicists point out that hoarding a drug that is in precious supply globally poses a bit of a dilemma. It may very well sit unopened in medicine cabinets until well beyond its expiry date - while people in high-risk parts of the world scramble to get their hands on a single pill. Kilian, for one, has declined to secure any for himself. "Maybe that's because I grew up in the U.S. during the Cold War, when people were building fallout shelters and buying guns so they could shoot their neighbours if they tried to break in when the bombs started falling," he says. "My response then was, that's a really wretched way to go." Moreover, there is no guarantee Tamiflu will even be effective against a mutated strain of avian flu. "I think it's unwise [to stockpile], in that it's a draw on a commodity that we don't even know will work," says Dr. Carolyn Bennett, Canada's minister of public health. "It worries me that people think having it should make them feel better."
GENERALLY speaking, when it comes to channeling fear, people don't tend to factor in probabilities. That's because we tend to most fear the scenarios that are the most spectacular and unfamiliar, rather than the most likely. "SARS was a good example," says Jeffrey Rosenthal, a University of Toronto statistics professor and the author of Struck by Lightning: The Curious World of Probabilities. In a recent analysis of the SARS outbreak of 2003, the Washington-based National Academy of Science's Institute of Medicine (IOM) concluded that the public mania was dramatically heightened by the newness of the disease, which originated in China; the relatively high case-fatality rate (even though most of the people who died were elderly and already had compromised immune systems); the speed of its global spread (within weeks it was in 28 countries, including Canada); and public uncertainty about our ability to control it.
In Toronto in 2003, hospitals began turning visitors away. Thousands of people were quarantined. As panic intensified, restaurants and hotels emptied, and concerts were called off. The World Health Organization issued an advisory against non-essential travel to Toronto. As a result, the IOM study concluded, this alarm likely exacerbated the economic blows that, in Canada, included hundreds of millions of dollars in lost tourism revenues. "The total number of people killed by SARS in Canada was fewer than 50," says Rosenthal, "and in fact more people were actually killed by the flu that same year than were killed by SARS, and yet nobody cancelled their travel plans or wore a mask because of influenza."
Perhaps what we can learn from SARS is perspective. "There are very real threats, but they don't always have to follow a Hollywood disaster movie script," says Furedi. "Flu epidemics do occur. It's part of our human experience. We've survived it before and we're in a much better position to deal with it now than ever before. We have ways to contain these things that would've been unthinkable even 10 years ago."
The fact of the matter is, we've been awaiting an imminent H5N1 outbreak for several years, and even in China, a country of 1.3 billion people, an epidemic has not materialized. We have no way of knowing whether the virus will mutate into a form that will spread easily among humans. And even if it does - unlike the 1918 situation when Spanish flu spread quickly and quietly in the disease-infested trenches of the First World War - today we have means to anticipate, plan for and contain viruses. The Public Health Agency of Canada has even devised the Canadian Pandemic Influenza Plan - which maps out how Canada will prepare for and respond to a flu pandemic. It includes establishing the infrastructure for pandemic vaccine production, managing a real-time alert system, and establishing quarantine services at international airports in all major centres. Also, bit by bit, Canada is creating a national antiviral stockpile (Roche processes orders on a first-come-first-served basis). The government has currently secured about 26 million doses of Tamiflu - enough to treat roughly eight per cent of the population - and has plans to eventually have enough to treat 20 to 25 per cent. (Antivirals will be distributed based on likelihood of falling ill - health care and essential-service workers first, healthy children older than 2 last.)
It could happen. Mathematically, says Rosenthal, chances are it won't. But even in the event of an avian flu outbreak, the likelihood is that we'll survive. "It's really interesting - the impact of fear," says Dr. David Butler-Jones, Canada's chief public health officer. "Something's going to get us. We're all going to die. It's a balance of preparation and getting on with life. The things that really make a difference are pretty basic: eating well, being active, having friends and family. It's the basic stuff that our grandparents could have told us."
In a recent essay, Furedi wondered if maybe the distinct feature of our time is not so much the cultivation of fear, but the cultivation of vulnerability. "And if vulnerability is the defining feature of the human condition," he concluded, "we are quite entitled to fear everything." Sometimes, it seems, we already do.
Maclean's October 3, 2005