Vital Systems Security

I have for a while now encountered skepticism from people who believe that the number of Novel Swine-Origin H1N1 influenza cases (especially in New York and Massachussetts) is being vastly underreported by public health authorities.  The claim is intriguing because of the fact that public health authorities are not testing comprehensively for H1N1, instead only testing cases of severe illness.  Thus the cases of “confirmed” H1N1 may be far lower than the actual total number of cases.

How is influenza diagnosed and why isn’t every suspected case tested?  First, testing for influenza is a multiple-tiered process.  Tracking the NYC Department of Health “Health Alerts” over the course of the epidemic demonstrates the rationale and infrastructure behind the shifting diagnostic policies in one public health department.  In the first report, from April 24th, the Department requested that physicians seeing patients in the following categories test for influenza A using a nasopharyngeal swab and a commercially available rapid test, PCR or immunofluorescence test (e.g., DFA or IFA):
(1) hospitalized patients with severe febrile respiratory illness of unknown etiology, or
(2) outpatients with influenza-like illness (ILI) who have traveled to California, Texas, or Mexico within the past 7 days
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A World Health Organization official today signaled that the agency is stepping back from plans to develop a way to grade pandemic severity, because its experts believe severity will vary from place to place, making the development of a severity index difficult and its use impractical.

In a recent Newsweek article on the swine flu pandemic, Laurie Garrett ties together two seemingly disparate problems: the global meat industry and “viral sovereignty.” First, she analyzes the swine flu outbreak through the lens of disease ecology, whose vision of pathogenic globalization was a central element in the “emerging disease” framework as initially articulated in the late 1980s.  In this vision, new diseases are constantly emerging due to the conjuncture of natural ecological processes and massive human transformations of the environment:

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A new study on the swine flu virus by Neil Ferguson and his colleagues, published in Science, has shown that transmissibility of the swine flu virus is substantially higher than seasonal flu and comparable with lower estimates of R0 obtained from previous pandemics. The reproduction number (Ro), defined as the number of cases one case generates on average, is a key measure of transmissibility.

http://www.sciencemag.org/cgi/content/abstract/1176062

Over the last few weeks – both before and after they were officially released – a great deal of critical attention has been turned to the “stress tests” that were organized by the Treasury Department to determine the health of major U.S. banks. A major criticism of these tests has been that the “adverse scenario” used in them is actually not that adverse. It makes assumptions about economic growth, employment, rates of mortgage default, and other factors that hardly constitute a “worst case scenario.” Consequently, argue these critics, the “stress tests” do not really “stress” the banks at all. 

In light of this criticism, a discussion has emerged about what the point of these stress tests really are, and I think that this secondary discussion is quite interesting for us in understanding how these stress tests relate to some of the phenomena that we have been thinking and writing about. A major argument that has been made by defenders of these stress tests – and it is an argument that I find quite convincing – is that in fact the “adverse scenario” is in no way shape or form intended to present a “worst case” scenario. We know what would happen in a worst case scenario: the government would take these banks over and guarantee their deposits. Instead, the stress tests are supposed to present a “moderately bad” scenario, one in which it is possible that a system of regulation based on mandated reserve ratios or capital requirements would allow banks to weather the storm without further government intervention.

The point I would make here is this: In some important ways, the stress tests resemble catastrophe modeling on a technical level. That is, they collect a tremendous amount of data about the banking system, and then run simulations to understand how it would respond to certain adverse conditions. But on the level of political technology it works differently. In areas such as civil defense, pandemic preparedness, or catastrophe insurance, the point was really to understand how a system would respond if the worst imaginable thing actually came to pass. In the case of the stress tests, the question is whether the system could make it through a reasonably adverse economic scenario without external intervention.

Taking this point one step further, it seems that what is emerging is perhaps a two-tiered system for financial system security. On the one hand, there is continued acknowledgement that in the absolutely worst cases – the “unthinkable” economic emergencies – the remedy will be government intervention to save the banking system. On the other hand, mechanisms like the stress test are intended to ensure that the banking system could survive on its own under moderately adverse economic conditions. In the future, the stress test might, of course, serve another role as well, as was suggested yesterday in the New York Times Breaking Views blog: It could be institutionalized as the basis for a more flexible kind of financial regulation, one that did not set hard and fast rules about capital requirements or reserve ratios, but that used much more intensive exchange of data to assess banks financial position, and to try to prevent the kinds of risk exposures that led to the current crisis.

How does this map onto our thinking about emerging concepts like systemic risk regulation as an example of vital systems security?

Gary Becker and Richard Posner on the economics of pandemic preparedness. Can’t say it is massively enlightening. But the Posner in particular has an interesting update of Foucault’s cost-benefit analysis of vaccination (in this case related to vaccine developement and other preparedness measures) to the modern global pandemic.

People are actively attempting to infect themselves with the “mild” strain of H1N1, hoping to give themselves immunity in case more severe strains appear in the future. Resonates with the DIY Bio folks. Also, another example of the power of the 1918 pandemic analogy: the rationalization is that the 1918 flu had a mild spring wave, and two severe fall and winter waves. My sense is that there is no reason to assume this strain will behave similarly.

“What things are contemporary? Consider a late model car. It is a disparate aggregate of scientific and technical solutions dating from different periods. One can date it component by component: this part was invented at the turn of the century, another, ten years ago, and Carnot’s cycle is almost two hundred years old.” – Michel Serres (1995)

“Rabadan suggests the way to think of this flu is like a homemade car with parts from different vehicles. The parts have all been in several different vehicles before. Sometimes the combination of parts is a dud and the car doesn’t move. And sometimes you get a race car. A pandemic is a race car.” – Associated Press (5 May 2009)

“We are far from out of the woods” seems to be the mantra among the public health officials who have to speak to the public. But for right now, it seems clear that this round of H1N1 is not nearly as serious as many initially feared. In this light, I wanted to provoke all those of you following this more closely to brainstorm a bit about what exactly the “lessons learned” might be from this event for different experts and policymakers, and what, for us, are the emerging sites of reproblematization, where existing undersatndings and practice are called into question.

One possibility is that there will be a certain amount of derision about the level of alarm that was raised. But my sense is that this will mostly be limited to late night comedy and right wing talk.

Another possibility is that there will be intensive discussions about the issues that Carlo has been raising, concerning the relationship between the current “phase” definitions and levels of political and medical mobilization and response. As Carlo wrote:

One of the interesting questions is the following: If this virus (which we are not allowed to name anymore …) continues to circulate among humans, will the WHO announce phase 6, i.e. a full-scale pandemic? With a virus that seems to cause not much mortality, this will be a difficult question. I really doubt that they will announce phase 6, even if all the criteria of phase 6 are essentially met. The pandemic alert scheme might soon need extensive revision …

A third area of reflection might have to do with interpreting the performance of health authorities in Mexico and drawing conclusions for global health surveillance. It seems to me that the initial sense is that once the Government got into its disciplinary lockdown mode, it did pretty well. But it is also obvious that everyone would have liked for there to be more laboratory capacity right at the beginning, such that the case and death counts would not have been exaggerated at the beginning. Everyone knows that basic public health surveillance globally is crucial to a global health preparedness system, but investment in basic lab capacity is a different issue.

A fourth area has to do with the question of how seriously to take H1N1 moving forward, what measures to take in preparation for a more serious outbreak, and what measures to take to prevent such an outbreak. In the former case, one key question is obviously going to be vaccine development. My understanding is that there is no decision about whether to proceed, but I don’t understand what the issues are. In the latter case there may be a whole series of questions, such as farm biosecurity. I have heard that one of the major concerns is large-scale transmission to pigs (again) which would create conditions for recombination into more virulent forms.

Thoughts on these or others?

WHO spokesman Gregory Hartl noted yesterday that the public may misunderstand the word “pandemic.” The term refers to where an illness spreads, not its severity.

That, of course, is true. But have they not themselves used the category in a very different way?