Abstract

The Harvard University Asian Flus and Avian Influenza Workshop, held in December 2006, introduced a biosocial approach to the preparation for and control of pandemics. A biosocial approach brings together the biological and social sciences to develop an integrative, collaborative response to the threat of pandemic influenza. The articles in this supplement provide a representative sampling of some of the ways in which the workshop worked toward this biosocial vision. These articles address the historical “siting” of epidemics, political and structural pandemic preparedness in China, lessons to be taken from the 1976 “swine flu affair,” possibilities for genetic engineering as an alternative to poultry vaccination, issues to be considered in the control of infectious disease in swine and avian species, the ecology of influenza in migratory birds, and issues of stigma and trust during the control of epidemics. The need to build public trust and public health infrastructure is one of the primary messages of this collection.

Since the avian influenza A(H5N1) virus reemerged in Asia on the heels of the severe acute respiratory syndrome (SARS) epidemic in 2003, scientists, politicians, and journalists have been warning that a global influenza pandemic rivaling that of 1918 is imminent. Many conferences have been convened and articles written in preparation for this possible event; indeed, one such collection of conference-based articles appeared in a supplement to this journal last year [1]. With all the attention that this “virtual epidemic” [2] has already received, it is sometimes difficult to remember that, to date, the anticipated culprit, the H5N1 influenza virus, has killed slightly more than 200 people worldwide over 4 years. The critical step required to launch a pandemic—that is, sustained human-to-human transmission—has not occurred, although a few sporadic probable cases of such transmission have been documented [3]. Still, the continued and accelerating spread of the virus globally among domestic poultry means that preparations for a pandemic are unlikely to lose momentum in the near future.

Other than repeated warnings and the continued drafting of plans for political and epidemiological preparedness, what can be done in the meantime? What can another set of articles on the topic of pandemic influenza contribute to the ongoing discussion? Rather than simply adding more layers of scientific or political analysis, the articles in this supplement to the Journal of Infectious Diseases propose a different way of preparing for and potentially intervening in an event such as an influenza pandemic—namely, a biosocial approach. A biosocial approach brings together the biological and social sciences in a collaborative effort to better understand a disease event. This is not a matter of simple translation across disciplines but, rather, of serious consideration of the contribution of many different factors not as separate influences but as mutually constitutive and inherently intertwined parts of a complex whole event. In the case of avian influenza, microbiologists have identified a potentially dangerous virus; historians have drawn comparisons between the epidemic that may arise from this virus and other viruses and epidemics that have come before it; epidemiologists, animal biologists, and ecologists have tracked the spread of the virus; and social scientists and journalists have probed ways in which people might suffer from it. What has been lacking is an attempt to combine this knowledge and examine the multidirectional interactions among the various pieces that too often are studied in isolation.

The goal of this supplement is to take a step toward institution of a biosocial approach. These articles are drawn from the diverse fields of molecular biology, veterinary biology, history, anthropology, ecology, public health, and political economy and represent a sample of the work that emerged from a high-level conference held at Harvard University in Cambridge, Massachusetts, in December 2006. The Harvard University Asian Flus and Avian Influenza Workshop, sponsored by the National Science Foundation, Harvard Asia Center, and the Michael Crichton Fund, brought together leaders in these and other fields to listen to one another and to exchange approaches in an academic setting oriented toward pragmatic goals, with perspectives from academia as well as governmental organizations, including the National Institutes of Health, Centers for Disease Control and Prevention, andWorld Health Organization. The conference concluded with a roundtable discussion that addressed the question of what should be done not only if a pandemic occurs but also if it does not occur.

The collection presented here begins with a short piece by Charles E. Rosenberg [2], professor of the History of Science at Harvard University and an expert on the social history of epidemics. Rosenberg's article argues for the importance of “siting” epidemics within their historical and geographical settings, pointing to previous outbreaks of cholera and yellow fever and the ongoing AIDS epidemic to underline the rhetorical and emotional resonances taken on by acute and mysterious outbreaks and the various responses to and uses of these events. He points out that the virtual epidemic of avian influenza has already produced certain reactions in the populace that are consistent with those during previous disease events. His historical context extends the discussion of a potential pandemic beyond comparisons with that of 1918, expanding its potential meanings to include other collective memories.

One such recent collective memory springs from the winter and spring of 2003, when SARS-associated virus spread around the world and suddenly focused popular attention on the risk of a global pandemic. Joan A. Kaufman [4] of Harvard and Brandeis Universities considers the pandemic preparedness of the government and health care system of the People's Republic of China against the backdrop of the brief but politically profound SARS epidemic and of 30 years of Chinese economic reforms. Kaufman argues that China's history as a source of influenza viruses, along with its weak public health infrastructure and failure to report past disease outbreaks, is reason for concern; at the same time, the government's effective mobilization against SARS indicates that this vast country also could be quite effective in its national and local control of a global pandemic.

Harvey V. Fineberg [5], president of the Institute of Medicine, considers other possibilities of historical relevance in his examination of the lessons that can be drawn directly from the 1976 “swine flu affair.” Fineberg analyzes how combinations of epidemiological uncertainty, political agendas and anxiety, lack of rigorous analysis, and media blunders all contributed to a public health response characterized by sloppiness and eventual failure. Urging us not to repeat history, Fineberg suggests ways in which the blunders made in 1976 can be recognized and avoided in the future.

In their article, Eileen Thacker and Bruce Janke [6] of Iowa State University also draw on connections between swine, avian, and pandemic influenzas, detailing the current prevalence of swine and avian influenza in domestic livestock populations, particularly in the United States; how these diseases are usually controlled; and what risks for outbreaks among animals or humans continue to exist. They remind us that neither swine influenza nor avian influenza is an exotic or unusual disease; rather, influenza viruses circulate constantly in domestic livestock populations and, in general, are well controlled in the United States through vaccination, surveillance, and targeted culling in the event of the eruption of disease outbreaks due to strains of highly pathogenic avian influenza virus. Thacker and Janke complicate both the common perception that zoonotic diseases are unidirectional, pointing out that animals can contract influenza from humans just as humans can contract influenza from animals, and the perception that pigs usually act as “mixing vessels” for zoonotic transmission events, pointing out that, instead, this is a possible but rarely observed process.

Jianzhu Chen and colleagues [7] at the Massachusetts Institute of Technology use the molecular biology techniques of RNA interference (RNAi) to introduce the potential for genetically controlling the circulation of influenza viruses in the animal populations that Thacker and Janke track. Chen's team presents a process by which RNAi techniques can be used to produce influenza-resistant transgenic poultry. By elimination of the circulation of influenza among domestic poultry, Chen's team argues that the likelihood of a zoonotic event leading to a pandemic is diminished. They also acknowledge that there is likely to be social resistance to the consumption of such transgenic birds but argue that Asian consumers will be more likely to accept such products.

In their article on influenza in migratory birds, Douglas Causey and Scott V. Edwards [8], ecologists at the University of Alaska Anchorage and at Harvard University, respectively, challenge the focus of Chen et al. on the prevention of influenza in domestic poultry, pointing out that poultry are only one of many reservoirs and many potential avenues for the zoonotic transmission of viruses. Almost every conceivable subtype of influenza virus can be found circulating in migratory birds, and any of these subtypes eventually could mutate into a strain capable of threatening humans. Birds flying through Arctic migratory pathways shed viruses that can be preserved in ice and transmitted later. Causey and Edwards remind us that the processes by which viruses are transmitted from birds to humans are poorly understood and that the role of migratory birds in such ecological transfers is even more poorly understood. Action taken to prevent such transmission is necessarily done so on the basis of scanty supporting evidence.

In the final article in this collection [9], Ron Barrett and Peter J. Brown of Emory University step back from biological considerations to combine anthropological analysis with comparative historical analysis in considering the impact of stigma during the course of acute epidemics. Drawing comparisons with the 1994 Indian plague epidemic, the 1918 influenza pandemic, the 1976 swine flu affair, and the ongoing HIV pandemic, Barrett and Brown suggest that stigma often plays an undesirable but important role in the control of epidemics. Stigma leads to barriers to seeking help, further impoverishment of already impoverished groups, lack of cooperation, and mass panic. Barrett and Brown point out that discussions of a potential pandemic often leave out discussions of socioeconomic inequalities. They conclude that building a “surge capacity for public trust” is essential to the success of any effective preparedness plan and that such a capacity must begin with an emphasis on public health infrastructure for all.

Barrett and Brown's article cuts to the heart of the Harvard workshop and of the biosocial approach. No one can predict with any certainty when or even if an influenza pandemic will occur or if it will come from the H5N1 influenza virus or from some other, as-yet-unknown source. What can be predicted is that greater public trust, based on a foundation of quality public health infrastructure and a deep knowledge of the many complex factors involved in gaining and preserving good health, will be essential to the response to any new disease event. Although this workshop focused on avian influenza, we believe that it provided a more general proof of principle for putting into action a truly integrated biosocial approach to major health challenges.

Acknowledgments

The Harvard University Asian Flus and Avian Influenza Workshop was hosted by the Harvard University Department of Anthropology, Harvard School of Public Health, and Harvard Asia Center and was supported by the National Science Foundation, Harvard Asia Center, and the Michael Crichton Fund.

Supplement sponsorship. This article was published as part of a supplement entitled “Avian and Pandemic Influenza: A Biosocial Approach,” sponsored by the National Science Foundation, Harvard Asia Center, and the Michael Crichton Fund.

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Potential conflicts of interest: none reported.
Presented in part: Harvard University Asian Flus and Avian Influenza Workshop, Cambridge, Massachusetts, 8–10 December 2006.
Financial support: supplement sponsorship is detailed in the Acknowledgments.