South America’s Swine Flu Winter

Just three weeks after the southern winter solstice, an already overloaded Argentine health service prepares for the second winter influenza peak expected in mid-July. Swine flu1 has flown south to winter in the southern cone; it has hit hard in Chile, Argentina, and Uruguay. Paraguay and Bolivia have also declared states of emergency.2 Argentina is the only country in the region in the "over 101 deaths" category, according to statistics from the World Health Organization.3

In Argentina, a society infatuated with psychoanalysis, the intellectual media interview experts in the field to separate the myths and facts. Photo: economiade.com.

Here in Argentina, a society infatuated with psychoanalysis, the intellectual media interview experts in the field to separate the myths and facts on the new disease and to analyze human response to fear of contagion and death.4 In such an aggressive flu strain, prompt, informed medical attention can be critical for health and for prevention.

Latin American media is overtly politicized and sensationalist news on fatal pandemics foments panic. Mass media messages are confusing. Fear sells pharmaceuticals, it sells alcohol hand-cleansers, face masks, and newspapers. Panic can lead to mass irrational behavior thus inadvertently helping the spread of the disease. Examples include lines of cold and flu patients outside the public hospitals, clinics, and pharmacies, most of whom do not have swine flu. This leads to unnecessary cross-infection and overloaded health services.

Health, the New Terror

In autumn, a tiny dengue fever outbreak (itself caused by climate change) fed the Argentine media appetite. When winter chills killed off the larger mosquitoes responsible for dengue transmission, swine flu took over. The swine flu pandemic has proven much more disruptive and a little more deadly, but the message about this virus is far from clear. Even the Ministry of Health is politicized, resulting in a change of health minister in Argentina after the elections in June. To get to the truth, one needs to talk to doctors directly.

In its "action plan" put out in mid-July, the Argentine Association of Respiratory Medicine notes that:

"In the last few weeks the number of patients requiring in-patient care for pneumonia has increased, many of them with severely compromised pulmonary systems, damage to multiple organs, and requiring mechanical breathing support."

Swine flu is an aggressive new strain but infections are rarely fatal. Most patients recover without treatment in four to seven days (some less when treated with expensive antivirals), however fatalities occur in a small minority of cases from an associated virulent pneumonia or the acute version of the influenza itself. Higher risk patients include those with reduced immune response (HIV positive, pregnant women,5 etc.), diabetes, or pulmonary issues; a few apparently healthy individuals also succumb. Swine flu infections observe no boundaries between classes or social strata.

There is no significant shortage of antivirals in Argentina, due to government purchase and distribution, however certain hospitals are short of specialized breathing equipment for the pneumonia patients. Popular media advertises shortages of the "Tamiflu" brand with reports of individuals crossing to Uruguay to buy private supplies. Argentine pharmacies have little Tamiflu on their shelves but the hospitals have adequate supplies for those who seek medical care.

Beyond the role of the media, the Argentine experience reflects the importance of how national and state officials react to this new experience. At issue is the lack of experience with this flu strain especially in winter conditions.

On July 9, the White House adviser on Homeland Security emitted a preparatory statement over the Internet for the winter flu season in the United States. One might ask why Homeland Security and not the Department of Health would put out such a message. Is flu the new terror?

When swine flu first broke out in Mexico, the Argentine government was one of the few countries in the region to shut down flights from Mexico in an attempt to avoid an outbreak. The Argentines have since installed scanners in airports that read the temperatures off the skin of travelers passing through security.

Policy, Not Politics

Government response in the southern cone has been, of necessity, somewhat improvised; anti-government press has been quick to criticize any policy failure. It has been particularly harsh on the government decision to delay the declaration of a state of emergency until after the elections. However, constructive criticisms from doctors emphasize policy, not politics.

Dr. Carlota Salomon, head of outpatient surgery in Hospital Pena, Buenos Aires, highlighted the ban on scheduled surgery.

"While pneumonia patients are filling whole wards, including those in my hospital, the order to cancel all planned surgery may well lead to more mortalities than it will prevent from swine flu," she said.

Also questioned are the inconsistencies of closing all public events while allowing private concerns to decide whether or not to close. Primary and secondary schools are closed, as are public universities. Private universities quickly followed suit but many events in the entertainment sector remain open.

On the global level, the World Health Organization (WHO) of the UN reported in their July update on the A/H1N1 pandemic a total of 134,503 cases and 816 deaths as of the beginning the outbreak in April.6 Infection statistics in Argentina are very imprecise. Juan Manzur, the new minister for health who took over this month, postulated that there could be as many as 100,000 infections in the country but he did not cite sources. He is probably right, but sources in terms of official statistics are not available. President Christina Fernandez de Kirchner criticized his announcement for inciting panic. If this number is valid then Argentina has more swine flu than admitted in the United States. The number of actually confirmed7 cases in private and government laboratories8 is less than 2,500 but hospitals are only testing in-patients so the statistics are skewed. Confirmed deaths directly attributable to swine flu in Argentina are at 137, according to the Ministry of Health. This is the highest death rate in South America, although Chile has reported more cases.

World Health Organization (WHO)—
H1N1 Deaths South American Region9

Interviews with doctors in the capital indicate that the real numbers are "at least 500 dead," but this is still similar to orders of magnitude for deaths from "normal" flu.

Doctors have been asked to send samples for statistics with a three-day turn-around on results. Patients showing flu symptoms do not have three days to wait for diagnosis, so doctors write prescriptions for the swine flu antivirals for patients who may not have swine flu. This increases costs and profits to pharmaceutical companies.

The Argentine experience is that a winter with swine flu is costly from an economic perspective and puts huge strains on health services. It is also a disease with very high media exposure but which kills very few people.

While media channels play a role in disseminating information to bring patients to prompt treatment, an overreaction to a minimally life-threatening pandemic can cause more problems than it solves. Experience also shows that policy responses such as mandatory closures of facilities need to be coordinated better between state and national authorities, and between the public and private sectors.

As swine flu spreads across the planet showing significant outbreaks in the southern winter, it may well take a few years before this flu becomes benign. Teams of health investigators are coming south from many northern countries to study the situations in the southern cone. Let us hope that they can learn from the experiences to face the northern flu season to come. They could do worse than to listen to Marc Siegel, a specialist from the University of New York:10

"This virus could mutate into something worse; it is possible, but this is not my prognosis and I have studied many flus. This virus does not survive more than two contagions before weakening. It is a weak pandemic, with virulent media coverage."11

End Notes

1. The official term for the influenza pandemic is A/H1N1 or Influenza type "A."
2. In contrast, the pandemic is significantly less acute further north in Brazil, where winters are less severe.
3. http://www.who.int/csr/don/Map_20090727.png.
4. http://www.pagina12.com.ar/diario/sociedad/3-127770-2009-07-05.html.
5. Pregnant women’s immunity to infection is of necessity slightly lower to prevent their body from rejecting the fetus.
6. World Health Organization Global Health Alert and Response report for pandemic A/H1N1 (2009)—update 59, http://www.who.int/csr/don/2009_07_27/en/index.html.
7. Argentine Ministry of Health: http://www.msal.gov.ar/.
8. National Administration of Laboratories and Institutes of Health: http://www.anlis.gov.ar/.
9. Situación de la Influenza A (H1N1), Organización Mundial de la Salud (WHO), Jul 13, 2009,
   http://docs.google.com/gview?a=v&q=cache%3AvSDqLroUjEsJ%3Awww.msal.gov.ar%2
   Farchivos%2FParte%2520nueva%2520influenza%252014%2520deJulio.pdf+OMS+Casos+
   de+Influenza+A+%28H1N1%29+en+Sudam%C3%A9rica+13+de+julio&hl=en&pli=1.
10. He took the same position about the much more fatal SARS epidemic in 2006, and he was right then.
11. Translation by author from following article: http://www.lavanguardia.es/free/edicionimpresa/20090501/53693890884.html.