The handshake that ends the human race

The next pandemic could begin with a handshake - and it might be the one which kills off the human race.

This apocalyptic vision was laid out by one of the world’s leading experts on global health, Sir Richard Feachem, of the University of California. His message at a Canberra seminar was that despite an international spend of $4 trillion every year on health care, we are woefully under-prepared to deal with the outbreak of an aggressive, fast-spreading virus.

Even if this worst case scenario is avoided, pandemics will still be the biggest killers in the 21st century, just as they were in the 20th, Sir Richard said. The Spanish flu outbreak, which occurred immediately after World War I, killed at least 50 million and maybe as many as 100 million.

“HIV-AIDS is the pandemic we all know about - the biggest pandemic in human history -and it continues to spread; we are nowhere near its end,” he said.

“XDR tuberculosis is spreading and there are no drugs that are proof against it. While we are getting on top of H1N1, watch out for N5H1. It is far more virulent and if it finds a way of easy human-to-human transmission, we are in trouble.

“We will be looking at a pandemic at least as serious as Spanish Flu, with no means of coping with it.”

The problem lies in a burgeoning and highly mobile world population. “At the time of the Black Death [which killed an estimated third of the world’s population in the 14th century] there were just 400 million humans on earth; by the time of the Spanish Flu this had risen to 1.8 billion and now there are 6.8 billion with a projected rise to 10 billion,” he said.

In the 16th century a journey from London to China took between 12 and 15 months; by 1900 ocean-going liners had cut this to 10 weeks; in 1950 a propeller-driven plane did the journey in three days while modern jetliners take 13 hours.

“In 1900 almost all journeys were longer than the longest incubation period of any virus,” Sir Richard said. “People became ill in transit, died and their bodies were probably thrown overboard. By 2006 the longest journey on earth was still far shorter than the shortest incubation period.

“Somebody could be infected, travel around the world, still not be picked up by airport scanners and only start to feel unwell in their hotel the next morning, by which time they would have infected hundreds of people, now travelling to other cities all over the planet.

“If you take the case of the H1N1 pandemic, on day one it was in one country, Mexico; 10 weeks later it was in 120 countries.”

The good news is that the methods through which pandemics can be transmitted have narrowed. Cholera outbreaks, which ran unchecked because of the insanitary conditions existing in big cities up to the end of the 19th century, have largely been eliminated in wealthy nations. Now the spread is mostly through respiratory or physical contact.

Which brings us back to that handshake. Sir Richard said that while it would be impossible to stop people sneezing in public, abandoning the handshake in favour of the Hindu-style Namaste (palms together, a slight bow) would cut out another route for disease to spread.

Turning to other world health issues, Sir Richard said it was paradoxical that both hunger and obesity were growing at faster rates than at any time in history. “There are 1.6 billion overweight adults in the world and it is estimated that one billion people go to bed hungry every night,” he said.

While the hungry had their condition imposed upon them, it would seem that most overweight and obese people were simply being over-indulgent. However, he said the actual situation was much more complicated.

“A combination of salt, sugar and fat tends to override appetite mechanisms, plugging into primitive man’s desire to feast on these substances when they were available, and known to science as hedonic feeding,” he said.

“The fast food people have picked up on this, so they load their products with these items, which appeals to a primeval need to eat to excess.”

Research has shown that in developing countries overweight and obesity tended to make its appearance in the middle classes. As the country grew richer, the middle classes started to heed health messages, abandon their bad diets and take more exercise. The poorer people, with a little more income to free them from actual hunger, began to feast on junk food.

“India and the United States are classic examples of each case,” he said. “In India, overweight and obesity is still a middle class problem while in the US it is almost exclusively found among poorer, less educated people.”

What he described as the “succession of dietary fads” actually added to the problem.

“There are so many confusing messages that people actually give up,” he said. “Dietary guidelines are impossibly complicated. The big message is simply prefer plants to meat, but this is obscured by all the micro messages.”

Sir Richard said the basic requirements of a good health system were easy access to high quality facilities at an affordable price. Many developing countries had a mirror image of this - poor access, dilapidated facilities and, where they were in reasonable condition, at a price that put them out of reach of all but the richest segment of the population.

“In Africa $16.5 billion is spent on health care, but 60 per cent of that comes directly out of people’s pockets because hardly anywhere has a properly functioning insurance system,” he said. “It means that a serious illness often results in incredible hardship both to the patient and their extended families.

“A typical district hospital is rundown, lacking reliable water, sanitation or electricity, with absent or broken equipment, inadequate supply chains for essential commodities, chronic staff shortages, low service quality and poor clinical outcomes.”

Despite all the bad news Sir Richard remains an optimist, saying organisations such as the Bill and Melinda Gates Living Proof Project point the way forward. However, the United Nations Millennium Development Goals may have to be revised.

“They concentrate on attacking hunger and improving nutrition, with hardly anything on pandemics other than HIV-AIDS and nothing about obesity and health systems,” he said.

“It will be important for new goals to be adopted when they are reviewed in 2015.”