December 2005 Archives

We arrived in Bankok, Thailand on the 26th of December at about 12:00AM last year and when we awoke in the morning people were standing around TVs trying to make sense of news about the tsunami. It was clear from the TV images that the waves were monstrous and destructive, but it was initially hard to fathom how many people were involved. Thais in Bankok desperately tried to reach their relatives in the South. As more footage of waves crashing through beach towns came through and people ominously failed to contact their families, the tension grew. We logged on to CNN and there the only news of the tsunami was a story about one American who was possibly lost on one of the islands¹. The family had mined some FBI connections to track their son and publicly pleaded to the president to mobilize efforts to help find him on the island of Phi Phi. They enlisted a senator in their search, who commented on her limited ability to help:

"What's really frustrating is this is the 21st century and you would think there would be some kind of communications . . . some kind of direct link from someone on the ground in [Phi Phi]"

Unbeknownst to the senator, the communication gap that frustrated her wasn't a 21st century technology glitch that inspires crankiness in all of us but the fundamental effect of an abrupt 20 metre vertical displacement of the ocean floor. The geology of the 9.15 earthquake and resulting tsunami in the Indian Ocean is difficult to imagine -- even if you were there in Thailand, India, or Sri Lanka. The further away you were from South East Asia the longer it took to realize what was going on, based on the steady stream of e-mails we got weeks after the initial earthquake. Some of it was the political process. President Bush was on vacation and took days to say anything.

Aside from distance and politics, the fact is that the communications infrastructure was literally wiped out, making communications logistics not so obviously impossible. Even watching natural disaster extravaganzas like "Deep Impact" or "The Day After Tommorrow", would hardly prepare one for the destruction. The fault slippage generated by the earthquake covered an area of 1300 by 100 kilometers. The energy released by the earthquake was estimated to be the equivalent of about 475 megatons of TNT -- 23,000 Nagasaki atomic bombs. The earth wobbled on its axis.

Waves generated from a large earthquake travel very quickly across the open ocean with speeds up to 500-1000 kph. They are short waves (one or two metres) on the ocean that then slow down when they approach land. There, the wave -- which is technically not so much of a wave, but rather a wall -- gains height. The resulting walls of water are extraordinarily powerful. Predicting their landfall is trickier then it may seem.

The Sumatra earthquake was initially measured as a 8.1-8.5 earthquake, then later revised upward to 9.15 using the moment magnitude scale rather than the seismogram amplitude (Ms) measurement. The difference between the size of the actual earthquake and the smaller initial measurement affected the tsunami predictions.

Cries for a tsunami warning system could be interpreted to indicate that this will solve the problem. It's true that before the tsunami there was a warning system implemented in the Pacific ocean but nothing in place for the Indian ocean where tsunamis were considered a rarer event. Warning systems are now being devised. The newest one is being designed by German researchers, who, relative to the Americans and Japanese, are newcomers to the field. The German system employs buoys that monitor surface conditions and relay this information along with sea bed information via satellite to a receiving station. Two of these buoys were installed in November. Tidal gauges will also eventually be engineered to monitor the data. These are part of the Global Sea Level Observing System (GLOSS) used in climate change studies. They are being upgraded to measure sea level information that will be useful to monitor tsunamis. There are also traditional communication systems based on seismic data that are now improved to forward warnings after earthquakes to countries vulnerable to tsunamis.

The improvements cannot come quickly enough. Der Spiegel reports that the stress of the Australian Plate beneath the continental shelf is higher then ever and the two recent earthquakes seem to have increased the tension since they only affected a small length of the border between the plates. But the 21st century communications system the senator laments may well be illusory.

We know that a warning system will never stop a hurricane or a tsunami. The warnings will help those who are capable and willing to heed them. Similiarly, during the rescue, technology will certainly improve the odds for many, though not all. But will it perform to the specs we expect? As with our all disaster, the response is as likely to depend on our neighbors as the technology -- on island or off; to whit, our neighbors judgement, instincts, and dare we say "emotional intelligence" will abet our survival or peril. These are the qualities in humans that sometimes seem disconcertingly unchanged since we all hunched over those first sticks trying to get sparks to fly. Sure there are enough heros, geniuses, and cats rescued from trees these days to buoy our spirits during the evening headline news. But in catastrophes, the weaknesses as well as the strengths of our fellow humans are evident, and as important as the "technological communications" systems. We will be as dependent on the chain of humans relaying the messages as we are on the physical limitations of technology -- even if the next tsunami leaves the infrastructure linked.

There were remarkable heroes in the tsunami last year. Some of the survivors stories are extraordinarily well told in the recent New York Times article "The Day the Sea Came", by Barry Bearak, which describes the turmoil and human toll of the event through the eyes of a few survivors. Many more stories we will never know, as those heroes perished with hundreds of thousands of others. If only technology could have saved them.

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¹The news must have gotten more in sync with the reality in time because CNN recently won the an award for best coverage for its stories on the tsunami.

The Seoul National University (SNU) team investigating the results of a recent cloning paper just released their initial findings in Seoul. The group will continue to investigate Professor Hwang Woo-suk's imaginary stem cell lines, but has made an initial judgement. The nine person panel determined that the results for 9 of the 11 stem cell lines described in the landmark paper of Hwang, Schatten et. al. in the journal Science were fabricated.

Before the news release some people speculated that perhaps it wasn't deliberate fraud but sloppy science and a string of of unfortunate lab events that led to bad results. At best, this seems like a tenuous distinction. That level of research sloppiness is inexcusable. Neverthless, careless technique perhaps seemed more palatable to these apologists, because it seems incongruous that any scientist would make such a monumental effort to deceive. Yet the SNU panel has made it clear that fraud was the root of the problem. The investigating group will finish the DNA testing on the two remaining lines to verify them.

Sad, really, a lot of people are affected by this news -- patients, scientists, collaborators, research in general and stem cell research in particular.

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Acronym Required previously wrote about the problems with the Hwang et al. research in Peer Grilling: Stem Cell Research", and "Stem Cell Ethics Glitch". We have also written about scientists self-reported transgressions and science reporting in medical journals.

Non-Stick Magic -- Some History

Teflon© promised moms of the 1960's that their frozen peas, canned spaghetti and fried eggs wouldn't stick to the pan. It accommodated unpredictably hot electric ranges. Even better, when cooks forgot the family supper on the stove for a minute -- say while ironing a shirt -- dinner didn't char to a crisp. Sure the pan got hot but the jury is out as to whether the fumes and particles are toxic to humans -- as some experts claim -- or just to birds and animals.

One might reason that if you were a chemical company, whose chemist by mistake polymerized tetraflouroethylene and hydrochloric acid while running experiments to invent a new Freon-like refrigerant, you would exhaustively test to see if the resulting surprise material was toxic to humans before making hundreds of domestic products with it. But that's not exactly how it works.

The initial challenges Dupont faced were chemical. Polymerized tetrafluoroethylene (PTFE) was originally used for military purposes; the tips of bombs, air planes and manufacturing explosives. Its domestic uses came after the war. How do you get a non-stick substance to stick to pans in order to be useful? Research money was targeted impressively towards getting the material to comply with the desired uses. Another priority was advertising. How do you get a war shocked society to spend money, now that supply is guaranteed? Gathering toxicity data apparently wasn't the highest priority.

Teflon© and related materials are synthesized and used for non-stick pans, as well as carpets, lenses, clothing, upholstery, stockings, coating for paper products, food wrap, roofing, cables, electrical equipment, engines, seals and sealants, floor waxes and coverings, beauty product containers, medicine containers, implants used for tempo-mandibular joint replacement, ocular surgery, and many other applications.

Hungry for Safety Data

The safety of these products is important to public health since many of the products or bi-products come in contact with skin, water supplies, air and soil. We assume Teflon© is safe. But cases brought to court about TMJ implants claim that the implants degrade in the body, and lawyers defended the safety of the degraded Teflon© based on "government data". Yet has the government found Teflon© to be safe?

If the products aren't safe is there any way of avoiding exposure? Tobacco was relatively easy to avoid. However these chemicals are ubiquitous. Zonyl, another Dupont chemical, is used to make grease resistant coatings for paper used in food packaging, paper cups, etc. It was recently reported by a whistleblower that PFOA from Zonyl© "'is absorbed by humans at three times the permitted level', said Glenn R. Evers, a DuPont chemical engineer from 1981 to 2002.

Ohio Citizen wrote to 19 companies asking if they used fluorotelomers like Perfluorooctanoic Acid PFOA containing Zonyl in their packaging. A few companies responded , while 12 didn't, including Starbucks, Pizza Hut, Dairy Farmers, Kraft Foods, Tyson Foods, Dreyers Ice Cream, Dole, Sara Lee, Kellogg and Nestle. Campbell didn't acknowledge the problem, Papa John's and Domino's didn't use PFOA, while several other companies did use PFOA and intended to continue. When you drink your organic non-fat super special latte at 8:00 in the morning should you worry whether the paper cup is safe to use?

In Dover, Pennsylvania today, observers found that in matters of religion's place in school science classrooms, despite much evidence to the contrary, intelligence sometimes prevails. District judge John E. Jones III ruled for the plaintiffs in Tammy Kitzmiller, et al. v. Dover Area School District. The judge found that the school board's changes to the science curriculum were unconstitutional when the board concocted a statement that students were read prior to the commencement of 9th grade science class. The statement dismissed scientific explanations for evolution and proposed Intelligent Design (ID) as a reasonable substitute.

The plaintiffs filed their case in 2004, claiming that the statement, read by the administrators because the science teachers refused, was a construct of the Intelligent Design (ID) movement and in fact a religious stance prohibited by the First Amendment to the U.S. Constitution and by Pennsylvania Commonwealth's Constitution. Based on established precedent, the judge applied both the endorsement test and the "Lemon test" to the case. The endorsement test prohibits the government from endorsing religion and provides that the opinion of an observer who is knowledgeable about history and social context of the community be considered in deciding whether certain an actions can be interpreted as "religious". The "Lemon test" asks whether "a government sponsored message violates the Establishment Clause of the First Amendment based on whether 'its purpose is secular', 'it advances or inhibits religion', or it 'it entangles government with religion'".

The court found that the action that required a reading citing gaps in evolutionary theory and endorsing Intelligent Design violated the Establishment cause of the Constitution under both tests and also violated Article I of the Pennsylvania Constitution. The court's decision was unequivocal on all points - in conclusion the opinion stated:

The breathtaking inanity of the Board's decision is evident when considered against the factual backdrop which has now been fully revealed through this trial. The students, parents, and teachers of the Dover Area School District deserved better than to be dragged into this legal maelstrom, with its resulting utter waste of monetary and personal resources."

The court detailed its findings in the one hundred and thirty-nine page opinion here. The opinion is quickly read and interesting, but we write about some of the highlights below.

Dr. Schatten, one of the investigators who collaborated with Hwang Woo Suk on a the stem cell paper published in Science earlier this year, has requested that the journal remove his name from the paper. The journal declined the request. (Normile et al. "Korean University Will Investigate Cloning Paper. December 13th). The editors responded:

"No single author, having declared at the time of submission his full and complete confidence in the contents of the paper, can retract his name unilaterally, after publication, and while inquiries are still under way."

Hwang, Schatten and their colleagues wrote a landmark paper published in Science in May, 2005, claiming that they had produced 11 stem cell lines from patients afflicted with various diseases. The therapeutic clones were produced via somatic cell nuclear transfer, where scientists transfer the nuclear material from the somatic cells - in this case of patients - to egg cells, which divide and develop via the transferred DNA. The research purportedly improved on a method the lab used the previous year to produce a single stem cell line by decreasing the number of eggs used to produce one line from 246 to an average of 17.

Scientists and the media questioned the lab earlier this year on ethical grounds because the researchers reportedly procured egg cells from junior lab members. Next, questions arose about several photos published in the Science paper that appeared identical, and the journal and researchers claimed there was a copying error. An anonymous poster on a Korean site - bric.postech.ac.kr - (where you can read articles via Googles amazing but "BETA" - translation software) has been opining on the validity of the research. DNA fingerprinting photos were submitted to Science to clear up questions about the clones. The poster then observed that the peaks and noise in the fingerprinting photos of the cloned cell lines and the somatic cells looked too similar to be authentic. Teams in Korea, Europe and the U.S. are now examining the results more closely.

Gerald Schatten was previously involved with another research scandal and in that one he emerged unscathed. At the University of Wisconsin in the 1990's, he collaborated with Dr. Ricardo H. Asch. Schatten used eggs from Asch's infertility clinic for research("Researchers 'Duped' Over Use of Embryos Without Consent"; Nature 379, p. 756, Feb. 1996). The article notes that an audit of lab records indicated that Schatten was misled by Asch, who provided several hundred eggs or embryos to the Wisconsin research lab. Asch and two colleagues at the University of California ran fertility clinics at UC Davis and Irvine, and were accused of multiple medical and ethical indiscretions in 1995, including harvesting women's eggs for the purpose of selling them to other couples and for research.

Asch vehemently denied the allegations for many months before fleeing to Mexico. His colleague, Dr. Jose Balmaceda fled to Chile. A third researcher, Dr. Sergio Stone, was put on administrative leave with pay for five years by UC while the investigation and trial proceeded, until being fired in 2000. Schatten moved to Oregon Health and Sciences University where he continued his cloning quest, with budgetary, if not scientific success, while again working at the fertility center, before moving on to Pittsburgh.

We've heard that America is floundering in science and that even India and China graduate more engineers and are more dedicated to science than the U.S. Maybe some of this is bravado, for instance abroad, foreigners sometimes brag to visitors that "all the doctors in America are from [fill in the blank]". And although many are, some of this is nationalism speaking. Acronym Required previously commented on the international sport of berating American students in the article "A Fine Balance".

It continues. The other day on NPR, a caller chastised American youth for being obsessed with movie stars, whereas in India, he said, kids were really focused on science and math. He did not mention that actually, in India, movie stars are sometimes elevated to Gods. Nor did he mention that sometimes those who work in Bollywood move on to Indian politics, just like the U.S., or land prestigious careers at engineering schools. Is this a threat?

And are the graduation numbers real, do they matter? Vivek Wadhwa wrote an article in BusinessWeek this week; "About That Engineering Gap...", to correct previous statistics for the graduation rates that were widely reported in the media. The numbers for India and China were inflated he said, because of various interpretations of words like "engineer" and "degree", in different languages. By the author's count, the popular statistics noting 70,000 engineer graduates each year in the U.S., 350,000 in India and 600,000 in China are wrong. Rather he says 137,437 graduate from U.S. schools, 112,000 in India, and about 351,537 (loosely counting) graduate in China. The full report is published here at Duke, where the author now works.

Not that we should sigh in deep relief, slouch in our lazyboys with a bag of microwave popcorn and ogle over 'Desperate Housewives' - or whatever voyeuristic disaster tale is in play this week - while our kids plead for algebra help in the background.

Yes, the spurious statistics were used in the recent National Academy of Science, National Academy of Engineering, and Institute of Medicine's report on science education (or lack of) in the U.S.. Acronym Required wrote about the report here. But those numbers are only a part of the picture, one of many indicators that the nation is struggling, some would say floundering, to successfully redefine its presence in science and technology education, employment and competitiveness. As Wadhwa says:

"[O]ur higher education system isn't in trouble -- in fact, it's still the world's best. We spend the most on research, produce the most patents, have the most innovative curriculum, and educate many of the world's leaders."

He says that claiming we have a weak education system will only make it weak. Perhaps the U.S. needs coaching in "technology education" marketing?

We reported last week in Burning Bridges" that "The Numbers Guy" also wrote an column in the Wall Street Journal stating that the graduation numbers seemed suspect.

Bats have a mixed reputation. Aside from their roles and fame in fact and fiction as vampires, they pollinate plants and have a voracious appetite for insects. Apparently little brown bats can eat 1,200 mosquitoes per hour.

On the other hand humans fearfully associate bats with rabies virus, and occasionally with histoplasmosis, a respiratory infection transmitted via the fungus Histoplasma capsulatum - found in bat guano. But Bat Conservation International (BCI) battles their bad reputation, and points out that bats are only responsible for 1 death per year in the United States and rabies is found in only 6 of 45 species continental U.S. bat species, whereas dogs - "man's best friend" - are responsible for more fatal maulings of humans every year.

However bats are increasingly found to harbor fatal viruses. Bats are natural reservoirs for the Nipah and Hendra viruses. Bats have been linked to West Nile Virus. They have also recently been found to be the natural reservoir of the coronavirus that causes severe acute respiratory syndrome (SARS). Researchers found that bats were immune to symptoms of SARS and were the natural reservoir for the virus, whereas civets, the animal suspected of being the reservoir, whose populations were culled by about 10,000 in China in 2004, is only a carrier of the disease. The coronavirus was found in three species of horseshoe bats which is a fruit bat, indigenous to China.(Li et al, Science vol.310 pp. 676).

Bats have long been linked to human cases of Marburg and Ebola viruses, primarily because they're routinely found in places where humans contracted the viruses, a barn in one case, a field in another case. Since the 1970's, following almost every Ebola virus outbreak, scientists have combed the surrounding areas for the source of the virus -- collected thousands of vertebrates and arthropods and tested them for the virus or antibodies to the virus. Most of these studies came to a dead-end -- no virus was found, no immune reaction detected in the specimens. Scientists also tried to infect cells and animals with Ebola virus, to no avail until earlier this year when they managed to infect a couple of bats. But the infection of the bats was not reproducible and the researchers did not have confidence in their data. (Pourrut et al.; Microbes and Infection, Vol. 7, pp 1005-1014)

They pursued that line of research though, and scientists reported last week that three species of fruit bats in Africa carried asymptomatic Ebola virus (Nature 438, 575-576). Researchers tested over a thousand small animals captured from around Ebola sites, assayed serum samples for antibodies to the virus, and spleen and liver samples for viral RNA and RT-PCR nucleotide sequences. Some bats were found to be Immunoglobin-G positive and others screened positive for nucleotide sequence analogy of Ebola viral RNA, however no bats were positive for both. Viral RNA could not be isolated. The authors discuss their results in their article. The fact that they found Ebola in the fruit bats helps solve a piece of the Ebola puzzle, but there are more unsolved questions. For instance, how do the bat's immune systems protect them from viruses and how do spillover events between species trigger the ever transient emergence of Ebola and other viruses?

Although scientists don't understand a lot about bat immunology they do know something about bat ecology. Bats often eat while flying. They eat fruits and insects, extracting the juice and sugars and leaving insect carcasses and partially eaten fruits for animals and humans to pick up and eat. As humans habitats increasingly overlap with bat habitats, chance interactions or disease spillover through other species like pigs or civets becomes more common. The link of the lethal viruses to bats is likely a harbinger of future infectious disease challenges.

The number of pathogens is arguably increasing with changing environmental, ecological and human factors, and many emerging viruses have lethal pathology including severe neurological symptoms. Over half of emerging infectious diseases come from animals (zoonotic), so understanding how the diseases are transmitted between species is critical to controlling them. It is increasingly important for understanding pathogens to probe anthropogenic affects on ecosystems and reconsider our relentless forays into nature and pension for development.

Ebola and other zoonotic pathogens have company among a growing number of emerging and re-emerging diseases. Bats are increasingly found to be the reservoir for viruses that are fatal to humans. While "zoonotic" is a biological term indicating the source of a pathogen, an anthropocentric understanding of the term has the rhetorical effect of pointing at the the reservoir animal. This does not bode well for bats. Animals suspected of harboring disease are culled as the first line of defense for humans.

As an aside, we'll mention the unfortunate events resulting from humans encroachment on ecosystems, which they change it to suit their short-term needs, and at the same time disrupt so that new species take hold and previously established species are forced to adapt - or by chance become natural reservoirs to emerging pathogens like Ebola...isn't the virus actually the result of human activity? Isn't the zoonotic "source" in fact an unfortunate ecological circumstance precipitated by the arrival of humans? Perhaps hard to say, but so far bats seem to conserve themselves through their immunity to the virus. Humans might be better served if thinking in conservation and environmental ecology was as deep as vaccine development and animal control measures.

Last month Acronym Required wrote about the conundrum of sophisticated technology treatments that are too expensive for patients who need them. Here are a few recent articles that discuss related issues or aspects of that article.

--Plos Medicine published "Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Choices and Consequences", in November. The premise of the article is that public discourse about rationing medicine and transparency in policy decisions will provide the most "socially desirable outcome". The article discusses rationing methods for AIDS medications that are currently used in Africa. An intentional rationing program exists in the treatment of infants with drugs that prevent mother to child transmission of the virus, a decision that allocates resources to save infants from becoming AIDS inflicted orphans. Unintentional rationing occurs when people are privileged to receive drugs, or when queueing favors those who have time to stand in line, the unemployed for instance.

--The Wall Street Journal (subscription) published an article, "Through Charities, Drug Makers Help People - and Themselves", (Dec. 1) that followed the stories of several patients who were aided by non-profit organizations funded by drug companies to provide co-pays to patients who have insurance coverage but can't afford the co-payment.

"...people with insurance are increasingly finding it difficult to afford these drugs. In response, drug companies are giving money to charities that are specifically set up to help patients pay such costs...Under this support system, drug-company money keeps patients insured -- and keeps insurers paying for the high-priced medicine."

Drug companies can often tax deduct their donations. Patients recieve medications but the benefits are sometimes short-lived since charities can arbitrarily limit a patient's participation.

--The University of Toronto Center for Bioethics published a report that urges open and ethical decisions ahead of a flu pandemic. "A key lesson from the SARS outbreak is that fairness becomes more important during a time of crisis and confusion. And the time to consider these questions and processes in relation to a threatened major pandemic is now.", said Peter Singer, M.D.. The report deals with issues around the duty of health workers, possible restrictions on travel and liberty and resource allocations in the time of an epidemic.

Only a few years ago, in 2002-2003, China dealt with outbreaks of Severe Acute Respiratory Syndrome (SARS) in a famously secretive manner that hampered international public health agencies as they tried to analyze and control the disease. Since then, China has made efforts to improve the swiftness and openness of its public health reporting. Yet outbreaks of the H5N1 avian flu strain occurred in China earlier this year and again the international public health community criticized China for not cooperating with international public health goals. They publicly suspected that China had wantonly authorized widespread use of the antiviral drug Amantine to innoculate chickens.

In the wake of SARS, China took pains to address its international public health image. The country invested millions of dollars to build an epidemic reporting system. The move to vaccinate its 14 billion domestic fowl against against H5N1 is somewhat controversial, nevertheless China is marching through the Herculean task. China itself is most self-congratulatory about these efforts, but it has also drawn recognition from public health organizations like the World Health Organization (WHO).

Despite progress, there are continual reports of information bottlenecks. There is persistent world-wide suspicion about the country's reported numbers because of China's historical lack of candor. Combined with increasing edginess on the part of health officials about an H5N1 pandemic, the atmosphere is ripe for rumors and panic. Last week Japanese virologist Masato Tashiro reportedly told a German newspaper that China had far more deaths from H5N1 than it led the world to believe. China defended its accounting vigorously and Tashiro has since denied his original accusation, insisting that he referred only to China's general issues with accurate reporting. At the heart of the unresolved questions, fears and suspicions, lie the real challenges to accurate reporting. Among these are geographic logistical challenges, disparate government agency agendas, and incorrect international perceptions of state power in China.

Real logistical barriers to collecting statistics are sometimes blithely ignored. New York Times wrote in, "Experts Doubt Bird Flu Tallies From China and Elsewhere", about discrepancies between Chinese officials' epidemic statistics, that seem far less then foreign expectations. It was an interesting article, but noted that "news on outbreaks has sometimes been slow to emerge from provinces and to the state media. Vietnam, in contrast, posts a daily 4 p.m. update on the Internet, detailing human and animal infections." It didn't weigh that China is about 9.5 million square miles, whereas Vietnam is 329,560 square miles, and that China's population is 1,306,313,812 people whereas Vietnam's is 85,535,576.

On top of very real logistical barriers to consistent reporting, observers see a striking lack of cooperation between government agencies. China Digital Times translated the October and November issues of Caijing Magazine recently, which reported that prior to 2003 veterinary epidemics were state secrets. China lifted this rule but there is uneven progress towards openness. The Public Health Ministry makes genuine efforts to appease foreign requests for information, however the Ministry or Agriculture is insistent that certain details of planning for an epidemic are "not public". Problematically, a subsidiary of the Ministry of Agriculture is reportedly the only organization that is authorized to research the avian flu virus. The lack of communication between agencies apparently figured in the obfuscation of pertinent information about the alarming number of human deaths in the outbreak of Streptoccocus suis in swine earlier this year according to Caijing. A WHO official investigating the S. suis epidemic shared this view -- that China's "human health side" was cooperative, whereas "veterinary" information was not forthcoming. (Science Vol. 309. pp 1308-9).

China's public health system is part of a maze of political and economic ambitions at the national and local levels. We often perceive China to be a centralized top-down authority, but the reality is that local politics and decentralized control often determine the outcomes of state policies. As economists and businessmen know, at different levels - provinces, districts, villages - officials have different approaches and capabilities for their duties. These individuals (as anywhere) are often motivated by personal ambitions that propel behavior that's not necessarily in national or international interests. Reporting is one certainly a critical aspect of public health; who's getting sick, where and how determine medical action. The AIDS epidemic is an example of devastation wrought when a disease gathers momentum because countries deny epidemics among their citizens. In China especially, infectious disease reporting depends both on the complicated and unpredictable social organization of individuals from the bottom up, and trust that key facts will survive the labyrinth of bureaucracy and political motivations.

Epidemics gain a foothold when public health is inadequate. China's health care was once centralized and rural health cooperatives and barefoot doctors provided insurance and care to people isolated in the country. This effective though sometimes idealized system was dismantled by the government in the 1980's. Health care was privatized, barefoot doctors abandoned their traditional practices to sell pills, and the cooperatives were disbanded. Medicine became expensive and decentralized, with resources concentrated in the cities and many individuals left without access to health care. Care facilities vary widely and different areas lack cohesive policies. Depending on where someone is located, if they are sick with flu, they may not be able to access a doctor who would recognize their symptoms.

China can try to rectify its public reporting system, but this on its own would be a superficial solution to problems within the current public health system. Nor does it address issues stemming from a political system habituated to secrecy, fiefdoms, and protecting local semblances of order. Its quite likely that the reports of an isolated case of a sick duck here or there covered up larger outbreaks of H5N1. While H5N1 was a "state secret" veterinary epidemic up to 2003, it had years to gain a foothold as a virus, and perhaps there are other diseases that are also threats. H5N1 is not the only infectious disease threat, in China or elsewhere.

The world's public health now relies in part, incongruously, on cohesive individual actions from the bottom up all over the globe. Today all eyes are on China. The world depends on a different type of China, but while the country seems to be moving towards transparency, change is slow. And its not only China, effective international public health care, which includes reporting, national and international cooperation, and sound politics (the position seems unfilled), all influence the outcomes of infectious diseases. Increasingly isolated country protocols affect global public health.