When swine flu first hit, Egypt killed its pigs. All of them. Now this senseless decision has left Cairo with a major public health problem on its hands.

The pigs used to eat tons of organic waste. Now the pigs are gone and the rotting food piles up on the streets of middle-class neighborhoods like Heliopolis and in the poor streets of communities like Imbaba.

Ramadan Hediya, 35, who makes deliveries for a supermarket, lives in Madinat el Salam, a low-income community on the outskirts of Cairo.

“The whole area is trash,” Mr. Hediya said. “All the pathways are full of trash. When you open up your window to breathe, you find garbage heaps on the ground.”

The pigs belonged to the city’s traditional waste collectors, Christians who lost their animals and their livelihoods. “They killed the pigs, let them clean the city,” says one. “Everything used to go to the pigs, now there are no pigs, so it goes to the administration.”

Update: It doesn’t make me feel any better about this story to see that the pigs seem to have been buried alive.

Click here to view the embedded video.

I’m also reminded of the 4 million or so cows the UK ended up slaughtering and burning during the BSE crisis, because we couldn’t be bothered to maintain basic standards of animal husbandry.

We know from the evidence we received prior to the outbreak of swine flu that there has been a significant amount of work undertaken to ensure UK pandemic preparedness. According to Ms Merron, the WHO recognised the UK “as one of the best-prepared countries in the world”. Professor Lindsey Davies, National Director of Pandemic Influenza Preparedness at the DoH, told us that “No other country in the world has done more than we have to ensure that we protect the population and that we minimise the pandemic’s impact”-other countries are now coming to the United Kingdom for advice.

Instead, the spotlight will be firmly on where the government has got it wrong:

Guardian: “Committee concerned over delays, failures and preparedness for expected ‘second wave’ of virus in autumn.”

Telegraph: “Committee says Government has failed to offer reassurance that NHS services can deal with a “second wave” of swine flu.”

Sun: “NHS can’t cope with swine flu.”

Independent: “The spy who blew the whistle on his former colleagues is now living in a squat, dressing as a woman, and railing against the ‘Zionist empire’.” [Sorry - seem to have got my wires crossed here.]

Of course, none of these stories is a surprise. The Committee made sure the bad news got out over the weekend, leaking the bad bits to the BBC. Ministers have been on the defensive ever since.

Three reasons why this matters. First, it feeds cynicism about the public sector, helping convince ordinary punters that civil servants are such morons that they haven’t done anything useful to prepare for the pandemic.

Second, it creates a cartoonish view of the nature, and limitations, of any response to a serious pandemic. With an attack rate of 30%, our social, economic and health systems are certain to degrade to a degree (though hopefully, in a controlled way). Resilience relies on individuals, families, communities and networks of all kinds to pull together.  Expecting the government to ride around dolling out magic bullets is both a self-indulgent and ultimately self-defeating strategy.

The final point, though, is perhaps the most serious one. The Lords’ criticisms are aimed mostly at patchy implementation of a good strategy. But what if the strategy itself is faulty – not just the detail of its execution? That would be a much more serious matter.

Two possible gaps are, I think, worth exploring.

First, the UK may be doing too little to prepare for a low(ish) probability/high impact scenario, where flu becomes a lot more deadly between now and winter. What if the case fatality rate (CFR) reaches 2%, as it did in 1918, or even higher (unlikely – but why not?)? Are we ready for a pandemic that is very suddenly much worse that we thought?

It’s happened before. According to the World Health Organization:

During the previous century, the 1918 pandemic began mild and returned, within six months, in a much more lethal form. The pandemic that began in 1957 started mild, and returned in a somewhat more severe form, though significantly less devastating than seen in 1918. The 1968 pandemic began relatively mild, with sporadic cases prior to the first wave, and remained mild in its second wave in most, but not all, countries.

DOH planning assumptions include reference to a pandemic with a 50% attack rate and a 2.5 CFR – leading to 750,000 deaths (on Twitter – Mike Bennet is focused on this risk) . I suspect we are thinking less about a ‘black swan’ pandemic today than we were twelve months’ ago – simply because there’s now so much to do to combat what is still fairly mild flu.

The Lords alludes to this concern in footnote 17 to annex three of its report, where they make reference to concerns of John Beddington, the Government Chief Scientist, that we should be planning for a higher mortality rate.

Beddington co-chairs the Scientific Advisory Group for Emergencies (SAGE), which is advising the government on flu responses. I would dearly love to know if this group has had further thoughts on increased virulence, but it meets in secret and even MPs are not able to see its minutes. According to Gillian Merron, Minister for Public Health:

We will not be placing copies of the minutes of each SAGE meeting in the Library at the present time. The majority of SAGE work is directly commenting on or providing input to the formulation of Government policy. In addition, in order for SAGE to work effectively, members need to be free to discuss issues openly, including confidential evidence in their deliberations. The publication of the minutes may therefore prejudice the effective conduct of public affairs. However, we will keep the publication of minutes under review.

This is a dumb move. Despite the barrage of criticism that surrounds government deliberations, it is vital that scientific advice is widely shared and robustly debated. It’s the only way of ensuring an effective response to some potentially catastrophic risks.

The second criticism was one I made when I appeared on a panel with the virologist, John Oxford, at RUSI’s resilience conference in 2008 (my talk). UK plans to manage the pandemic through a call centre model were already far advanced at the stage and I found them quite impressive.

But are we prepared for the consequences of others being less well prepared than we are ourselves? Or is our planning predicated solely on what happens within the UK’s national borders?

The last flu pandemic was in 1968, when global systems were much less tightly linked and just-in-time inventory strategies had not spread far beyond Japan. How will globalization – already under the cosh due to the economic crisis – fare if countries see 20% or more of their workers stay at home?

And then there’s the potential impact on fragile states. During the last pandemic, the developing world had only 680 million people living in towns and cities. Today, the figure is around 2.5 billion.

Here’s Alanna Shaikh on the possible impact of flu on megacities:

The dense living conditions let the flu spread quickly, especially since poor people have less immune resistance to infectious disease. In addition, pollution and living conditions will make the flu more severe in people who contract it, and people often lack access to quality health care services. In my opinion, Mexico City’s huge size was a major factor in why swine flu was so much more severe in Mexico than in the United States…

That high transmission rate will be compounded by substantially increased death rates from swine flu in megacities. The risk factors for death from swine flu are asthma, cardiovascular disease, obesity, and diabetes. All of these things are more common in the megacities of the developing world. Asthma is a particular risk factor, and it’s made worse by air pollution.

The death rate will be made worse by lack of health care. Megacity slums are consistently deficient in access to good health care. Residents may be unable to afford health care, facilities may be poorly equipped or staffed, or there may simply be no health care provider available.

So, a lot of factors are going to come together in an ugly interconnected way. More sick people being hit harder by the virus, and no health care providers to look after them. It could be devastating. My grim guess, however, is that misery and death from swine flu in megacity slums will be ignored, just as we ignore misery and death in the slums from everything else.

The only part of Alanna’s post that I disagree with is the last sentence. If flu is really bad in states that are already struggling to function, then state failure could be the pandemic’s most destructive legacy. British citizens would then be affected more by what was happening in Lagos than London, or Karachi than Manchester.

Addendum: While we’re considering potential wild cards, I’ve been wondering whether an swine flu pandemic makes avian flu less or more likely to emerge, or whether the two are independent. Could we have swine flu this year? Avian flu next?

I’m not really sure there’s an answer to this question, though the current pandemic will mix a lot viral bits and pieces together. According to WHO:

In these early days of the outbreaks, some scientists speculate that the full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is more widespread. This, too, could alter the current disease picture, which is overwhelmingly mild outside Mexico.

Apart from the intrinsic mutability of influenza viruses, other factors could alter the severity of current disease patterns, though in completely unknowable ways, if the virus continues to spread.

Scientists are concerned about possible changes that could take place as the virus spreads to the southern hemisphere and encounters currently circulating human viruses as the normal influenza season in that hemisphere begins.

The fact that the H5N1 avian influenza virus is firmly established in poultry in some parts of the world is another cause for concern. No one can predict how the H5N1 virus will behave under the pressure of a pandemic. At present, H5N1 is an animal virus that does not spread easily to humans and only very rarely transmits directly from one person to another.

We’re not supposed to take our swiney selves or our swiney children into doctors’ surgeries, and doctors are far too busy for house calls, so, as far as I can see, we’re all in the dark. Also, I don’t like the sound of Tamiflu, with its side effects and lack of long-term trials. But then I don’t like the sound of death, either.

No wonder every parent I spoke to last week was in a state of controlled panic — except for the ones who’ve had swine flu, who were all cheerful and said, “Pah, it’s not so bad; you just go to bed for a few days” — although they all said there was absolutely zero support or advice available to them other than: “Don’t go to work.”

This — “it’s not so bad” — had been my take on it until healthy people started dying. Now I’m hovering between, “Yes, but healthy people still die of normal flu — not many, but some, just as some women still die in childbirth and nobody gets pregnant and then starts running around wailing about death,” and, “Oh my God, oh my God, what are we going to do?”

So far I have failed to come up with a plan. I used my low journalistic cunning to sweet-talk two chemists into telling me where the stocks of Tamiflu for my area of London were held, so now I know where to break into if we suddenly find ourselves burning up in the middle of the night. And I’ve ordered some homeopathic remedies.

Update: In the comments, Eleanor suggests a dose of homeopathic A&E.

Click here to view the embedded video.

In each of the four major pandemics since 1889, a spring wave of relatively mild illness was followed by a second wave, a few months later, of a much more virulent disease. This was true in 1889, 1957, 1968 and in the catastrophic flu outbreak of 1918, which sickened an estimated third of the world’s population and killed, conservatively, 50 million people.

As the small print in stockbrokers and pension funds’ ads always tells us (if only we’d listened), the past is not always a guide to the future, but if the swine flu scare wanes over the summer, it would be dangerous to get complacent.

His advice: “We should all just wash our hands and go to the doctor if we have flu symptoms.” Er, wrong. According to the Centers for Disease Control and Prevention (area of expertise: public health):

If you get sick with influenza, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

CDC is happy for people to contact their doctor if they need advice, but it only recommends adults seek emergency medical treatment if they have: (i) Difficulty breathing or shortness of breath; (ii) Pain or pressure in the chest or abdomen; (iii) Sudden dizziness; (iv) Confusion; (v) Severe or persistent vomiting. (The advice for children is similar – the list of warning symptoms different.)

In the UK, health authorities are even more explicit about the fact they don’t want people with flu sitting around in doctor’s waiting rooms. “If you have flu-like symptoms and have recently travelled to Mexico or been in contact with someone who has, stay at home and contact either your GP or NHS Direct on 0845 4647,” advises the NHS. Treating people without requiring face-to-face contact with healthcare professionals is at the heart of of the UK’s pandemic flu plan.

Carafano’s sins are minor compared with this preposterous Guardian article by Simon Jenkins (core expertise: frothing at the mouth).  According to Jenkins, swine flu is “a panic stoked in order to posture and spend” – with the public too moronic to resist having the wool pulled over its eyes:

We appear to have lost all ability to judge risk. The cause may lie in the national curriculum, the decline of “news” or the rise of blogs and concomitant, unmediated hysteria, but people seem helpless in navigating the gulf that separates public information from their daily round.

The government was “barking mad” to convene its emergency planning committee, Jenkins argues, while the World Health Organization is not really worried – it’s just making a pathetic bid to shore up its funding. Attention-whore doctors, health and safety hysterics, and rapacious drugs companies are all in on the plot, while ‘professional expertise’ (presumably from shrinking violent newspaper columnists) is being completely ignored.

BSE, SARs and avian flu, meanwhile, provide cast iron assurance that no pandemic is on the way.

What Carrafano, to his credit, understands, but Jenkins and his ilk refuse to accept, is that risks are risky, precisely because, for a long period, we simply don’t know how serious they are. This creates a huge quandary for governments. Anthony Giddens capture the tension well in his 1999 Reith Lecture:

There is a new moral climate of politics, marked by a push-and-pull between accusations of scaremongering on the one hand, and of cover-ups on the other. If anyone – government official, scientific expert or researcher – takes a given risk seriously, he or she must proclaim it. It must be widely publicised because people must be persuaded that the risk is real – a fuss must be made about it. Yet if a fuss is indeed created and the risk turns out to be minimal, those involved will be accused of scaremongering.

Suppose, on the other hand, that the authorities initially decide that the risk is not very great, as the British government did in the case of contaminated beef [early in the BSE scare]. In this instance, the government first of all said: we’ve got the backing of scientists here; there isn’t a significant risk, we can continue eating beef without any worries. In such situations, if events turn out otherwise – as in fact they did – the authorities will be accused of a cover-up – as indeed they were.

Being grown up about risk means planning in conditions of uncertainty – not allowing policy to be driven by Simon Jenkins and other petulant pub bores. His article may be one step up from the conspiracy theories I was tracking over the weekend – but that’s not saying very much…

So how would such a map look if used to plot the spread of a pandemic today, Kedrosky wonders? Well:

there would be similarities, of course, but there would also be big differences. Instead of contiguous, banded advance you would see viruses hurled ahead of the index cases by air travel, like spot fires a mile ahead of a Santa Ana-driven wildfire. Instead of bands you would have clusters and jumps, mostly corresponding to airline disease vectors. And instead of four years to travel through a corner of the known world, you would have the virus around the world in four days, as is the case today with this H1N1 swine outbreak.

Interesting coda: in comments, Matt Dubuque notes that when the Black Death wiped out a significant chunk of the English labour force in 1340, remaining agricultural labourers were able to crank their wage rates sky high. Presto! – major resource transfer from rich to poor.