Expertise: Cultures and Technologies of Knowledge

A Pathography of the H1N1 Influenza Pandemic

Theresa MacPhail

• Publisher: Cornell University Press
• Year: 2015
• ISBN:
  9780801454882
• Topic: Medicine
• Subtopic: Pathology

In The Viral Network, Theresa MacPhail examines our collective fascination with and fear of viruses through the lens of the 2009 H1N1 pandemic. In April 2009, a novel strain of H1N1 influenza virus resulting from a combination of bird, swine, and human flu viruses emerged in Veracruz, Mexico. The Director-General of the World Health Organization (WHO) announced an official end to the pandemic in August 2010. Experts agree that the global death toll reached 284, 500. The public health response to the pandemic was complicated by the simultaneous economic crisis and by the public scrutiny of official response in an atmosphere of widespread connectivity. MacPhail follows the H1N1 influenza virus's trajectory through time and space in order to construct a three-dimensional picture of what happens when global public health comes down with a case of the flu. The Viral Network affords a rare look inside the U.S. Centers for Disease Control, as well as Hong Kong's virology labs and Centre for Health Protection, during a pandemic. MacPhail looks at the day-to-day practices of virologists and epidemiologists to ask questions about the production of scientific knowledge, the construction of expertise, disease narratives, and the different "cultures" of public health in the United States, Europe, Hong Kong, and China. The chapters of the book move from the micro to the macro, from Hong Kong to Atlanta, from the lab to the WHO, from the pandemic past in 1918 to the future. The various historical, scientific, and cultural narratives about flu recounted in this book show how biological genes and cultural memes become interwoven in the stories we tell during a pandemic. Ultimately, MacPhail argues that the institution of global public health is as viral as the viruses it tracks, studies, and helps to contain or eradicate. The "global" is itself viral in nature.

1

SEEING THE PAST OR TELLING THE FUTURE?

On the Origins of Pandemics and the Phylogeny of Viral Expertise

It is so difficult to find the beginning. Or, better: it is difficult to begin at the beginning. And not try to go further back.

LUDWIG WITTGENSTEIN, On Certainty

Gene Segment PB2. Biological function: Encodes a protein that slices open a host cell’s mRNA (messenger RNA), producing a short primer used to begin the process of viral transcription. In human influenza viruses, PB2 also interacts with the host cell’s mitochondria, inhibiting the cell’s natural immune response. The biological pathway for this second function is unknown. Pathographic function: Examines a key biological or scientific narrative about the origins of influenza pandemics. This segment slices opens our pathography of the 2009 H1N1 pandemic by first defining its protagonist—the H1N1 virus itself—and depicting how a “pandemic” becomes a pandemic in the first place. An exploration of the production of genetic phylogenies, this segment is the primer that begins our exploration of viral expertise and the production of knowledge during the 2009 pandemic. Knowledge about a virus’s genetic lineage is interpreted and used differently by virologists and epidemiology to carry out different tasks.

On Origins

In late March 2009, a new strain of the Influenza A (H1N1) virus began to unfurl out of a remote region in Mexico. It seemed to many as if the developing pandemic might be the denouement of a harrowing story that public health workers had been telling and retelling for decades. Epidemiologists and virologists working on viruses have been sounding warning sirens about the potential for another lethal—and global—outbreak of infectious disease since the discovery of HIV/AIDS in the early eighties. Sporadic admonitions related to the collective weakness of our pandemic preparedness highlighted the very real threat posed by such emergent or “novel” viruses. These forewarnings only intensified after the 2003 SARS epidemic and in the wake of increasingly frequent outbreaks of “bird flu” in East Asia beginning in 1997. For a brief moment in the spring of 2009, then, it appeared as if all the past predictions about the epidemic future were finally coming to pass.

But were they?

And perhaps more importantly, how would we know?

Answering this all too urgent question would ultimately rely upon an understanding of what a novel Influenza A virus is in the first place, where the term “novel” is used to indicate not only biological or genetic variance but also a particular viral strain’s potential for causing a deadly pandemic in an immunologically naïve population.1 But how does the public health community come to a conclusion about whether or not a virus is both novel and dangerous enough to warrant attention and formulation of an aggressive global response? How do virologists and epidemiologists tell the difference between routine changes in seasonal influenza and modifications that could presage a killer pandemic?

Such questions are never easy to answer, but they pose a particularly thorny set of problems during a potential crisis situation as it is developing, when the speed and accuracy of decision-making matter more than ever. Throughout my fieldwork during the 2009 H1N1 pandemic, I discovered that the answers revolved almost entirely around a complex set of relationships and exchanges among evolutionary virologists, epidemiologists, and the influenza viruses that they study. As a social scientist caught up in the puzzle of determining the severity of the 2009 Influenza A (H1N1) virus, I found all the myriad social and professional exchanges vexing to trace. Mapping out the connections between people and places necessitated an almost continuous rethinking of how we experience and embody our social and professional connections through time in an increasingly digital age. The experts I encountered thought about themselves and their work in association not only with other people, places, and institutions, but also in terms of a complicated and mutating relationship to the past and the future.

By late summer 2010, as I began to write the pathography of the pandemic, I realized I was entangled in my own temporal dilemma. The WHO had officially declared the global pandemic over, and yet I discovered that I still had far less perspective on events than any thoughtful scholar attempting to write a “factually accurate” account might desire or require of herself. I chose—perhaps artificially—to begin my initial examination of the 2009 H1N1 pandemic through an analysis of the biology of the virus. Biology and genetics might seem a peculiar place to begin any investigation of the historical origins of a particular virus or pandemic, but it becomes far more appropriate to the task at hand once one considers how the spread of a particular strain of influenza virus becomes labeled as a “pandemic” in the first place. In retrospect, beginning within the realm of the scientific laboratory also seemed like a good choice primarily because examining the biology of the virus, explaining H1N1 through its virology and genetic makeup, would be “easier” than examining its social, political, and economic aspects. It would delineate what I meant when I referred to H1N1; in effect, it would ground my pathography by defining my protagonist (and public health’s antagonist)—the object at the very center of the 2009 pandemic.

Once I began the painstaking process of reviewing scientific articles, re-interviewing virologists and epidemiologists, and going through my copious field notes, however, I realized almost immediately that I had been horrifically naïve in my initial assumptions. The biological beginnings of the 2009 A (H1N1) influenza virus are anything but simple. In fact, the biological—or scientific—story is one of the trickiest narratives about the H1N1 virus, or the resulting pandemic, to recount or analyze. It is, if you will, an always mutating or drifting narrative. As any virologist can tell you, viruses are forever in flux.

Any attempt to retell the tale of the 2009 pandemic, whether beginning from the history of influenza pandemics, or from the threat of avian influenza, or from global funding for international influenza surveillance networks, or from the social and political aspects of decision-making during a pandemic, eventually leads back to biology—to the genetic sequence of the virus—and converges upon the moment that the virus first became “known” or understandable. A virus’s unique genetic sequence is often conceptualized as a kind of scientific Rosetta Stone, essential not only for an accurate reading of a virus’s present (or sudden presence on the global stage), but for working out its evolutionary past and predicting its epidemic future. From an evolutionary virology standpoint, the genetic sequence of an influenza virus is integral to answering the central question: Where did this virus come from and how does it work? And yet, as any evolutionary virologist will tell you, the predictive qualities of phylogenetic trees (or the evolutionary “lineage” charts of viruses) are deficient. Still, from the standpoint of epidemiology or public health, the genetic sequence provides crucial information about a virus’s virulence, its severity, its transmissibility. For epidemiologists, genetic phylogeny is seen as “good enough” to serve as the foundation for scientific “best guesses” regarding a novel influenza virus’s pandemic potential.

In this chapter, I am interested in how phylogenic trees of the H1N1 virus became central to the enactment of virological expertise as well as to the decision-making process of epidemiologists during the 2009 pandemic. From an anthropological perspective, then, genetic phylogeny is key to understanding how the social comes to insert itself into the biological and back again, or how human culture invades viral cultures and vice versa. The story of a pandemic or a particular influenza virus cannot simply be told from the singular perspective of science, or history, or epidemiology, or culture. A virus’s genetic lineage is much more complicated than that; it refuses any simple explanation of its being in the world, just as it defies any traditional methods of taxonomy. Here I utilize the sequencing of influenza viruses and their resulting genetic phylogeny trees—or evolutionary trees—as an anthropological lens. In what follows, I trace the ways in which speculation about a future deadly influenza pandemic shaped not only the direction of scientific research on influenza viruses, but also helped to formulate the possible ways in which virologists and epidemiologists conceptualized the pandemic in March 2009. Our historical “pandemic past” was used not only to anticipate the epidemiological future or to influence action in the present, but helped to create the network of experts working on influenza. I take seriously the ways in which the various experts I interacted with were “tacking back and forth between the past, present and future” (Adams, Murphy, and Clarke 2009, 255) in their attempts to make better decisions about which actions to take in March 2009, a moment when it was still highly uncertain whether or not the H1N1 virus would develop into a deadly influenza pandemic. The routine practice of genetically mapping influenza viruses not only highlights biological connections among viruses through time and space, but also produces and reifies larger social structures. Genetic information is exchanged rapidly and widely among participants in the scientific network. The resultant network of information collected, analyzed, and shared is both representative and generative of the superorganism that is global public health. The playful idea of a resultant “phylogeny” of viral expertise is my attempt to highlight all the complex relationships that develop between scientists, farmers, public health institutions, and even the viruses themselves, or what the scientists themselves often referred to as “alliances” between “partners.” In this framing, viruses and their genetic phylogeny trees are both derivative and constructive of biological and social relationships.

In the end, I suggest, the evolutionary tree of a virus is often “read” by virologists and epidemiologists as a type of kinship chart; by reading a phylogenic tree, one can arguably be said to know the origin story of a particular virus. But what stands out—especially in the process of discovering, analyzing, and naming a virus—is not the biological heritage of a particular viral strain, or its relationships to places, people and other objects—but its centrality to the “enactment of expertise” (Carr 2010), the assessment of risk, and the emergence of the global public health network. Nodes in the global public health network are fashioned through work done on the influenza virus, so it should also not be all that surprising if those same interpersonal and institutional relationships ultimately reflect certain characteristics of the phylogenic trees crafted through the process of sequencing, analyzing, and sharing genetic information. This chapter ultimately examines not only how a pandemic becomes a pandemic in the first place, but also how human cultures and viral cultures intersect to produce expertise.

A Brief History of Flu Research and Pandemic Planning

When an unusual late-season outbreak of an influenza-like illness hit central Mexico in March 2009, it is no surprise that epidemiologists who responded to the growing epidemic instantaneously thought of influenza. In many ways, since pandemic planning efforts began in 2003, epidemiologists had never stopped thinking of it. Public health experts were primed to respond to the beginnings of a new influenza pandemic. After the 2009 virus was subtyped as a descendant of the infamous 1918 H1N1 strain, influenza experts immediately began to worry that it might be the start of “the next big one” for which they had all been preparing. Hence there is no way to talk about the 2009 H1N1 pandemic without recourse to both the 1918 H1N1 pandemic and the more recent predictions of a potential H5N1 pandemic. This is a pathography of the 2009 pandemic, but it is also—of necessity—a story about the interrelationship between the past and future that often drives decision-making in the present moment.

Whenever I asked about the history of scientific research on influenza, when it began or how Influenza A came to be at the center of a global surveillance program, virologists or epidemiologists had to pause to think. Despite a renewed sense of urgency, which began after 9/11 in the wake of the anthrax attacks that same fall, research on potentially hazardous microbes such as influenza had already been ongoing for decades. For the “flu people,” sometimes also referred to as “flu guys” since the majority of people who specialize in influenza are male, flu research already seemed ubiquitous. It is their natural milieu, and hence it is hard for them to put an exact date on its beginnings. The history of influenza itself is no less elusive. Medical historians have identified outbreaks of an influenza-like disease in historical records dating as far back as Greece in 412 BC. The first medical description of an outbreak of influenza was recorded in Philadelphia as early as 1793 (Oldstone 1998, 179). But the events which form the backbone of this pathography span the more recent history of the field of influenza virology.

It is not at all spurious to argue that everything began in 1918. A pandemic of H1N1 Influenza A virus that year impelled what has now become almost a century’s worth of intense scientific study on a single infectious disease agent. During the deadly 1918 pandemic, which lasted approximately eighteen months, it is estimated that between twenty and forty million people died worldwide as a result of the flu. As millions of people fell ill and died in record numbers, an animal husbandry inspector working for the US government noticed that swine on farms were falling prey to a disease with a similar set of symptoms. Over a decade of subsequent research on porcine influenza provided scientists with concrete evidence that influenza is caused by a virus (and not a bacterium, as had been suspected). Even so, the influenza virus was not isolated and confirmed in a laboratory using Koch’s postulates2 until 1932 (Potter 2001), during a relatively minor epidemic of influenza subsequent to the 1918 pandemic. During that epidemic, researchers at Wellcome Laboratories in London who became infected with influenza noticed that ferrets in their research facility also fell ill,3 and quickly confirmed that influenza was transmitted via virus (Oldstone 1998, 181). In essence, this single event marks the official start of modern influenza virology.

For the following two decades, laboratory research on influenza progressed slowly. In 1941, the HA and NA surface proteins were first described, and their usefulness as markers for detecting and tracking influenza viruses was immediately recognized (Artenstein 2010, 194). The discovery of the roles of these surface proteins in invading a host cell also helped to advance the biological understanding of how influenza functioned. At the same time, beginning in 1940 and continuing throughout the 1950s, MacFarlane Burnet, an Australian scientist, made significant progress in the use of chicken embryos for research on influenza. He established the practice of cultivating influenza viruses in eggs (Oldstone 1998, 182)—a technological advance that made it possible not only to grow large amounts of the virus for scientific study and diagnostic assays, but also enabled the development of influenza vaccines.4

Given that World War I had precipitated the deadliest influenza pandemic in memory, the United States had influenza near the top of its list of concerns as it approached World War II. Preparations for that war included the establishment of a Commission on Influenza (Artenstein 2010, 198), which would be instrumental in the development of effective vaccines. World War II also inaugurated the practice of mass vaccination campaigns among US soldiers, thereby providing virologists and epidemiologists with their first chance to study vaccine effectiveness in a large population. The Commission on Influenza financed a bevy of scientific research over the three decades of its existence, and spurred broader advancements in research on other viral pathogens. By 1957, when another pandemic of influenza spread around the globe, virologists and epidemiologists were equipped with far better methods and equipment (Artenstein 2010, 200), marking the beginnings of modern virological analysis of Influenza A. Since then, laboratory work on influenza has progressed apace, increasingly reliant upon new techniques in genetic sequencing and analysis, and focused on unpacking the virus’s origins, understanding its ecological environment, and decoding its biological processes and functioning inside host cells. With the establishment of the WHO’s Global Influenza Surveillance Network (GISN)5 in 1952, and the network’s expansion over the ensuing decades, laboratory research on influenza continues to receive a generous amount of international attention and funding.

The history of scientific research on the influenza virus is, of course, deeply intertwined with that of pandemic planning. Did advances in v...

Table of contents

• Acknowledgments
• List of Abbreviations
• Prologue to a Pathography
• 1. Seeing the Past or Telling the Future? On the Origins of Pandemics and the Phylogeny of Viral Expertise
• 2. The Invisible Chapter (Work in the Lab)
• 3. Quarantine, Epidemiological Knowledge, and Infectious Disease Research in Hong Kong
• 4. The Siren’s Song of Avian Influenza
• 5. The Predictable Unpredictability of Viruses and the Concept of “Strategic Uncertainty”
• 6. The Anthropology of Good Information
• 7. The Heretics of Microbiology
• Epilogue
• Notes
• References