Note: This article, written by health writer Jo-Anne Smetherham, originally appeared in the April 2010 issue of Men’s Health South Africa. With this story, Jo-Anne won the MPASA PICA Award for Best Health & Wellness Writer in 2010 – and we liked it so much, we’re reproducing it here as part of our long-form #MHReads series.
By Jo-Anne Smetherham
Photographs by Morné van Zyl
Chaos. That is what greeted Dr Gerry Parolis when he walked into casualty at Groote Schuur Hospital on a Monday morning in mid-August last year. As acting head of the emergency unit, Parolis works under extreme pressure at the best of times. He is used to juggling a flood of TB and Aids patients with a host of others – severe asthmatics, heart attack victims and, on weekends, a spike of drug overdose and psychotic patients.
The unit works on a triage system first introduced in World War I, colour-coding patients according to the urgency of their needs. Parolis first passed the “green” area, where patients are kept if they don’t need immediate care. “All the chairs were full,” he remembers. “Then I passed the yellow area, where patients need more urgent attention. Normally there are only a few patients there so early, but on that day there were about 20.
“The holding rooms, where patients are kept before being admitted to hospital, were jam-packed, with trolleys wall to wall. There wasn’t even space to move between them. There were about 10 people on chairs, a couple standing and some even sitting on the floor.
“I carried on to the anteroom – the red, or orange area, which has the most urgent cases. It’s meant to take about 11 trolleys, but there must have been close to 30. And there were about another 20 patients sitting, which shouldn’t be the case unless they are on asthma chairs.”
Starting his rounds, Parolis came across one swine flu case after another. “We’ve got a new epidemic on our hands,” he realised, with a twinge of anxiety. “An epidemic that has struck really quickly.”
Parolis was on the frontline of the swine flu pandemic, which tapped into a vein of anxiety and panic in us all when it swept across the world last year. Only weeks after first being identified in two children in California in April, it was cropping up across the world. Soon it had replaced seasonal flu as the dominant flu strain. If you had flu, you had swine flu.
Was this the killer virus that experts had been warning us about?
Swine flu – so named because the virus probably first arose in a pig – turned out not to be so deadly after all. There were tens of thousands of South Africans infected, although the official tally was only 12 600, and 92 recorded deaths in this country. Globally, less than one percent of those infected died. This was a catastrophe for their families, of course, but a negligible mortality rate compared to the 50 percent among those who caught bird flu several years ago.
As summer set in, the number of swine flu cases seemed to be dwindling and we all breathed a sigh of relief. Virologists did not.
Some strain of swine flu will probably be the dominant flu virus this winter as the virus wends its way around the world again, says head of virology at Tygerberg Hospital, Professor Wolfgang Preiser. And last winter, virologists feared that the second wave might just be far more deadly than the first.
There is a remote possibility that swine flu could combine with bird flu somewhere in the Middle East, where many small farmers keep poultry in their homes, says Neil Cameron, of the Centre For Infectious Diseases at Stellenbosch University. This might unleash a virus with the virulence of bird flu and the transmissibility of swine flu.
How likely is such a mutant? “What’s the chance of being struck by lightening when you walk out of your office?” says Cameron. “I think it’s very small.”
These fears have abated – for this season, at least. The swine flu virus in the northern hemisphere winter did not sharpen its fangs this year. Our flu patterns follow those of the north, so we look set for a pandemic similar to the one last year.
But virologists admit they cannot predict the future, and over the long haul, a far more deadly flu may strike. After all, they are grappling with the most unpredictable and fastest-changing forms of life – all part of the thrill of the job.
The origins of epidemics are like shadows in the history of hunting and livestock farming. We get most flu viruses from poultry, directly from birds, or indirectly through other animals such as pigs. These flu viruses have lived in wild birds for millions of years, in mammals more recently and in humans only very recently on the evolutionary timeline, says Barry Schoub, executive director of the National Institute of Communicable Diseases.
The dreaded avian flu, or H5N1, jumped straight from birds, probably poultry, into the human body, according to recent research published in the journal Science. The TB bacteria hopped from cattle into humans, probably in the Middle East in about 5 000BC – friezes have been found in Egyptian tombs of mummies with a particular humpback that is a signature for a TB that attacks the space between the vertebrae, says Cameron. HIV is believed to have jumped from a chimpanzee into the human body in central Africa, probably when some unwitting hunter ate bush meat. But there are two viruses that caused major epidemics in South Africa that do not come from animals. Polio and smallpox viruses originate in the human body, and they have a sinister kind of stamina – they’re able to survive in water and sewage for weeks on end while waiting for a long-term host.
Plague is carried by fleas on rats, and did not disappear after the Middle Ages as some of us thought – it broke out only recently in India, Mozambique and Zimbabwe.
Swine flu is a “real mutt” of a virus, as one American expert said. It contains elements of human, bird and pig viruses, but probably was first formed in pigs, which are the “mixing vessels” for many flu viruses, as they are susceptible to both human and bird flu. Humans are usually only marginally susceptible to bird flu.
There have been sporadic cases of classical swine flu in humans since the Fifties, leading to pneumonia, and a few deaths, in even some previously healthy adults. But the early versions did not spread easily between humans.
Worry as we may about a killer virus, we should get a grip. Marc Mendelson, head of Infectious Diseases at Groote Schuur Hospital, points out that we’re already facing a very serious pandemic and it’s not going away any time soon: HIV is still wiping out between 600 and 800 of us every day.
One of the reasons we’re so much more scared of swine flu is that we can choose whether or not we will get HIV, while exposure to swine flu is more or less unavoidable. Nevertheless, our response to HIV remains nothing short of idiotic, as many of us continue having unprotected sex. “Amazingly, we are so far into the HIV epidemic in South Africa and there is still this idea that ‘It can’t happen to me’,” says Mendelson. And, of course, seasonal flu kills thousands of people globally every year, but people don’t go and get the routine flu jab.
TB and HIV are a double-whammy in South Africa, each epidemic fuelling the other. TB causes a large proportion of all Aids deaths, and more than half of all TB patients have HIV. And it’s not only the poor who get TB. Like Parolis, you could be one of many healthy, middle-class South Africans who have it. Parolis had an X-ray and the telltale TB spot was found on his lung. “Most well-nourished, middle and upper-class people will have been exposed to TB,” he points out. It’s another reason for you to stay fit and healthy.
Talk of a second wave of swine flu has echoes in the past: it was the second wave of the 1918 Spanish flu that killed about 50 million people worldwide. This pandemic was commonly called the Spanish flu because Spain did not censor news about it, as other countries did. Its effects have been largely ignored by South African history syllabi, which is absurd because the flu caused “the worst natural catastrophe to have hit this country,” says history professor Howard Phillips, who wrote the book Black October on the subject.
This flu killed half a million South Africans and had South African cities under siege, bringing them to a standstill. Shops, businesses, schools and universities closed, cemeteries were overwhelmed and mass graves had to be dug to bury the dead during the short, sharp onslaught of the disease. “There are not enough gloomy adjectives to describe what it was like,” says Phillips.
Like swine flu, the 1918 flu was an H1N1 strain – named after the pattern of H and N proteins on its surface, although the genetic structures of the viruses differ. In fact, the 1918 flu has been called “the mother of all flu epidemics”, as it is the common ancestor of swine flu and many seasonal flu viruses.
And, like swine flu, the 1918 flu struck previously healthy young people. In both cases, this might be because this age group missed the older generation’s exposure to a previous, related virus, explains Preiser.
Should a virus as virulent as that of 1918 flu strike again, would it finish off a large number of us? Both Preiser and Schoub say such a disease could probably be contained using modern drugs and isolation measures. Also, hygiene has improved vastly since that post-war era.
But sick patients would have to get treatment extremely quickly, so a lot of it would have to be readily available. And who knows how stretched emergency units in the public sector would cope with the added burden? “It’s very, very difficult to predict what would happen,” says Mendelson.
As it is, the best weapon hospitals had against swine flu last winter was basic hygiene. It will be a main ally this winter, too, he agrees. To prevent spreading the contaminate, doctors and nurses must wash their hands before and after treating swine flu patients, and wear disposal gloves, aprons and masks. And swine flu patients should be isolated from others, to avoid further widespread infections.
There’s one major new weapon against the pandemic – the new flu jab is designed to prevent swine flu. Healthcare workers will be urged to get vaccinated, as will the groups that were most at risk last winter: pregnant women, the elderly and people with underlying illnesses such as HIV, TB and chronic respiratory disease.
The flood of World Cup visitors might bring a flood of extra flu cases to our hospitals. But these visitors will be coming from a summer destination, so will not bring the virus themselves, points out Schoub. And they will be a tiny fraction of the number of locals in the country. If all the basic precautions are followed, our hospitals should cope.
Viruses have a major ally these days – our passion for plane travel. About half a million people are airborne at any one time, and two billion people travel by air at least once a year. It took only months for swine flu to spread across the world after it was first identified in California. So it was predictable that the first swine flu cases in South Africa, as elsewhere, were travellers. We know a killer virus could wing across the world very quickly after mutating in some far-flung region.
But what if you’re stuck on one of those planes with someone carrying a new virus?
Or – and we’ve all been here – you’re on a train or bus and someone is coughing, possibly spreading a dreaded lurgy far and wide?
There’s no need to run, but keep your distance. Flu droplets are relatively heavy and can travel only about a metre before dropping to the ground, says Mendelson. Two metres is a safe distance to keep.
The same applies when colleagues at work are sick. But keep in mind that the swine virus survives for between two and eight hours on doorknobs, kitchen utensils and other objects. You could become exposed by touching one of these, and then your mouth,
if you don’t wash your hands in-between. This is why janitors in schools in Mexico, where swine flu first reached epidemic proportions, had to disinfect doorknobs every two hours.
However, there are not as many coughers around as you might fear. “I travelled by train recently, and nobody was coughing,” says Preiser, who would have noticed.
Viruses and bacteria are found in the wild in animals, plants and even soil but those cunning enough to infect humans come from animals. So until every earthling becomes a vegan, we’re all set for exposure to one infection after another.
Virologists love viruses for fine-tuning the definition of life itself: they do not breathe, grow, move or show irritability, as do all human life forms, yet there is no doubt they’re alive. The definition for life, then, is simply the ability to reproduce, says a UCT website introducing molecular virology.
And viruses are masters at this process of replication, hijacking the metabolic process of the host’s cells to produce billions and billions of copies of themselves every year. With each new copy, as evolution dictates, there is the possibility of mutation into a weaker, or stronger, virus.
“Flu viruses are masters of disguise,” says Preiser. “They keep changing all the time. That’s why we need a new vaccine every year.”
When swine flu overwhelmed the Groote Schuur emergency unit, the nursing staff feared it was a deadly virus that would attack them. “None of the nurses wanted to get close to the patients,” remembers a senior sister. “We all went to Dr Parolis and said, ‘What must we do? Everyone is so scared of catching this thing’. ”
One or two pregnant nurses mysteriously disappeared from work – justifiably, perhaps, as pregnant women were a risk group and several in South Africa actually died of swine flu complications. Mendelson was called upon to allay the staff’s fears. He told them how the virus was transmitted and the simple steps for avoiding it – routine hand washing, wearing the correct mask and apron when treating patients, and disposing of these afterwards. He told them a mask was unnecessary unless they were close to patients.
Some of his advice was ignored. Everyone carried on wearing a mask in emergency, he recalls ruefully. But the fears were natural under the circumstances. “That’s what happens when a pandemic evolves so rapidly,” he says. “It was like a war zone.” And the doctors on the front line were – and still are – learning on the job.