A syringe containing a test H1N1 vaccine at the University Hospital of Antwerp, Belgian.FRANCOIS LENOIR/Reuters
The last Haida left the village of K'uuna Llnagaay, or Skedans, off the north coast of British Columbia, almost a century ago - long enough even for cedar to crumble back into soil.
The house timbers were all gone years ago; the frontal and mortuary poles are all that remain of human handiwork - but even these lie at increasingly acute angles. Soon the forest will take them back. The stylized orca and thunderbird representations gazing out at the sea are bearded with moss. The poles themselves have been reduced to a crust of grey carved cedar around a core of disintegrating rot.
K'uuna Llnagaay was 26 houses, about 500 people, until the smallpox epidemics began in 1862. After these reduced the Haida by more than 95 per cent throughout the Haida Gwaii archipelago (now also called the Queen Charlotte Islands), the remnant population of just 558 gradually abandoned the coastal villages. The northern villages coalesced mostly into Masset, the southern ones into Skidegate, both on Graham Island.
This is where most of the Haida lived when the next viral cataclysm struck them - the influenza of 1918, which laid waste to their settlements and left many islands permanently uninhabited. The effect of the Spanish flu on the indigenous peoples of the planet is one of the underappreciated details of its cruelty. No one who witnessed the devastation wrought upon the Haida then would have been surprised this year, when the first ripples of the current influenza pandemic showed up in Canada, that native communities were hit first and hardest.
Now, the whole country is bracing for autumn, colder weather and the re-opening of schools. The portents seem clear: The average death toll of influenza, about 4,000 Canadians annually, will be exceeded significantly. In hospitals, Tamiflu is locked up with the narcotics, to remove any temptation. This year's influenza vaccine is the most anticipated ever, as the Canadian Medical Association showed this week by calling for a speed-up in the review process to get it to high-risk populations.
In 1918, the tolls were worst in remote regions; among American Indians, 8.5 per cent died - but in Nome, Alaska, 55 per cent of the Inuit were killed. It was comparable among the Alaskan Haida and Tinglit: In fishing village Micknick, 42 of the 50 residents were killed. The Canadian Haida died similarly.
On the same latitude, but 3,000 miles to the east, in Hebron, Labrador, 150 out of 220 Innu were killed. This against a world-wide case-fatality rate of 2.5 per cent.
That year's influenza was extraordinary in several ways beyond its lethality: It affected the young and the healthy disproportionately; it also spread readily beyond the lungs to injure the brain, the kidneys and the heart.
But in its appetite for indigenous peoples, the Great Flu was drearily typical. Tuberculosis, HIV, measles, E. coli - all the important pathogens claim Inuit and first-nations people at rates many multiples of what is seen in cities. This was the case at the outset, with initial exposure to European infections, and it remains so half-a-millennium later - the T.B. infection rate on reserves in 2004 was 20.9 per 100,000; the national rate was 1.6.
When the discipline of public health first arose, and directed its attention to the death rates on the reserves, much was made of indigenous peoples' innate vulnerability to introduced infections such as influenza, presumably on a genetic basis, presumably as a consequence of different - the subtext here is apparent - evolutionary pressures.
In the popular discourse this susceptibility continues to be emphasized. Given the calamitous 500-year history of infections and aboriginals, it is easy to understand how such an idea might gain traction, but the truth is more complex and difficult.
There are differences in immunity between various racial groups - the Inuit, for instance, may suffer more middle-ear infections than other populations, partly because of differences in inflammatory responses; African Americans seem to suffer fewer, for reasons less well-explained.
But the main reason native people die of infections, at rates that would be inconceivable and entirely unacceptable to other Canadians, is because they are poor. The poor die of everything - heart attacks, diabetes, suicides, homicides, drowning, house fires - at rates that would not be permitted along the various Bridle Paths of the nation.
In 1918 the Haida lived on the verge of malnutrition, in crowded, smoky houses without running water, resident physician services or adequate sewage. Ninety-one years later, this June, H1N1 influenza hit Canada the deepest on the Cree reserve of St. Theresa Point in Manitoba - for precisely the same reasons: crowding, malnutrition, poverty and indifference.
Which would be lethal enough without any genetic differences in immune response. But just to make matters worse, they exist.
"A hundred years ago, the pendulum was all the way to the side of genetics," says Dr. Pamela Orr, of the University of Manitoba's departments of community medicine and infectious diseases. "Then the thinking shifted and it was realized just how important the extreme poverty of northern reserves is. And now we still think that's important, but there's probably also an important difference in immune response.
"This means that health-care interventions need to be more aggressively and more precisely tailored to the needs of First Nations populations. It means that the deprivation is even more disastrous."
Fifty of the 2,000 residents of Saint Theresa Point required evacuation to Winnipeg hospitals this summer for H1N1; over the course of the Manitoba-wide outbreak, seven died. The majority of other Manitobans requiring intensive-care-unit admission for H1N1 were of native descent. The average age of those requiring hospital evacuation was an incredibly youthful 35.
Forty million people were killed worldwide by the last great pandemic. This is the first pandemic of any size at all in 41 years. How could it not be catastrophic?
A catastrophe exists already, and will manifest itself further and with great predictability in Pukatawagan and Sioux Look-
out and Shamatawa and Arviat and Hobema and Hazelton and Masset and Kasheshewan and Davis Inlet in a few months, when influenza fully comes ashore.
A pathogenic pas de trois
Epidemics unfold as a kind of pas de trois between pathogen, host and the environment they unfold in. Everything about them depends on that interaction. With flu, the pathogen's nature and virulence vary a little each year; 31 times in the last 400 years - and now 32 - it has abruptly worsened.
At the same time, the host's behaviour and the circumstances under which he or she (or, in the case of animals, it) lives strongly influence the course of an epidemic, especially through the number of other hosts typically infects - this is termed the Ro, or the reproductive number.
The 1918 strain's Ro was 3, meaning each infected person infected an average of three others; thus far, the 2009 strain's has ranged from as low as 1.4 (based on the Mexican experience) to as high as 4.28, in an outbreak at the St. Francis parochial school in New York. Among populations where people are packed together, as in classrooms, the Ro will reliably increase.
Add in residential crowding and limited sanitation and that number inches higher.
Conversely, and ironically, nomadic hunter-gatherers living traditionally suffer no epidemics at all: Density is dangerous in infection, as in war. The infantry motto "don't bunch up" can be applied usefully to all sorts of attacks.
The Ro influences the attack rate, which is a little more intuitive and useful in estimating the scope of the problem. This is the expected portion of the population who will be afflicted in the course of the pandemic. The usual attack rate in pandemic influenza ranges between 25 and 40 per cent. In New Zealand, where the winter flu season has already begun, the data suggest a Ro of 1.96, which corroborate Japanese estimates.
The secondary attack rate - that is, the likelihood that any given close contact of an infected person will get the virus - ranges between 12 and 18 per cent. Multiple contacts may drive the final attack rate much higher than that, and usually do in pandemics, which is both cause and consequence of their severity.
The ultimate significance of the likelihood of infection is determined by the case-fatality rate (CFR): Most years less than 0.1 per cent of people infected with influenza die as a consequence of that infection. The data out of Australia suggest a CFR between 0.14 and 1.4 per cent for the H1N1, though this can change over time and between different populations.
The process of mutation that gives rise to pandemics in the first place does not cease with their inception, and there is nothing to say that the virus's nature will remain constant. This is the source of considerable anxiety with respect to the current outbreak - like last spring's, the initial waves of the 1918 epidemic were mild, but grew in virulence and lethality with each resurgence.
The rate at which an epidemic spreads is referred to as generation time; with a generation time of two to three days, H1N1 is capable of doubling the number of affected cases every 72 hours. A similarly brief generation time in 1918 caused stories such as whole crews of miners in Spitzbergen abruptly falling ill at once and dying within hours, like H.G. Wells' Martian invaders. One may imagine the impression such events left on the public consciousness.
Nevertheless, for those who live in expansive apartments with gleaming kitchens, the current pandemic will inevitably be a much different experience than 1918. This has less to do with advances in medical care (Tamiflu-resistant H1N1 strains have already emerged) than with what we can anticipate the Ro will be, as a consequence of wealth and the epidemiologic features of wealthy societies - small families, low burden of chronic illness, uncrowded classrooms, sick time.
The reproductive number may be influenced further by public-health measures that discourage the ill - especially health-care workers - from going to work or out in public. Together these may explain the relatively low mortality seen in Australia in the current southern-hemisphere winter, hopefully presaging what will be seen to the north.
The most effective vaccine against any infection is affluence. In this respect, southern and, especially, urban Canadians are among the most thoroughly inoculated anywhere. But the importance of the huge disparities in affluence - between the races, between the north and the south, between rural and urban communities - becomes not merely a matter of fairness but one of life and death when epidemic disease appears.
The relationship between health and wealth has been clear since the dawn of the Industrial Revolution; it was aptly demonstrated by tuberculosis. In 1828 the death rate from TB in Britain was 4,000 per million - at a time when the death rate from all causes was 9,000 per million. By 1948, immediately prior to the discovery of the antibiotic streptomycin, it had fallen to 400 per million.
The difference in the intervening 120 years did not lie in medical care. TB specialists spent that century pursuing a range of violent treatments - repetitively collapsing consumptives' lungs, even filling chest cavities with foreign objects to keep them collapsed; hydrotherapy, spa stays, everything new was old again then and the advocates of those treatments might as well have been peddling megavitamins and aura manipulation.
What did change was affluence. Britain began to know sustained growth in GDP per capita and with it, tuberculosis death rates sank. When, in their turn, the countries of the European continent began to experience the same economic trends, the same thing happened to their TB death rates, eventually falling, as Britain's did, 90 per cent, even prior to the availability of effective antimicrobial therapy.
As autumn looms and anxiety about H1N1 mounts, the most useful responses will revolve around maximizing just those advantages made possible by being wealthy and educated - keeping personal contact between the sick and the well to a minimum, emphasizing hand-washing and hygiene generally, and getting people vaccinated.
The case-fatality rate still may be much higher than what is usual for seasonal influenza, but will likely be within the range of what was known with the Asian, Hong Kong, and Fujiian strains of the last decades. This will not collapse the health-care system, much less society itself. No one has to stockpile ammunition.
Straining the cities' webs
And yet it will likely be bad.
In Winnipeg, the demands placed on the city's ICUs by people who came there from Saint Theresa Point during its outbreak, together with a smaller simultaneous outbreak in the city itself, nearly overwhelmed that city's critical-care community. Intensive-care physicians and nurses and respiratory technicians were stretched nearly to the breaking point by a weekly doubling of H1N1 cases over the course of two months.
Saint Theresa Point is 2,000 people - one-five-hundredth of Manitoba's population - and it generated enough critically ill people nearly to swamp the province's critical-care capacity.
The SARS outbreak in Toronto is still a fresh memory for the critical-care community there, and by every estimate, the numbers of critically ill and dying patients that may be anticipated this autumn and winter will exceed the numbers that generated those crises by many orders of magnitude. Overall, there isn't enough ICU capacity in the country to begin to treat the numbers sickened by the great pandemics of the past.
H1N1's predilection for the young bodes ominously, too. Forty-one per cent of U.S. deaths from H1N1 have occurred in the 25-49 age group. The death rate among the Haida and Tinglit in 1918 was so high not solely because of the direct effects of the influenza, but also because the young adults who did the fishing and the hunting and the food preparation were incapacitated. Villages simply starved to death, to the last soul, even though many inhabitants survived the actual pandemic.
Modern cities are even more interdependent, their citizens' skills more specialized and the citizens themselves less self-sufficient. Even if the CFR is within the Australian estimates - up to 10 times the norm - if this is coupled with a high attack rate and a shift of the affected to the young from the elderly and infirm, then the functioning of police services, transportation, utilities and trade throughout cities will be seriously affected.
Dr Bruce Martin, associate dean of the University of Manitoba and director of that institution's Northern Medical Unit, was one of the team that flew to Saint Theresa Point to direct community care. "Just keeping the building open under that kind of work load is incredibly difficult," he says.
"As bad as the outbreak was, and as sick as the many of the ill were, there is another huge body of people who are less sick, who don't require evacuation, but do need to be assessed and reassured. And then sent home, to stay home, until they are better. Keeping any of the community's basic services working in that situation is very difficult."
The isolation measures made necessary by an outbreak of such severity will prove just as draconian to interdependent urbanites. SARS infected only 251 in the Greater Toronto Area, yet it collapsed the municipal economy for three months. An influenza attack rate of 30 per cent will affect 1.5 million Torontonians. If the CFR is as high as 0.5 per cent, then 7,000 of those may perish. SARS killed just 43.
A severe epidemic demonstrates the interdependence of humans with unusual concision. Picture a city bedbound by the flu: The image is one of empty markets, neglected shut-ins and unrepaired sewer lines. Humans are communal animals as much as bees or ants. A threat to any is a threat to all from every perspective: epidemiological, civic and moral.
Which is why the desperation of the reservations really is everyone's problem.
Eventually, a pandemic response strategy tailored to the particular challenges faced by first-nations people will be created, if not for this pandemic, then for the next. Hopefully it will be part of a more meaningful strategy to level out the burden of illness known by first-nations people, especially diabetes, which threatens to become a slower-moving smallpox among the people of the boreal forest.
In the meantime, everything I've said concerning the impact influenza will have on cities will play itself out on the reserves this winter, but worse many times over. The Saint Theresa Point experience will be re-enacted so regularly that eventually only the local media will bother even to mention it. However, suffering itself does not localize. It flies around in aircraft and takes over the ICUs and it comes to the Bridle Paths and it affects 1.9 to 2.2 other people, on average, within 2.1 to 3.0 days.
It will begin among the most vulnerable - and it is in the nature of that particular vulnerability that it will encompass us all.
Kevin Patterson is a physician and writer based on Salt Spring Island, B.C.