Intended for healthcare professionals

Reviews Book

The Monster at Our Door: The Global Threat of Avian Flu

BMJ 2005; 331 doi: (Published 24 November 2005) Cite this as: BMJ 2005;331:1275
  1. Geoff Watts, freelance medical journalist (geoff{at}
  1. London

    Is the threat of avian flu “the monster at our door” or, to use an alternative and zoologically mixed metaphor, a frightened chicken crying wolf? We need to know.

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    Mike Davis

    The New Press, £12.99, pp 212 ISBN 1 59558 011 5

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    Now, as throughout the past few decades, the health scare industry continues to cut dark swathes through the sunny fields of reason, evidence, and proportionality. The MMR (measles, mumps, rubella) vaccine, mercury in tooth fillings, listeria, mobile phones, microwave ovens, beef, coffee, electromagnetic fields, pesticide residues, and a score of other such items have clawed their way up the news agenda, basked in the media spotlight, then slipped back to their true level in the league table of environmental risk. The number of times that some of these items have made the return trip would lead one to believe they must have purchased a season ticket.

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    Has public health failed to keep up with globalisation?


    In recent weeks, a few world-weary commentators have begun hinting that avian flu will soon be joining that dismal list. Remember severe acute respiratory syndrome (SARS), they say. We heard all the same stuff about a pandemic, all the same horror stories about deaths running into millions. But the containment measures worked; the international public health system triumphed. In the end SARS killed fewer than 800: small beer by comparison with the mortality attributable to normal flu in a normal year. So why should this latest viral threat be any different?

    If we do label avian flu as the next “scare that never will be,”and if we do start to scorn the efforts of the public health authorities to prepare for it, we may find ourselves making a grievous error. The point was made last year in a review of the 2002 SARS outbreak by Professor Roy Anderson and colleagues from the department of infectious diseases at Imperial College, London (Philosophical Transactions of the Royal Society B: Biological Sciences 2004;359: 1091-105). As they say, the low transmissibility of the SARS virus, combined with the fact that victims didn't reach peak infectiousness until they were already showing clinical symptoms, made it feasible to control the epidemic using public health measures such as isolating patients and quarantining their contacts.

    Speaking to a meeting about SARS organised by the Royal Society, Professor Anderson added that while draconian public health measures might be relatively simple to implement in China, it was difficult to be certain that North Americans and western Europeans would be equally compliant in the face of demands for mass quarantine. In the next global epidemic we may not be so lucky—biologically or geographically.

    In the light of all this, the timely appearance of a popular book on avian flu ought, you might think, to be welcomed. Its author, Mike Davis, has achieved every publisher's dream: a book ready to be released at precisely the time when its subject matter is making headlines. And given the leisurely pace of publishing, this volume is as up to date as you could hope for; the most recent references are from April.

    The book highlights what Davis sees as some of the errors that have been made in dealing with previous outbreaks of infectious disease, points to the current lack of commercial enthusiasm for vaccine development, and regrets the failure of international public health to keep up with the galloping pace of globalisation.

    He also draws attention to the bizarre research priorities that operate in Bush's America with its obsession over homeland security. To the current US administration, the significance of any particular threat appears to be judged not by the damage it might cause, but according to its origin: manmade as opposed to natural. All sorts of people doing all sorts of research in America have recently “discovered” that their work has hitherto unnoticed implications for homeland security—for which the supply of funds seems to be virtually inexhaustible. Microbiologists have, quite reasonably, not refrained from enjoying this largesse; but neither avian nor any other form of influenza ranks high in the terrorists' biological weapons catalogue. Davis quotes the plaintive comment of one expert: “It's too bad that Saddam Hussein's not behind influenza.”

    The relative insouciance with which recent US governments have treated the prospect of a flu pandemic is difficult to fathom. All public health schemes, of course, reek dangerously of “socialised medicine.” By contrast, anyone struggling against a terrorist assault on wellbeing can wrap Old Glory around the enterprise and claim the immunity conferred by displays of patriotic fervour.

    The Monster at Our Door has come at precisely the right time; whether it is also precisely the right book is another matter. The basic virology in the early chapters is not well explained, and creates the impression of an author impatient to move swiftly through it and get on to the more polemical stuff that is closer to his heart. Mike Davis comes brandishing a certain reputation—as the jacket of the new book makes no effort to conceal. “The United States' most engaging prophet of doom,” runs one of the comments on his previous work. And the front of the jacket is illustrated with a malevolent looking chicken gazing beadily over the word “monster” in the book's title.

    Avian flu deserves to be taken seriously. But when the facts themselves are so chastening, any attempt to overexcite them is likely to prove counterproductive.