Witness: El Chapo’s wife was in on plans for prison escape
By TOM HAYS
Thursday, January 24
NEW YORK (AP) — The wife of Mexican drug lord Joaquin “El Chapo” Guzman played a key role in his infamous 2015 escape from prison through a tunnel dug into the shower of his cell, a witness testified Wednesday at the kingpin’s U.S. trial.
Damaso Lopez Nunez, once a loyal lieutenant for Guzman, told the jury that Emma Coronel Aispuro helped her husband communicate with his sons and others who coordinated the breakout at Altiplano prison in central Mexico.
Coronel “was giving us his messages,” Lopez told a New York jury, adding that she also was in on meetings about the escape.
After the Sinaloa cartel boss was recaptured and thrown in another Mexican lockup, the orginization paid a $2 million bribe to a prison official in exchange for getting him moved back to Altiplano, the witness said. Before that could happen, Guzman was sent in 2017 to the U.S., where he’s been kept in solitary confinement while facing drug-trafficking charges he says have been fabricated by cooperators like Lopez.
The testimony cast a harsh spotlight on a spouse who has sat quietly in the courtroom for most a trial that began in mid-November. Most of the attention on her so far has been for her wardrobe and her reaction to waves from the defendant. She didn’t speak to reporters on Wednesday and Guzman’s lawyers declined comment.
As described by Lopez, the escape in 2015 was far more elaborate than one Guzman pulled off in 2001 by hiding in a prison laundry cart. It included smuggling a phone with GPS to Guzman so the plotters could determine where best to tunnel in, he said.
His followers also bought property near the facility as the starting point the mile-long (1.6-kilometer-long) escape route, Lopez said. Work went on for months and was so loud it could be heard behind bars – to the point where inmates were complaining about it, he said.
On the day of the breakout, a motorcycle was used to race Gurman to the exit of the tunnel, where an ATV took him to a warehouse, the witness said. He later was flown to his mountaintop hideaway.
In further questioning, Lopez also touched on the 2017 slaying of journalist Javier Valdez outside his office in outside his office in Culiacan, Sinaloa’s capital city. He claimed that Guzman’s sons – not their father – ordered him shot down because he ignored their threats related to his reporting on drug-trafficking.
The government’s case at the trial in federal court in Brooklyn is expected to conclude this week. The defense has included Guzman on a list of potential witnesses its case, but lawyers have been mum about whether he would chance actually testifying.
Associated Press writer Claudia Torrens contributed to this report.
El Chapo trial shows why a wall won’t stop drugs from crossing the US-Mexico border
January 16, 2019
Author: Luis Gómez Romero, Senior Lecturer in Human Rights, Constitutional Law and Legal Theory, University of Wollongong
Disclosure statement: Luis Gómez Romero does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Partners: University of Wollongong provides funding as a member of The Conversation AU.
The trial of Mexican drug kingpin Joaquín “El Chapo” Guzmán Loera has exposed just how powerful Mexico’s cartels really are.
The trial has now run for two months. On Jan. 15, a Colombian drug trafficker who worked for Guzmán’s Sinaloa Cartel from 2007 to 2013 testified that Guzmán paid former Mexican president Enrique Peña Nieto a US $100 million bribe while he was in power, a charge Peña Nieto’ office denies.
It was just the latest allegation of the cartels paying off high-ranking politicians in Mexico, presumably to exert influence over the government.
Guzmán is charged with drug trafficking, murder, kidnapping and money laundering – crimes he allegedly committed over the past quarter-century as head of the Sinaloa cartel, the Western Hemisphere’s most powerful organized crime syndicate.
With its witness accounts of extreme violence, political corruption, international intrigue and entrepreneurial innovation, Guzmán’s trial is a telenovela-style explainer on why a wall is unlikely to stop the lucrative U.S.-Mexico drug trade.
The Sinaloa cartel
Founded in Mexico’s Sinaloa state in the 1990s, the Sinaloa cartel now distributes drugs to some 50 countries, including Argentina, the Philippines and Russia.
Determining the scale of Guzmán’s global empire is difficult, since gangsters usually don’t keep books and charts of accounts. But his 2016 indictment in the U.S. sought forfeiture of more than $14 billion in proceeds and illicit profits from decades of narcotics sales in the U.S. and Canada.
The Sinaloa cartel controls perhaps half of Mexico’s drug market, with annual earnings of around $3 billion. Mexican estimates suggest that each month it moves two tons of cocaine and 10,000 tons of marijuana – plus heroin, methamphetamine and other substances.
The drug business
Illegal drugs are a highly lucrative business.
In 2016, the year El Chapo was captured in Mexico, the wholesale price for a gram of cocaine was approximately $2.30 in Colombia and $12.50 in Mexico. The same gram had a wholesale cost of $28 by the time it got to the United States. In Australia, that same gram of cocaine fetched $176.50 wholesale.
Drug prices rise significantly during transit as intermediaries demand compensation for the risk they assume in getting the product to consumers.
Retail prices per gram of cocaine are even higher, reflecting the addition of even more middlemen: $82 in the U.S. in 2016 and $400 in Australia.
This liability markup is one reason why some prominent policy experts and even conservative economists call for legalizing and regulating illicit narcotics. Keeping drugs illegal is what makes them so profitable for the people who traffick them.
Bribes, violence and threats
Illegality is also what makes the drug business so violent.
Running an illicit operation, cartel leaders must both enforce their own business agreements and protect themselves from authorities and competitors.
They do so using a combination of violence, threats and bribes.
At least eight armed groups worked under Guzmán’s command in Mexico, according to Mexican government reports, attacking competitors and killing defectors.
Guzmán also bribed as many politicians, police officers and prison guards to stay in business.
His elaborate disappearances from Mexican high-security prisons are the stuff of legend. In 2015, Guzmán escaped jail by riding a motorcycle through a lit, ventilated mile-long tunnel constructed underneath his cell.
The Sinaloa cartel didn’t become the world’s biggest supplier of illicit drugs by coincidence. It has flourished because the United States is the world’s biggest consumer of illicit drugs.
Mexican cartels serve Americans’ “insatiable demand for illegal drugs,” as Hillary Clinton once said.
Despite President Donald Trump’s focus on Mexican drug traffickers, his former chief of staff, John Kelly, has admitted that the U.S. is part of the problem.
“We’re not even trying,” he told Congress in 2017, calling for more drug-demand reduction programs.
Kelly added that Latin American countries chide American authorities for “lecturing [them] about not doing enough to stop the drug flow” while the U.S. does nothing to “stop the demand.”
Trump’s continued insistence on securing the southern border with a wall seems to disregard the economic forces driving the drug trade and diminish Mexican cartels’ innovative distribution strategies.
A high-tech border fence constructed in Arizona long before Trump’s inauguration has proven virtually useless in stopping drugs from crossing into the U.S.: Mexican smugglers just use a catapult to fling hundred-pound bales of marijuana over to the American side.
“We’ve got the best fence money can buy,” former DEA chief Michael Brown said to The New York Times in 2012, “and they counter us with a 2,500-year-old technology.”
Then there’s the other ancient technology perfected by Guzmán: the tunnel.
Officials have discovered about 180 cleverly disguised illicit passages under the U.S.-Mexico border. Many, like the one Guzmán used to escape prison, are equipped with electricity, ventilation and elevators.
Trump has admitted that anyone could use “a rope” to climb over his wall, but believes that more border guards and drone technology would prevent infiltration.
Corruption in the US
Corruption is not an exclusively Mexican trait.
Over the past decade some 200 employees and contractors from the Department of Homeland Security have accepted nearly $15 million in bribes to look the other way as drugs were smuggled across the border into the United States, The New York Times has reported.
Some U.S. officials have also given sensitive law enforcement information to cartels members, according to the Times.
“Almost no evidence about corrupt American officials has been allowed at [El Chapo’s] trial,” New York Times reporter Alan Feuer said recently on Twitter.
This article is an updated version of a story originally published on Feb. 19, 2017.
In Haiti, climate aid comes with strings attached
January 25, 2019
Haiti had not yet recovered from its devastating 2010 earthquake when it was hit hard by Hurricane Matthew in 2016. It is one of the world’s most vulnerable nations to climate change.
Author: Keston K. Perry, Postdoctoral researcher, Fletcher School of Law & Diplomacy, Tufts University
Disclosure statement: Keston K. Perry does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Partners: Tufts University provides funding as a founding partner of The Conversation US.
Perhaps no people know better than Haitians just how dangerous, destructive and destabilizing climate change can be.
Haiti – which had not yet recovered from a massive 2010 earthquake when Hurricane Matthew killed perhaps a thousand people and caused a cholera outbreak in 2016 – is one of the world’s most vulnerable countries to climate change.
Scientists say extreme weather events like hurricanes, floods and droughts will become worse as the planet warms. Island nations are expected to be among the hardest hit by those and other impacts of a changing climate, like shoreline erosion.
For poor island countries like Haiti, studies show, the economic costs, infrastructural damage and loss of human life is already overwhelming. And scientists expect it will only get worse.
To help Haiti address this pending crisis, international donors have stepped in with funding for climate action. The problem with that system, as I found in a recent analysis of international climate aid in Haiti, is that the money may not be going where it’s most needed.
Though Haiti’s greenhouse gas emissions amount cumulatively to less than 0.03 percent of global carbon emissions, it is a full participant in the 2015 Paris climate agreement and has committed to reduce its greenhouse gas emission by 5 percent by 2030.
To meet that goal, Haitian officials say, the Caribbean country must switch 1 million traditional light bulbs for more efficient LED bulbs, grow 137,500 hectares of new forest and shift 47 percent of its electricity generation to renewable sources. Those are just a few objectives in Haiti’s 2015-2030 climate plan.
It needs help to meet them.
Haiti is among the poorest countries in the Western Hemisphere. Nearly 60 percent of the population lives on less than US$2.41 per day, according to the country’s 2012 household survey, the most recent poverty data available.
More than 20 percent of its national budget is funded by loans from the World Bank and the International Monetary Fund – a setup that gives international lenders an unusual level of control over Haiti’s government expenditures.
The same is true of Haiti’s climate mitigation efforts. The majority of the money behind its 15-year plan to finance climate mitigation and adaptation activities – from disaster preparation and renewable energy development to increasing food security – also comes from international donors.
The crowdsourced nature of Haiti’s climate budget can make it hard to determine just how much money Haiti has to spend – and what, exactly, the government can spend it on.
So, last year, I worked with the Climate Policy Lab at the Fletcher School at Tufts University to analyze Haiti’s climate budget.
A hodgepodge of climate funding
In an unpublished 2018 study, we found that the World Bank and Inter-American Development Bank are the two biggest donors to Haiti’s $1.1 billion climate fund. Switzerland is also a major financier, having given the Caribbean nation $64.4 million since 2009, as is Japan, which has given $14.8 million to help fund Haiti’s climate efforts.
Most of this $1.1 billion comes in the form of grants, not loans – it’s free money. And, in a country with a gross domestic product of $8 billion, $1.1 billion for climate mitigation is a substantial sum of money.
However, as my recent analysis of the Tufts climate study shows, the bulk of the money appears to be misallocated.
Numerous international donors, each of which has set its own climate objectives, fund climate action in the country. The result, I found in my analysis, is that Haiti’s climate budget is a mashup of donor priorities that puts too much money behind certain initiatives while underfunding other environmental needs.
Fully 70 percent of Haiti’s $1.1 billion climate budget – $773 million – is earmarked for making energy production more sustainable in Haiti. This involves improving hydroelectric power and increasing solar usage, among other energy upgrades.
Renewable energy may have seemed like a sensible priority for the World Bank and other individual donors. But, put together, this is a disproportionately high investment for a country with such low carbon emissions, my analysis shows. My research suggests the money could be better used to connect more Haitians to the energy grid. Currently, just 20 percent of Haitians – most of them in Port-au-Prince – have semi-reliable electricity. Power is a necessity after any disaster.
Reforestation projects are also notably absent in Haiti’s climate budget.
Haiti is the Carribean’s most deforested nation. Seventy percent of forests on the island have disappeared since the late 1980s. It desperately needs reforestation projects to reduce flooding, coastal erosion and water pollution and prevent mudslides.
Yet in my analysis of the total $116 million in donor funds earmarked for watershed management and soil conservation, I found barely a mention of reforestation.
Hillside neighborhoods like this area outside Port-au-Prince are prone to mudslides during heavy rain. Reuters/Swoan Parker
Mismatch between perception and reality
Other areas of Haiti’s climate change plan are somewhat better funded but, to my mind, misguided.
Take disaster risk reduction, for example. Of the $269 million earmarked for reducing disaster risk in Haiti, most funds are set aside for rebuilding after disasters.
That may seem sensible in a country prone to earthquakes, flooding and hurricanes, but research shows that sustainable construction – not merely rebuilding – better prepares a country for disasters and other long-term effects of climate change. Planning saves time, energy, money and human life.
Haiti’s international donors have set aside little money for ensuring that new highways, buildings and other critical infrastructure in Haiti are constructed in a resilient, climate-ready manner – before the next big disaster happens.
Addressing the power imbalance
This kind of mismatch between local needs and donor priorities is a common hazard of internationally funded budgets.
Donors call the shots about how their money is spent from afar. Often they don’t have enough on-the-ground information to be making such important executive decisions.
In interviews, local Haitian officials told me that the municipal agencies that actually engage with people and communities have little say over how they may spend climate funds or which environmental projects are implemented.
In Haiti, this problem is not limited to climate funding – it’s a hazard of running a national government on the largess of other countries.
Last year, the International Fund for Agricultural Development, a United Nations donor agency, announced a community-based strategy to building climate resilience in Haitian agriculture by partnering with local organizations and agencies.
“This community-based approach will support Haitians working together to enhance their economic potential, resilience and coping strategies when faced with climatic and economic shocks,” a 2018 report said.
My climate research in Haiti supports this assessment.
If international donors allow Haitian authorities more control over funding, working more closely with local community organizations, they would not only help address its most important needs, the strategy would be cost-effective. Money channeled to where Haiti most needs it is money well spent.
Political shifts, sales slump cast shadow over gun industry
By LISA MARIE PANE
Wednesday, January 23
When gunmakers and dealers gather this week in Las Vegas for the industry’s largest annual conference, they will be grappling with slumping sales and a shift in politics that many didn’t envision two years ago when gun-friendly Donald Trump and a GOP-controlled Congress took office.
Some of the top priorities for the industry — expanding the reach of concealed carry permits and easing restrictions on so-called “silencers” — remain in limbo, and prospects for expanding gun rights are nil for the foreseeable future.
Instead, fueled by the deadliest mass shooting in modern U.S. history, the federal government banned bump stocks and newly in-charge U.S. House Democrats introduced legislation that would require background checks for virtually every firearm sale, regardless of whether it’s from a gun dealer or a private sale.
Even without Democrats’ gains in November’s midterm elections, the industry was facing a so-called “Trump slump,” a plummet in sales that happens amid gun rights-friendly administrations. Background checks were at an all-time high in 2016, President Barack Obama’s last full year in office, numbering more than 27.5 million; since then, background checks have been at about 25 million each year.
Gary Ramey, owner of Georgian gunmaker Honor Defense, says the mood at last year’s SHOT Show, which stands for Shooting, Hunting and Outdoor Trade, was subdued. He’s expecting the same this year.
“There was no one to beat up. You didn’t have President Obama to put up in PowerPoint and say ‘He’s the best gun salesman, look what he’s doing to our country,’” he said.
“Numbers are down,” he added. “You can’t deny it.”
Robert J. Spitzer, chairman of political science at the State University of New York at Cortland and a longtime watcher of gun issues, said that not only have shifting politics made it difficult for the gun industry to gain ground but high-profile mass shootings — like the Las Vegas shooting that happened just miles from where the SHOT Show will be held and the Parkland, Florida, high school shooting — also cast a pall.
“After the Parkland shooting, (gun rights’ initiatives) were kind of frozen in their tracks,” Spitzer said. “Now there’s no chance that it’s going anywhere.”
It’s easier to drive up gun sales when there’s the threat or risk of gun-rights being restricted, he said. “It’s harder to rally people when your target is one house of Congress. It just doesn’t have the same galvanizing effect.”
The National Shooting Sports Foundation’s SHOT Show has been held annually for more than four decades. This year more than 60,000 will attend the event that runs Tuesday through Friday — from gun dealers and manufacturers to companies that cater to law enforcement. There’s a wait list for exhibitors that is several hundred names long and it will have some 13 miles of aisles featuring products from more than 1,700 companies.
Last year’s show in Las Vegas was held just months after a gunman killed 58 people and injured hundreds at an outdoor music festival. The massacre was carried out by a gunman armed with bump stocks, which allow the long guns to mimic fully automatic weapons.
Organizers last year restricted media access to trade journalists. This year’s show will again allow reporters from mainstream media to attend.
Gun-control advocates are rejoicing in the gun industry’s misfortunes of late and chalking it up to not just shifting attitudes among Americans but a shift in elected political leaders.
“Without a fake menace in the White House to gin up fears, gun sales have been in a Trump slump and, as a result, the NRA is on the rocks,” said John Feinblatt, president of Everytown for Gun Safety, a group founded by former New York Mayor Michael Bloomberg.
Joe Bartozzi, the new president of the National Shooting Sports Foundation, said the industry isn’t disturbed by the drop in gun sales or the shift in federal politics. While Democrats who ran on gun-control platforms made huge gains in the House, he sees the Senate shifting to the other end of the spectrum.
“Having been in the industry for over 30 years and seeing the trends of gun sales ebb and flow over time, it’s very hard to put your finger on any one specific issue as to why this happens. It’s just the cyclical nature of the business,” he said.
Trump’s campaign was bolstered by about $30 million from the National Rifle Association and when he took office, the industry had hoped that a host of gun rights would be enacted. The Trump administration quickly nixed an Obama-imposed rule that made it more difficult for some disabled people to purchase and possess firearms.
But other industry priorities, such as reciprocity between states for carrying certain concealed firearms and a measure that would ease restrictions on purchasing suppressors that help muffle the sound when a gun is fired, failed to gain traction.
For now, Bartozzi said his organization is focused on a measure that would expand public gun ranges, funded by an existing tax on firearms and ammunition sales that supports conservation, safety programs and shooting ranges on public lands. The hope is that increasing the number of public ranges will encourage more people to become hunters.
Accused bank shooter fascinated with violence
By TERRY SPENCER
Thursday, January 24
SEBRING, Fla. (AP) — A former prison guard trainee accused of fatally shooting five people inside a Florida bank branch has long been fascinated with the idea of killing, but people who could have done something about it didn’t take his threats seriously, a woman who identified herself as his former girlfriend told a television station.
Zephen Xaver, 21, “for some reason always hated people and wanted everybody to die,” Alex Gerlach told WSBT-TV in Indiana, shortly after Wednesday’s massacre in Sebring. “He got kicked out of school for having a dream that he killed everybody in his class, and he’s been threatening this for so long, and he’s been having dreams about it and everything.”
“Every single person I’ve told has not taken it seriously, and it’s very unfortunate that it had to come to this,” Gerlach said.
Gerlach told The Washington Post that Xaver said he purchased a gun last week and “no one thought anything of it” because he had always liked guns. Public records and neighbors say Xaver and his mother moved to Sebring in the fall from Plymouth, Indiana, a small city south of South Bend, home of the University of Notre Dame.
Investigators said Xaver called police from inside the SunTrust Bank branch Wednesday, saying “I have shot five people.”
Then he barricaded himself inside and when negotiations failed, the SWAT team burst in, capturing Xaver and discovering the bodies, police said. Investigators did not offer a possible motive, and a police spokesman said he did not know if the attack began as a robbery. The victims were not immediately identified. No one else was inside the bank.
The bank sits between a hotel and a hair salon located in a business district of U.S. 27. The four-lane highway passes through farming communities and small towns as it connects South Florida and central Florida. Sebring, with 10,000 residents, is known internationally for its annual 12 Hours of Sebring endurance auto race that draws world-class drivers.
“Today’s been a tragic day in our community,” Sebring Police Chief Karl Hoglund said during a Wednesday news conference. “We’ve suffered significant loss at the hands of a senseless criminal doing a senseless crime.”
He said more information would be released at a Thursday morning press conference.
Witness Stefan Roehrig told WFLA in St. Petersburg that the SWAT team attached cables to the door handles but ended up pulling the handles off, so they drove the armored vehicle into the bank. They then led Xaver out in handcuffs.
“The suspect, they slammed him pretty good I think and brought him out here,” he told the TV station.
Florida Department of Corrections records show that Xaver was hired as a trainee prison guard at Avon Park Correctional Institution on Nov. 2 and resigned Jan. 9. No disciplinary issues were reported. Xaver lived in a non-descript pre-fabricated home about 4 miles (6.5 kilometers) from the bank. No one answered the door Wednesday night after police finished searching the home
John Larose, who lives next door, said Xaver kept to himself, but he could hear him playing and yelling at video games in the middle of the night.
Xaver briefly was an online student of Salt Lake City-based Stevens-Henager College. A spokeswoman for the college, Sherrie Martin, confirmed that Xaver was enrolled from September 2018 until December, when he withdrew.
Gov. Ron DeSantis was in the region for an infrastructure tour and traveled to Sebring after the shooting. He said the Florida Department of Law Enforcement would assist Sebring police and the Highlands County sheriff’s office.
“Obviously, this is an individual who needs to face very swift and exacting justice,” DeSantis said of the suspect.
This was at least the fourth mass shooting in Florida with five or more dead in the last three years. A gunman killed 49 at an Orlando nightclub in 2016, five died at the Fort Lauderdale airport in 2017 and 17 died in February at Marjory Stoneman Douglas High School in a Fort Lauderdale suburb.
SunTrust Chairman and CEO Bill Rogers released a statement saying the bank was “working with officials and dedicating ourselves to fully addressing the needs of all the individuals and families involved.”
The bank’s “entire team mourns this terrible loss,” he said.
AP reporter David Fischer in Miami contributed to this report.
2019: The Year to Examine Toxic Masculinity
by Laura Finley
Toxic masculinity strikes again, this time in Provo, Utah on the day of the 2019 Women’s March. Police were alerted to the problem when Christopher Cleary posted on his Facebook page that All I wanted was a girlfriend. All I wanted was to be loved, yet no one cares about me I’m 27 years old and I’ve never had a girlfriend before and I’m still a virgin, this is why I’m planning on shooting up a public place soon and being the next mass shooter cause I’m ready to die and all the girls the turned me down is going to make it right by killing as many girls as I see.”
Cleary was arrested on a charge of felony threat of terrorism. Although no official link has been made, it appears that Cleary identifies with incel culture, which blames women for their lack of relationships. Cleary is already on probation for stalking and harassing a woman in Colorado.
This week also saw heated discussion on what to do with racist, sexist, privileged white boys. Several boys from Covington Catholic School in Kentucky had what appeared to be a confrontation with Native American elder Nathan Phillips at the March for Life in Washington, D.C., whilst wearing “Make America Great Again” hats. While the boys argue that Phillips was the aggressor, and that despite video showing disdainful smirks, they were not doing so, the situation ignited passionate discussion. What also emerged, however, was reports that the same boys had sexually harassed some young women. Details are still emerging, but as would be expected, President Trump weighed in, referring to the various videos and media discussions of the incident as smears.
Still not done. In the last two weeks, musicians R. Kelly and Chris Brown were both (again) embroiled in abuse scandals. Sony reportedly dropped R. Kelly after repeated allegations, detailed in a new documentary called Surviving R. Kelly. Brown, who was sentenced to five years of probation for beating his former girlfriend, pop star Rihanna, was accused of sexual assault by a model in Paris and has been arrested by French police.
At the same time, the American Psychological Association (APA) issued new guidelines about the dangers of toxic masculinity. It emphasizes that while men still dominate powerful positions in the U.S, they also suffer in unique ways. Life expectancy is shorter, and men are far more likely to be the victims of both homicide and suicide, among many other health measures. The basic focus of the guidelines is that “traditional” masculinity, or what sociologists have called hegemonic masculinity, which emphasizes stoicism,competitiveness, dominance and aggression, is bad for both men and women.
That these things keep happening so frequently is absolutely disgusting. Yet, perhaps the confluence of incidents and the ongoing debates might actually lead to something good. It is far past time for the U.S. to follow Finland, for instance, and begin teaching about gender role norms and equality to our children. For those of us who are educators, we absolutely must help both young men and women understand the devastating effects of toxic masculinity for everyone.
Laura Finley, Ph.D., syndicated by PeaceVoice,teachesin the Barry University Department of Sociology & Criminology.
Acute flaccid myelitis: What is the polio-like illness paralyzing US children?
Updated January 23, 2019
Author: Jay Desai, Clinical Associate Professor of Neurology, University of Southern California
Disclosure statement: Jay Desai has received funding from Epilepsy Foundation of Greater Los Angeles, Novartis, UCB, and Neurelis.
I experienced déjà vu when I took care of a child with acute flaccid myelitis in 2014, one of the first cases of its kind at Children’s Hospital Los Angeles in many years.
I had taken care of polio patients in India in 1990s and also participated in the pulse polio campaign that led to the country successfully eradicating the devastating disease. But that was almost two decades back, and I had not seen polio or anything like polio since moving to the U.S. back in the late 1990s.
Now, the U.S. and several other developed countries are seeing outbreaks of this polio-like disease, stumping public health researchers on the reasons why. And, the Centers for Disease Control and Prevention has recently announced that a record number of cases, 201, were diagnosed in 2018 in the U.S.
Acute flaccid myelitis, or AFM, a descriptive term for the clinical manifestations, can be caused by polio or several other related viruses. The term acute stands for the fact that the onset is sudden; flaccid denotes that there is a loss of tone in the limbs that become weak; and myelitis indicates that the spinal cord is involved and abnormal. Acute flaccid myelitis falls under a broader category called acute flaccid paralysis – a term that encompasses several other conditions such as botulism besides acute flaccid myelitis.
According to the CDC, there have been 527 confirmed cases of AFM in the U.S. since 2014. Most of them have involved young children.
The cause of AFM
The U.S. has been polio-free since 1979. The AFM cases in the U.S. since 2014 are polio-like but not due to poliovirus. The cause has been definitely established only in a handful of these recent cases with detection of coxsackievirus A16, enterovirus (EV)-A71, or EV-D68 in cerebrospinal fluid (CSF). These three viruses are types of enteroviruses just like poliovirus is. Enteroviruses are viruses that typically enter through the intestinal tract.
Doctors have suspected that many of the recent AFM patients, in whom the spinal fluid did not identify a virus that caused AFM, may have been due to EV-D68. This is based on circumstantial evidence. At Children’s Hospital Los Angeles, where I practice and conduct research, my group has documented that EV-D68 was circulating in the respiratory fluid of children at a higher rate in 2016 when compared to 2015. This was associated with a higher rate of AFM in 2016 compared to 2015. According to the CDC, the spike in AFM cases in 2014 corresponded with a national outbreak of respiratory EV-D68. It is not known why only a handful of those who have the respiratory illness go on to develop AFM. Researchers hypothesize that genetic factors as well as unusual immune responses may be responsible.
The recent AFM cases have typically occurred in a cyclical pattern in late summer and early fall, and “skipped” a year, with more cases reported in 2014, 2016 and 2018 compared to 2015 and 2017.
Many children have symptoms suggestive of an upper respiratory tract viral infection and fever. This is followed by the most dramatic manifestation of weakness of arm or leg due to nervous system involvement. Either one or all four limbs may be affected. This is accompanied by a loss of tone and deep tendon reflexes. Sometimes, there may also be facial weakness or swallowing disturbances. In extreme cases, respiratory muscles are involved, leading to a need for artificial breathing support. The ability of patients to feel sensations is usually preserved, but pain is often prominent.
Once the disease is suspected, it is important that the child quickly undergo magnetic resonance imaging of the spine which typically shows changes involving the gray matter of the spinal cord. In cases with symptoms suggestive of cranial nerve involvement in the brain, such as facial weakness, brain imaging shows changes involving the gray matter of corresponding regions. Spinal fluid may show an increase in number of cells from what is otherwise found in normal children. Doctors may order nerve conduction studies and they show abnormal nerve impulses. The overall scenario with AFM is distinct and relatively easy to differentiate from diseases with some overlapping manifestations such as transverse myelitis and Guillain-Barré syndrome.
A majority of interventions tried in the initial stages of the disease to date have had no success. Drugs that work in several other neuroimmunological illnesses, such as intravenous immunoglobulins, and corticosteriods, have not been effective. Plasma exchange has been tried but has not shown benefit. Antiviral medications have not worked well either. Fluoxetine – an antidepressant – was noted to have in vitro antiviral property and efficacy against EV-D68, and tried by neurologists at several centers around the country in 2015 and 2016, including at my hospital. However, fellow researchers from centers around the country and I, led by Children’s Hospital Colorado, recently published our collective experience, noting that fluoxetine was not effective in improving outcomes.
The cornerstone of treatment in the initial phase is supportive care. Those with less severe manifestations at the outset are likely to do better in the long term than those with more severe initial presentation. Experimental surgical interventions with nerve grafting, after the acute phase is over, has shown some success in several patients.
The CDC has constituted a task force to investigate AFM. It is collaborating with the AFM Working Group, consisting of clinicians and researchers from around the country, in building a consensus to streamline treatment, in looking into and fostering research, and in leading advocacy efforts.