Effect Measure

One of the knocks on the alarms about bird flu is that it is just another in a series of false alarms like Y2K, West Nile and SARS. Not true. Pandemic influenza is indeed another in a series of alarms, but the only one that might conceivably be considered a false alarm (and this isn’t even sure) is Y2K. Let’s take them one at a time.

The investment in fixing the Y2K bug was substantial on the part of business and government world wide, extending over several years prior to 2000. It is difficult to say what the results might have been without that investment. In many respects it is similar to an investment in public health preparedness, where the perennial problem is expressed by the old adage, “When public health works, nothing happens.” Not a recipe to build a political constituency, but a good way to live a longer and happier life.

What about SARS? SARS was first thought to be H5N1 and then discovered to be a hitherto unknown virulent coronavirus. It spread to 29 countries via air travel in a short time and infected more than 8000 people (WHO). It had an unusually high case fatality ratio of just under 10%. In the 9 months of the outbreak, no one knew what to expect from this previously unknown disease. If you reflect on it, the concern by health and civil authorities and the public was well justified. We dodged a bullet with this one, and vigorous action, enabled by appropriate concern, may have played an important part.

What about West Nile Virus? When WNV first appeared in Queens, NY in 1999 it dominated the headlines in US newspapers. WNV was not a new disease, like SARS, but it was new and exotic for the US. Most infections are mild, but a certain percentage are serious and some are fatal. Health authorities warned it would become widespread and endemic throughout the US in a short time. They were correct. Like a stone in our shoe, we have become used to it. But it is as serious as first thought and should not be considered a poster child for public health false alarms.This disease is now the most common mosquito-borne encephalitis in the US. It is just about to start its annual assault on the US population.

Indeed, WNV infected mosquitoes have already been detected in 16 states this season. Like influenza, WNV is primarily a disease of birds, with humans (and horses) being dead-end hosts. We are collateral damage in the virus’s quest to make copies of itself, using birds as a factory. A few wild bird species (notably corvids like crows and ravens) are killed by the virus, but most seem to suffer little, again like influenza. The virus is passed from bird to bird by mosquitoes which bite an infected bird and then bite an uninfected one. It is not passed directly from bird to bird or human to human. Human to human spread via mosquitoes is considered unlikely since most people don’t have significant levels of the virus in their blood to make this happen.

There are some special circumstances that need to be fulfilled for humans to be infected, primarily being bitten by a “bridge vector,” that is, a mosquito that bites both birds and humans. Most mosquito species are fairly host specific and like to bite only one or a few species. Despite this requirement, WNV has managed to gain a foothold and now infects tens of thousands of US residents each year and causes serious illness in a small proportion of them. CDC estimates that in the seven years since its introduction, 1.2 to 1.3 million Americans have become infected, most subclinically or with mild symptoms. About 10% get hit hard. We don’t know why some people do and not others.

Still, West Nile has killed almost 800 people in the U.S. in that brief period, and caused severe neurologic illness, meningitis or encephalitis, in more than 8,300. Others are left with polio-like paralysis.

Even the less severe West Nile fever is “really quite a horrible kind of illness,” says [CDC's Dr. Lyle] Petersen. He caught the disease himself in 2003 — spending a week in bed and a month afterward battling bone-deep fatigue — and he worries that people don’t take the threat seriously enough.

“I guarantee it’ll ruin your summer.” (AP)

Health authorities in the Katrina-ravaged Gulf Coast are especially nervous, not because of the flooding but because of the botched clean-up. Flooding actually decreased mosquito prevalence by washing away larvae. But important bridge vectors for WNV are in the genus Culex, which includes common household mosquitoes. They breed in tiny pools of water, like puddles, lids of cans, bottoms of empty pots, etc. When the weather is hot and dry, birds and mosquitoes compete for scarce water and come together. Culex species also like to bite people.

As predicted, WNV is now nationwide from its original focus in a small section of Queens in 1999. Only two states (Maine and Washington) have yet to report a human case. All continental states have found the virus in mosquitoes. The US blood supply is routinely tested for WNV because it can be passed through the blood of an infected person and many people don’t know they are infected. WNV has lived up to its advance billing — and more.

The track record on warnings has been pretty good. And pandemic influenza is potentially the most consequential of all of them. We had no experience with SARS to calibrate the possibilities. We have experience with influenza.

That experience does not bring comfort.

Comments

#1 Abel Pharmboy
June 28, 2006

We dodged a bullet with this one [SARS], and vigorous action, enabled by appropriate concern, may have played an important part.

Great perspective (and prospective) on WNV as well – since reading Laurie Garrett’s books, I’ve always contended that public health initiatives (and professionals) don’t get the respect they deserve because no one ever understands the number of lives saved.
#2 Mark Paris
June 28, 2006

I just have to weigh in on Y2K. It was the biggest technological hoax in history. What would have happened if the US government and business had not spent billions of dollars to prepare? Just look at the rest of the world for the answer: a couple of ATM machines would have malfunctioned and a few paychecks would have had the wrong date. I remember reading in the Atlanta Journal-Constitution editorial page that airplanes would fall from the sky at midnight on Dec 31, 1999. The Y2K hoax was the result of a few savvy consultants who made lots of money on it with the connivance of IT professionals who saw the mothrlode staring them in the face. Why would the IT manager say he didn’t need an extra couple of million dollars to fix the Y2K problem? The general news media excused their chicken-with-head-cut-off approach on the basis that heads of large corporations didn’t think it was a hoax. Yeah, sure, the head of a corporation knows something about computers. Sure. And he probably sweeps the floors, too. Oh well. No one seems to remember the hoax, so I guess no lasting harm was done.
#3 revere
June 28, 2006

Mark: I’ve seen varying opinions on this and it is out of our area of expertise. I don’t think it changes much of what we said, though, except that the non-public health warning was not firmly based in your opinion. Could be. That’s why we left that one a bit open.
#4 John Wilson
June 28, 2006

Mark, as someone who has been writting software for a great many years, I was one of the many software programmers who was working very hard to ensure that the Y2K problem didn’t materialise. Sure, there were sensationalists who overhyped the problem, but the problem was still very real, and the enormous effort expended to prevent it was not limited to the USA. You can’t look to the rest of the world to see what would have happened if the money hadn’t been spent, simply because the rest of the world did spend that time effort and money.

There was certainly notoriously over-hyped – principally by people who didn’t understand that the we were dealing with a very specific type of failure, that would fail in a very specific way – but that doensn’t really make it a hoax.

Of course, we still have the 2038 and the 2050 bugs to look forward to..!
#5 Kevin
June 28, 2006

Y2k was no hoax. I am a software engineer; I worked at a major bank and later for a major IT vendor during the transition. I can tell you the effort was large and the consequences of failure serious. For many people in the IT industry, Y2k *was* their life 1997-2000. That there was so little impact is a tribute their skill and effort.
The naysayers are predictable, if irritating. I learned long ago in IT never to expect thanks for a job well done.
#6 Lenn Sisson
June 28, 2006

Hi All,

I have to comment about Mark’s Y2K comment. I was a technical writer throughout the whole Y2K thing, so I saw it from inside, without being directly involved with the programming aspect and without having my pay check dependant on it (I did other stuff). Thus, I think I have a fairly neutral perspective on it.

While I think there was a lot of sensationalizing and “hoaxing” going on, at its heart the issue was a real one with complex and potentially dangerous consequences.

For example, though no one I know was concerned with planes falling directly out of the sky, they were concerned that air traffic control software might respond to a date of 01/01/00 in some unpredictable manner that might jeopardize the air traffic controllers’ abilities to safely direct aircraft.

In terms of utilities, banking, and credit, at the time, my roommate’s brother was notified by his gas company that he was late paying his bill, which was due on something like 01/10/00. Since he had not paid his bill since 1900, the computer reported him to the three credit agencies, which effected his credit report. While he was able to sort it out in a couple of months, what would have happened if this had been done by all of the utility companies in the country. It might have overwhelmed the credit agencies, effected a lot of people’s credit ratings, and caused the loss of much time and money while the errors were fixed.

Finally, on a medical topic, I periodically run across people who advocate doing away with polio vaccinations in the US, because almost no one gets polio anymore, while a small number have adverse reactions to the vaccine. What these people never seem to take into account (in my opinion, of course) is that without the vaccinations many thousands of people would have the disease each year, just like occurred before we had the vaccine.

In situations like all of these, one must always weigh the risk of events occurring and the possible consequences of not acting versus the time and money spent to fix them. Risk versus consequences are the main elements of risk assessment, and for my part, I think the country (and much of the rest of the world) did the right thing by addressing the problem, even if we spent more money than we should have. So, next time let�s spend the �right� amount of money, rather than going to extremes in either direction.

That’s my two cents, anyway.

— Lenn
#7 Mark Paris
June 28, 2006

Despite what others have said here, the Y2K hoax was not widely observed outside of the US. Other Western countries spent far, far less than the US, and “underdeveloped” countries (which still, by the way, had plenty of computer controlled systems) spent virtually nothing. Funny thing, though; they suffered few consequences. As I said, IT personnel loved it.
#8 anonymous
June 28, 2006

the problem isn’t one of legitimacy of health threat, as you maintain – granted these are all real or potentially real problems – the false alarm has to do with conveying a massively looming and extensive quality of the threat to the public that doesn’t fit the true extent of the risk at the time. In the case of WNV, the potential risk is limited by biology in the way you describe, but the public doesn’t always have access to the knowledge of these limitations or limited extent.
#9 Interrobang
June 28, 2006

I live about 250km from Toronto, which, in Canadian terms is close enough to say that SARS was, in fact, a very big deal here. I’m pleased to say that procedures regarding influenza-like illnesses have changed dramatically at every hospital and medical clinic I’m aware of in this area. They’re now a lot more aggressive about it, and if you come in with a respiratory infection that looks like it might be flu or something, they make you mask up and sit in a separate designated area. If we get pandemic H5N1, and if any place in Canada does get hit early and hard by it, it’ll be Toronto and region, so they’ll be glad they put even some procedures in place years ago.

I’m a technical writer too, and, while the risks were overhyped, a lot of the overhyping was from people (both in the media and in the lay public) completely misunderstanding the nature of the problem. I actually had someone ask me, “So, if computers are so smart, how come they can’t just recognise the real date?” People who were doing risk communicating were not doing a very good job, and computer literacy was a lot lower even 6-10 years ago. Hindsight is also 20/20.
#10 tan06
June 29, 2006

Revere: This publication, the question ‘can we have access to Internet in pandemic times’ I post here.
Although not exactly in line with your posting here, I dare ask if any IT expert knows what will happen when electricity falls out in large parts of a country.
When you can generate your own power, will Internet work or not?

http://www.computerworld.com.au/index.php/id;1330379098;fp;16;fpid;0
#11 Chuck
June 29, 2006

About Y2K.
I spent all of 1998 and 1999 evaluating, testing, and modifying computer code and databases to prevent over 500 billion of investors dollars from going down the toilet for a major mutual fund company. It was not a hoax. Had we not done our job, and thousands of others in the IT field, YOU would have seen massive problems trying to invest and manage your 401K’s and stocks and bonds and home mortgages, etc.
#12 Mark Paris
June 29, 2006

The Y2K hoax was kind of like those devices you can buy to keep lions and elephants away from your house. If you sell them in the District of Columbia, you can guarantee that they work.
#13 caia
June 29, 2006

As entertaining as all this argument-from-authority about Y2K is(n’t), I think it misses the point. Whatever the extent of the threat, Y2K differed significantly from SARS and West Nile in two key respects: it was entirely human-made, and remediation was still entirely within human control. (The latter being different from a hypothetical bioterror attack and/or catastrophic breach of safeguards that might cause an outbreak of disease.) So even if Y2K were nothing but a hoax, we’d still have two real disease outbreaks to contrast it to. H5N1 is a disease, so playing that old “one of these things is not like the other” game, the obvious conclusion is that H5N1 is like SARS and West Nile, and the misfit is Y2K.

The other pertinent issue is the level of concern required. I think people are justified in displaying some degree of skepticism about warnings they get from the news, because the television news in particular is in the business of hype. There’s no nuance, no sense of proportion, no broad continuum of possibilities, in their fictional world… only nothing happening vs. total disaster. So people who were freaking out about SARS or West Nile back when they happened may suspect H5N1 would be the same ��a real thing, but ultimately a risk to comparitively few people, and not worth getting upset over. Even if a reporter wanted to emphasize that a pandemic would be very different than SARS was or West Nile is, they’d have little room to elevate their warnings. The problem then becomes not a matter of the reality of the potential problem, but in imagining and conveying its scope.
#14 Mark Paris
June 30, 2006

Yeah, regardless of whether Y2K was a hoax, it is interesting, at least, to consider the response to that perceived threat compared to the response to the perceived threat of the two diseases. I have seen some estimates of what was spent by the US government and private organizations to prepare for the big New Year’s celebration, but I can’t recall it right now. One source estimates the government spent upwards of $8 billion, but I think that number is quite low compared to the total.