Effect Measure

There is an apocryphal story of a politician during the Revolution of 1848 desperately running after a crowd in Paris’s Jardin du Luxembourg. “I’m their leader,” he cried. “I must follow them!” A couple of years ago most national pandemic planners were occupied with procuring stockpiles of antivirals, worrying about the lack of a vaccine and reassuring people that they had the matter under control if a pandemic were to strike. No one believed them and they knew they were whistling past the graveyard, but the poverty of vision was amazing. There has been much progress since then. Now there is open talk about the need and potential efficacy of non pharmaceutical interventions, or as the jargon has it now, “community mitigation guidelines.” Whatever you call it, the objective is to reduce contact through measures of social distancing (closing schools, theaters, etc.). So the planners are getting there. Now a just published survey in CDC’s journal, Emerging Infectious Diseases, shows the public was there long before the planners.

Some 3500 subjects in Europe and Asia were asked which of the following responses would be most likely in the event of a pandemic:

  • Avoid public transportation
  • Avoid going out for entertainment
  • Limit shopping to the essentials
  • Take leave from work
  • Keep children out of school, even if it remains open
  • Limit physical contact with friends and family
  • Avoid seeing doctors, even when sick from something unrelated to flu
  • Stay indoors at all times

CIDRAP has an excellent summary of the study. Here’s some of it:

A recently published survey of Europeans and Asians showed that, when faced with an influenza pandemic, most would avoid mass transit and limit shopping to essentials, and many would avoid other public places, including restaurants, theaters, and the workplace.

The study, published online Jul 20 in Emerging Infectious Diseases, found that “avoidance of public transportation was consistently reported across the region as the most likely precautionary behavior,” with about 75% of respondents choosing that option.

Reactions to other risk-avoidance measures varied by region. For example, 79% of Europeans would likely avoid places of entertainment such as cinemas, restaurants, and theaters, while only 33% of Asians said they would. And 52% of Asians said they would stay home from work, compared with 35% of Europeans. (CIDRAP News)

The responses didn’t seem to be conditioned on whether the pandemic was mild or severe. And the survey was done in late 2005, before the time when planners were seriously discussing these kinds of social distancing policies. People were already someplace it would take planners another year to get to.

I am not inclined to give much weight to the specific differences or levels for the various responses. This is a hypothetical question and not quantitatively transferable to what would happen in a real event. What it does show, however, is that a substantial proportion of people have a good idea of what they might do in the way of spontaneously altering their behavior. While political leaders and planners wring their hands over what the criteria will be for closing schools (a Draconian measure with huge economic and social implications for most communities), the decision will most likely be made by people without reference to what the planners think. The governor or prime minister or provincial leader will officially close the schools when students and teachers stop showing up.
This isn’t an argument for not thinking about what should trigger a school closure. But it is an argument for shifting the major effort away from trying to figure out what the trigger will be to planning to manage the consequences. Similarly for the effects on trade, commerce and travel.

People will vote with their feet. And the leaders will follow the crowd. Both should think ahead about what this will mean.


  1. #1 herman
    July 29, 2007

    If multiple drug resistant and extreme drug resistant tuberculosis (mdr-tb and xdr-tb) become resistant to all drugs, social distancing will not help, since the pandemic will not come in waves, but will be constant over time.
    And if the patient does not respond to the toxic drugs used to treat this tuberculosis, or cannot tolerate these drugs; the only alternative left will be isolation of the patient, and possibly surgery. This means the patient will probably be quarantined.
    With over 400,000 people infected in the world each year with mdr-tb, and thousands more infected with xdr-tb; there is a real threat tuberculosis strains will develop which are resistant to all first line and second line drugs; and the Aids epidemic will speed this process.
    In the 19th century, about one in every 4 deaths was the result of tuberculosis. Will this happen again the the 21st century?

  2. #2 bklff3
    July 29, 2007

    Who will run the hospitals when all the nurses/doctors are at home looking after their kids that aren’t in school?

  3. #3 M. Randolph Kruger
    July 29, 2007

    Only the brave ones Bk.

    Revere, have you seen anything regarding post pandemic (whatever it is) treatment of psychiatric cases. I ran up on something that a friend sent and it was interesting. Seems that people at about the one year mark post H1N1 started offing themselves due to loss of family, income, homes… you name it. It lasted until March of 1920 when the “Roaring 20’s” started.

    You know of any pandemic preps for that? I think we might need them.

  4. #4 Nomen Nescio
    July 30, 2007

    most of those responses seem to be of the “couldn’t hurt” variety, at worst. with the exception for avoiding doctors, perhaps. me? i’d do any and all of them that were financially and practically possible for me, which might turn out to be none.

  5. #5 caia
    July 30, 2007

    I do generally know better than to feed the trolls, but…

    Herman, I recently finished Mountains Beyond Mountains by Tracy Kidder, about Dr. Paul Farmer, and he (among many others) is working on treating and curing MDR TB in places like Peru and Russia, as well as treating and preventing AIDS, and providing comprehensive quality care to indigent patients in Haiti. Since you are so worried about MDR and XDR TB, you might be interested in learning about and supporting Partners in Health, his organization.

    Meanwhile, clinical trials have started on a new TB vaccine which, if successful, could help stanch potential worldwide disaster.

    Obviously it’s not guaranteed to be successful, but knowledgeable people are concerned, and work is being undertaken to address the problem.

  6. #6 Bob, DVM
    August 1, 2007


    You raise some good questions about the looming crisis in the treatment of TB, but I believe you’re also mixing apples and oranges. A message which has not been well communicated in the wake of Andrew Speaker’s splash is that TB is not an infectious disease that sweeps through populations at breakneck speed, so the questions of how the public will respond in the wake of pandemic influenza don’t apply in quite the same way.

    I second caia’s suggestion to read Mountains Beyond Mountains. Paul Farmer is one of my personal heroes for what he has accomplished. Although they’re from a few years back, the information in a couple other titles is still quite relevant: The Coming Plague and also ___ (drawing a complete blank on the title) by Laurie Garrett.

  7. #7 caia
    August 1, 2007

    Bob, DVM: Do you mean Betrayal of Trust: The Collapse of Global Public Health? I haven’t read it yet. I think I started to read The Coming Plague when it came out, and was so powerfully freaked out by it that I stopped.

    Which was one thing I appreciated about Mountains Beyond Mountains: it painted a grim picture of the health of the world’s poor, but Farmer and his people were so committed to changing it, and so amazingly locally successful, that the overall tone wasn’t terrifying or depressing.

    And now I’m getting into off-topic book reviews, so I’ll stop.

  8. #8 SoCal
    August 2, 2007

    Beware of the statistics: We can’t assume that avoiding mass transit is “spontaneously altering their behavior.” Where I live, 75% of people already avoid mass transit! It’s easy for people to say they’d stay off a bus, when they wouldn’t ride one anyway.

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