Effect Measure

Crafting a message on swine flu is not easy, and it’s easy to make missteps. I think CDC has gotten it pretty much right over the last two months, but not everyone has. We’ve written here since the beginning (some examples here and here) that describing any flu outbreak as “mild” is inapt. Flu always has the potential to be a serious disease and kill people, even in flu seasons termed “mild” by comparing them to flu seasons that are “bad.” Even with virulent flu viruses many people have minimal illness — in comparison to those who don’t. But flu, even in its most common form of a self-limiting illness with complete recovery, is often a miserable affair during its acute phase and it can leave a person debilitated for extended periods afterwards. For some there’s nothing mild or self-limiting about it. A bout with the flu becomes a mortal threat that can make good on its fatal potential.

Now the frequent use of “mild” by public officials to characterize swine flu is causing concern:

The heavy reliance on the word “mild ” could be creating a false impression of what is actually going on and what the world may face in coming months, some experts worry.

Peter Sandman, a risk communications guru from Princeton, N.J., suggests if authorities are trying to ensure people don’t panic about the new H1N1 outbreak, they are concerned about the wrong thing.

“In North America, swine flu panic is much rarer than swine flu deaths,” Sandman says.

“The problem isn’t panic or even excessive anxiety. The problem is complacency, both about what’s going to happen and about what might happen.” (Helen Branswell, Canadian Press)

Officials tend to minimize the seriousness of these things for two reasons, one conscious, the other unconscious. The conscious one is to allay public anxiety, anxiety which can have significant public health consequences if it causes emergency rooms to clog up with people worried they might have something much worse than how they feel. The unconscious reason is that public officials don’t want it to be bad, because they know what that would mean. Their job would become orders of magnitude more difficult and if they were wrong about the seriousness they’d be accused of overreacting. It’s a fine line. Here’s how CDC’s Dr. Anne Schuchat walked it last week during a press briefing:

In the U.S., our antiviral recommendations are based on the observation that the vast majority of people who get this new virus have illness that is mild and clears on its own or they have illness that gets better. It’s not mild, you can be quite miserable in bed for a few days, but it doesn’t lead to complications in most people. On the other hand, pregnant women, people with underlying medical conditions like asthma and diabetes, can have a much worse outcome. They can get pneumonia. They can have severe hospitalizations and, of course, some of them are dying. (CDC transcript)

Not perfect, but on the whole, accurate. The only thing missing is to be clearer that a significant proportion of people who become seriously ill are otherwise healthy and relatively young for having a bad flu outcome. Over the years I have become aware that most people have no idea what it’s like to have a solid case of influenza. They still think of it as like a “bad cold,” even though public health authorities have tried to dispel this myth. Unfortunately the message that swine flu is a mild disease has reinforced this misconception.

We have still to get a good handle on how nasty this virus is, even in flu terms. WHO’s Keiji Fukuda has termed the severity of this pandemic “moderate,” similar to the 1957 pandemic. In the northern hemisphere the virus continues to circulate robustly, even though it is summer. Reports from the southern hemisphere, which is just entering its traditional flu season now, suggest it is building up quite a head of steam there. Whatever its virulence (which is uncertain at this point), it is behaving epidemiologically like a pandemic strain, which means it is infecting and making seriously ill younger people (and in fact seems to be sparing the elderly) and because of the lack of population immunity it may be capable of infecting many more people than the usual seasonal flu. If the virulence remains the same, a proportionate increase in infected people will result in a proportionate increase in seriously ill people. But virulence may also change. Even moving the average virulence a small amount can cause extremely large proportionate changes in the serious cases. If you double the demand for pediatric ventilators you can have a very big medical care problem, just to take one example. How fast cases accrue will also be critical. If it happens fast it has a very different effect than if it is spread out over many months.

Public health authorities up north are counting on having some advance warning on how bad things can get by seeing what is going on in the southern hemisphere. But the virus may not give anyone that luxury. Countries like Australia, Argentina and Chile are already getting hammered and the virus seems to be increasing in places in the north at the same time. In other words, we have yet to take the measure of this virus.

Whatever that measure turns out to be, I feel pretty confident that “mild” won’t be a word to describe it.


  1. #1 Tom DVM
    June 29, 2009

    An excellent summary…thanks.

    “Over the years I have become aware that most people have no idea what it’s like to have a solid case of influenza.”

    If we apply the KISS principle…is it possible that case distribution-numbers of seasonal influenza and by extension immunity is not what we think?

  2. #2 BAW
    June 29, 2009

    A 35 year-old family member living in Massachusetts got sick last week with cough, etc. and reports that “mild” is a relative term.

  3. #3 Mark
    June 29, 2009

    Good post. The message many healthcare employers and healthcare workers are getting from their state and local health departments is that H1N1 is just like seasonal flu. So many facilities are not training their workers, not identifying and isolating suspect cases quickly, not requiring proper PPE and infection control protocols. These employers also continue policies that penalize healthcare workers who call in sick. We’ll likely be in trouble this fall.

  4. #4 Curious
    June 29, 2009

    I’ve gotten the flu exactly once, 10 years ago. I haven’t missed a flu shot since (I had one that year too, actually) because I’m in no hurry to go through that experience again anytime soon. Not mild. My kids have both been immunized every year as well, though last year my three-year-old caught it anyway. Again, not mild.

    I saw a note yesterday that a Texas flu expert thinks that the school year should be delayed until a vaccine is developed. Do you think this is something they’ll actually do? I’m all for it — but then again, I’m a work-at-home mom, so I don’t have to worry about daycare. I’m really nervous about sending the kids back to school.

  5. #5 Don Williams
    June 29, 2009

    1) In my opinion, one reason the flu is downplayed is because government officials are nervous about what will happen to their careers when people see how screwed up things are.

    2) How many N95 masks do we need? How many does the government have stockpiled? What many millions of Americans will have NO chance at getting a swine flu vaccine in the fall?

    3) How can a nation spend almost $1 Trillion on “Defense” every YEAR and not have the ability to defend its citizens from a flu virus?

    4) Would the flu have spread throughout the world as rapidly as it has if the USA had closed the southern border early on and kept the USA –with global air flights — from becoming the world’s second largest incubator/transmitter of the virus?

    5) Our US bureaucrats are seeing what’s happening in Argentina: Health Minster Graciela Ocaña has just resigned
    and the newspapers are reporting that the number of sick is far above the government’s “official figures”. President Kitchner’s party didn’t do too well in yesterday’s election, either.

    Ref: http://www.buenosairesherald.com/BreakingNews/View/5187

  6. #6 S Lakshmi
    June 29, 2009

    “Over the years I have become aware that most people have no idea what it’s like to have a solid case of influenza.”

    I honestly believe I’ve never had the flu and, whenever I tell people this, they refuse to believe me (I’m 35). My husband claims to have had the flu several times! I’ve had very bad colds, and finally had RSV a couple of years ago, which was truly a nasty bug and aggravated my asthma immensely. People seem to call every bad upper respiratory infection the flu, just as they think every bad headache is a migraine.

    There’s a question I’ve had for a while, though, about whether people as immunologically “naive” to the flu as I am – and as I believe many other people are – are affected more by this novel flu virus simply because their body has never even seen a flu bug before. Could this explain some of the age discrepancy that seems to be occurring with this flu? Could this also partly explain why the First Nations communities in Canada are having so much trouble?

    If so, would it be useful for people who’ve never been exposed to the flu virus to get at least a seasonal flu shot at this stage? (I’ve never had a flu shot either.) I recognize that the seasonal flu shot ultimately confers no immunity against this novel virus, but could it be of some small help in priming the system for those completely naive to any flu virus?

  7. #7 bostonERDoc
    June 29, 2009

    Don, Most people in public health I know are saints and they deserve our respect and praise. I agree that we are unprepared for the onslaught but I don’t think we will ever be unless our science and vaccination abilities far advance or you are willing to let Uncle sam have 70% plus of your gross annual salary to make the public infrastructure ideal. God made pandemics for a reason : to “thin the herds”. Really think about it. Our bodies were designed on a teleological basis, to walk 12 km daily and scavenge for food and run from the saber tooth tiger–who maintained the herd to acceptable levels and health. We dont have saber tooth tigers anymore for herd thinning and many people complain about wars so pandemic influenza strains have been created to fill the void and sometimes they do a very good job.

  8. #8 rehana
    June 29, 2009

    I’m not sure most people even understand that flu is different from a cold–I’ve heard people saying they got flu shots and “got sick anyway.” Thinking they realize it’s worse than a normal cold might be too optimistic.

  9. #9 raven
    June 29, 2009

    OT but not by much.

    A/H1N1 Swine Flu (Influenza) Timeline | June 29 | Denmark (DK …
    source | – The first case of H1N1 with resistance to oseltamivir (Tamiflu ®) in the pandemic has been found in Denmark. This is the first identified cases.

    I’ve been expecting this but not so soon. The swine flu virus is already resistant to amantadine/rimantadine.

    If Tamiflu resistance becomes widespread (who knows but it is likely), that leaves Relenza, a drug in the same class of neuraminidase inhibitors.

    We really need more and different flu antivirals to keep up with evolution. We aren’t going to get them in time for this pandemic.

  10. #10 another
    June 29, 2009

    bostonERDoc wrote: ‘God made pandemics for a reason : to “thin the herds”.’


    Say, Doc, which ER do you work in?

  11. #11 Anon
    June 29, 2009

    Off topic, but the Reveres should know this if anyone does – NYU’s Jay Rosen would like to know if it is technically possible to put a pox on the house of the person who puts a pox on both houses.

  12. #12 Steve Watkins
    June 29, 2009

    Would it also be fair to say that the wide variation in level of symptoms is also a big part of the problem when trying to educate people about flu?

    I mean considering some people will be asymptomatic or have some symptoms but not fever for example, I always end up having trouble with both sides of the ‘you dont know what real flu feels like’ debate.

    At my place of work right now there is a problem with complacency, not taking flu seriously. But one of the associated issues this is causing is that people who are ill, but not feeling absolutely dreadful, are still coming to work, coughing etc. And generally they refuse to entertain the idea that its even a possibility that they could have the swine flu, even though wider community spread is happening in my part of the UK now. This is often because they can remember having ‘real flu’ at least once and they know they dont feel that bad this time. Now it could be that I have misinterpreted data and that nearly everyone who gets swine flu will feel real terrible and have a fair idea they had it, Im not entirely sure.

    Still the effects of both the misuse of the word mild, and moderate symptoms in many, could quickly come undone once there have been quite a lot of deaths of previously healthy young people in local area.

  13. #13 revere
    June 29, 2009

    Anon: A small one, yes.

    Steve: I agree the wide spectrum of severity is confusing. In a sense the disregard of an illness that for most is not serious is rational, which makes it harder to make people realize that the bad outcomes are a sort of lottery. But as lottery losers become more visible and not hidden or discounted as not ordinary ticket holders it is harder easier to convince people they may also get a bad ticket.

  14. #14 sors
    June 29, 2009

    “But as lottery losers become more visible and not hidden or discounted as not ordinary ticket holders it is harder to convince people they may also get a bad ticket.”


  15. #15 Steve Watkins
    June 29, 2009

    Did you mean to say harder to convince or easier? If, for example, the number of hospitalisations of previously healthy young people was talked about more in the media, I think it would be easier for people to believe they might get a bad ticket, or are we talking about denial mechanisms setting in?

  16. #16 revere
    June 29, 2009

    Easier. My error. I’ll correct.

  17. #17 CPG
    June 30, 2009


    News just out on tamiflu resistance developing, to A/H1N1. We know it’s already resistance to 99% of seasonal H1N1.

    Also this cdc advisory committee now recommending Relenza as the first choice in fighting all flu. How long have I been banging this drum !!! If the world is caught short re Relenza supply you can blame one thing. GSK non-support of this drug. (See Biota/GSK legal battle)

    ”ATLANTA, June 29 — Zanamivir (Relenza), a neuraminidase inhibitor, should be the preferred treatment for patients with influenza-like illness, whether infection is caused by a seasonal virus or the pandemic H1N1 virus, an advisory committee to the CDC said.”


  18. #18 Jonathon Singleton
    June 30, 2009

    Revere, thank you for this post. It’s important to point out, as you have, the conscious and unconscious processes operating within the minds of people entrusted with the health and well being of the public.

    Fundamentally, Helen Branswell’s CP article (below) is an accurate pandemic overview, more in touch with science and medical reality than most media briefings from “officials” — why!?! Why is it becoming increasingly necessary to poke the “psychoanalytic stick” at a large group of well educated professionals!?!

    Crof’s H5N1 Blog — Branswell: “Mild” is the wrong word for H1N1 (June 28, 2009)

    Edited reader posting excerpt: “Helen Branswell has done a concise job exposing the psychology of officialdom’s fear and confusion regarding H1N1/2009. In creating a false and misleading media impression of what is going on epidemiologically, many government officials, paid experts, and Big Pharma spokespeople risk instilling complacent cynicism in the very people most at danger. I recently wrote about the Oceania experience where officials are downplaying the here and now seriousness of a transgenic pathogen affecting younger age groups. There is also denialist silence about the implications and increased evolutionary virulence (eg. Tamiflu resistance mutations) of a second wave viral explosion during 2010 and 2011.

    It’s bizarre and excrutiatingly upsetting to watch those officials running the proverbial show not talking openly and honestly to the public…

  19. #19 Doug
    June 30, 2009

    The WHO and CDC have been fairly useless agents of propaganda. Have they prevented a single case of the flu? Have they saved a single life? It is very likely that the majority of the susceptible population will get infected before any vaccine is available. This virus is widespread and everywhere. Only self quarantine for 6 months might spare an individual till a vaccine gets here. I see nature taking its course. The weakest will die off. Government officials will continue to exaggerate their importance. The vaccine companies will make record profits because the money has already been appropriated. The flu isn’t waiting on the vaccine.

  20. #20 revere
    June 30, 2009

    Doug: Without CDC we wouldn’t even know about swine flu. They are not a regulatory agency and they have little authority. They are repositories of expertise and knowledge and resources for state and local health depts. WHO saves many lives from all sorts diseases and it is extremely cost effective. Compared to the Dept. of Commerce or Defense, they are engines of real production. If you don’t believe in vaccinations, don’t get vaccinated. But stay away from me and my family.

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