Effect Measure

I’m afraid I have to complain about crappy journalism again. AlterNet is an online newsmagazine I quite like. We’ve been linked by them numerous times and know their influence. Sometimes, though, some very smart writers write some very dumb things, even if they do it in a smart way. Alas, Joshua Holland has done it today on the front page of Alternet.org with a supremely wrongheaded story about why you don’t have to be scared shitless about swine flu. We agree with that bottom line, but how he got there is the problem (that and the fact that he doesn’t understand much about influenza).

Let’s take our points of agreement first. Holland says that in years past we wouldn’t have known about swine flu at all. Indeed this is a historic event in the long history of influenza infections, the very first time we have the ability to watch a pandemic with this virus unfold in real time. One of the reasons is the same as why we can read Joshua Holland’s writing: the internet and its speed and reach. That doesn’t mean that because we wouldn’t have known about ten years ago that it could have happened without our knowledge. The global spread of a novel influenza virus happens only occasionally, and when it does it is an event of some significance for public health. We found out about it but after we can do anything.

But we do know it is happening, and since I’m an epidemiologist, it’s a Big Deal for me and my colleagues. It will also be a big deal for your doctor or other health care provider (assuming you have access to health care; thank you Chuck Grassley and Max Baucus for putting some uncertainty into that assumption). But does that mean it should be a Big Deal for you? Joshua Holland thinks not, on the grounds that it is the business of me and my colleagues but not the average citizen based on his version of what makes something important: the media and how he interprets the “statistics.” Presumably the rationale is the same for climate change. Take it up with climate scientists. Don’t bother the public about it. No one has died from it yet and there isn’t that much they can do about it. If you read AlterNet, you know that’s not exactly their position. Nor should it be.

It’s true from the clinical point of view this isn’t a particularly unusual influenza virus. Every flu season is different and the various types and subtypes are different, not just from year to year but from month to month and season to season. Flu is an unpredictable disease, and Holland acknowledges this one could take a turn for the worse, because “viruses mutate.” True enough, but not the point. It’s also true that the media has run many stories about it. For example, there are plenty of “it’s all hype” versions (of which Holland’s is an example), there is the “deadly virus” version, which are absolutely predictable. MRSA is a big problem. So we get stories about flesh eating bacteria. Hey, pal. It’s your profession, not mine. Mine has malpractice and Medicare fraud. But before blaming the media for everything (something the media itself likes to do) we should note that there are also many more stories that are purely factual and accurate than terrible. This is partly because Holland’s colleagues in the media are so lazy or so overworked that they just take official press releases and rewrite them, the same kind of stenography that brought us the Wars in Iraq and Afghanistan and so much else we know and love. But it’s also because there are some superb science journalists out there who understand the science; Holland isn’t among them. Holland is just another example of inaccurate media reporting contributing to public confusion. But that’s the system. The system that Holland is an integral part of and his article is just another example.

Even the premise that media reporting is causing widespread public panic is pretty stupid. I’d like to see the evidence. Are there scary stories? Sure. Alternet itself is full of scary stories. Journalists make their living writing scary stories. We all know that. They also earn their living writing stories that allegedly debunk scary stories. As members of the public we have a zillion things vying for our attention, of which swine flu is one but not the biggest. Losing our jobs or paying our rent or getting sick and bankrupted come way, way ahead of swine flu. It doesn’t happen to most of us, statistically speaking. So why write about it? It’s news. So is swine flu. Swine flu is more than news. It’s news that can and probably will affect everyone. Do I wish every story written about it was exactly accurate? Of course. I wish Joshua Holland’s article were exactly accurate.

I won’t go through his misunderstandings point by point. It’s a long article and much of its wrongheadedness is related to how he strings together facts and his emphases. While there is nothing to say that this virus will be comparable to what happened in 1918 (possible but this looks much more like 1957 than 1918), comparisons and suggestions to the contrary are inevitable, especially in the media. Duh. Straw man argument. The trouble is, Holland doesn’t understand that influenza — not this influenza particularly, but all influenza — is a serious public health problem. And he doesn’t understand that this is a pandemic strain and isn’t the same as seasonal influenza. That’s not because of the “statistics” he cites about how many people have died of it; or how it compares to lightning strike risks (a fatuous technique beloved of wingnuts trying to trivialize whatever their paymasters find inconvenient); or that more people die of seasonal influenza (we don’t even know how many people that is, but if this isn’t any different than seasonal influenza and it’s the only flu A strain out there, then presumably hardly anyone will die of flu this year according to Holland’s “statistical context”); or that more people die of malaria (so we shouldn’t worry about the ones that get polio?).

The problem is not the virulence of this virus (all influenza viruses are potentially virulent for certain people) but its epidemiology. It’s a pandemic strain, which means it is infecting a much different population (the very young, and adults through middle age), making more of them sicker, continuing to circulate at unprecedentedly high levels during times of year when flu is almost absent, and confronting an extremely brittle and unprepared medical care system especially vulnerable to just this kind of virus.

Holland makes much — as did the bird flu deniers of a few years ago, who, if we’d have listened to them, would have left us much less prepared to deal with this pandemic virus — of the fact that conditions in 1918 were far different than now. For one thing there was the historic event of World War I. He forgets to mention this old chestnut of the flu deniers, but does claim that we now have medical tools we didn’t have then, namely antibiotics. Even though he doesn’t mention it, let’s talk about World War I. We’re at war now, but compared to WWI, it’s nothing. So that’s certainly a big difference. But in 1918 we didn’t have factory farms, either, those exquisite hothouses of virulent viruses. What are the biggest factory farms? Hogs and poultry. It doesn’t much matter if this virus came from one originally or not. Their very existence means that if an influenza virus gets into that population (as it has for avian influenza) it will become enzootic and constitute a continuing experimental laboratory for the virus to find the right recipe to wreak havoc. I don’t say this to scare you. I say it because it’s true and we can do something about it. The response to this bad possibility is to regulate factory farms and do continuous and adequate surveillance of animals for zoonotic disease. Does Holland think I shouldn’t write this? I wonder.

Now to our vaunted medical capabilities. Joshua Holland has never cared for a critically ill person with Acute Respiratory Distress Syndrome (ARDS), which is often the terminal event for flu patients. So I’ll tell him. It doesn’t matter if it’s caused by bacteria (many are). Half of them die no matter what you do and no matter what intensive care unit you have available to you or what antibiotic or what computer controlled respirator. We still can’t do much. But we don’t even have the beds to give it a try to begin with. Our big city emergency rooms periodically and routinely go “on diversion,” meaning that they divert the ambulance that’s on its way their hospital to another hospital. The main reason is not the already ludicrous long waits in the ER but the shortage of critical care beds, the ones with the ventilators and skilled nursing that Holland thinks will now save people seriously ill with flu. It’s a common mistake. But it’s a mistake. Even a bad regular flu season can break the system. And because the people who are winding up on ventilators are in their 20s and 30s and not in their 70s, this is a different kettle of fish. As for Holland’s recital of the “official” statistics on flu deaths and cases, no one knows the true numbers. Everyone stopped counting long ago, for reasons Holland doesn’t understand. We don’t even know how many people die each year of seasonal flu. But we’ve covered this ad nauseam on this site, so we won’t repeat it.

If we didn’t know this was happening, would we, as Holland avers, just go on about our business? Likely, until the ER and ICUs filled up. Same with global warming. We certainly do it with malaria, which is happening far away to people of color and which he thinks deserves more attention than it gets (it does, but so do a lot of other things). So what? As for comparing it to cigarette smoking, as my friend Bart Laws at Tufts does (quoted by Holland), I don’t get the relevance. Bart is a friend and very smart. He and I disagree about flu. He thinks too much attention is being paid to it and I’m one of the people that pays attention to it. It’s an interest of mine. Do I think the danger of a pandemic is worse than the danger from climate change? No, I don’t. I think overall climate change is a bigger threat to public health. But neither Bart nor I write much about climate change although we both write about it to some extent. So? Bart has his reasons for objecting to what he feels is a misplaced attention to flu. I respect him and our differences. But Holland, unlike Bart Laws, doesn’t know what he’s talking about, and he has no good reasons.

He’s just another journalist mining swine flu for readership.

Comments

  1. #1 Joe Richey
    September 26, 2009

    I love debunker journalism. But not as much as your debunk of the debunker. Thanks for this cogent coherent rebuttal of Mr. Holland. Maybe you both can make it to the big top? the live argu-tainment shows out of New York and Los Angeles!

  2. #2 Chrtowsky
    September 26, 2009

    Why is this virus infecting mostly the young? Are all pandemic strains like that? Great article by the way.

  3. #3 revere
    September 26, 2009

    Chrtowsky: Yes, all pandemic strains do this, presumably because the older members of the population may have had some exposure from two generations before, although the reasons aren’t exactly clear. A “shift to the left” in the age distribution is one of the characteristics of a pandemic, in fact, one of the cardinal signs.

  4. #4 Peter Christian Hall
    September 26, 2009

    Great post, Revere. It’s sad that AlterNet stooped in all of the wrong directions to write a run-of-the-mill debunker piece. Give him half a star for leaving Rumsfeld/Gilead out of it (because that stock was 10th among Obama’s holdings last year?). I did expect more from AlterNet–even if more was nothing at all on the subject. What’s really funny is that he cites Lawrence Gostin on “irrational fears and discriminatory behaviors among individuals and governments.”

    Gostin is the voice and pen that so energetically pushes those repressive state health laws (Florida long ago, and one is now halfway through the Massachusetts legislature) that the CDC started proposing after 9/11. The statutes that look on sick people more as enemies of the state than as partners in any efforts to halt an epidemic….

    Best, PCH

  5. #5 revere
    September 26, 2009

    PCH: You sure have Gostin pegged right. If you want the poster child for the use of public health arguments to abrogate cvili liberties, you can’t do much better. Unfortunately he has quite a bit of influence, but the ACLU has taken him on (lawyer-bioethicist George Annas has been on his case for years). I didn’t mention it because the rant was getting out of control and there was too much background to give to that, but it happened because Holland doesn’t know or understand any of the issues or the players or the arguments.

  6. #6 raven
    September 26, 2009

    We’ve got H1N1 swine flu cases here on the west coast already. Hard to say whether this is the summer background level or the pre winter herald wave.

    My two predictions have already been made.

    1. Swine flu will crowd out the seasonal flu strains to a large extent.

    2. The pandemic wave will be early this year. The fall weather on this coast has been unusually warm and dry so far, The test will come later when it gets colder and damper.

  7. #7 Chrtowsky
    September 26, 2009

    …the older members of the population may have had some exposure from two generations before.

    That’s what I don’t understand. From where do older people get the immunity? Isn’t this a new virus?

    I read the article about the 1918 pandemic on Wikipedia. Is says (about the second wave): It was the same flu, in that most of those who recovered from first-wave infections were immune, but it was now far more deadly.

    How did it became more deadly? If the virus mutated how can it still be the same? Would people who already got the swine flu be immune if the virus mutated in the following months? If it mutates will the vaccines we’re making now still be effective?

    Thanks in advance.

  8. #8 revere
    September 26, 2009

    Chrtowsky: When you find the answers to your questions tell the rest of us. In fact there is some substantial controversy as to whether it did become more deadly and whether there was even a herald wave. Two flu luminaries, Taubenberger and Simonsen have squared off over this. A consistent theme here over the years is that there is a great deal we don’t know about flu that we used to think we knew but were wrong about.

  9. #9 Richard Hendricks
    September 26, 2009

    Isn’t flu made up of 8 different parts that can be easily exchanged during co-infections? I could see how a flu virus swaps out a module controlling virulence but keeps the outer envelope module, leaving the previously infected immune, but naive new patients with a higher chance of death.

  10. #10 revere
    September 26, 2009

    Richard: Alas it is possible to conjure many narratives about what might or might not happen with flu. It is a remarkably unpredictable little piece of protein and genetic material. For some of the complexities click here and then elsewhere on the blog (check the categories in the sidebar).

    Despite the fact that the virus has only 8 genetic segments and makes only 11 proteins we still do not know what governs transmissibility, virulence, host specificity, seasonality or a bunch of other things. There are lots of guesses but so far we can’t look at a genetic sequence and predict any of those things.

  11. #11 Chrtowsky
    September 27, 2009

    Which part of the virus does our immune system recognize? To what do the antibodies attach? Is it Hemagglutinin, neuraminidase, something else?

  12. #12 Chrtowsky
    September 27, 2009

    Well, i just read about 20 articles about influenza on this site. I didn’t realize there was so much we still don’t know.

  13. #13 Pierce R. Butler
    September 27, 2009

    … there is a great deal we don’t know about flu that we used to think we knew but were wrong about.

    On my shelf, as yet unread, are John M. Barry’s The Great Influenza (2004) and Gina Kolata’s Flu (1999). (How badly) will I end up misinformed if I open them and start reading?

  14. #14 revere
    September 27, 2009

    Pierce: I’ve read them both (and I know both authors) and they are both good to read and won’t lead you astray on the science. John Barry’s book has been challenged on some of the historical interpretations and I have some problems with “the great man” version of history of science but it is interesting and informative about 1918. Will probably be the standard account for some time to come, although the literature is expanding fast (on the history). Kolata’s book is informative and interesting. But the topic of flu is so huge each only gives you a little piece of the picture we are concerned with today.

    But you can safely read them both. They don’t get into the weeds of the science that is so confounding today.

  15. #15 JK
    September 27, 2009

    sorry, I’m not convinced by your critique. You say that if we had listened to the ‘bird flu deniers’
    we would be far less prepared. But is there good evidence that any of the preparation has made very much difference to the way that swine flu has played out so far? Or is your case all about what might happen?

  16. #16 Pierce R. Butler
    September 27, 2009

    revere – thanks for the mini-reviews!

    I guess for a definitive and reliable account of what’s happening in 2009, I’ll have to wait and see what’s published in 2090…

  17. #17 revere
    September 27, 2009

    JK: The state pandemic flu plans and vaccination programs were all developed with bird flu in mind. More importantly, we wouldn’t know about swine flu if it weren’t for the lab capability that was developed to deal with untypable subtypes. Many, many more examples. Now if you are like Josh Holland you may think it’s better we didn’t know about it. I am not of that persuasion.

  18. #18 JK
    September 27, 2009

    Statements such as “if you are like Josh Holland you may think it’s better we didn’t know about it” are part of the reason I’m not convinced by your critique. I think that his argument is more subtle than that.

    I think I agree with Holland when he writes “Public-health officials, epidemiologists and clinicians have to worry about H1N1. As things stand, you really don’t.”

    Perhaps with your professional interest you don’t see a distinction. For me, I feel as if high concern has spread further than it needed to.

    To get to your example of state vaccination plans, in that sense I’m not even arguing that they are an over reaction. They may make good sense. But they seem an odd example of something that has already made a difference to the way that swine flu has played out, which was my original question.

    With international travel I have found myself filling in special landing cards for swine flu monitoring. Has this made a difference, is there no difference yet but better safe than sorry, or is it just theatre?

  19. #19 JK
    September 27, 2009

    Please excuse my ignorance, has the lab capacity to deal with subtypes made a difference for vaccine development, or what?

  20. #20 revere
    September 27, 2009

    JK: The lab capacity allowed us to know a pandemic was happening and that makes possible the vaccine development. Even if we had detected it some other way, it gave us many months head start in vaccine develop, a had start which is turning out to be crucial.

    The state vaccine plans, which may or may not make a difference, exist because of pandemic planning, as do many of the things, like detailed social distancing schemes and many other items. If the media had done its job, we would also have an adequately funded public health infrastructure, which we don’t. And surge capacity will be another problem. That’s an important news issue.

    I see nothing at all subtle about Holland’s argument. He doesn’t understand influenza or the current situation and wrote a crappy piece. Where’s the sbutlety? That media coverage hasn’t made a difference? Nothing subtle about that. It’s kind of stupid, in fact.

    Regarding who “needs” to know, one can ask that about any topic. I used climate change as an example. You could say that’s a subject for policy makers and climate scientists and not the rest of us. But if you read AlterNet you know they don’t think that. So what’s the difference here? The flu season makes a difference in people’s lives every year and will do it more so this year. That’s news reason enough, I’d think. The question is, why isn’t it covered every year?

  21. #21 DemFromCT
    September 27, 2009

    JK, in partial answer to your question I can tell you at the local level that the years of planning for bird flu have made a huge difference for H1N1/swine flu. Planners including Public Health and non-PH and local businesses, schools, first responders, etc now know each other, meet regularly, have an idea of what a pandemic is, and have developed contingency plans that were modified for swine flu relatively quickly. Communication channels built for bird flu functioned for swine flu. Local town meetings were better informed for the efforts previously. And on and on…

  22. #22 simonito
    September 27, 2009

    Forgive my ignorance, but I have been quite confused about the reasons for seasonality of flus in general, and about the current non-seasonal swine flu in particular. Is the swine flu pandemic simply because of the widespread lack of immunity (ie the enviroment it’s circulating in), or is there a difference in some property of the virus itself? I’ve been assuming it’s the former, which brings to mind even more questions, such as:

    *Is it thought that swine flu will itself become a seasonal flu in a year or two, ie after it’s finished cutting its global swath and there’s widespread immunity?
    *If so, will it most likely permanently “crowd out” one or more of the currently circulating seasonal flus, or co-circulate?
    *If I remember what I’ve read correctly, aren’t there already 2 seasonal flus out there? So if this co-circulates with them there will be 3? Am I correct in assuming that the more seasonal flus there are out there, the greater the possibility for co-infection and hence gene trading among the different flus–and the greater the chance for some deadly super-flu mutation? Wouldn’t this be kind of a big deal?
    *Or is the currect swine flu expected to die out after it has made its rounds (which is I assume what happened with the 1957 flu, since it seems like more/ younger people would have had some immunity otherwise)?

    Obviously I am just a science blog lurker and I have only the shallowest understanding of these issues, so please forgive me if I’m asking questions with answers that are obvious and well-known to all of you. If you know of any specific resources that address these questions, I’d love to know them. I know there’s a crowding-out post on this blog that I haven’t had time to read yet; perhaps it will answer some of my questions. Also, I assume there’s info on what drives seasonality in regular flus out there somewhere (and I don’t mind looking around for it), but if there’s a quick and easy answer that someone could post here I’d be delighted to read it.

    And thanks, everyone. This is a great blog.

  23. #23 Leah
    September 27, 2009

    In my world of well – educated adults in the DC area, people are NOT taking this seriously. MSM has sent out a series of conflicting messages.

    I think this Washington Post story highlights the consequences of unwarranted panic, and then, at the very end,gives a snippet which may cause some unwarranted panic without ever telling readers the symptoms that DO warrant seeking immediate medical attention.
    http://www.washingtonpost.com/wp-dyn/content/article/2009/09/26/AR2009092601254.html?sub=AR

    Thanks to this blog, I learned the following and was able to share this knowledge with my clients, family, and friends:
    1. Yes, the Swine Flu is serious — especially if / when medical resources get overwhelmed.
    2. No, we should not panic (see #1), but should take all appropriate precautions: handwashing, social distancing, and VACCINATION to prevent catching and spreading this flu.
    3. Most importantly, I learned the danger signs to watch for in the Reveres June “Swine Flu Comes Home” — specifically that if someone starts to get better but then gets worse, THAT means to seek medical help IMMEDIATELY.

    In spite of my efforts to disseminate this information, a friend who holds a relatively senior government position let me know last weekend that she was surprised to find out that “this Swine flu thing is REALLY SERIOUS” when she was briefed at work. Tamiflu is stockpiled for her along with her immediate family, and she has a concierge doctor on call 24/7. How about THAT public option??? On the plus side, our federal government will not collapse due to everyone being out sick w/ the Swine Flu. On the minus side, based on MSM reporting — especially TV news, this very educated person was under the impression that the swine flu was a whole lot of over-hyped non-sense until real alive medical experts came to her workplace to say otherwise.

  24. #24 blondesprite
    September 28, 2009

    Thank you sincerely for this article. I shared my flu experience on Mr. Holland’s/Alternet’s comments section, in the hope that the damage he has done might be undone.
    As someone who is now recovering (can sit upright without agony and sip fluids) I would hate the idea that someone reading Mr. Holland’s article would ignore the potential severity or think they did not need a flu shot.
    Thanks for taking him to task.

  25. #25 djw3505
    September 28, 2009

    Thanks to blondesprite for link your criticism to Holland’s article. one issue with flu vaccines that came up is that whether mercury/thimerasol is still being used in flu vaccines? straight dope answered a question in 2007 saying that thimerasol causing autism is not supported by evidence, but it does cause neurological problems and is still being used in flu vaccines. is thimerasol in Tamiflu and h1n1 vaccine in 2009? I intend to get flu vaccine irregardless, (work at college bookstore under 50 with prediabetes) but what about my 3 month old son? I understand he can’t get until 6 months but will it contain thimerasol?

  26. #26 Tsu Dho Nimh
    September 29, 2009

    But perhaps the most striking aspect of the swine flu quasi-panic is, if it had emerged just a few short years ago, we would have gone about our lives without any sense that anything unusual was even under way.

    I think the overflowing ERs, higher than usual school and work absences, and maybe a few deaths from a mystery illness that looked a lot like flu might have tipped off those fusty old newspapers.

    Even the newspapers in the 1918 epidemic were full of news about the epidemic.

  27. #27 Marilyn Mann
    September 29, 2009

    Hm . . . I wonder what you think of the title of this forum sponsored by the Science Communicators of North Carolina: “INFLUENZA — What’s more contagious, the virus or the hype?”
    http://scienceblogs.com/terrasig/2009/09/sconc_tomorrow_at_duke_influen.php

  28. #28 revere
    September 29, 2009

    Marilyn: Yikes. Abel’s a really good guy. I just left a gentle remonstrance about the title as a comment over there. Thanks’ for alerting me.

  29. #29 SQB
    September 30, 2009
    Why is this virus infecting mostly the young? Are all pandemic strains like that?

    Yes, all pandemic strains do this, presumably because the older members of the population may have had some exposure from two generations before, although the reasons aren’t exactly clear. A “shift to the left” in the age distribution is one of the characteristics of a pandemic, in fact, one of the cardinal signs.

    Could it be the other way around? Could the fact that the virus infects not just the older members of the population give it pandemic possibilities?

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