There is an attitude toward the prospects of an influenza pandemic and what, or what not, to do about it that I have little patience with. We saw examples a couple of years ago with the writings of Wendy Orent and Marc Siegel and now it is surfacing again from Philip Alcabes, in an op ed in the Washington Post over the weekend. All three are smart and well informed -- but that doesn't prevent them from being wrong headed. The Alcabes piece, ironically entitled "5 Myths About Pandemic Panic" is either built on myths or strawmen, take your pick. Here is my commentary on the "5 Myths":
- Infectious diseases are spreading faster than ever.
Alcabes says this is a myth, and gives as examples the speed with which the Black Death, cholera and 1918 flu spread. This is a straw man. His examples only show that diseases can spread fast. Influenza, which is spread from person to person, is particularly worrisome from that standpoint, since the spread over long distances can be on the order of days through the kind of network topology characteristic of today's interconnectedness. But the fact that disease also spread relatively quickly in the past (although we are talking months, not days) only means we are at least as vulnerable today. Alcabes cites SARS as a disease that was contained before it went out of control, implying we could do this with influenza. We don't know why SARS burned out as it did. Current evidence now suggests the swift public health measures were not the reason, but in any event SARS is epidemiologically a very different disease, contagious primarily when the victim is very sick and in the late stages, not pre-symptomatic as with influenza. Similarly, the fact that TB is not especially contagious on airplanes (a true fact we discussed often here) is irrelevant. We're not talking about TB on airplanes. We are talking about influenza. This claim:
So germs do fly, but outbreaks don't go global that much more readily than they did before. And we can handle most of them by monitoring infectious people and distributing medicine quickly -- precautions that have been in place for years and even centuries.
is not borne out by any evidence. It is Alcabes's opinion, which may or may not be true, but since it's not based on anything I don't think it is prudent to use it as a reason not to be concerned.
- To learn how to prevent a pandemic, look to the past.
According to Alcabes, the disease we have to prepare for is the one we've never seen before, so planning for an influenza pandemic is fighting the last war. I'm not sure what the point of this is. The way you prepare for an influenza pandemic is by building as sound a public health and social service infrastructure as you can -- an all hazards infratructure. If you prepare for influenza you also prepare for much else. But Alcabes's argument is too easily construed to be "don't worry, be happy," an attitude which makes it harder to strengthen our public health system.
- We should brace ourselves for another Spanish flu.
This, at least, is not a straw man. Advocates for preparation do indeed invoke the 1918 flu as an example of what could happen, or worse. Unfortunately Alcabes's argument doesn't refute it. No argument could, because no one knows what made the 1918 flu so deadly. The claim that the key element was the conditions of World War I troops may be true, but unlikely. There were clearly other elements at work, most importantly the jump from birds to humans. But the virus itself was uncommonly virulent and today's H5N1 subtype is more virulent still. The fact that most deaths were likely secondary bacterial infection doesn't mean much. Yes, we have antibiotics today, but they don't always work and have not prevented an unusually high case fatality ratio among human H5N1 cases. Moreover, in a pandemic the system that would administer these drugs could well be itself incapacitated. Urban emergency departments are already overwhelmed when seasonal flu is worse than usual. And while H5N1 remains a zoonotic disease, the whole issue is to prepare for an event like 1918 when an avian virus achieved the ability to go from person to person. Bird flu is not currently a pandemic virus (although it managed to be a panzootic in a relatively short period of time). And while we don't have the crowded troop carriers of 1918, we do have massive industrial poultry operations where the virus is endemic. There was nothing of the type in 1918. So, yes, things are different. But not necessarily better.
- The annual flu season is nothing compared to a pandemic.
Another straw man argument. Alcabes notes that just because a virus is pandemic, doesn't make it virulent. This is true. So what? What if it is a pandemic virus that is virulent? There's already a candidate out there: H5N1. While it is mistakenly supposed that easy transmission forces a virus to become less virulent, this is false (see our post on this here, or just consider smallpox or HIV). Maybe we'll have another influenza pandemic where the virus is relatively benign. I hope so. Do I want to bet the ranch on it? No, especially as the things I would do to prepare for it are things that will make public health better across the board -- unless of course, we have arguments that say it isn't necessary, that it is just fear mongering. And note, that while a pandemic might not be much worse than a "regular flu season," a regular flu season is pretty bad in terms of its demands on the health care system, on our economy and in terms of lives lost. We aren't even ready for "regular" flu.
- There's no such thing as being too prepared.
Of course there is such a thing as being too prepared if what we do to prepare isn't needed, has a high opportunity cost or is itself harmful. But Alcabes's example of the 1976 Swine Flu affair is, in my view, a bad one. Gerald Ford made an amazingly courageous decision, given what we knew then, and he did it without regard for political cost (and he suffered at the polls for it). I can't think of any President since that I would feel confident would do the same (let me make it clear that I didn't like Ford, but he deserves credit here). The fact that there may have been some side effects from the vaccination campaign is regrettable. Unfortunately that's an argument that can be used for any mass vaccination campaign and we see the consequences today. We make decisions in the face of uncertainty. I wonder what Alcabes thinks was the right thing to do in 1976, given the evidence.
But in any event, this is another straw man. We are talking about strengthening public health and social services as the best way to prepare for what could be a catastrophic event. The concern is based on a very plausible scenario: that an existing highly virulent virus that can and does infect humans will adapt to a new host (humans) and cause widespread illness for which we currently have no adequate therapy or vaccine, and even if we did, not an adequate public health or health care system to cope with it. This is an RNA virus that mutates relatively easily and it is panzootic in animals in relatively close contact with people. If you don't think we should prepare for that, then we live in different worlds.
Alcabes's implicit premise, however, is the one that I find most troubling. It is that public health is being distorted by overblown fears of a pandemic and that people are being induced to behave irrationally out of panic. The fact that publishers try to sell newspapers with scary headlines doesn't mean that the public is in a panic about a pandemic. Indeed a persistent problem is that they tune out. We are inundated with frightening headlines, including those that say that fear and dread are more harmful than preparing for an influenza pandemic. This is not that far from the stance of many health departments that they shouldn't inform the public of environmental hazards because it will induce panic.
The fact that we have prepared badly and in the wrong way is not because people are paralyzed by fear but because the only way the Bush administration would allow anyone to prepare is through ways that enriched their patrons while not empowering public health. That's an entirely different issue. Now that we have an administration more attuned to investing in the Common Purpose, we should be pushing for stronger public health, not vitiating such preparations by claims it is based on fear mongering.
Update, 2/16/09, 2130 EDST: A clarification was posted by Dr. Alcabes in the Comments thread which we believe deserves a more visible position:
It's gratifying to know that my Washington Post piece has touched off serious discussion on the public health realities around flu. Â Influenza, a grave public health problem that shows no signs of disappearing anytime soon, requires care in planning and preparation. Revere correctly points out that developing and supporting sound public health programs and strong social services is fundamental to the planning endeavor. Â I completely agree. For readers who want to follow the argument more closely, I've posted on my website a longer essay on the problem. Â Go to www.philipalcabes.com and click on the "News" tab.
Free and open discourse is a good thing. Much appreciated.
Excellent post! Alcabes is no slouch, but he seems to be wrong-headed about the H5N1 virus and its potential. Your point at the end about the new context we have in this country is particularly cogent. We need to push for stronger public health infrastructure, or, dare I say it: "Health not War."
Your words, "..in a pandemic the system that would administer these drugs could well be itself incapacitated." are prophetic and eloquintly highlight that the loss of manpower in all public support sectors could foil "the best made plans of mice and men". Empowering public health and encouraging personal preparedness pays double dividends by keeping people alive, and ensuring the manpower required to implement local, county, state, and federal plans will be available. That will in turn save more lives. Think about it.. there is no greater contribution that you can make than staying healthy, so that you can help others.
I tried to express similar ideas in the comment section of the Washington Post article but you have done a much better job.
There is just one thing that I think that you fail to point out. While Alcabes creates a lot of strawmen in his article he does not discuss what virologists are really worried about, namely that H5N1 will mutate so that it starts to spread from person to person.
If you want to accuse scientists of creating fear and hysteria you should at least have the decency to discuss the same topic as the people you are attacking. Because of this, the article by Alcabes was not only an example of disinformation but of dishonesty.
Is there any way you can post a rebuttal op-ed at the Washington Post? This is a serious issue, and many people could be influenced by the Alcabes op-ed.
In Alcabes's response to comments at Crof's blog, he seemed to echo this blog's mantra of "strengthen public health infrastructure instead of preparing specifically for one disease." His position is still that he finds a future pandemic of something other than H5N1 more likely than H5N1 (the Reveres would disagree with his reasoning I'm sure), but ultimately, he feels there is a good chance for a catastrophic pandemic of something in the future that we should prepare for. So he does stand on some solid common ground here.
Edmund: I think he said much the same to DemFromCT. He is welcome to say it here. I wish he had expressed it more clearly when standing on the very tall platform that is the WashPo OpEd page.
I like iconoclasts but there is a fine line between
extreme iconoclastic thinking and simple
dunderheadedness. PR's righteous indignation is
justified, all the more so since attacking straw
men is really a slovenly way to make an argument.
Do you have something novel to say, Prof. Alcabes?
Or you just gonna say we've all been duped. Well,
thanks for setting us straight.
TB risk on airplanes is hyped, sure. But it's
mind-numbingly cynical to write what Alcabes writes
about TB, in light of the thousands who die of this
disease every day, most of whom will never have
stepped foot in an airplane in their lives. (I'm
talking worldwide now, of course.)
Itâs gratifying to know that my Washington Post piece has touched off serious discussion on the public health realities around flu. Influenza, a grave public health problem that shows no signs of disappearing anytime soon, requires care in planning and preparation. Revere correctly points out that developing and supporting sound public health programs and strong social services is fundamental to the planning endeavor. I completely agree. For readers who want to follow the argument more closely, Iâve posted on my website a longer essay on the problem. Go to www.philipalcabes.com and click on the âNewsâ tab.
It is well that you correct the record but Effect Measure, as brillant as it is, is not widely read.
If you are to tailor your comments, I would suggest it would be appropriate to do so in the Washington Post.
By the way, your Washington Post article did many things but "touching off a serious discussion" was not one of them.
An accurate history would give credit where credit is due...to DemFromCt, Pooge, Melanie and the Revere's...however many there are of them.
You, in my opinion, are an imposter in this regard.
Tom DVM "You, in my opinion, are an imposter in this regard."
Edmund: "In Alcabes's response to comments at Crof's blog, he seemed to echo this blog's mantra of "strengthen public health infrastructure instead of preparing specifically for one disease." " So he does stand on some solid common ground here."
Dr. Alcabes/ Revere,
Thank you for offering an open stage to learn the different speculations on pandemics.
I tend to agree with Edmund that there are many common areas between these two speculations nevertheless with different perspectives.
Dr. Alcabes, please ignore sometimes very rude comments -as unfortunately it has been part of the style here. I speak for myself, there are many commenter here are staunch independent pursuers and learners. I take this chance to appreciate your courage and facilitation on this important topic.
My grateful email to Dr. Alcabes:
I was so relieved to read your article in the Washington Post today. I must admit I was worried about an H5N1 pandemic,and now I realise after reading your illuminating piece, that my concerns were bordering on panic, and were irrational. I have 2 young kids, and I paid attention to the Case Fatality Ratio with respect to children that seemed to indicate that over 90% of kids that got H5N1 died within a week of infection, despite intensive care 24x7 in good medical facilities.
What a relief to hear from you that most of these kids would have been saved by antibiotics if only the silly medical carers had had your clinical skill and experience to administer antibiotics to stop the secondary bacterial infections. I guess the lab work at autopsy that showed extensive viremia and destruction of liver, kidney, brain and heart were wrong then. Well, that's good to hear.
And perhaps even better news was your revelation (at least to me) that there will never be another 1918 scale viral pandemic. Thank God for that! Previously, I had been misinformed by reading eminent virologists who seemed to be saying that H5N1 was an RNA Type A influenza virus that could mutate, or recombine with other virus types, to become infectious human to human with high transmissibility AND the same virulence as the current H5N1. Boy was I glad to hear from you that this is not possible.
So although I feel rather foolish for having swallowed all the hype of the "preparedness warriors", I am truly grateful for your wise counsel that there really is nothing to worry about.
Thanks for the advice, Our family will be counting on it.
Dear Dr. Alcabes
The debate is alive and well and has been in many forums for many years. Regretfully your contribution â as posted by the Washington Post â has not âtouched of serious discussionsâ so much as precipitate a major damage limitation exercise. Even in your reply at crofsblog â which was less problematic than the WaPo article â you said ârather than plan for a reprise of 1918, we ought to be setting up the public-health systems to accommodate human cases that occur in just the way that the H5N1 cases have happened to date, i.e., as fallout from the bird epizooticâ. I apologies if I misunderstand you but this seem to be advocating not planning for a pandemic but limiting ourselves to victims of zoonosis. Fortunately the audience at crofsblog are likely to ignore such a message but the consequences of that message being adopted by the readership of the Washington Post is frightening.
I want to second all of the above comments refuting Dr. Alcabes' hilarious, narcissistic, and naive statement of gratification that his WaPo article "touched off" serious discussion on the health realities of flu.
What are the rest of us, chopped liver?
What about the hundreds of meetings and conferences we have attended and participated in, the tens of thousands of emails and letters and blog entries and newspaper comments and phone calls we've all made?
It is true that none of us has "touched off" serious discussion to nearly the extent that we wish. I would better appreciate Dr. A.'s having contributed another drop to this large bucket if his drop weren't contaminated with such a high dose of misinformation.
One technical point: While the public health response to SARS was pretty spectacular, consider how belated it was (months of rumors of atypical pneumonia in Guangdong, before a public announcement), the experts I know think SARS was contained due to:
1. Luck that it didn't significantly spread to more Third World cities, i.e. in Africa, and
2. A fairly low reproductive rate (Ro) except for the rare and lethal superspreaders.
Wow. Feels good to get that off my chest.
Rob T, your faux-relieved letter was hilarious! I will use it as a lovely role model for gentle sarcastic ripostes to panflu-scoffers.
From the theory of evolutionary biology, the speculations that DR. Alacabes have brought are relevant.
1.H2N5 to become H2H, the chance is as much as any virus mutates to become H2H, or even less. Therefore the weight of effort must be re-sketched proportional among the known past pandemics and future unknown ones. The future unknown ones are much higher than the past. This supports two points that presented by Dr. Alacabes.;
2.The learning from the past should be guided by the theory and move forward to achieve the wisdom of unlearning of the past mistake and relief from phobia-syndrome. The unlearning perhaps is more poised and resilient, therefore is valued to be fitting to the principle of leverage.
I agree that H2N5 should be placed under FAO coordination; at least the leadership role must be by FAO. WHO should stay as the public health stakeholder to interact with FAO for managing food production manner? I have posted several times on this blog. And I would like to stress this point again.
I noted that Revere and Dr. Alacabes somehow have pointed the similar concern as stated by Edmund, especially in the fundamental public health system, in terms of the sound facility and ongoing medical personnel training in facing the flu viruses-relating epidemics.
One point that I disagree with Dr. Alacabes is the reliance of antibiotics; it shall not be stressed in the public education. IMO, it should stress on healthy personal lifestyle in food eating, exercises and immunity empowerment.
"What about the hundreds of meetings and conferences we have attended and participated in, the tens of thousands of emails and letters and blog entries and newspaper comments and phone calls we've all made?"
This is the best example of "hilarious, narcissistic, and naive statement of gratification". It combines ignorance and stupidity.
Gee, Paiwan, and I thought I had appropriately "humbled" our effort by immediately adding, "It is true that none of us has "touched off" serious discussion to nearly the extent that we wish" after the excerpt you quoted.
And by referring to the drops -- represented by our efforts -- in the "large bucket".
I'm not trying to say "We've DONE IT! Hooray US!" The job is only just begun, despite all the effort since early 2004.
I'm sorry if I sounded triumphalist. I am among the humblest among us about what we've been able to accomplish so far, but nowhere close to giving up.
And for the record, I'd like to change "hundreds of meetings and conferences" to "most likely thousands of meetings and conferences." But it is still a drop in the large bucket.
Path Forward, perhaps you agree that science is unlike politics and not judged by majority, neither by frequency. Creationists have repeated creationism for a millennium and for a million times, but they have not proven something scientifically correct.
To me, Dr. Alcabes after being notified by Revereâs rebuttal, he had came to comment here and said, âRevere correctly points out that developing and supporting sound public health programs and strong social services is fundamental to the planning endeavor. I completely agree.â , was a good example of humility. Revere after that responded with addendum and appreciated somehow was a kind of humility.
We were going to have graceful and open discussion; with your quote then the tone completely destroyed the best chance of learning for us. So, Dr. Alcabes could not come again, it is your fault. : -)
When Beethovenâs music just composed, in his time it was commented a low class music and was not accepted.
If one day Alcabesâ speculations are proven more correct, then it would be embarrassing to find the record of being commented narcissistic.
To respond to your comment, I was somehow stupid and over-reacted. Apologize.