On Car Insurance and Public Health Programs: The Swine Flu Edition

Back when I owned a car*, car insurance payments were always depressing. In the best case scenario, I'm paying money for no purpose; in the worst case, I've been in a collision. Public health is a lot like car insurance, in that it's really important when something bad happens, but when something bad doesn't happen--either because it didn't happen due to dumb luck, or because other public health measures prevented the problem--public health appears to be wasteful spending. Once the waste charge get bandied about, some people won't be content with that--they have to start indulging in conspiracy mongering.

Which tragically is happening with the swine flu vaccine. Declan Butler reports:

"Drug firms 'encouraged world health body to exaggerate swine flu threat'," screamed Britain's Daily Mail newspaper on 4 June. "2 European reports criticize WHO's H1N1 pandemic guidelines as tainted," headlined The Washington Post the next day. To judge from media coverage last week, a major scandal had been exposed in the handling of the H1N1 flu pandemic by the World Health Organization (WHO). But nothing could be further from the truth.

The news articles reported on two investigations: one by journalists at the BMJ and the Bureau of Investigative Journalism, a non-profit body in London launched in April; the other by the health committee of the Parliamentary Assembly of the Council of Europe (PACE) -- a human-rights body based in Strasbourg, France, independent of the European Union.

Both reports allege that the WHO might have been unduly influenced by the pharmaceutical industry in declaring H1N1 flu a pandemic, and in backing widespread vaccination and stockpiling of antiviral drugs, a claim often made by conspiracy theorists. They also complain that a 2004 WHO pandemic-preparedness document did not reveal that some of its authors had been paid for work by pharmaceutical companies -- although the scientists had declared their competing interests elsewhere.

There's a pretty fundamental problem with this argument--even if the scientists were compromised, it is impossible for them to have influenced the decision to declare a pandemic and influence pandemic responses (italics mine):

"A key question will be whether the pharmaceutical companies, which had invested around $4 bn (£2.8bn, â¬3.3bn) in developing the swine flu vaccine, had supporters inside the emergency committee, who then put pressure on WHO to declare a pandemic," says the article in the BMJ (D. Cohen and P. Carter Br. Med. J. 340, c2912; 2010). "It was the declaring of the pandemic that triggered the contracts."

This is false. Many countries -- including the United Kingdom, France, Belgium, Finland, Canada, the Netherlands and Switzerland -- had already placed large orders for H1N1 vaccine weeks before the WHO declared H1N1 a pandemic on 11 June 2009. The United States, for example, ordered US$649 million of pandemic H1N1 influenza vaccine antigen and $283 million of adjuvant on 22 May 2009. So the Emergency Committee could not have influenced these in any way.

"You are absolutely right," conceded the authors of the articles in the BMJ when challenged with this timeline.

Both reports also seize on the WHO's April 2009 revision of its criteria on what constitutes a pandemic, which removed the need for an assessment of the 'severity' of the disease, based on estimates of future mortality. Flynn speculated in the Daily Mail that this was suspicious: "In this case, it might not just be a conspiracy theory, it might be a very profitable conspiracy." Neither report provides any evidence to substantiate its implication that the WHO rushed to declare a pandemic to boost pharmaceutical company sales. Moreover, the WHO says that the revisions were finalized in February 2009, before pandemic H1N1 was on the horizon.

As I mentioned at the beginning, public health suffers from the negative effect problem--you should always prepare for a reasonable bad-case scenario:

Marc Lipsitch, an epidemiologist at Harvard School of Public Health in Boston, Massachusetts, says that the WHO's advice on the pandemic has been sound, and has reflected the state of scientific opinion. Comparing the situation with the ongoing Deepwater Horizon oil spill, Lipsitch says that "it is ironic, as we watch for the second time in five years the catastrophic results of 'best-case scenario planning' in the Gulf of Mexico, to have the WHO coming under criticism for planning for, and raising awareness of, the possibility of a severe pandemic. That is what public-health agencies should do, and what most did in this instance, and they should be commended for it."

Lipsitch is absolutely right: this is what any responsible government agency should do. Shamefully, the BMJ embraced conspiracy theory crapola. But since it's in a (formerly) respectable, peer-reviewed scientific journal, it will now be used by batshit lunatic anti-vaxxers and contrarian assholes when they attempt to obstruct the appropriate responses to the next potential pandemic.

Fucking morons.

full disclosure: I've known Lipsitch for many years, and am currently collaborating with him. I am, therefore, a shill for Big Streptococcus. Or something.

*I live in Boston. Getting rid of my car was the equivalent, after you calculate taxes, a $9,000-$10,000 pay raise.