Something to fear from fear of fear [updated]

by revere, cross-posted from Effect Measure

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":

1. 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.

2. 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.
3. 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.
4. 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.
5. 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.  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, I've posted on my website a longer essay on the problem.  Go to www.philipalcabes.com and click on the "News" tab.

Free and open discourse is a good thing. Much appreciated.