Philip Alcabes discusses myths of health, disease and risk.

Council of Advisors’ Flu Report: Does the Narrative Precede the Facts?

Reading this week’s report by the President’s Council of Advisors on Science and Technology (PCAST) on swine flu preparations…

The PCAST’s 2009-H1N1 Working Group has some illustrious names, and some great scientists.  So did the Advisory Committee on Immunization Practices which met in early March 1976, resolving to recommend mass immunization against swine flu.  And the parallels don’t end there.

This month’s PCAST report has some strengths.  One is its emphatic assertion that we are not looking at a reprise of the 1918 flu.  Another is its reminder that America must occupy a generous place in the world — offering advice or help to countries whose structures or resources don’t allow them to purchase vaccine or otherwise organize themselves for a bad flu outbreak.

But some of the report’s pieces just don’t quite connect up.

For one, the third chapter “Anticipating the Return of H1N1,” makes clear that the PCAST’s flu working group aimed to develop scenarios for a second wave of H1N1 cases in the U.S.   It set out to look at possibilities, not to make predictions.  “We emphasize again that the baseline scenario and the alternatives above are given as examples for planning purposes; they are not predictions of what will happen,” reads a caveat on p. 18.

Fair enough — but that begs two questions.

First, what’s the distinction between a scenario and a prediction?  Surely, when a Washington Post article is published within hours of the report’s release, with the lede that “Swine flu could infect half the U.S. population this fall and winter, hospitalizing up to 1.8 million people and causing as many as 90,000 deaths,” the PCAST is understood to have made a prediction — not just projected possibilities in an academic way.

Second, what predictions the PCAST makes!  By the day after the report was released CDC was expressing doubts about the estimate (sorry, “scenario”) of 90,000 deaths.  As VaccineEthics reports, CDC officials distanced themselves quickly — one telling Don McNeil, Jr. of the NY Times that “if the virus keeps behaving the way it is now, I don’t think anyone here [at CDC] expects anything like 90,000 deaths.”  And the estimate of 50% of Americans being infected by H1N1 would require much greater infectivity than we’ve seen so far.

The report doesn’t address the caution about the timing of H1N1 “waves” offered by Morens and Taubenberger in their recent JAMA article “Understanding Influenza Backward” (JAMA.2009; 302: 679-680) — PCAST’s scenarios simply assume that H1N1 will be back in the fall.  With WHO now explicit about a “second wave,” there will be even less impetus to (as Morens and Taubenberger suggest), look back.

The PCAST report also features a disconnect between the infectivity estimate and the mortality estimate.

It’s hard to explain how, if flu transmissibility really were to become high enough that a third to a half of all Americans were infected with H1N1 flu, virulence would remain so low that only 0.03% of the population would die of it.  If PCAST’s scenario of 150 million infections came to pass, then surely PCAST would want to caution authorities to watch for the development of high-virulence viral variants, either arising spontaneously within the genome of the current strain or through recombination with other circulating human or animal flu viruses.

Why bother to get people worked up over a horror scenario of 150 million infections if you aren’t going to remind flu watchers that your darkly viewed future  would allow for even further horrors in the form of new strains?

Narrative seems relevant here.  The PCAST report, its weak disclaimers about scenarios-not-predictions aside, sometimes seems to aim at crafting the leading narrative more than at practical planning.

The narrative, as told by PCAST, involves inevitable return of swine flu, America unprepared, special needs that can only be met by vaccine manufacturers and pharmaceutical companies, and vulnerable groups who need special administrative attention.

Here, too, the PCAST report is reminiscent of the 1976 swine flu episode.  The main effect of the meetings held by officials in the Department of Health, Education, and Welfare (the predecessor of today’s Health and Human Services) in March of ‘76 was to create a narrative of inevitable return of a dreadful flu strain, America unprepared, and special needs that can only be met by immediate production of vaccine.

One lesson we learned from 1976 was the danger of allowing the narrative to precede the facts.

By Philip Alcabes | August 29th, 2009 | Categories: Disease, Health Professions, Narratives, News, Outbreaks, Uncategorized, epidemics, public health | Tags: , , , , , | Comments Off

Mass Flu Immunization: What’s the Bail-out Point?

The President’s Council of Advisors on Science and Technology has released its report on H1N1 flu.  We’ll have something to say soon about the report’s specific “scenarios,” its sometimes-mystifying use of language to communicate them, its several strong points, and the problems both epidemiological and ethical that are likely to arise when it is (if it is) put into practice.

A concern at first glance is whether this panel of estimable scientists is repeating an error of commission made by an earlier panel of also-estimable scientists — in 1976.

As DemFromCT points out at DailyKos today, “timing is everything” when it comes to response to this flu outbreak.

Along this line the PCAST report is clear:  Having made the point that a return of swine flu this fall could infect a great many Americans, PCAST suggests that the federal government might decide to accelerate production of H1N1 vaccine.

The idea, generated by the PCAST’s 2009-H1N1 Flu Working Group, is that an early resurgence of flu would encounter an essentially unimmunized population — based on current expectations about availability of H1N1 vaccine.  On p. 18, the report states that

“if an increase in severity is detected with the expected rate of transmission, broader administration of vaccine before complete clinical trial data are available may be appropriate…”

But here we note a disturbing replication of a disturbing history.  The Advisory Committee on Immunization Practices, meeting on 10 March 1976, voted to recommend rapid preparation of swine flu vaccine and mass immunization of the American public in response to findings of H1N1 flu at Fort Dix, NJ.

At the March ‘76 meeting, Russell Alexander of the U. of Washington School of Public Health asked how, if there were to be a mass immunization program, federal officials would know when to abandon it.  What was the bail-out point to be?  Would the committee specify a level of adverse vaccine events beyond which mass immunization would be suspended?  Would it specify an incidence of H1N1 cases, or deaths, below which vaccine would be stockpiled but not administered?

The answer to Alexander was No.  The directors of the CDC and other federal agencies did not want to be caught stockpiling usable vaccine if people were getting sick and dying of flu.

As it happened, Alexander’s suggestion might have saved a few lives, a lot of money, and a few officials’ jobs.  By the time the 1976 immunizations began, it was known that there had been very limited spread of the swine flu strain beyond Fort Dix.  Watchful waiting might have forestalled the 1976 fiasco.

If flu vaccine is again to be rushed into production and disseminated early, how should officials know when to put the program on hold — or to bail out entirely?

By Philip Alcabes | August 25th, 2009 | Categories: Disease, Health Professions, News, Outbreaks, Physicians, Uncategorized, epidemics, public health | Tags: , , , , | 1 comment

How to Think About Vaccination

Over at H5N1, Crof picked up a story from XinHua reporting the concerns of Canadian medical ethicist Arthur Schafer about swine flu immunization.  “There are serious public health issues and issues of ethics as to whether we should be distributing (vaccines) massively to healthy people… when there are really big question marks about their effectiveness and their safety,” Schafer said.

Schafer is arguing for a precautionary-principle approach:  why would you take the chance of exposing a lot of people to a vaccine too new to allow its long-term effects to be known perfectly?  Especially, we might add, when the flu outbreak you are confronting is very mild, thus far?

Not everyone finds this satisfying, though.  In fact, some people feel there’s a duty to protect the public against the eventuality of widespread virulent flu. (Two facts should trouble this argument:  the historical fact that such a flu outbreak has happened exactly once in history, and the ancillary fact that, even in 1918, before flu immunization existed, the outbreak spared over 99% of the American public. But they don’t.  We’ll ignore them for now, just as most people do.).

Of course, if you really think there’s a duty to protect then you make immunization mandatory.  There’s precedent, and it’s been upheld by the nation’s highest court of law — in Jacobson v. Massachusetts (1905).  Justice Harlan, writing for the majority, held that the state of Massachusetts was within its rights to require Henning Jacobson to undergo smallpox vaccination when an outbreak threatened the city of Cambridge, and to fine him $5 for his refusal to be immunized.

The Jacobson case is taught in schools of public health as a prime assertion of the police power, i.e., the right of states to make laws to protect the public’s health.  And to validate the reach of such laws, even to mild intrusions on individual liberty. Harlan writes that “the liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint.”

But the nuances of Justice Harlan’s decision are instructive.  He made the point that the state’s legislature deemed smallpox vaccination to be effective and of minimal harm, and allowed the city to require vaccination only when a properly constituted board of health determined that that was necessary for public health.  In other words, the police power allows a state to limit liberty in the name of public health, but not for just any excuse, by any means, or without considering consequences.

And, we note, Harlan’s decision hinged on the legislative power.  That is, mandatory vaccination wasn’t  okay just because a board of health had said so; it was okay because the legislature had passed a law allowing the board to make such a decision, and the law was reasonable and sound.

Harlan’s basic standard was the “necessity of the case.”   Cambridge could make Mr. Jacobson undergo vaccination because the state law gave the board of health the power to decide when universal vaccination was necessary, in view of the situation.  And the board had looked at the situation, and decided that vaccination was indeed necessary

What should we make of that today?  In view of the current swine flu situation, should we then stand with Schafer, and argue that the most basic of the tenets — necessity — on which the police power is predicated has not yet been met?

Or should we say that the potential for a severe flu outbreak — a possibility not yet realized but, well, possible — creates a necessity to vaccinate?

Or is Jacobson simply out of date?

By Philip Alcabes | August 20th, 2009 | Categories: Disease, Health Professions, Physicians, Uncategorized, epidemics, public health | Tags: , , , , , , | 2 comments

Are NYC Officials Turning the Screws to Force Flu Vaccination?

At the end of July, according to Crain’s, NY State proposed that flu vaccination be made mandatory for health care workers.

Alex Jones reports that the proposal was ratified early this month, over the objection of the NY State Nurses’ Association.

Word on the street is that NYC’s Department of Health and Mental Hygiene is now getting into mandatory vaccination in a big way.  It is strong-arming medical centers into forcing their staff to undergo flu vaccination, telling administrators, we hear, that they would be required to fire employees who refuse to undergo flu immunization.   And the mandate would extend beyond direct-care personnel, to include general staff — anyone who might come into contact with a patient.

Since specific vaccine against H1N1 flu is not yet ready, the current plans are said to be for mandatory vaccination against seasonal flu; presumably swine flu vaccine would be added if it becomes available.

No official substantiation yet of the NYC officials’ actions — in fact, we really hope we’re wrong on this.  But we notice that requiring universal vaccination for health care workers would not be out of line with the city’s Pandemic Influenza Preparedness and Response Plan — especially chapter 7, “Vaccine Management.”

Clearly, a plan to require immunization of all health care workers — in a city whose health care workforce numbers in the hundreds of thousands — could be a boon to the vaccine makers.

Would it help the public?   If this coming flu season is mild, universal immunization of medical-center staff will be at least partly superfluous.

If there’s a widespread outbreak of virulent flu, the effectiveness of mandatory vaccination in health care centers would depend on the current level of flu-immunization coverage among med-center staff.   As many caregivers routinely undergo seasonal-flu immunization anyway, it isn’t clear that mandatory immunization orders would add any public health value to the current situation.

So far, there hasn’t been much outcry from the public health profession. Perhaps that will change as we get into autumn.

By Philip Alcabes | August 18th, 2009 | Categories: Disease, Health Professions, News, Physicians, Uncategorized, public health | Tags: , , , , , | 2 comments

Medicine and Magic

In his post at The Atlantic yesterday, Abraham Verghese made the case that magical thinking is a powerful driver of debates over health and health care.

“We all want to believe that a pill or potion that comes from sea coral or from the Amazon jungle will cure that pain for which little else has worked,” Verghese writes.  The “flip side,” he says, “is that we are extraordinarily sensitive to any suggestion that someone is taking away something we think is good for our health.”

And magical thinking’s influence isn’t limited to cruising the natural supplements aisle or reading the ads in a health magazine.  Sometimes it’s part of expert opinion — and so it becomes part of widespread belief.

Consider how the flu experts talk about the possibility of swine flu’s return this fall. In Monday’s Washington Post, the experts’ words wax electric.  Dr. William Schaffner, chair of Preventive Medicine at Vanderbilt U.’s medical school, asserts that “The virus is still around and ready to explode…. We’re potentially looking at a very big mess.” And Dr. Arnold Monto, a physician epidemiologist at U. Michigan’s School of Public Health, worries “about our ability to handle a surge of severe cases.”

So, even as H5N1 reports that an article in The Independent finds scientists skeptical as to whether there will be a so-called second wave of serious flu outbreaks in the northern hemisphere this fall, we’ve got American scientists suggesting — in high-voltage terms — that something awful is going to happen.

They’re not wrong: something bad might happen.  That’s always true.

But language matters.  And language coming from so-called experts matters a lot.  It has magic.

Vigorous metaphors promote popular fears.  The last time swine flu came around, in early 1976, respected virologist Edwin Kilbourne published an influential op-ed piece in the NY Times (13 Feb 1976), called “Flu to the Starboard! Man the Harpoons! Fill with Vaccine! Get the Captain! Hurry!” Kilbourne urged officials to prepare for an “imminent natural disaster.” Fair enough:  a serious H1N1 flu might have happened in ‘76 (it didn’t) — but his whaling metaphor appealed to more than just preparation.  It was about power and authority (”get the captain!”).  Presumably, the authority of science, industry, and government.

And so with other metaphors that are meant to be calls to arms.  There were the warfare metaphors about the alleged threat of bioterrorism, and the plague metaphors about AIDS.  Now, there are explosive metaphors about obesity.

Last year, acting U.S. Surgeon General Dr. Steven Galson called childhood obesity a “national catastrophe,” for instance.  And Dr. Risa Lavizzo-Mourey, president of the Robert Wood Johnson Foundation, warned of obesity’s “corrosive” effects, which, she asserted, imperil a generation of America’s youth.  According to Dr. Matthew Gillman of Harvard “You build [obesity] up over generations” — like an electrical charge in a capacitor, like explosive potential, the reader has to presume.

Talking about childhood obesity, Dr. Eric Hoffman of Stanford told the Washington Post that “we have taught our children how to kill themselves.”

Invoking metaphors to create magical thinking isn’t just an American habit.  Childhood obesity is a “time bomb,” according to physician Howard Stoate, chair of Britain’s All-Parliamentary Group on Primary Care and Public Health.

Verghese’s right.  People can be afraid to let go of what they believe they need for their health — however magically.  And magical thinking is inside the way our experts talk to us about health.  That sort of magic can run deep.

By Philip Alcabes | August 13th, 2009 | Categories: Disease, Health Professions, Myths, Narratives, Physicians, Uncategorized, obesity, public health | Tags: , , , , , , , , , , | Comments Off

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