Philip Alcabes discusses myths of health, disease and risk.

CDC, Measles, and Propaganda

This week, the Centers for Disease Control and Prevention invokes measles  to make you feel guilty and frightened.

The agency announced on Thursday that there have been 175 measles cases in the U.S. in 2013, whereas only about 60 are seen in a typical year lately. Measles, the CDC press release says, “still threatens health security.”

Are they joking?, you might wonder. At a time when nearly 50 million Americans can’t get medical care because they don’t have insurance, and about 30 million will continue to lack health insurance even if the Affordable Care Act is fully implemented — at this point in American history, do the wonks at CDC really expect Americans to believe that an extra 100-odd measles cases represents a threat to the nation’s health?

No, they are not joking. CDC Director Frieden says:

“A measles outbreak anywhere is a risk everywhere.”

That sentence doesn’t exactly parse in standard English, but we get the point: be on guard, be on edge.

“With patterns of global travel and trade,”

Frieden continues,

“disease can spread nearly anywhere within 24 hours.”

This is not true, but truth isn’t at issue. Frieden is settling comfortably into his role as Minister of Propaganda for the unending War Against Risk, that existential danger to our well-being in which we are all supposed to be foot soldiers.

The media have responded as per their wont.  Measles is still a threat, there’s a spike in cases,  it’s about lack of vaccination, and so forth.

Here, the real story is that there’s no grave threat. There were over 100 measles cases in the U.S. in 2008 and over 200 in 2011. So it’s not at all clear that this year’s toll is out of the ordinary. And, of the 175 cases in 2013, most were acquired abroad. Measles transmission in the U.S. occurred in outbreaks among people who weren’t vaccinated for religious reasons, including 57 people in a Hasidic neighborhood in Brooklyn who were infected by a traveler who acquired measles virus in England, and 22 in North Carolina infected by a traveler returning from India.

That these outbreaks occurred among people who were not vaccinated reveals little about vaccination campaigns in the U.S. — religious exemptions have long been recognized for people who do not want their children to undergo immunization. And they have not been severe: a pregnant woman infected with measles in the Brooklyn outbreak miscarried, but there is no way to know whether measles was the cause. One adult was hospitalized with respiratory complications in the North Carolina outbreak.

It’s probably a good idea to be immunized against measles. Measles rarely causes severe illness, but not never. And there is plenty of measles in the world, although it is extremely rare in the U.S.  Immunization is like washing your kitchen counter tops.

But there’s no reason to sign up for Dr. Frieden’s army. Measles doesn’t threaten our health security (when it comes to threats to Americans’ health security, nothing comes close to Congressional Republicans!). We do not need to report our neighbors to the authorities if they aren’t getting their kids immunized. And we really don’t need any more inspections at airports. Our way of life is not under siege.

Civility

Yesterday there was a carjacking at gunpoint across the street from my house. By all accounts (I wasn’t home at the time), a livery-cab driver, parked at the curb, was eating his supper when a man rode up on a bike, pointed a gun, forced the driver out of his car, and drove the car away.

This took place at about 6pm, in the Bronx. Which is to say, it took place in daylight on a residential street in a neighborhood where it’s usually unnecessary to look one’s door and where the biggest street-scene commotion is normally the recycling pickup performed by noisy sanitation trucks on Saturday mornings.

I’m grateful that few people in my neighborhood have guns. Nobody was hurt in this incident, frightening as it was. And, after all, the only thing the thief took was a car. If passers-by had been armed, or one of the neighbors, someone might have tried to stop the carjacker by opening fire, and then, most likely, there would have been mayhem and wounds, or worse.

I say this as a counterweight to the dismal response of most Americans to the mass shooting at the Navy Yard in D.C. on Monday the 16th. After 13 deaths, the obsession with the details of the shooter’s religious beliefs, psychiatric record, and security clearance seems bizarre and macabre.

The insistence by the main news media on covering firearm incidents as if there were somehow two sides to the story, as if it were a question of rights or ethics, is a betrayal of the public responsibility of journalists. And this betrayal includes, especially, the supposedly liberal New York Times, and Washington Post, and NPR, and so forth. And the willingness of the media to run with stories about psychology and brain scans and heroic school teachers and the virtuous souls of those who “sadly” (inconveniently, they mean) died after being shot is a camouflage for their cowardice, and their moral weakness.

Today’s Brian Lehrer show on WNYC featured Paul Barrett, the author of a book about guns in America, saying that some Americans simply like guns and the rest of us ought to be practical and learn to accept that.

Allow me to be clear, then. I do not accept that Americans should have guns. Gun ownership is a crude and barbarian residue of a less civilized time, and should simply stop. Gun owners may, as Mr. Barrett alleges, like their guns, and this affection for potentially deadly objects may arise for all sorts of interesting reasons (or in some cases it might be, as I sometimes suspect, for reasons of sexual perversion, which is really not very interesting and could surely be sublimated onto, say, weed whackers or egg beaters or fancy dildos). But liking deadly weapons is no reason that society must allow them. Not even if a majority of people like them.  It may be democratic to learn to live in a society where people shoot other people, but it isn’t civil.

Barrett says that gun owners will be offended if we gun-averse people don’t understand their affection for their weapons. Fair enough. They are welcome to be offended. I don’t share this affection. I find it medieval, and bizarre, and, in a society with so much horror-engendering killing, I find the tolerance for the market in guns to be simply immoral.

Gun owners distract the conversation away from civility, turn it into a muddled discourse on rights. But there is no question of rights when it comes to guns, only a question of the wording of the second amendment, which is not at all the same thing as a right in the natural-rights sense, or in the human-rights sense.  We should not be drawn into discussions of gun rights. We should discuss murder, we should discuss 30,000-odd deaths each year, we should discuss the acceptance of guns in America as a thinly disguised mechanism for our society to allow the intimidating and utlimately thinning of the population of black males. But we should not pretend this is about rights.

In a civil society, people do not own guns (except if they are going to hunt for food, which really doesn’t apply to most of us). Citizens of civil societies don’t shoot one another. Once the guns disappear,  all sorts of supposedly thorny issues, like security clearances and mental-health records, will be revealed for the trivial conversations they are.

The carjacking outside my house worries me, the more so as the thief was armed. I’ve locked my door, and am going to be more watchful, I suppose. But I remain glad that there weren’t more guns involved, and wish there had been none.

 

Influenza, Epidemics, and Science

Back in March, thinking about the controversy over Gain of Function (GOF) research on influenza viruses, I suggested that the debate isn’t really about science, nor

about morals, no matter what some self-important researchers claim.   The debate is about who will be able to control scientific research and who will benefit from the consequences (including, presumably, vaccines or other marketable preventive agents).  Don’t be misled by assertions that the debate over GOF research is about public health, or ethics.  It’s about the usual:  political power and profit making.

Now that a new flu virus, H7N9, has caused over 130 human flu cases in the far east, with 37 deaths (per WHO’s summary of 29 May 2013), the questions on GOF studies might seem to take on new significance.

The insightful Guenther Stertenbrink brought me up on my assertions about GOF research, saying

I don’t see that connection and motivation, how they  (signatories) might benefit from flu-research reduction politically or financially,  the ”marketable agents”…  And don’t you think this should be discussed by hearing both sides,  giving them the opportunity to reply, with links etc. to support the claims  ? Have you contacted them ?
I’m trying to estimate the pandemic risks and I’m in the process of contacting them to see the letter to the ethics commission, how the signatories and 200 nonflu researchers were selected and approached, what their expertise is to judge and weigh and assess and quantify flu-specific benefits and risks.

Stertenbrink is working assiduously to assess both real pandemic risks and the scientific issues involved in the GOF research debate.  He is hosting a useful colloquy  and has also posted a timeline of commentary and findings.

But I’m sticking to my guns.  Guenther is perfectly correct when he intimates that many of the complainants who ask that GOF flu research be controlled or curtailed have nothing financial to gain.  But it’s not true that they have nothing at all to gain.  In science, and especially in science that bears on public health, controlling the narrative is of nonpareil importance.

The only reason why external commissions should be convened to assess the possible dangers of success of GOF  experiments is to make sure that the “right” people get to control the narrative.  Because, really, to claim that the actual danger to humans arising from transfering genes in flu virions is knowable and predictable is to misrepresent the deep uncertainty in assessing risk. 

There are three consequences of indulging in this misapprehended risk assessment.

First, it creates a false voice of authority.  ”We know that bad things are likely to happen with probability X if experiment Y succeeds” implies that “we” (the experts?) have knowledge beyond what is actually available.  People who have claimed to have exceptional knowledge have done some very, very bad things to the world.  All claims of extraordinary knowledge of the future are to be rejected, on moral grounds, in a civil society.

Second, the claim to be able to assess the risks of successful experiments works against the inspired tinkering of science.  If our civilization want to have science — and I think it should — we are going to have to live with some unwanted disasters, and with some people (scientists, I mean) doing unseemly things.  We may reasonably regulate what they do, in order to prevent animals from being tortured or people killed for the sake of science.  But we can’t expect that science will always be “well behaved,” in the sense of a well-behaved mathematical function.

Third, claims that GOF experiments are unethical are really assertions that some other kind of science is ethical.  Some other science, in other words, is closer to an imaginary Platonic sort of correctness.  Science, as Paul Feyerabend argued, is anarchic.  Properly so.  But that means there are no hard-and-fast rules of Truth.

As a result, Truth in science is usually the thing that the most vocal and powerful people agree on. If certain kinds of science (GOF research, in this case) are declared off limits because the powerful people, such as those who are doing other kinds of research and think GOF research should stop, deem it to be “unethical,” then it is a sure thing that the truths of the powerful will be the only Truth.  But why shouldn’t everybody  have their chance at Truth?

I stand by my assertion.  The debates over GOF research, just like debates over “ownership” of the MERS coronavirus sequence or the carefully constructed fear  over whether the world is  sufficiently frightened about MERS, aren’t about science, or public health, or ethics.  They are about who controls the narrative.

 

Further Feuding on Flu

My stand on prohibiting flu-virus research hasn’t changed: as I told the NY Times last year, even if flu experimentation is overseen by a group of so-called experts, it’s just not clear who should keep an eye on the experts.

And the question about minding the experts just got more complicated.

The issue has been whether researchers should be allowed to conduct experiments with modified strains of H5N1 (avian) influenza virus, in order to find out more about the potential for bird flu to spread among humans.  Concerned about possible dangers of experimenting with extra-transmissible bird ful, a moratorium on such research was declared.  The moratorium ended in late January of this year.

But now some distinguished scientists are calling for fuller constraints on this kind of research — called gain-of-function (GOF) experimentation, because it involves creating novel strains of viruses with capabilities not known to occur in nature.  The ostensible purpose of such research is to figure out how to prevent harm associated with inevitable genetic changes in viruses.  Think of it as creating disaster scenarios at the molecular level, so as to determine how to avert damage if the disaster comes to pass.

CIDRAP gives a nice summary of the new controversy, reporting that the Foundation for Vaccine Research, an advocacy group, has written to Dr. Amy Guttman, chair of the Presidential Commission for the Study of Bioethical Issues, raising what the Foundation says are “moral and ethical” concerns about GOF research.

An editorial by Simon Wain-Hobson in Nature the other day advances reasons why scientists should get together to limit GOF research.  Wain-Hobson questions the scientific validity of the predictions such research makes (since natural selection in the real world might produce changes in viruses quite unlike those manufactured in the lab), and criticizes WHO for failing to generate a broad discussion on the dangers of GOF research.

Then, he asks what will happen if the viruses created in GOF research leak out of a lab.  Who will take responsibility, who should make decisions, who should own the information arising from the research?  He says,

The global ramifications of GOF research have simply not been sufficiently explored and discussed. Influenza virologists are going down a blind alley and the powers that be are blindly letting them go down that alley, which is tantamount to acquiescing. So let’s be clear: the end game could be viruses more dangerous than the Spanish flu strain.

And Wain-Hobson goes on to propose a suspension of all GOF research until

virologists open up and engage in public discussion of their work and the issues it raises. Given that the flu community failed utterly to use the year-long hiatus to good effect, it is clear that an independent risk–benefit assessment of GOF work is needed.

Here is where it gets complicated.  One group of scientists (Wain-Hobson and the FVR) is angry with another group (the so-called flu community, basically those influenza researchers who conducted the 2011 H5N1 experiments and their defenders).

At the same time, both groups are unwilling to have government regulate research. In fact, Wain-Hobson worries because

Officials in Washington DC are putting the finishing touches to new guidelines for the review, regulation and oversight of this kind of research. The chill winds that we can anticipate blowing from policy-makers as a result could affect all of us who research viruses and their pathology.

The terms of the debate aren’t scientific, that is.  And they surely aren’t about morals, no matter what some self-important researchers claim.   The debate is about who will be able to control scientific research and who will benefit from the consequences (including, presumably, vaccines or other marketable preventive agents).  

Don’t be misled by assertions that the debate over GOF research is about public health, or ethics.  It’s about the usual:  political power and profit making.

Against Universal Flu Immunization

In a strong piece at CNN online yesterday, Jen Christensen points out that no European countries expect the entire population to be immunized against flu — unlike the US, where everyone over the age of 6 months is urged to get flu vaccine every year.

Why does CDC recommend (based on advice by the Advisory Committee on Immunization Practices in 2010) that all Americans — from infancy on up — get immunized against flu?

A few possibilities:

1.  Public health benefit?

No.  Over the past twenty years, flu-vaccine coverage — the proportion of the population that is immunized — has been going up progressively.  But flu hospitalization and mortality rates have been basically constant.  If mass immunization had any public health value, those rates should go down as coverage goes up

(A technical note: this means that coverage remains below the threshold needed to reduce influenza transmission population-wide, i.e., it isn’t high enough for herd immunity.  But that’s the point.  In order to be of public health benefit, flu vaccine would have to be accepted by almost everybody, every year.  And even that might not be enough:  For a nice explanation of why the efficacy of flu vaccine is limited, see Vincent Racaniello’s blog post.)

2.  Exceptional efficacy of the vaccine?

No.  Based on an observational study of acute respiratory illness patients published this month, the effectiveness of this year’s flu vaccine is 55% against illness caused by influenza type A (which accounts for about 80% of flu cases).  Effectiveness is 70% against type B.  Overall, the chances of being protected against symptomatic flu are less than two out of three.

Jefferson and colleagues found that the overall efficacy of  flu vaccines at reducing influenza A or B infection in children aged 2-16 is only about 65%, and that inactivated vaccines (i.e., the usual injection) had little impact on serious illness or hospitalization from flu-like conditions in this age group.

As with this month’s observational study, Jefferson et al.’s meta-analysis of multiple studies on flu immunization found that the inactivated vaccine had about 73% efficacy at preventing infection in healthy adults — but that efficacy can be as low as about 50% in years when the vaccine isn’t well-matched to the season’s circulating viruses.

Importantly, the Jefferson studies found that effectiveness of immunization — the prevention of serious illness or hospitalization from influenza-like illness — is very low.

There’s no sound public health rationale for encouraging everyone to be immunized against flu every year.

People who are likely to develop serious complications if they are infected can benefit from immunization.  But for most of us, immunization only reduces (by two-thirds) the already rather small chance of infection with influenza.  And it doesn’t protect us much from serious respiratory illness during flu season.

I commented in 2011 on public officials striving to help pharmaceutical companies profit from flu fears. And that’s what we’re seeing again this season — with exaggerated warnings and declarations of flu emergencies. Even though the latest national summary from CDC shows that less than 30% of all influenza-like illness is actually caused by flu this season — and that’s likely an overestimate, since it’s based on testing of more severe cases of acute respiratory illness.  And the surveillance data suggest that the season’s flu outbreak might already be past its peak.

Get immunized against flu if you’re worried.  But keep in mind that vaccination against flu is not going to help the public’s health, and it isn’t highly likely to help yours — it’s primarily your contribution to the profits of Sanofi-Pasteur, Novartis, GSK, or Merck.