Henrietta Lacks died of cervical cancer in the “colored” ward at Johns Hopkins Hospital, in 1951.  From samples of her cervical tissue, the immortal cell line called HeLa was developed (by Dr. George Gey, at Hopkins).  Skloot’s story covers the family’s travails before and since, but also digs deep into the problem of race in the business of American medicine.  Her account challenges, or should move us to challenge, the smug certainties about our supposedly post-racial society, and the convenient formulae about “informed consent” and “access to care.” I guess I should say, The Immortal Life should make us ask just what “care” means in today’s system.

Henrietta Lacks and her family members were almost never taken seriously as humans with real problems.  First, they were poor and uneducated black people from tobacco country relocated to Baltimore; then, they were the bearers of the same genes as a woman (Henrietta) who had died of a remarkably aggressive, and therefore medically interesting, cancer; later, they were background and local color to the story of the origin of the thriving, and therefore scientifically interesting, HeLa cell line.

To Skloot’s credit, she’s taken to heart, and acted on, the problem:  she founded the Henrietta Lacks Foundation to help raise funds for education and medical expenses for Henrietta Lacks’s family.  Skloot’s blog, Culture Dish, carries updates about some of the achievements of the foundation and sometimes takes up issues germane to the book, especially regarding personal rights to genetic information (here, for instance).

It’s also impressive that Skloot interweaves in her narrative (and takes up more fully and explicitly in an Afterword) the vexing question of ownership of tissue samples.  She highlights how the expanding capacity to extract information from genetic sequencing ups the ante on the questions of privacy of tissue samples — since it’s now possible to ascertain potentially identifying information from genetic sequences even in a sample from which the usual verbal identifiers (name, address, and so forth) have been removed.  And she asks how the profits potentially available from exploitation of new discoveries should be shared.

The intersection of these problems with the matter of race makes The Immortal Life of Henrietta Lacks, like James Jones’s Bad Blood and Harriet Washington’s Medical Apartheid, a book that should be required reading for everyone involved in the health sector today.

What has changed?  How does the story of wrangling over the sodium content of American food merit space in the main news sections of the most influential media — even the front pages of the NY Times or LA Times?

1.  One answer is that health occupies much of the American conversation today.  A visitor from another planet watching our TV news shows or reading the main newspapers would have to be forgiven for thinking that Americans are dying from a multitude of irrepressible disease threats.  We can’t seem to stop talking about how to improve our health.

(In fact, as Michael Haines notes at the Economic History Association website, U.S. life expectancy almost doubled between 1850 and 1960, from 39.5 years to 70.7 years; since then it has increased slowly, and is now estimated to be about 78.2 years.  In other words, health wasn’t a matter of news much during the time when longevity was improving dramatically, in the late 19th century and first half of the 20th.  By the time health became a cultural preoccupation, the majority of Americans were living well past middle age.)

2.  Another answer, perhaps more important is that when we talk about health today we mean personal responsibility.

When I began studying epidemiology, in the late 1970s, public health essentially meant disease control.  Yes, lip service was paid to so-called health promotion — much was made of the World Health Organization’s definition of health, promulgated in 1946:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

But no metric for complete well-being was widely recognized.  And the usual epidemiologic measures of incidence and mortality rates, life expectancy, and so forth seemed to work just fine as ways of understanding why some groups of people lived longer and more capable lives, while others lived miserably and died young.

Sometime since then, the health sector, including public health, has turned to individual responsibility as the key to well-being.

If each of us is responsible for his or her own health, then it’s our own fault if we get sick.  Naturally, advice abounds:  buckle up, use a condom, eat less fat, know your cholesterol level, wash your hands, use mosquito repellent containing DEET, wear sunblock, eat fresh fruit and vegetables every day, lower your stress.

The advice adds up to this:  know your limits.  Federally sponsored research tells us that self-control is ontagious.

The personal-responsibility view of health says, “control your appetites.”

3.  But let’s think about another change:  more people are concerned about the American diet.  As noted last week, the food movement has given us ways to think about eating that go beyond the tiresome story of obesity and hypertension — Beyond Fat and Salt, you could say.

Of course, the main media outlets still tell the food story in Fat-and-Salt language, as the news articles in the NY Times, LA Times, and others show.  It’s the food industry vs. the foodies, or the food industry vs. public health, or the food industry and public health vs. appetites — anyway, somebody against somebody in the name of health.

The media aren’t quite past obesity and hypertension yet.  But as the culture moves beyond obsessive self-inspection in the name of health, no doubt media will, too.

Reviewing five books on what he calls the “food movements,” Pollan notes the widespread discontent with contemporary industrialized food production (I’ll call this “American eating,” although its dominance is increasing around the world).  And he suggests that its common theme is cultural discomfort. The food movement, Pollan argues, has “set out to foster new forms of civil society”:

It makes sense that food and farming should become a locus of attention for Americans disenchanted with consumer capitalism.  Food is the place in daily life where corporatization can be most vividly felt…  The corporatization of something as basic and intimate as eating is, for many of us today, a good place to draw the line.

This is a refreshing insight.  It’s thankfully broad, taking  the focus away from health, and therefore from the anti-obesity crusade and the “toxic food environment” view promoted by health advocates.

But Pollan’s perspective is especially refreshing because it renews the conversation about our private lives — particularly the extent to which we’ve ceded our innermost values to the demands of corporate profit and government policies.  And those demands, as Marion Nestle often points out (recently here), are generally linked.

Pollan reminds us that our innermost values are literally innermost:  they have to do with what goes into our stomachs.

I’ve already stated my argument that the anti-obesity crusade is really about control, not health (see here and here).   The crusaders do cite “public health” as a rationale for the war against obesity.  But when they describe what’s wrong, they do so in terms that are sometimes medical (diabetes, hypertension), sometimes technical (serving sizes, calorie counts, the infamous toxic food environment), and sometimes medieval (gluttony, laziness).  Their inability to articulate the source of the problem is a signal that they’re sure something is out of control but unsure exactly what.

The public health approach to obesity is a failure.  It doesn’t let us talk about what needs to be reformed.  And it’s often allied with efforts to make sure the poor stay poor — even though wealth inequality is surely part of the problem in the first place.  The public health industry’s demands for additional regressive taxation in the form of increased “fat” taxes on sugary beverages or high-calorie foods reveal its preference for the status quo.  Make the poor pay more for their soda and fast food; that will make them think twice about supporting industries that are making us fat.

Even well-meaning public health professionals who advocate government intervention against low-price-but-low-nutrition food  as a way of curtailing obesity ignore the central role of food and eating to liberty and happiness — they’re interested primarily in how many additional years of life (however unhappy) could be purchased by trading in the fries in favor of broccoli.  Or, worse, they’re interested only in the dollar costs to taxpayers — in terms of hypertension and heart disease — of tolerating obesity.

Pollan, today’s most thoughtful and insightful philosopher on the subject of food and eating, offers a more satisfying view.  Sure, you may want to change American eating because you think obesity is bad for people’s health.   But you might want to change eating simply because the food scene is distressing, because it crystallizes and exemplifies the many ways that we give over our private (innermost!) moral decisions to the influences of corporate/consumerist thinking.  You might want to change it because, as Pollan reminds us (in regard to a new book by Janet Flammang), the dominance of American statecraft by corporations allows the preparation of food to be relegated to the least valued, least powerful, and lowest paid workers.  You might want food to taste better — valuing pleasure over longevity.

With Pollan’s broad view, you  don’t have to join the anti-obesity crusade.  You don’t have to speak the technical language of risk.  The common language of freedom, desire, and pleasure will do.

But how can every day not be AIDS Day?  Over 5,000 people die of AIDS each day, worldwide — even now, in the era of effective therapy.  In south Asia alone, more people die of AIDS every two weeks than have died of the H1N1 swine flu worldwide in the past six months (about 8,000).  In Africa, AIDS takes that toll every two or three days.

AIDS is a big problem in far-away poor countries, in other words.  But unlike the usual poor-nation problems that are easily ignored in comfortable North America — malaria, sleeping sickness, dengue, diarrhea, and more — AIDS is still a problem here, too.   Surely, you might think, we ought not to need any reminders about AIDS.

Much has been said about AIDS, and much has been done.  What does World AIDS Day add?

A harder question, perhaps: why can’t AIDS just be an ordinary disease? Surely, you might think, it isn’t special anymore.

Here are some thoughts on the problem of ordinariness, published in the American Scholar a few years ago.  The occasion was the 25th anniversary of the announcement of the first U.S. cases of AIDS.

In dealing with the issue of a pandemic, if we stick to finding out how to block the infection completely, we may take extreme measures and, as a result, trigger a pandemic panic. Is there a way to avoid the pandemic without adding to people’s concern more than necessary? (full text of query here).

Since the question of balancing response with panic promotion is on many minds, this seems worth addressing.  But there’s the larger problem:  do we need even to ask this question?  Is there a crisis on hand with flu?

We think not.

“Marx claimed that great events of history occur twice, first as tragedy and then as farce,” we pointed out.

“The swine flu of 2009 certainly looks like a farcical replay of the great influenza outbreak of 1918…. [It's] not a funny farce…but death from contagion is a normal part of life in an unpredictable universe.”  A few thousand deaths in the course of six months is lamentable, certainly.  But it’s hardly out of the ordinary for flu.

The collusion of officials and big corporations has been allowed to construct a global crisis. The farce is that the imagined flu crisis will benefit exactly the people who constructed it.

The vaccine manufacturers can expect to see a great expansion of markets (don’t miss Brownlee and Lenzer on flu immunization in the Nov. ’09 Atlantic).

The antiviral-medication manufacturers, the makers of Tamiflu especially, are already bringing in plenty of money for a treatment that is useful in rare clinical situations but has never been shown to stop the spread of flu in large populations.

Officials benefit, too.  They claim they must roll out flu vaccine and provide frequent information updates in order to  “prevent panic.”  And then they’ll look like they’ve done a good job — since, there being no crisis, people are staying calm.

Read the full post here.

Joshua Holland’s post at AlterNet yesterday tries to explain why H1N1 swine flu shouldn’t be cause for hysteria.  He puts this outbreak in the context of flu history and the threat posed by other, more harmful, conditions — malaria for instance.  Holland plays a little bit fast and loose with the numbers:  it probably isn’t accurate to extrapolate, from the number of confirmed flu deaths so far, to get a total number of deaths that will be caused by the swine H1N1 strain this year — more efficient spread in the  cities of the Northern hemisphere in the coming few months is likely to produce fatalities at a higher rate than the more sporadic outbreaks here in April and May.  And he’s overly critical of the media — a point brought out by Revere in a response to Holland at Effect Measure today.

But, as Frank Furedi has been telling us (recently in Erasmus Law Review, for example), try to explain how people’s deep-seated anxieties drive perceptions that risk is extraordinary and unprecedented (and contribute to demands for more and better high-cost technology to deal with it) and you get some people riled up.  Disappointingly, even Effect Measure, whose assessments are consistently level-headed and cogent, slips here, flashing the moral-entrepreneur card at Mr. Holland:

Joshua Holland has never cared for a critically ill person with Acute Respiratory Distress Syndrome (ARDS), which is often the terminal event for flu patients. So I’ll tell him. It doesn’t matter if it’s caused by bacteria (many are). Half of them die no matter what you do and no matter what intensive care unit you have available to you or what antibiotic or what computer controlled respirator. We still can’t do much.

Nobody thinks it’s a good idea to let people get ARDS, and Holland acknowledges that flu is a problem that should be dealt with.  But that’s not always enough.  Question the intensity of perceived risk or the need for all the technology, and you find this out fast.

But Revere is back on track when noting that lots of problems — including malaria — are horrendous and deserve attention, and probably don’t get it because they happen to people far away.

Where would the impetus to deal with global problems besides flu come from?  A global organization that can keep things in perspective would be useful.  Poor W.H.O. isn’t positioned to do that.  Yesterday’s flu advisory from W.H.O. emphasizes the use of antivirals (oseltamivir and zanamivir) to treat people with severe or possibly severe flu:

Early treatment is especially important for patients who are at increased risk of developing complications, those who present with severe illness or those with worsening signs and symptoms.

Yet, the W.H.O. also warns against hastening the development of resistance.  This agency gets a lot of flak for not doing more and for panic-mongering when it does do more.  But, really, it’s only doing its job:  offer advice, and support interventions when invited.  It isn’t consistent, naturally.  It can’t make binding policy.  It faces a limitless and essentially insuperable legitimation problem.  In a way, W.H.O.’s hardest job is simply to maintain its own legitimacy.

Still, in a world poised to interpret signs of illness as evidence of risk and eager for technical fixes to alleviate the sense of vulnerability risk instills, the W.H.O.’s announcements can seem authoritative — and look like beckoning to the drug makers.  A Reuters story yesterday is entitled “Early Use of Antivirals Key in H1N1 Flu: WHO,” and highlights the value of the two antiviral medications more than the caution W.H.O. wants to instill.

Meanwhile, agencies that should be making real policy are focusing on immunization.  In today’s Washington Post, Rob Stein reports on health care workers’ resistance to mandatory flu vaccination.  New York State made flu immunization mandatory early on, not only for salaried health care workers but for anyone — including medical and nursing students — who might come in contact with patients, and is putting teeth into the requirement with sanctions for refuseniks.  The state resorts to high  moral rhetoric to justify its policy.  The state’s health commissioner told Stein that “the rationale begins with the health-care ethic, which is: The patient’s well-being comes ahead of the personal preferences of health-care workers.”

And at CDC, the director is cautioning that there might be a rough start-up to the swine flu immunization campaign, as the first doses of vaccine will be made available in early October.  According to the NY Times, there should be 40 million doses of vaccine available by mid-October.

We wonder whether immunization will be of any public health value at all, by the time there’s enough vaccine that it can be offered to anyone other than health care workers and a few of the people who really need protection (young people, infants’ caregivers, and pregnant women, especially — DemFromCT’s round-up at DailyKos is always worth reading).  Given the rapidity of spread of flu — in 37 U.S. states, H1N1 spread is already regional or widespread; flu is spreading locally in 12 more states, Puerto Rico, and Washington, D.C. — and based on the usual course of flu outbreaks, it seems possible that this outbreak will peak by mid November.  There’s no knowing if that will be so, obviously.  Even if it is, immunization would continue to be useful to prevent severe cases among people who are likely to get very sick if infected.

But mass immunization would no longer be of much use in preventing further incidence of infection on a population level if high levels of acquired immunity are reached across much of the population by the time vaccine is widely available.

That’s the problem with relying on mass immunization as the centerpiece of public health response: as in the old joke about comedy, timing is everything.  In 1976, there was too much immunization, too soon.  It might turn out that this year, there’s too little, too late.  The dynamics of vaccine availability and the dynamics of flu spread have to be watched in tandem, and policy updated accordingly.

In any case, with vaccine at the center, the rest of the story — the complex environmental interactions that allow flu genomes to recombine, the trade in animals and feed that allow viruses to move around, the problems of affordability and immune status and competing viral subtypes, the health care facilities to handle severe cases, and so on — gets shoved to the side.

“Deadly Choices” is heartbreaking.  It recounts a situation that was miserable, terrifying, and in some cases, fatal.  Fink reports that, among 45 Memorial Medical Center patients who died in the days during and immediately following the storm, 17 were deliberately administered lethal doses of morphine, sometimes along with a sedative, by physicians who apparently intended to hasten the patients’ deaths.  (Many of these 17 were patients at a hospital-within-the-hospital, a long-term care hospital under separate ownership that shared some staff with MMC.  At Slate today, Josh Levin discusses some of the troubling truths about the financing of long-term care hospitals, and Fink fills in some more of the blanks with a response at ProPublica.)

As Fink explained to Amy Goodman in an interview with Democracy Now earlier this week, at least one of the patients who were killed was not in extremis; he had not given up.  He was

“Ready to rock and roll, wanted to get out. And apparently, according to several people who later spoke with investigators, a discussion was had in which they talked about how they might get him out, and they decided that because he was so heavy and it was so hot and people had—I mean, just imagine….They had been going on no sleep for days, the medical workers. They were tired. They were terribly disturbed by all the suffering that they felt that they saw around them. And so, in this sort of moment, they apparently decided that [the patient] could not be brought down, could not be evacuated, that there was no way to get him out.”

The story of what happened at MMC is also profoundly disturbing.  It moves us to ask what sort of moral world physicians are expected, and allowed, to operate in.  And to wonder why moral boundaries should be so elusive to exactly the people who, with access to the means to both prolong life and hasten death, walk on morally fraught territory more often than anyone.

The horrifying events at MMC are especially  germane today — because they highlight a vexing question about health care reform that is very hard to answer:   Is our doctors’ job to alleviate suffering, or is it to improve health?

A favored guru on health care ethics, Ezekiel Emanuel, is explicitly in favor of the latter.  In “Justice and Managed Care” (subscription) in Hastings Center Report in 2000, he writes

“The allocation of health care resources should aim at and be justified by the improvement in people’s health…. The special aim or purpose of health care is curing disease, relieving pain and suffering, promoting public health, pursuing research to improve health, and so on.”

The “and so on” means that improving health — the obligation of a health care system, Emanuel asserts — amounts not just to the relief of pain and suffering but also to research and public health, and other tasks as well.  The relief of suffering might not be a priority, that is.  Or it might be a contingent priority, of importance for a limited time, or in certain circumstances — but not the only thing to worry about.

The point is not to vilify Emanuel.  He has opposed euthanasia and physician-assisted suicide, so we should assume that he was as appalled by the actions of the chief physicians at MMC as others were.

But the Emanuelian sensibility is that the system in which physicians work is not meant to be dedicated to the relief of suffering alone.  Rather, it bears other duties as well:  a broad obligation to the public to promote health, and another obligation to contribute (through research) to the future of health care.

In this narrative, the physician is marshal of a campaign — not merely joined in a series of caring relationships with each of a number of patients, but commander of troops who have a long-term goal and territory to win.   By implication, the rights of patients might take second seat to the needs of the public, or to the desire to learn more about how to improve health in the future.  Patients shouldn’t be killed, this thinking goes, but they will have to understand that the prolongation of life is a luxury commodity to which physicians have the keys — and not everyone can have access.

The sense of the physician as a responsible manager, not merely a giver of care, connects with the utilitarian credo, “the greatest good for the greatest number” — a phrase that occurs three times in Fink’s piece as she strives to characterize the sensibility of MMC providers.

But the killings at MMC should, at the very least, make us ask whether it’s a good idea to have doctors making decisions about the greater good — or whether we want them to recognize individual persons above all.

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.

“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.

Back in April, a fast-food establishment in Leytonstone, in the northeastern part of London, was shut down as a public-health threat.  As Patrick Hayes explains at Spiked, a 2009 initiative of the local council, called the Sustainable Community Strategy, outlaws the establishment of new carry-outs within 400 meters of a school.

Supporting the rhetoric, Professor Kathy Pritchard-Jones, president of the European Society for Paediatric Oncology, stated in February that “If we don’t … tackl[e] how much exercise our young people take and how concerned they are about what they eat and their weight, we are going to have another explosion of cancers.”

Last week, the U.K.’s Environment Secretary, Hillary Benn, invoked the fight against obesity as rationale for increasing access to open spaces, asserting that “green spaces are good for us” – a pitch which moved Spike’s sharp-eyed Rob Lyons to note that “You can’t even go for a stroll these days without it being turned into a health initiative,” and to anticipate that “chubby people [will be] quick-marched around a south London park for 30 minutes on a regular basis to help them lose excess pounds.”

There are so many pieces to the fanfare over the “obesity threat” that it’s impossible to assign one cause for the commotion. For a long time, Junkfood Science has investigated the sociology of the “science” of obesity in detail, and has exploded many of the central myths of the anti-obesity movement – most importantly the apocrypha about fatness and mortality.

And Paul Campos’s brilliant book The Obesity Myth (Gotham, 2004) explains how a constellation of wealthy industries together support the lose-weight-now rhetoric.

Elizabeth Kolbert’s assessment of some new books on the topic in this week’s New Yorker embraces the tired rhetoric, assuming that fat is bad and asking why people eat so much.  To her credit, Kolbert takes the plunge into examining the new field of fat studies.  But she ends up disparaging fat studies for “effectively all[ying] itself with McDonald’s and the rest of the processed-food industry, while opposing the sorts of groups that advocate better school-lunch programs and more public parks.” Apparently, asking that fatness be examined in the context of both social structures and individual liberties strays too far from the central dogma of the anti-obesity crusade.  To which (pace Hillary Benn) public parks are balm and tasty fries are anathema.

But an often-neglected aspect of the anti-obesity panic is the overtone of class and the undertone of race. In Leytonstone, for instance, it turns out that the community has been troubled by the profusion of cheap eating establishments, especially in regard to the “anti-social behaviour” that it supposedly brings.

Yet, as Hayes notes at Spiked, it was a Jamaican establishment that was singled out for closure – while more echt-English outlets, like fish-and-chips shops, have been ignored.  The decision that behavior is anti-social being always in the eyes of the beholder – or the skin color of the beheld.

In most of the developed world, fatness is more common among the poor.  In the U.S., it is far more common among African Americans.  Obesity is a marker for being out of power.  To assert that you are against obesity is to state that you intend to identify with those who have power, and mean to keep it.  You can wag your finger at the misdemeanants who eat fast food and fail to exercise — without having to come out and say that what is really troubling you is that your people are starting to look like those people – like the poor, like the dark-complected … like the fat.

No wonder the anti-obesity rhetoric has heated up in Britain, and is catching on in Europe.  It’s a winning way to wage the war against the poor and unentitled, without having to seem arrogant or racist.

In other words, everyone had their guard up – but not for the right thing.

How was the public health apparatus so beguiled by the possibility of disaster that, when a relatively mild outbreak of flu took shape, the entire public health industry responded as if disaster were truly at hand?

To investigate, we tracked mentions of flu in news articles (letters and op-ed pieces were not included) published in the NY Times.  The pattern turned out to be revealing about how a pandemic is made.

From 1981 through 1996, inclusive, there were between 5 and 16 stories on flu each year – with the exception of 21 articles in 1986 (when a very mild flu season was predicted and a rather severe flu season surprised people).  On average, the Times ran 8.7 stories per year in that period.

Flu fever at the Times spiked in 1997, when the first cases of avian flu were announced and there was interest in how the W.H.O. would handle it.  Through 1999, there were 20-25 stories per year, an average of 22 – about two articles per month.

But in 2003, which was both the year of SARS and the peak of the bioterrorism-preparedness psychosis, coverage exploded:  the Times ran 50 stories on flu.

In 2004, the failure of any bioterrorists to take the field forced the Bush administration to claim that it wasn’t bioterrorism it had been worried about, it was pandemic flu.  As that administration was always a fountain of unassailable truth, it will be recalled, Secretary Tommy Thompson’s August ’04 Pandemic Preparedness plan convinced many people that flu is our real security problem.  The Times complied, running 130 articles on flu in 2004, with a slight fall-off thereafter.

If you were a dedicated Times reader, you had encountered an article on flu roughly every six weeks back in the early ‘90s.  But by 2006 you read about flu twice a week, on average.  And that was often in the context of pandemic preparedness.

The Washington Post’s pattern was similar (differences in the Post’s search engine and archive arrangement required a slightly different analysis), but its coverage was even more flu-prone.  A dedicated Post reader saw five articles on flu in the A section each week, by 2006.

Does this mean that media created a flu crisis singlehandedly?  Of course not – media make stories, or deliver other people’s, but they alone can’t make crises.  Much of the coverage followed leads provided by scientists – who, let’s face it, have to make sure the grant money keeps flowing in their particular direction (that was the origin of the 1976 fiasco over swine flu vaccine).  And much of the crisis was driven by business, especially the growing market for flu remedies.

But the media analysis sheds some light on why the preparedness rhetoric was so powerful in shaping American public health around security – and therefore juicing up the current flu outbreak into a global crisis.

H1N1 flu is a health problem, sure.  As DemFromCT has been explaining, it’s a problem that can and should be dealt with through standard public health channels, and with a circumspect eye on what we know and what we don’t.

But if it weren’t for weak government, overeager scientists, and compliant media infusing flu with a global-crisis flavor, would it register as such a grand problem?  We feel sad about the 332 swine flu deaths, but we also recognize that that total equals just a few hours worth of mortality from TB or malaria in the poor parts of the world.

As for media, the number of flu deaths registered in the U.S. is almost exactly equal to the mortality on American highways on any given Saturday.  (At Effect Measure today, revere notices the similarity between seasonal flu mortality and vehicle-related mortality.  Alas, revere misses the larger point:  this similarity demonstrates that flu can be called a “crisis” when it causes far lower mortality than usual, whereas highway accidents are never called a crisis.)

Any preventable death is lamentable, of course.  But you don’t read much about an epidemic of vehicle crashes in the papers.

n.b.  This is a slightly amended version of the original post, which because of faulty hyperlinking, improperly implied ineptitude where there wasn’t any.

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At Smallpox2009, Robert posts a note following Abigail Zuger’s review of Dread, which appeared in the NY Times on 26 May.  The post picks up Zuger’s wording as to whether fear of epidemics is “hard-wired” — not the most felicitous term but an apt question to ponder.  More happily, it also picks up her evident fascination with the question of why our society is so intrigued by epidemics.

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At change.org, Kristina Chew wonders about the question of whether autism is an epidemic.  She picks up the idea from Dread that once we call something an epidemic we give it “a story line, with a beginning and an end.”

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Crawford Killian reviews Dread at The Tyee, homing in on the links between the epidemic narrative and social anxieties — and economic disparities.  “Much of what we consider hygiene is little more than an attempt by the anxious middle class to control the dirty, lawless, sexually profligate poor,” he reminds us.

Based on the evidence of the last few weeks, officials are going to be expected to generate substantial plans to curtail a pandemic whenever something out of the ordinary happens with flu – whenever they say that an outbreak can “no longer be contained.” And they’ll be applauded – as Margaret Chan is in a paean in yesterday’s NY Times – for (as Chan herself puts it) “managing a high pressure crisis … with a sense of urgency.”  Pharmaceutical companies will be urged (and paid, of course) to produce extra-large lots of vaccine and antivirals.

In other words, flu will have followed the pattern set by many other illnesses, both real and imagined.  We live with them for a time; we figure them as being among the countless travails of normal life; they’re unremarkable, even if lamentable. At some point, they seem to resonate with specific anxieties, and we become more attuned to their occurrence.  They become epidemic threats (or, with flu, a “pandemic threat”).

Tuberculosis had a trajectory like this – an unremarkable cause of suffering and death for centuries, until it came to be associated with ethereal spirituality.  Later on, TB took on a new resonance because of its association with poverty, which by the 20th century had started to carry an ideological flavor (or several flavors).

Syphilis had many meanings heaped on it, but it only came to be seen as a public health problem when the Progressive movement shaped it into a rationale for combining moralism with medicine, ca. 1900.  And syphilis became a social crisis after the Progressives’ approach called for epidemiologists to make sense of it (statistical findings always help craft the narrative of rising threat), and the new data helped to further the narrative of social failing and personal misbehavior.

The flu scene is thick with epidemiologists now, fogged with rumors about what went wrong, and filled with theories about causes.  This is exactly what it takes to create an epidemic.  Some people think that’s good, because more attention will be paid, and more funding appropriated, and we’ll be better able to “fight” flu.  That remains to be seen.  In any case, you have to wonder who is going to benefit, and what the price will be.

Perhaps it shouldn’t be surprising that we, and especially our health agencies, overreacted to the early news from Mexico.  As Gardiner Harris points out in today’s NYT, the furor seems to have started in mid April when a CDC operative saw a connection between two reports:  One was of two cases of flu in San Diego that represented infection with a virus that contained genetic sequences from flu viruses previously seen only in swine.  The other was of an unusual burst of pneumonia cases in Mexico.  It turned out that the latter came from scans of media reports, which detected news articles reporting on a cluster of severe respiratory illness among adults in La Gloria, Mexico, where pork processing is an important industry.

On 24 April, in its first article to make the link between a flu outbreak in Mexico and isolated cases in the U.S., the NYT led with two facts that would turn out to shape the narrative: the new flu virus contained genetic sequences from pig, bird, and human viruses, and many of the flu deaths in Mexico were young adults (later it would turn out that many of those Mexican deaths were not actually caused by this flu virus – but of course pausing for all the facts would have interfered with the creation of the desired pandemic story). By featuring these two facts, the news story pointed to the 1918 outbreak – the Times article allowed an infectious-disease doc to make the case explicitly, but for readers who know about the 1918 flu the connection would seem obvious.

From there, the horses were out of the gate.  Health agencies, media, and lots of intelligent people began to imagine a coming pandemic.  Who can blame them? Having been prepped by the W.H.O. pandemic preparedness campaign and the U.S. one over the past few years, they were primed to seize on any little piece of news and turn it into the fantasized reprise of 1918.

W.H.O. was probably trying to help when it cranked up its threat barometer from 3 to 4 to 5 (on a 6-point scale).  By issuing warnings, the agency could give leverage to health authorities in poor countries who had to plead with their governments for more funding, and it might have helped shake loose some foreign-aid change from the pockets of the rich countries (at least, this is what I hope the W.H.O. was thinking).  But all the talk about “possible pandemic” just played into visualizing the horror scenario.  Officials haven’t learned that when they say “pandemic” they merely mean “the same flu strain produces human illness in multiple countries,” but when most people hear “pandemic” they hear “tens of millions of people are going to die.”