Philip Alcabes discusses myths of health, disease and risk.

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.

 

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.

 

The Myth of Normal Weight

Don’t miss Paul Campos’s commentary on overweight and obesity in today’s NYT.  Responding to the latest report by Katherine Flegal of CDC and coworkers, Campos points out that

If the government were to redefine normal weight as one that doesn’t increase the risk of death, then about 130 million of the 165 million American adults currently categorized as overweight and obese would be re-categorized as normal weight instead.

The report by Flegal et al., published this week in JAMA, is a meta-analysis of 97 studies on body-mass index (BMI) and mortality.  This new analysis found that mortality risks for the “overweight” (BMI 25-29.9) was 6% lower than that for “normal” BMI (18.5-24.9) individuals.  And those in the “grade 1 obesity” category, with BMIs from 30 to 34.9, were at no higher risk of dying than those in the so-called normal range.   Only those with BMIs of 35 and above were at elevated risk of dying, and then only by 29%.

In other words, people who are overweight or obese generally live longer than those who are in the normal range.  Only extreme obesity is associated with an increased probability of early death.

Flegal and colleagues already demonstrated most of these findings using administrative data, in an article appearing in JAMA in 2005.  There, they reported no excess mortality among people labeled “overweight” by BMI standards, and that about three-quarters of excess mortality among the “obese” was accounted for by those with BMIs above 35.

What’s notable about this week’s publication is that it has attracted the attention of some heavy hitters in the media.  Pam Belluck covered the JAMA report for the NYT.  Although her article seems more interested in propping up the myths about the dangers of fat than in conveying the main points of the new analysis, Belluck does acknowledge that some health professionals would like to see the definition of normal revised.

Dan Childs’s story for ABC News gives a clear picture of the findings, and allows the obesity warriors, like David Katz of Yale and Mitchell Roslin at Lenox Hill, to embarrass themselves — waving the “fat is bad” banner under which they do battle.  MedPage Today gives the story straight up.   In NPR’s story, another warrior, Walter Willett of Harvard, unabashedly promoting his own persistently fuzzy thinking, calls the Flegal article “rubbish” — but the reporter, Allison Aubrey, is too sharp to buy it from someone so deeply invested.  She ends by suitably questioning the connections of BMI to risk.

Campos’s op-ed piece does the favor of translating the Flegal findings into everyday terms (and without the pointless provisos that burden the NYT’s supposed news story):

This means that average-height women — 5 feet 4 inches — who weigh between 108 and 145 pounds have a higher mortality risk than average-height women who weigh between 146 and 203 pounds. For average-height men — 5 feet 10 inches — those who weigh between 129 and 174 pounds have a higher mortality risk than those who weigh between 175 and 243 pounds.

Is the hysteria about overweight and obesity is over?  I’m sure not.  In today’s article, Campos — who was one of the first to explode the fiction of an obesity epidemic, with his 2002 book The Obesity Myth – reminds us of a crucial fact about public health:

Anyone familiar with history will not be surprised to learn that “facts” have been enlisted before to confirm the legitimacy of a cultural obsession and to advance the economic interests of those who profit from that obsession.

There’s too much at stake with the obesity epidemic for our culture’s power brokers to give it up so quickly.  One day, some other aspect of modernity will emerge to inspire dread (and profits).  In the meantime, we might at least hope to see some re-jiggering of the BMI boogeyman.

 

Gun Violence: The Silence of the Officials

A week after the murderous fusillade in Aurora, Colorado, not one public health official has stepped forward to call for gun control.

Attribute the 9 deaths and dozens of injuries in Aurora to the rash act of an unbalanced man if you wish.  But what about the tens of thousands of other deaths caused by firearms in the U.S. each year?

If HIV infection (9,406 deaths in 2011) and painkiller overdose (estimated at 15,000 deaths per year, according to a report  by Trust for America’s Health and the Robert Wood Johnson Foundation) are public health problems worth discussion, why not firearms?  In 2009, the last year for which complete data are available, there were 31,347 deaths by firearm in the US, according to the US National Center for Injury Prevention and Control.

At The Pump Handle, Celeste Monforton — always worth reading — provides the data showing how out-of-scale America’s gun problem is on the global public health scene:  Our gun-violence death rates are an order of magnitude higher than those of other wealthy nations.

At CNN, Daniel Webster calls for America to wake up to the public health problem of guns.  ”America’s high rate of gun violence is shameful,” Webster writes.  ”When will we change?”

NYC Mayor Michael Bloomberg can be a tyrant when it comes to personal habits that he thinks impair the city’s health, but he has been courageously forthright on the need to control firearms.

But, like me, Monforton and Webster are academics.  And Mike Bloomberg is, well, Mike Bloomberg.

Where are the health officials?

Kathleen Sibelius, Secretary of Health and Human Services, has been silent.  She’s been vocal on healthcare fraud, and earlier this week announced a new public-private partnership to keep people with AIDS in care.   But not a word on guns.

Thomas Frieden, CDC director, can’t be accused of shying from the spotlight.  But he has said nothing about guns.

Under these corrupt officials, gun violence has been cleaned from the public health radar screen.

Try finding an entry on firearm violence at the Department of Health and Human Services website.  Or, go to the CDC’s “A-Z Index” (what other letters would bound an index, one wonders? well, anyway…).  There’s no entry for “guns” or “gun violence.”  Nor for “firearms.”  The entry on “violence” leads to a page on injury prevention that includes links to entries on Elder Maltreatment and Intimate Partner Violence — but not a word on guns.

At Salon, Alex Seitz-Wald wonders whether the NRA has suppressed research.  There’s some evidence for this:  Paul Helmke of the Brady Center to Prevent Gun Violence wrote to Secretary Sibelius over a year ago, asking whether it’s true that Frieden’s CDC has agreed to tip off the NRA when researchers who receive CDC monies are going to publish anything on gun violence.

Seitz-Wald might well be perfectly right.  Certainly, the NRA is unseemly, manipulative, and morally vacuous.  But it doesn’t have the power to program anyone’s thoughts.  It doesn’t cause our officials to be spineless in the face of the infestation of American homes and streets — and movie theaters, schools, colleges, and so on — by guns.

No, it can only be that Frieden and Sibelius — and a tremendous host of less prominent health officials — are all silent about  guns because, really, they aren’t concerned about 31,000 deaths and upward of 400,000 injuries from firearms each year.  Or, not as concerned about the carnage as they are about their jobs.

It’s self-evident that our health officials don’t care about the real health of Americans nearly as much as they do about their own continuation as officials.  More important than saving lives or limbs, apparently, is the officials’ capacity to mount the bully pulpit in order to decry other dreadful scourges.  Like big cups of soda, defrauding the insurance companies, or not exercising.

Our public health officials:  put to the test, and found to be feckless at core.

 

Disaster for Health Care Reform: Supreme Court Upholds Affordable Care Act

Chief Justice Roberts is the diabolical genius of free-market jurisprudence.  Reformers have been sucker-punched.  Any possibility of creating an equitable system for delivering medical care has been postponed for at least a generation.

Yet, liberals are rejoicing at yesterday’s Supreme Court ruling, in which Roberts left the three arch-conservatives (Thomas-Scalia-Alito) and Kennedy, to join the usually liberal wing (Brier-Ginsberg-Kagan-Sotomayor) in order to uphold the Affordable Care Act, the health care financing law of 2010.  Paul Krugman says that the “real winners are ordinary Americans — people like you.”

The celebration is misguided.  After yesterday’s ruling, there will be no national health system.  There will be no single-payer nonprofit insurance plan.  For the foreseeable future, diagnosis, treatment, and corporate profit will remain the inseparable triumvirate of medicine.  Hardly party-worthy.

Sure, there are a few things worth cheering about.  As Josh Levs set forth yesterday in a particularly cogent summary of the new law, insurers won’t be able to deny coverage to people with pre-existing conditions (young people immediately, everyone from 2014 on).   Until you’re 26, you will be able to get health insurance from your parents’ insurance policy, especially useful now with unemployment so high among the young.  Some of the “doughnut hole” in Medicare prescription drug reimbursements will be closed.

But Roberts’s brilliance was revealed in his handling of the vexatious issue of the mandate — the requirement that each non-indigent American purchase health insurance coverage or be fined by the Feds.  The fine would begin at $285 per family or 1% of income, whichever is higher, in 2014 but climb to over $2000 or 2.5% by 2016.  Instead of looking at the mandate and accompanying fine for noncompliance as a regulation, Roberts picked up on the fall-back argument adduced by Solicitor General Donald Verrilli, Jr. — he asserted that it’s really a tax.  And, of course, Congress can levy taxes.

At Slate, Tom Scocca explains that Roberts used his majority opinion on this case to undercut Congress’s right to regulate commercial activity.  For Scocca,

the health care law was, ultimately, a pretext. This was a test case for the long-standing—but previously fringe—campaign to rewrite Congress’ regulatory powers under the Commerce Clause… Roberts’ genius was in pushing this health care decision through without attaching it to the coattails of an ugly, narrow partisan victory. Obama wins on policy, this time. And Roberts rewrites Congress’ power to regulate, opening the door for countless future challenges. In the long term, supporters of curtailing the federal government should be glad to have made that trade.

According to CDC’s summary of the latest Congressional Budget Office estimates, about 30 million uninsured Americans will gain coverage under the ACA in the next few years, leaving about 27 million without health insurance at all.  That’s an estimate, because undocumented immigrants are untouched by the ACA.  Ditto prisoners, who supposedly get health care in their institutions but, by all indications, often don’t.

And, the Roberts ruling opens the door to questions about the Federal government’s capacity to get the states to expand Medicaid coverage.  Roberts and four justices say it’s limited.  Four others say it doesn’t exist at all.  As Charles Ornstein explains at ProPublica, that means that some states might simply refuse to expand Medicaid, which would undercut one of the aims of the ACA.

The final score is hardly a victory for “ordinary” Americans.

  • We now have a Congress that may tell Americans to give money directly to private corporations, or pay a penalty to the Federal government.  At least when Congress can claim that paying private corporations is in our best interest.  In other words, now private insurance companies may collect taxes.
  • We will have insurance companies that may continue to profit from Americans’ suffering.
  • We will still have nearly 10% of the population without access even to primary care.
  • We now have questions about whether Congress may impel the states to indemnify the sick poor.  (Hardly cause for optimism, especially at a time when states are seeking ways to lighten budgetary obligations, for instance by reducing pension benefits for public employees.)

And the Roberts ruling accomplishes this victory for corporate power by upholding the law, not striking it down.  That means that Congress won’t re-consider health care financing anytime soon.  Which means that the single-payer system will rest in its grave for the time being.

Yesterday was no cause for celebration.  It was a dark day for health care reform.