As Martin Enserink reports at Science Insider:

Two groups of scientists who carried out highly controversial studies with the avian influenza virus H5N1 have reluctantly agreed to strike certain details from manuscripts describing their work after having been asked to do so by a U.S. biosecurity council. The as-yet unpublished papers, which are under review at Nature and Science, will be changed to minimize the risks that they could be misused by would-be bioterrorists.

The “biosecurity council” in question is the U.S. National Science Advisory Board for Biosecurity, an arm of the NIH’s Office of Science Policy.   It has recommended censorship of research on genetic alterations of avian (H5N1) flu that might make the virus easily transmissible between humans and pathogenic as well — ingredients for a potentially serious human outbreak.

I attach little public health importance to the experimental work, carried out by Fouchier in the Netherlands and Kawaoka in the U.S.  Flu’s behavior in human populations has been notoriously difficult to predict, even with relatively advanced molecular information about viral strains.  Flu forecasters repeatedly predict bad outbreaks and even (as in 2009) devastating pandemics — which fail to materialize.

Even when it comes to the most studied flu outbreak of all, the 1918 pandemic, opinions still differ on why so many millions of people died.

This week, what concerns me is the biosecurity industry.  It seems more than ever eager to terrify people.   The Fouchier and Kawaoka experiments themselves are interesting but hardly recipes for disaster.   And yet, some voices say the research shouldn’t have been carried out in the first place.  Surprisingly, they include the respected D.A. Henderson, here much mistaken.  He editorializes this week with two coauthors for the online publication Biosecurity and Bioterrorism.

It’s not opposition to science — it’s just the biosecurity “experts” making a living.

The move to suppress publication of research results because scientific findings might tip off some chimerical evildoers is ridiculous.  Fouchier, Kawaoka, and their teams were obviously trying to contribute to the search for ways to make people safer.   That’s what most people want science to do.  Instead of urging caution, the many scientists on the NSABB should be standing up for the wide dissemination of scientific findings — not for suppressing them.  Made-up concerns over “bioterrorism” should not trump public access to scientific research.

And the NSABB scientists shouldn’t be cowed by the self-professed biosecurity “experts” at the Center for Biosecurity.

The sole raison-d’etre of the “biosecurity” business is to keep itself in business — by keeping people terrified.   It does that by continually invoking impossible scenarios that are supposed to (a) frighten the public and (b) cause the public to buy products that we don’t need or give up rights that we do need.

After being scared into thinking the 2009 H1N1 outbreak was going to be a reprise of the 1918 flu calamity and finding that it was exceptionally mild instead, surely the public is not going to be taken in by the biosecurity industry much longer.

It’s anybody’s guess as to whether the new findings about H5N1 are at all meaningful in (human) public health terms.  Which is what happens with science.  That’s why the point of suppressing the findings isn’t to make anyone safer – - it’s just to keep the biosecurity experts in business.

In an article in the July issue of Emerging Infectious Diseases, just out, Piarroux and colleagues assert that (quoting from their abstract) “Our findings strongly suggest that contamination of the Artibonite [River] and 1 of its tributaries downstream from a military camp triggered the epidemic.”

So the mystery is solved, more or less.  The news media have taken note:  articles on the EID report have already been written by the AP, Guardian, and other sources, and are being picked up fairly widely today.

The news, based on a report ordered by UN Secretary-General Ban Ki-moon,  is being treated as an about-face on the UN’s part — because the organization, along with WHO and CDC, refused last fall to do an in-depth investigation of the origin of the outbreak.  So, according to the media’s coverage, this week’s report exposes some hypocrisy on the part of the health organizations.

That’s silly, and wrong.   I’m usually critical of WHO and CDC, but in the case of the Haitian outbreak they were completely correct to refuse to “investigate.”  As I wrote last fall, cholera isn’t a detective story, it’s a disaster.  To investigate the so-called origin of an outbreak that is as self-evidently the result of  calamitous conditions, state poverty, and helpless officialdom is to shift the blame.  Dodge the truth.

The work by Piarroux and colleagues in establishing a clear description of the origin and progress of the Haitian outbreak is impressive, often elegant, quite convincing.  But to believe, as some do, that it somehow proves that the UN and WHO are responsible for a catastrophe, or that sending foreigners into Haiti is always bad, or even that (as the authors of the EID paper say)

Putting an end to the controversy over the cholera origin could ease prevention and treatment by decreasing the distrust associated with the widespread suspicions of a cover-up of a deliberate importation of cholera

is to misunderstand public health.

The problem in Haiti is, and has been, a problem of predisposition — nature out of balance, people on the move, dire straits of all kinds (food, medicine, clean water, toilets, housing, etc.)  too tolerable to weak leaders.  Colonization by one aid group after another (UN included).  It was inevitable that cholera was going to break out.

To take the Piarroux report as definitive is to mistake the germ for the disease, mistake the outbreak for the problem, mistake the detective story for the real disaster — the real disaster being self-explanatory and not in need of “investigation”:  not enough money and not enough political will to keep the public from getting sick.

I’ve covered the profit-motivated thinking behind vaccine recommendations generally and specifically with regard to flu immunization.  Epstein’s main interest is in the role of pharmaceutical companies in promoting oseltamivir (Tamiflu®) and other neuraminidase inhibitors as public health responses to flu fears.  Her story features the brilliant work of Tom Jefferson and colleagues, and the shady behavior of the global biotech firm Roche in trying to block Jefferson et al.’s efforts to investigate the safety of neuraminidase-blocking agents.

Jefferson was lead author on the Cochrane Collaborations’ main paper on neuraminidase inhibitors for flu prevention and treatment.   But when reports of adverse effects of these drugs emerged and he and colleagues tried to re-assess the underlying reports on which the effectiveness of oseltamivir and similar drugs was based, Jefferson was stymied.  His colleague, Peter Doshi, related the story in BMJ.   The journal’s editor-in-chief, Fiona Godlee, along with Cochrane director Mike Clarke, wrote in an accompanying editorial:

The review and a linked investigation undertaken jointly by the BMJ and Channel 4 News cast doubt not only on the effectiveness and safety of oseltamivir (Tamiflu) but on the system by which drugs are evaluated, regulated, and promoted.

The take-home message is that while there is evidence that Tamiflu can be effective in treating flu, the evidence is shakier than it seems, and troubling reports point to potentially serious adverse effects.

How does a questionable medication get to be the basis (or part of the basis) for public health policy?  The answer is that the policy makers and the money makers work hand in hand.

Maryann Napoli at Center for Medical Consumers tried to point out the troubling links between WHO and big pharma last year, and Steven Novella at Science-Based Medicine brought it up around the same time.

But most of the coverage focuses on the involvement of individual scientists and/or physicians who are receiving payments or other forms of remuneration directly from drug companies.  It’s not hard to police such straightforward conflicts — and so it was easy for Margaret Chan, WHO Director-General, to say last year that “at no time, not for one second, did commercial interests enter my decision-making.”

Epstein’s great contribution is in showing that obvious conflicts of interest aren’t the main way that for-profit companies influence policy.  It’s done through stonewalling, as Jefferson encountered when he tried to examine Roche’s data.  It’s done through widely accepted collusions.

For instance, the CDC Foundation — “Helping CDC Do More, Faster” is its motto — is a nonprofit organization, created by the U.S. Congress, whose job is to

connect the Centers for Disease Control and Prevention (CDC) with private-sector organizations and individuals to build public health programs that make our world healthier and safer.

Of course, calling them “private-sector organizations” suggests that these are not-for-profits — and some, like the District of Columbia Department of Health, the Medical College of South Carolina, and UNICEF, really are.  But most of the private-sector collaborators who are linked with CDC’s policy makers by the CDC Foundation are big corporations.  They include all the giants of Pharma world:  Merck, Pfizer, Roche, Sanofi-Pasteur, etc.  (They also include some who are just giants:  Google, Dell, YUM! Brands, and IBM, to name a few.)

So when CDC’s updated flu response plan now recommends antiviral (i.e., neuraminidase-inhibitor) treatment “as soon as possible,” it’s worth asking whether this is because it has any public health value (answer:  no) or just because CDC is cozy with companies that make money when people get sick.

Still, it’s hard to avoid wondering:  is Wakefield right when he alleges that he’s being persecuted by the vaccine industry?

Last week, I discussed the BMJ article by Brian Deer asserting that Wakefield’s research was fraudulent, and the accompanying editorial supporting immunization.  At that point, I thought that the BMJ pieces were, together,  a one-off.

I was wrong.  In fact, it looks this week like the vaccine industry has armed some of its main warriors and sent them out to do battle.

The Battle Against Anti-Vaccinationism

In the Jan. 13th issue of the New England Journal of Medicine, two powerful chiefs, Gregory Poland and Robert M. Jacobson, claim that there’s an “age-old struggle” to make vaccines available.  Their aim is to vilify the “antivaccinationists” who “have done significant harm to the public health.” [Note the use of the holy article in this phrase, to signal just how sacred these warrior-priests hold "the" public health to be.]

The Poland-Jacobson piece is pure propaganda.  Theirs is a tale of heroic struggle on the part of ever-embattled Believers against the satanic forces of Antivaccationism — who have been trying “since the 18th century” to shake people’s faith in the vaccine gospel.  And nowadays the nasty antivaccinationists are using scarily modern forms of communications, such as TV and the Internet, in order “to sway public opinion and distract attention from scientific evidence.”

Wow:  TV and the web.  Sounds satanic alright.

I guess I shouldn’t be surprised that a couple of crusaders make their own work sound salvationist.  What troubles me is that they make it sound like they’re disinterested do-good-ers.

In fact, Poland and Jacobson are in bed with Big Pharma.  Poland runs the Mayo Clinic’s Vaccine Research Group.  Although as far as I can tell, Poland and Jacobson are not currently in the direct pay of the vaccine manufacturers, they and the VRG have benefited handsomely from vaccine makers’ largesse.

For instance, Poland’s and Jacobson’s work on human papillomavirus vaccine, as they acknowledge in a 2005 Mayo Clinic Proceedings paper, was funded by Merck, and their co-workers were Merck employees.  Later, in conjunction with a continuing medical education module on meningococcal vaccine in 2009, Poland disclosed the following ties:

Sources of Funding for Research: Merck & Co, Inc, Novavax, Inc, Protein Sciences Corp; Consulting Agreements: Avianax, LLC, CSL Biotherapies, CSL Limited, Emergent Biosolutions Inc, GlaxoSmithKline, Merck & Co, Inc, Novartis Vaccines, Novavax, Inc, PowderMed Ltd

And on his disclosure form for this week’s NEJM article Poland acknowledges funding from Pfizer and Novartis for vaccine studies.

So when Poland and Jacobson write that our society “must continue to fund and publish high-quality studies to investigate concerns about vaccine safety,” they’re really talking about preserving their livelihood.  It’s very much in their interest to ensure a steady flow of such funding.

And when they say that “society must recognize that science is not a democracy in which the side with the most votes or the loudest voices gets to decide what is right,” they’re being completely disingenuous.  Because Poland and Jacobson know quite well why science is not a democracy:  in the type of research they do, it’s the big money that decides what is right.

A High Priest of Vaccine “Science”

Then there’s Paul Offit making the rounds.  Offit has been the subject of lots of attention by Age of Autism, most recently as a “denialist.” Offit probably profited somewhat from the licensing of Rota Teq vaccine, which he helped invent — although AofA’s allegation that he is therefore beholden to Merck seems unsubstantiated.

What’s obvious about Offit is that he is contemptuous of people who don’t agree with his version of truth.

Offit appeared on Lenny Lopate’s radio show in New York yesterday, and presumably will be appearing elsewhere.  His aim is to explain the “grave public health problem of vaccine avoidance.”  The “anti-vaccine movement threatens us all,” he says.  In fact, that’s the subtitle of his new book, Deadly Choices.

Where Poland and Jacobson are militant and sanctimonious, Offit sounds a note at once sentimental and officious.  It’s “tragic” that there have been measles outbreaks because of parents refusing to have their kids vaccinated, he says.  And the problem is that people just don’t understand science.  In fact, Dan Olmsted at AofA gets it quite right when he critique’s Offit’s blinkered version of science:

Anyone concerned about [possible harms of vaccination] fits Offit’s definition of anti-vaccine, because vaccines don’t cause any of them, because Paul Offit says so, a solipsism that is really quite breathtaking: “[B]ecause anti-vaccine activists today define safe as free from side effects such as autism, learning disabilities, attention deficit disorder, multiple sclerosis, diabetes, strokes, heart attacks, and blood clots — conditions that aren’t caused by vaccines — safer vaccines, using their definition, can never be made.”

I had the same reaction to Offit’s self-important — and, to my mind, unscientific — claims.  Offit shows no interest in the open inquiry that marks science.  People who don’t agree with him are uneducated, poorly informed, maybe just stupid.  And, of course, dangerous.

“Tragic” Consequences of Unbelief

On the Lopate show, Offit resorted to the now-common formula of the “tragic” consequences of parents’ belief in Andrew Wakefield.

What’s the tragedy, exactly?   It’s true that there have been outbreaks of measles in the British Isles that have been traced to parents’ refusal to have their children immunized.  An excellent review in BMJ in 2006 provided some of the data for the U.K. — including that one child died in a 2006 measles outbreak that was related to poor immunization coverage.  A few children died in Ireland in 2000.  A CDC account of a measles outbreak in California in 2008 reports that it hospitalized a few children, although none died.

It would be great if nobody ever died from an infection that could be prevented in any way.  It’s surely tragic to the parents of a child who dies from a preventable infection.   The sympathies of each of us should go out to such parents, as to those whose kids are killed by bad drivers, sports injuries, or infections for which there’s no vaccine.

But in what sense is one child’s death more of a collective “tragedy” for all of us than the other deaths that go unremarked every day?   Why is it tragic when one child dies of a vaccine-preventable infection and not when a lot of them die of poorly regulated handguns or as troops fighting wars that never endanger our leaders, only our young?

The Ramp-up of Aggression by the Vaccine Crusaders

Why are the vaccine warriors rampant now?  Perhaps the vaccine makers are terrified that the low uptake of H1N1 flu vaccine despite all the hype in 2009, along with low MMR compliance in some places (the U.K. especially), means that their profits are going to slide.  Maybe their friends, like Offit and Poland, are worried that reduced uptake of vaccines will translate into diminished research funding or fewer conferences in delicious places.

Or maybe the vaccine industry finds Wakefield so obstreperous that they can’t rest until he is destroyed. Wakefield’s no choir boy, but he might not have realized just how much control the pharmaceutical industry can exert in the U.K.

In a review essay in last week’s New York Review of Books, Simon Head points out that Big Pharma is “the only major segment of the British economy that is both world-class and an intensive user of university research,” and implies that it exerts control over both the substance and volume of U.K. research productivity, especially in medicine.  Head sees reason to believe that Pharma will “tighten its hold over scientific research in the UK” in the future.

It’s Not a War

There need be no either-or about vaccines.  If our society can live with guns and automobiles (together accounting for roughly 50,000 American deaths a year), if we tolerate alcohol, processed foods, acetaminophen, high-rise construction, and all the other things that occasionally cause harm but mostly contribute to the way of life we prefer — then we can stop calling it “tragic” when a few parents don’t have their kids immunized.

Because to call one measles death “tragic” is to further the vaccine warriors’ campaign — the campaign that pretends to be on behalf of science or healthy kids, but is really fought to protect the fortunes of vaccine makers.

The campaign protects the power of shiftless public officials who claim to be protecting the public from harm when they serve up millions of taxpayer dollars to vaccine manufacturers for barely useful vaccines (H1N1 2009), or for vaccines that are undoubtedly helpful but might be harmful in some cases and haven’t been thoroughly examined (HPV vaccine).  And who, to this day, won’t even consider the very good question that Andrew Wakefield posed in the 1990s:  is it a good idea to give kids three immunizations in a single preparation?

I had my child immunized when she was the right age for that.    But I’m not certain that absolutely everyone has to do the same.  Neither are the courts, which is why they allow exemptions from immunization for personal belief.

I don’t think measles is a menace to civilization.  I know that only a very tiny percentage of children who contract measles get dangerously sick from it, that flu vaccine doesn’t work for everyone (and isn’t an effective public health measure to stop flu outbreaks even though it can protect individuals from illness), and that varicella vaccine can make the problem of shingles worse even though it reduces the problem of chicken pox.  And so forth.

I mean that immunization is complex and fraught.  Not everyone can be expected to agree with every vaccine recommendation.   Even while some people are opposed to vaccination and refuse to immunize their kids, life will go on, and society will continue to thrive, and Paul Offit can continue to say arrogant things about “science.”

So, could someone please call off the crusade?

Finger pointing about the “cause” of the outbreak — finger pointing at Nepalese peace keepers, the UN mission, relief workers, or Haitian health workers — is a way of avoiding the fundamental problem:  insufficient political will to create working infrastructure for poor countries.  Haiti being the leading example, the cholera outbreak being the case study.

Given how shaky the living arrangements have been for many Haitians since the January earthquake, given the pre-existing destitution and the anemia of efforts to fix that, it’s a tribute to the Haitian health system that cholera didn’t break out until October.  It might have been much sooner.

But now that cholera is spreading, it seems that more energy is going into using the outbreak to whip up political animus in, and about, Haiti than to figuring out how to make sure it doesn’t happen again.

This week, the politicization of the cholera outbreak seems to get worse by the day (Crawford Kilian’s cholera coverage at H5N1 continues to keep abreast of both the cholera outbreak and the political uses it’s being put to).   I talked to John Hockenberry and Celeste Headlee about this on The Takeaway yesterday, pointing out that the problem is social crisis, not Nepalese troops.  It’s poverty, lack of adequate sanitation, poor access to clean water — not foreigners.

Here’s the segment of The Takeaway:

In contrast to the misleading headline of Reuters’ piece, what Ms. Fox covers is not the (pseudo) mystery of “who brought cholera to Haiti?”  It’s the effort by CDC, the Haitian health ministry, and PAHO to determine whether the outbreak likely started from a single source or multiple ones.

The findings are reported in the Morbidity and Mortality Weekly Report this week:  Haitian cases all carried Vibrio cholerae of the O1 serogroup, serotype Ogawa (a very common strain), with DNA of a single pulse-field gel electrophoresis pattern.  Because of the propensity for mutation or recombination events in the reproduction of bacteria, it would be extremely unlikely for different people to be carrying bacteria with the identical PFGE pattern unless they had all been exposed to an identical strain.  [N.B.  Strictly speaking, cholera is not an infection:  the illness results from poisoning by V. cholera in the intestine, not from actual infection of tissue.  Therefore I write "exposed to" rather than "infected by."]

Based on the findings so far, CDC and its partners concludes that the outbreak probably began with a single strain.

Did this strain arrive in cholera recently, or has it been around for some time and only recently came to attention as a cause of mass morbidity and mortality?  Did it arrive in a person and contaminate the environment via feces, or arrive in food or water?  Was there a single initiating exposure, or did cholera arrive inside multiple people or food items?  As Fox points out, the study can’t answer these questions.

It makes sense to seek information on how the outbreak got started in order to plan for better systems to prevent future outbreaks.  CDC is on the right track here.

But by calling this a whodunit, Reuters is pandering to people who want to inflame tempers, not spreading information about what can be done to make Haiti healthier.  Shame on you, Reuters.

Early this month, a couple of friends, thinking they might splurge on a downtown hotel to celebrate their tenth wedding anniversary, were soliciting bed bug reports before choosing where to stay.  And at a family gathering last week, one young man — recently graduated from an elite college, an intellectual usually given to ironic mockery of the nuttier trends evident in the generation that still uses e-mail — told me that while he’s afraid of bees and doesn’t like mosquitoes, bed bugs really terrify him.

Bed bugs are unpleasant.  Their bites can itch.  Their feces and molted shells can set off asthma attacks or other allergies.  It’s sensible to avoid them, and get rid of them if they’re in your home.  I wrote a few months ago that it makes perfect sense that health authorities do something to limit bed bug woes.

But if you ask me what insects worry me most as a public health professional, I certainly wouldn’t say “bed bugs.”  Ticks, especially as Lyme disease spreads geographically.  Phlebotomine (sand) flies, as leishmaniasis becomes a more serious problem.  Mosquitoes, always.   Bed bugs are far from the top of my list.

The Aedes mosquitoes that carry yellow fever, dengue, rift valley fever, and chikungunya viruses, are most troubling right now.  Ae. aegyptii most of all, of course, but increasingly Ae. albopictus.

An extensive outbreak of rift valley fever in South Africa produced dozens of human cases earlier this year, and seems to be continuing among livestock.  An epidemiologist friend in Europe told me a few weeks back that he and other European disease control specialists, already concerned about dengue and yellow fever, are looking at RVF exposures in the southern part of the continent — a worrisome finding for a virus that has primarily been African.   The European Center for Disease Control is, appropriately, concerned about the establishment of Ae. albopictus in Europe.

Ditto chikungunya, which as produced 33 cases in Delhi, India, this year, possibly including an illness in the city’s mayor.

Dengue  demands control most pressingly of all.  Although the CDC is busily advising Americans not to worry (“Nearly all dengue cases reported in the 48 continental states were acquired elsewhere by travelers or immigrants,” its info page reads), there is active spread through much of the Caribbean basin — see the map at Dengue Watch, for instance.  The Mexican ministry of health reports dengue transmission in areas bordering the U.S.  There has already been an outbreak in Texas (in 2005).  And other highly industrialized countries with strong surveillance and control systems are experiencing dengue cases, including the first report of domestic transmission within France this summer.

(Hats off to Crof at H5N1, who has been following both chikungunya and dengue assiduously.)

The expansion of the range of Ae. albopictus, a secondary but by no means ignorable vector for dengue, makes the geographic extension of these pathogens worthy of concern.

With climate changing, trade routes always in flux, area spraying of insecticide disfavored because of environmental considerations, and of course mosquitoes evolving to take advantage of new niches, it seems unlikely that North Americans can go on counting on the mere improbability that virus and vector will coincide.

Mosquito control programs are in place, and U.S. authorities expend considerable effort at controlling Ae. aegyptii in Puerto Rico.  But the West Nile fever outbreak of 1999 and its subsequent extension in North America reveals the porousness of mosquito control.

Mosquitoes are much more worrisome than bed bugs.

Haiti today: in the mouth of death.  Not just Haiti, of course.  Deadly, gruesome, and hard to stop, cholera seems emblematic of the many failures that preceded the earthquake and have been exacerbated since.  We Americans are paying attention to Haiti lately — because of the earthquake; because of proximity; or because however bad things are here, what with high unemployment and poor economic prospects, Haiti conveniently reminds us of what we’re not.  But really much of the world, of the dollar-a-day world, is in the mouth of death much of the time.

With cholera, the relief agencies are hard at work.  Ansel Herz, a freelance journalist who blogs at Mediahacker, writes that there have been five cholera deaths in Port-au-Prince as of this morning, although the authorities say those people came to the capital from elsewhere and that cholera isn’t yet spreading in Port-au-Prince.  Still, cholera mortality is over 200 nationally.   Herz describes the earnest efforts of aid workers.  But his reportage, along with that of the Miami Herald, the NY Times, and others, also reveals the shortcomings of relying on aid organizations to contain the complex problems — of which cholera is the latest.

Partners in Health, to my mind the most earnest and committed of the aid organizations, is compiling reports on the spread of cholera and, of course, trying to do something about it.  But here’s the problem: if it’s the aid workers who are trying to stop cholera, it’s too late.  I don’t mean that they’ll fail; I mean that there should have been infrastructure in place to make sure cholera doesn’t break out at all.  And if there’s no such infrastructure, cholera will happen again, however well it’s halted this time.

It’s hard to escape the image, provided by Herz, of a new water tank installed near Cité Soleil by the International Organization for Migration — which stands empty, because nobody has provided clean water to fill it.

This is the problem with aid:  of course there must be organizations, like Partners in Health or MSF, that provide relief to the suffering.  But if there’s no support, or demand, for permanent public health infrastructure, the aid workers will always be scrambling to keep up with crises, and the crises won’t stop happening.

In the New Yorker this month, Philip Gourevitch takes a skeptical view of humanitarian aid (abstract here; full article requires subscription).  He summarizes the message of Dutch journalist Linda Polman sympathetically:

Now, Gourevitch is talking specifically about crises created by political conflict.  But something of this dilemma pervades the problem of relief.  Public health is political.  It takes political will — not just oral rehydration therapy — to install water supplies and sewage systems, and housing with running water even for the poor.

Canada is going to send a million dollars to Haiti to help with the cholera problem (thanks to Crof at H5N1 for picking that up).  No doubt the U.S. will outdo its neighbor in looking mournful and concerned, and donating even more money.  But where’s the support for good government, and real public health, and necessary infrastructure?

What are we doing to promote the implementation of good public health? What are we doing to generate the political will to install even just the ordinary civil engineering works that we take for granted in America, but which would make a difference to the people who are living in the mouth of death?

What I value about H5N1 is the tracking of the mosquito-borne viral diseases, like dengue and chikungunya as well as H1N1, that reveal the effects of the elision of ecosystem boundaries; the close attention to outbreaks that stem from changes in human-animal interactions — like the recent outbreak of plague in Tibet and, of course, H5N1; and the watch it keeps on the vaccine trade, as in yesterday’s post picking up a report in The Nation on the purchase of flu vaccine from France and one last week on a US tech company’s trials of a new flu vaccine (which won’t help the public but is, apparently, already helping the company to get richer).

The kind of close attention to the details of complex interactions amongst humans, animals, and both the natural environment and the economic one that H5N1 shows is indispensable.   It should spur more interest in wresting public health away from the simple-minded mass-vaccination schemes of medical officials in the U.S. and other wealthy countries — the point of which is usually to transfer public monies into the hands of pharmaceutical companies.  And move us to toward a more complex and inclusive view of the nature of health.

While it would be foolish to dismiss such warnings as this latest one on bird flu, it is important we keep a sense of proportion and not let them distract us from countering the unfashionable but widespread potential killers such as tuberculosis, HIV/Aids, diabetes, cancer, dengue and malaria. These are the diseases already causing widespread illness and economic harm….

Rather than competing for cash, the threat from newer diseases should serve as a catalyst to combat existing epidemics.

Competing for cash is key.

Funding for TB languishes, dengue incidence expands, more people with the AIDS virus are getting treated but new infections continue to occur, water scarcity (and displacement because of wars and natural disasters) makes diarrheal illness a persistent problem, and malaria transmission continues to threaten billions of people who live in tropical and subtropical regions — but flu preparedness dominates the public health scene.   Why?

Here’s the infernal logic of WHO and the public health officers of wealthy countries (U.S., U.K., etc.):  (a) At the start of the H1N1 outbreak in 2009, a sensible worst-cast forecast was about a million deaths worldwide; the more likely scenario was well under 500,000 deaths.  (b) TB + malaria + diarrhea + AIDS together kill 6 or 7 million people a year.   (c) Immunization against flu is notoriously variable in its effectiveness and mass immunization is almost never effective (except if instituted in an isolated population well before the flu virus makes inroads into the population).

Sounds like it would be worth it to pump lots of resources into reducing the incidence of malaria, TB, AIDS, and diarrhea.  But that’s hard.  It takes political will.  Whereas immunizing against flu is easy: it just takes money.  And national health officials were eager (it turned out) to transfer billions of dollars, pounds, and euros into the hands of vaccine manufacturers in order to be able to immunize their populations against H1N1 flu.

To an official whose job is to watch out for the needs of the economic machine, immunization pays.

One flu vaccine manufacturer estimates that in the U.S., employers lose $2.1 billion each year in productivity because of flu-related absences from work.  Let’s be skeptical about this estimate, coming as it does from one of the beneficiaries of federal largesse in response to flu fears.  But the point is clear enough:  it was a great boon to the private sector to have the federal government spend $1.6 billion of taxpayer money on flu vaccine in 2009 even though the outbreak was mild and vaccine did virtually nothing to stop it.  Because with the feds footing the bill, the burden on corporations was slight, whereas the private sector would have lost a lot of money if many Americans had fallen ill with flu.

It’s not just the vaccine manufacturers and pharmaceutical companies who stand to capitalize on the absurd calculus of protecting American businesses instead of poor people’s lives:  scientists do, too.

Robert Webster is an eminent virologist who has become dean of those American scientists who purport to be able to foresee a future flu catastrophe.  Perhaps he’s right, but of course nobody knows.  So when Webster says

We may think we can relax and influenza is no longer a problem. I want to assure you that that is not the case,

as he just did in a meeting in Hong Kong, it’s a good sign that the preparedness crusaders are worried about their funding.  They should be.

The preparedness crusaders have been unmasked as shameless shills for the private sector,  even if the vaccine and antiviral manufacturers aren’t paying them directly.  And the ones who are scientists have been revealed as self-important promoters of their own research — so fiercely protective of their own turf that they might use their prestige and the imprimatur of science to hoodwink officials into ignoring the more serious, and more certain, problems of the developing world.

Let’s hope that more opinion makers take the stand that the editors in Bangkok just did.

At H5N1 yesterday, Crof picked up the U.K. government’s announcement that it would sponsor an independent review of decision making in response to H1N1 swine flu last year.  The U.K.’s Minister of Health, Liam Donaldson, told WebMD that it is

vital that we learn from what we have seen in this pandemic, for the sake of those who find themselves tackling … the next. It is likely to be worse.

Anybody who claims to know what the next pandemic will be like is asserting a special ability to read mysterious auguries that nobody else can see.  So it’s all the more shocking that Donaldson goes on to obfuscate his own failure to ask critical questions by claiming to have been using expert predictions:

Would it have been acceptable to hide and conceal statistical projections provided by statistical modellers of international standing, even though releasing them publicly caused alarm in some quarters?

As if the flak he had taken last July were for a perfectly rational assertion, not an apocalyptic forecast — when he said that there could be 65,000 deaths from flu in Britain.  Donaldson later dropped the forecast to 19,000 deaths.  (The actual number was less than 400 during 2009, 457 to date.)

And as if Donaldson had not made the same off-base prediction back in October 2005, when he said that there would be an avian flu outbreak in the U.K. with 50,000 deaths.  That was Donaldson’s excuse to use public money to purchase two and a half million doses of antivirals for stockpiling.

As if, that is, the problem were that people are just benightedly opposed to science — not genuinely concerned about malfeasance.

To its credit, the Parliamentary Assembly of the Council of Europe continues its investigation of decision making around the H1N1 outbreak response, holding a second public hearing on Monday.  Briefs of experts’ statements at the first hearing, back in January, are available here, and links to full statements and video are at the PACE site here.

Some of my friends and colleagues in public health wonder if this kind of questioning comes from misunderstanding the seriousness of flu and others are fearful that it will diminish the authority of public-health physicians.  A few, but too few, back the redoubtable Tom Jefferson, who has been questioning the reliance on flu vaccine for a long time.  Shouldn’t scientists — especially scientists — question authority?

Officials’ legitimacy ought to be diminished if they’re not serving the public.  Particularly when their decisions mean that private companies benefit from taxpayers’ monies.  Clearly, the transfer of funds is what happened with the H1N1 flu response.  Was it based on sound decision making?  More transparency would be a good thing.

Now that the Council of Europe and the U.K., are investigating official responses to H1N1 flu, could we please hear from the United States?

Is it the Advertisement?

A full-page ad taken out by DHHS in the main news section of today’s NY Times sounds very defensive when it claims that “H1N1 Flu Vaccine is Safe and Effective.”

The advertisement makes it seem like getting immunized against swine flu is a kind of patriotic duty.

Fighting the flu is a shared responsibility.  We ask you to join this fight to protect yourself and your community by getting the H1N1 flu vaccine.

And it’s signed by leaders of 35 health- or safety-related organizations — “top medical professionals,” according to the page’s header — who seem to be collaborators in a DHHS attempt to guilt the public into getting a flu shot.  Do it for your neighbors if you won’t do it for yourself, the text seems to say.

The clumsy production of the ad itself makes it all the more abject:  there’s a quarter page of grey text in a swimmy, sans-serif font, below which are two stacks of logos (of the 35 organizations) — vaguely impressive as a color border to the text in the version posted at flu-dot-gov, but just visual noise spilling down the Times page in black and white.

And some of the logos are trademarked or registered — requiring a tiny-type footnote reminding any reader intrepid enough to have reached the bottom of the page that DHHS doesn’t endorse private enterprises.  (It’s a little hard to understand how the collaboration on flu vaccination does not constitute an endorsement of private enterprises, but let’s not get bogged down.)

Is it the armada of PSAs and posters?

The ad is just the latest attempt by DHHS to muster enthusiasm for the flu campaign.  It makes available a panoply of printed material at its flu website, intended for Spanish-speaking Americans, African Americans, Asian and Pacific Islander Americans, “asthma patients,” and others.  With a separate flotilla of posters and publications for parents, many bilingual (“I’ll protect my baby/Protegeré a mi bebé” and others), plus additional ones meant for older people, diabetics, and travelers.

It’s hard to escape the feeling that DHHS is trying too hard.  And hard to avoid wondering why.

Is it the information itself?

The second sentence of the Times ad tells the sad story:  Over 136 million doses of H1N1 vaccine are now available.   Since the number of flu vaccine doses actually administered so far is probably about 60 million, it takes only grade-school arithmetic to realize that the federal government purchased much more H1N1 vaccine than Americans are willing to take.

DHHS’s desperate need for everyone to get vaccinated is disheartening.  After all, this is the organization that created and carried out the previous swine flu fiasco entirely on its own:  the 1976 immunize-every-American campaign to prevent the Flu Outbreak That Wasn’t.

So it’s bad enough that CDC, with more experience and research findings than it had in ’76,  badly overestimated the intensity of the 2009 H1N1 flu outbreak.  It’s worse that DHHS  grossly overestimated the ardor of the American people for media-heavy health crusades at a time of tight budgets and high unemployment.  Most dispiriting of all is that the agency finally resorts to wheedling the public to get immunized against swine flu.

Which gives us a glimpse of another contributor to the sense that DHHS is floundering:

There is a widespread feeling that official agencies overplayed their hand on swine flu.

Everywhere, it seems, doubts are being voiced about the decisions by both U.S. authorities and WHO — declaring the pandemic, publicizing the unprecedented danger, supporting mass immunization, purchasing and distributing Tamiflu, and so on:

• There are concerns about conflicts of interest on the part of flu experts.
• There are suspicions, reflected in the resolution introduced by Wolfgang Wodarg and passed by the Assembly of the Council of Europe (thanks to Ed Silverman for covering that) to launch an inquiry into the influence of vaccine makers on WHO’s flu policy.
• There are the accusations of hype coming from both the democratic left and libertarian right, from vaccine supporters who feel that the overstatement of the swine-flu threat diminishes the public’s faith in immunization in general, and from those who believe vaccines induce autism.

A conclusion:  it feels like DHHS is drowning because it is.  Officials made bad choices, fell for the preparedness charade, lost sight of what it would mean to protect the public’s health and strove instead to protect the professional organizations’ campaigns for attention and the pharmaceutical companies’ ploys for profit.

An appeal to Secretary Sibelius:  just say “We goofed.”

Say “We should have used the resources to help people quit smoking or to control MRSA or to verify the safety of pharmaceuticals. We didn’t; we overestimated flu.  We meant well but we loused up.  We’ll try to do better next time.”

Say “At least we didn’t kill people with vaccine, like in ’76″ (okay, for legal purposes, you probably have to say “…allegedly kill people,” since the U.S. government has not admitted that the 1976 vaccine actually caused the deaths from Guillain-Barré syndrome).

Say “How much better to have prepared by urging hospitals to consider surge capacity and then to find it wasn’t needed, than to have done nothing and seen people die who could have been saved by administering antivirals.”

Say “We know that vaccines are not the answer to flu.  We know that the flu vaccine isn’t very effective, we know that immunization against flu is not very useful as a public health intervention unless everyone is immunized, we know that it’s impossible in this country to force everyone to be immunized, we know that immunization is good for people who stand to get very sick if infected but that all it offers to the majority of the population is a reduction in the odds of getting sick.   We know that we need to take a more complex approach to flu control.  We’re working on all that.”

But please spare us the embarrassing advertisements.

May CDC become a force for real public health, not an advocate for the risk-avoidance canard.  May the new director, Dr. Frieden, stop favoring pharmaceutical companies’ profit making through expansion of immunization.  And may he direct the agency to begin to address legitimate public needs, like sound answers about vaccines and autism, and clear communication about what is — and isn’t — dangerous about obesity.

May WHO officials stop playing with the pandemic threat barometer.  May WHO begin demanding that the world’s wealthy countries devote at least the same resources to stopping diarrheal diseases, malaria, and TB as they do to dealing with high-news-value problems like new strains of flu.   Diarrheal illness kills as many children in Africa and Asia in any given week as the 2009 swine flu killed Americans in eight months.  So does malaria.   Direct policy, and money, toward sanitation, pure water free of parasites, adequate treatment of TB, mosquito control, and prevention of other causes of heavy mortality in the developing world — not just flu strains that threaten North America, Europe, and Japan.

May public health professionals lose their obsessions with bad habits. May the public health profession return to the problem of ensuring basic rights — access to sufficient food, clean water, decent housing, good education, a livable wage, and adequate child care — and ease up on its moralistic obsessions with nicotine and overeating (for recent examples of the preoccupation with tobacco, see this article or this one (abstracts here; subscription needed for full articles) in recent issues of the American Journal of Public Health).

May science be what Joanne Manaster does at her incomparable website: looking at the world with wonder, asking without dogmatic preconceptions how it works, and accepting that its irrepressible quirkiness makes it impossible to know the world perfectly.  May science not be the crystal-ball-gazing thing whose so-called “scientific” forecasts are really doomsday scenes worthy of the medieval Church — predictions of liquefied icecaps and rising seas,  hundreds of millions of deaths in a flu pandemic, or catastrophic plagues sparked by people with engineered smallpox virus.  There are plenty of reasons to be concerned about both the environment and disease outbreaks based on sound here-and-now observations; leave the forecasts of Apocalypse to the clergy, who know how to handle dread.

A new year’s wish (from the valedictory exhortation in Tony Kushner’s Angels in America):  “More life!”

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.

In this week’s Lancet, Dr. Steven Black, from Cincinnati Children’s Hospital, and colleagues present calculations of the expected frequencies of adverse consequences (abstract at link; subscription required for full text) likely to result from flu immunization.  The intent being to provide a basis for comparison, so that when events do occur following immunization, the vaccine won’t be blamed for them.

“Widespread beliefs that such false associations [of adverse events with vaccination] are true can and do disrupt immunization programs, often to the detriment of public health,” the authors write.

Testament to the persuasiveness of the rhetoric, an experienced and knowledgeable Reuters reporter is taken in.  Covering the Lancet article, Maggie Fox writes:

People have special fears about Guillain Barre Syndrome (GBS). a rare neurological condition that was linked to a 1976 U.S. swine flu vaccination campaign. Although no case of GBS was ever linked to the vaccine, a belief that the vaccine was worse than the illness remains widespread.

Not exactly.  At least 500 cases of GBS were linked to flu vaccine in 1976 — “linked” in the sense that Fox uses the word in the first sentence:  they occurred in vaccine recipients and were in excess of the number of GBS cases likely to have occurred had there been no adverse effect of vaccination.  Thirty-two of those cases were fatal.  That they were not “linked” in her second sentence means that the criteria for association have shifted, or can shift.

The method by which the 1976 GBS cases were linked to vaccine was exactly the same as the method Black and his colleagues propose as the test for determining whether adverse events are linked to the 2009 immunizations.

But if the nature of association can shift, then Black and company can play a double game.  On the one hand, no illness or death can be attributed to vaccine if it occurs at a rate less than that expected in normal times, sans vaccination.  That’s the premise of this week’s Lancet article.

On the other hand, no illness or death that occurs at a rate greater than expected can be attributed to vaccine unless there is some additional proof — not just statistics but, we imagine, pathology results from surgery or autopsy — demonstrating a link between vaccine and illness, or vaccine and death.  That’s the conclusion that the Reuters correspondent drew after talking with Black and company.

In other words, the vaccine “scientists” have already demonstrated that you’re wrong if you think vaccine has done anything bad.   Don’t bother alleging that vaccine harmed your child, spouse, or parent.

We have to wonder why physicians (the main authors of the Lancet paper are all MDs, as are the public health officials who are promoting mass immunization as a flu-control strategy) are mounting their defense of flu vaccination, when hardly anyone has been immunized yet.

And we have to wonder why physicians call themselves scientists when they don’t want to deal with evidence — only their own certainty that vaccination is a good public health strategy.  A strategy whose inevitable shortcomings they’re already defending.

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.

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.

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?

The CDC’s travelers’ health website recommends vaccination against typhoid (as well as hepatitis A and B, and routine childhood immunizations) for travelers visiting small towns and villages in Ukraine.  Since we expect to be doing exactly that, we opted to be immunized.

Picking up the oral typhoid vaccine at a pharmacy in the Bronx made us reflect on inequities in health, and inequalities of opportunity.  How odd, to stand in an air-conditioned pharmacy on a busy street in New York City and prepare to fortify oneself against a disease that, here, we consider of historical interest.  Typhoid makes us think of the sad episode of Mary Mallon, the infamous typhoid carrier, and the struggles of Almroth Wright to develop a vaccine that would limit the terrible toll that typhoid took on British troops in the Boer War.  All a very long time ago.

That typhoid is still a public health problem in much of the world attests to real differences in opportunity.  Clean drinking water, and the sanitary systems that allow water to stay clean, being aspects of opportunity.

The American conversation about health uses the grammar of risk.  Our health professionals talk about the possibility that illness will ensue if people persist in some behavior (smoking, inhaling others’ cigarette smoke, using certain pharmaceuticals, driving while intoxicated, etc.), if authorities fail to inform, if vaccine isn’t produced on time.  But a sense of scale is lost.

Flu preoccupies the risk conversation right now, for obvious reasons having to do with the current outbreak of H1N1 influenza.  The risk conversation sometimes appeals to the terrible pandemic of 1918, the worst single-strike disease outbreak of all time.  But it doesn’t often recall that, in the United States, the 1918 flu spared over 99% of the population.

The talk of risk, the sometimes-lurid conversation about what might happen, almost always occupies itself with the tiny tail of the broad distribution of health – the minuscule proportion of the population that, even in a frightening outbreak, actually dies from it.

What’s left out is the real situation that confronts most people, most of the time.  Not the sudden outbreak, but the persistent struggle to stave off more mundane problems that rarely appear in the media.

Junkfood Science this week reminds us to keep the care in health care.  Care seems relevant here.  The risk conversation gives us clues – sometimes valuable ones – about how to diminish somewhat the number of people who are sickened or killed by a threat, like flu.  But to really get at people’s health – to offer a more thoroughgoing and humanistic form of care – will mean moving past the narrow conversation about risk, and asking about opportunity.

It isn’t risk that keeps most people from achieving capabilities — from escaping poverty, living comfortably, or being free of disability.  It’s more usually bad water, bad food, or just bad government.  A broader and more effective health conversation would start with the conditions of living, and not be preoccupied with the risks of illness alone.

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.

And now it’s Toll House chocolate chip cookies.  The dough has been recalled by Nestlé because some batches contain E. coli O157:H7, a potentially dangerous strain, with at least 66 cases in 28 states.  There have been 7 severe cases of hemolytic-uremic syndrome, although no deaths.

At the Center for Science in the Public Interest, food safety lawyer Sarah Klein says “If there was anyone left in America who didn’t realize we need to reform the food safety functions at the Food and Drug Administration, this latest recall of Nestle Toll House Cookie Dough provides a sobering wakeup call,” telling the NY Times that “If there was ever any doubt that we’ve reached a crisis, this should provide the proof.”

But crisis of what?  The FDA itself isn’t sure how the bacteria got into the dough, and CDC is still investigating. What are we supposed to wake up to?  Is it toxicity?

According to research recently reported in the Milbank Quarterly, the metaphor that Americans most commonly hold responsible for obesity is a toxic food environment. — over 75 percent of respondents subscribed to this view of the obesity epidemic.

With foodborne disease, it isn’t obesity that’s at stake, but it seems that the same view of American eating shapes responses.  That the foods recently associated with bacterial outbreaks are so quintessentially American helps.  So does awareness of the tortuous journey that many foods take to market now, which is what makes it hard to know exactly how, where, and when contamination might occur.

But surely the U.S. doesn’t face a food crisis of the sort that the impoverished countries of the world do — a crisis of environmental change, political struggles over land use, access to clean water, and food shortage for a billion people worldwide.

Americans generally manage not to talk about the lives of people for whom food crisis means dirty water and the questionable availability of cassava flour or cornmeal mush, but are pleased that our own food crisis does not involve such deprivation.

At the same time, a lot of people here feel suspicious of the technical apparatus that has afforded us our cornucopia.  They are suspicious of the ways Americans (or most Americans) have access to the modern groaning board without our having to hunt, scrape the soil, haul water, or collect firewood – just park the car, enter the store, and take out cash or a debit card.  It seems too easy.  It isn’t traditional, natural, organic.

The occasional news story on food contamination validates those concerns, tells anxious people that they were right to be suspicious – that American food producers are poisoning us all.

To say that an event (cookie-related or other) is a wake-up call is to demand surveillance and control.  It says that someone has done something wrong (CSPI doesn’t need to tell us who that is – they mean the usual suspect:  big business, aided by lax government).

If someone has done something wrong, then surveillance – better food-plant inspection, for instance – and control will fix the problem.  But the wake-up call doesn’t really wake anyone up to the larger problem, or its nuances.

We’d like everyone worldwide to have enough to eat.  And not just enough rice or roots – we’d like everyone to be able to eat a diverse and nutritious diet.  We’d also like to be able to have chocolate chip cookies and other tasty processed food, at least from time to time.  We’d like all that to happen with a minimum of suffering caused by the food itself.  It’s unreasonable to think that nobody will ever get sick from contaminated food — but we’d like foodborne disease to be limited.

The technology and the transportation know-how exist to make that future possible.  But people concerned about food content, food safety, and food plenty have barely started the sort of conversation that would allow all the many pieces to be fit together globally.  The way to make such a vision of food adequacy and diversity possible still isn’t clear.  To argue for better surveillance and oversight of American food production is fine – but it doesn’t move us far along the road to solving the larger food crisis.  It’s going to take more than FDA inspection to get us there.