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.

The anti-tobacco crusade is a modern-day version of Revivalist religious fervor.  It sure isn’t science.  And it isn’t about protecting people’s health.

The CDC estimates that 442,000 Americans die from tobacco smoking each year.  These estimates are slippery; they’re based on a fairly loose definition of what it means to die “from” a behavior — but let’s agree that a lot of people die sooner than they otherwise would because they smoke cigarettes.

Alternative ways of self-administering nicotine allow users to avoid the disastrously harmful drug-delivery device, the cigarette.  You’d think that Big Public Health, 45 years into a campaign to get people to stop smoking, would be promoting all sorts of safe methods of nicotine delivery.

That’s not what happens.  Instead, the industry pours anathema on light cigarettes, smokeless tobacco, and other safer-than-cigarettes products.

The latest sermon is an article in this month’s The Nation’s Health — the newsletter of the American Public Health Association (APHA, which has turned into the High Synod of Public Health Religion).  The article  claims that “New Types of Smokeless Tobacco Present Growing Risks for Youth.”

The title is a double rhetorical turn now (alas) typical of APHA:  (1) your kids are going to die, and (2) the “risk” to them is increasing.  The piece would seem silly if the author, named Kim Krisberg, weren’t so serious.  After all, it isn’t kids who die from smoking, and the risk of smoking-related death isn’t increasing at all.  But we’re not in the realm of truth here.

Since Big Public Health isn’t dealing in truth when it comes to tobacco, evidence isn’t part of the story.   The head of the Campaign for Tobacco-Free Kids can say “the time to stop the spread of dangerous products is before they become the fad of today,” insouciantly sidestepping the fact that smokeless tobacco products aren’t dangerous.  Brad Rodu’s invaluable website Tobacco Truth explains — see Brad’s June 16th post, for instance.  Or go to this page at the excellent resource TobaccoHarmReduction, or see this article published in Cancer Epidemiology, Biomarkers & Prevention in 2004.

The public health industry’s animus for tobacco leads it to label as harmful something that is really a boon to public health — the increasing use of products that provide nicotine without burning tobacco.  Surely it’s better to have people chewing nicotine-containing products that won’t harm them than to allow them to continue smoking tobacco in order to get a nicotine dose.

Moralistic fervor makes you stupid.  Stupid enough to write, as two physicians with FDA’s Center for Tobacco Products did,

As state and local communities across the United States adopt indoor clean-air laws that restrict smoking in public areas and workplaces, the tobacco industry seems increasingly focused on the development and introduction of novel smokeless tobacco products

… as if the tobacco industry were magically making Americans who would otherwise stop smoking suddenly crave smokeless tobacco — and as if that would be bad for them.  Drs. Deyton and Cruz, you should know better.

But Matthew Myer with Tobacco-Free Kids isn’t unintelligent.  Nor, I assume, are Deyton and Cruz.  And I can’t imagine they really want people to suffer.

Still, do they really think that safe non-smoked tobacco products are going to bewitch our kids?  Do they believe that apocalypse comes in a package of smokeless tobacco?

Are they just so obsessed with battling tobacco companies that they’ve lost sight of the aim of public health, i.e., to reduce suffering?

Or is it simpler?  Has the public health industry’s big-money anti-tobacco campaign allowed too many people to make too good a living by saying stupid things about tobacco?

The cigarette manufacturers have been scurrilous, dastardly, and sometimes appallingly inured to the misery and death their products have hastened.  Maybe they deserve the Myerses of the world.

But the public health industry could be a lot more focused on helping people to live less painful lives, and less obsessed with its private demons.

As Carl V. Phillips suggests in a post this week, the FDA will have to break with the public health industry’s moralism if people who use nicotine are going to protect themselves from cigarettes.

If the FDA can’t overcome Big Public Health’s obsession with satanic tobacco rituals, re-introduce truth into the discussion, and re-focus on making real people’s lives less miserable, the zealots are going to turn stupidity into bad policy.

But this AP article grabbed me.  According to New York City, over 6 percent of residents who responded to a community health survey claimed to have dealt with bedbugs in the past year.  In response, the city will withhold half-million dollars normally budgeted for the city’s health department  and redirect the funds to an anti-bedbug campaign.

Some might argue that the $500,000 would be better used for preventing deadly illnesses and accidents, not just bug bites.  Still, the campaign seems right.  According to the AP story, environmental health people will work with a “top entomologist.” (Professionals collaborating across sectors:  One City, One Health.  Good.)  A note by Javier Hernandez at the NY Times‘s City Room blog is guarded, but some (like Molly Fischer at the NY Observer) seem relieved that there will be a big anti-bedbug crusade at last.

Not a very big crusade, but at least a multifaceted one, as the Bed Bug Advisory Board’s Report suggests.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In an article posted on the NY Times website Sunday (and published in the print edition Monday), McNeil reports on the inability of treatment programs in parts of Africa (this piece focuses on Uganda) to keep up with the need for AIDS medication as funding falls.   A very compelling video report accompanies the online version of the article.

An accompanying article explains the decline in funding, starting with the fall in the U.S. administration’s request on behalf of PEPFAR, as a Times graphic shows.

The number of new infections with the AIDS virus is estimated to be about 2 million per year now.  Some observers think annual incidence will rise as the population expands; even if not, the annual number of new AIDS virus infections is unlikely to fall in the near future, given present circumstances.

At the same time, the Times reports, anticipated PEPFAR funding is essentially flat to 2013, at $5 to $5.5 billion per year.  Financing for AIDS medications through the Global Fund to Fight AIDS, Tuberculosis and Malaria is in dire straits.

In terms of people, not dollars:  of the 33 million or so individuals who are infected with the AIDS virus worldwide, only about 4 million get regular antiretroviral therapy.

A few years ago, I wondered why,  after a quarter-century of AIDS and with the availability of effective treatment (at least in wealthy countries), Americans still didn’t see AIDS as an ordinary illness.

Now I have an answer:  we do see AIDS as ordinary… for poor countries.  To us, AIDS is no longer an epidemic problem worth our getting worked up over, or so it would seem judging by PEPFAR.  AIDS is like malaria, tuberculosis, or schistosomiasis.  It’s like diarrhea.  The Bill and Melinda Gates Foundation will put money into research or specific programs but we as a country will not need to care anymore.  We shift the funding away from the people in Africa, who are going to die young anyway, and put it into the hands of institutions (often, pharmaceutical companies) that can give us the promise of immunity from disaster.

The U.S. put less funding last year into PEPFAR than it did into preparations for H1N1 flu ($7.6 billion) or the school lunch program ($14.9 billion, according to the Robert Wood Johnson Foundation’s Center to Prevent Childhood Obesity), battleground in the war against childhood obesity.

Flu and obesity are epidemic.  They threaten American assumptions about ourselves.  “Epidemic” means:  crisis in our society.  Our epidemiologists say that malaria, diarrhea, and the other problems that collectively kill 20,000 or 25,000 people (mostly children) every day are endemic. 

“Endemic” means:  not our problem.

AIDS is endemic too, now.  It has gone to ground, gone the route of other once-dreaded infections that caused calamity in America and triggered heated debate (yellow fever, cholera, typhoid, TB) but have disappeared from our scene.  It’s their problem, now.

The policy seems to be based primarily on a secondary analysis of longitudinal data from a multi-center study of HIV-infected people in the U.S. and Canada, the NA-ACCORD study.  The results were reported in the New England Journal of Medicine a year ago.  In that analysis, people with HIV whose CD4 counts were between 351 and 500 who began ART immediately were compared to those who deferred ART until CD4 count was 350 or less.  The deferred-ART group was found to have a 69% higher risk of mortality (from any cause) than were those who began ART before CD4 count fell to <350.  Similarly, among HIV-infected people with CD4 counts above 500, those who began ART after CD4 count was <500 had a 94% higher risk of mortality compared to those who began ART immediately.

But is this a good basis for across-the-board policy for a city the size of San Francisco?  Some physicians worry about the development of drug resistance among viral strains.  Others are concerned about toxicity, always a problem worth considering.  Paul E. Sax tracks the history of the idea and includes a few quotes in his blog post yesterday.

Some commentators wonder whether the new policy is meant to be a boon to pharmaceutical companies.  That’s not a crazy concern:  the Bay Area Reporter noted a couple of weeks ago that San Francisco plans to shift to a “status awareness” policy, increasing HIV testing by 70,000 people per year in an effort to halve the rate of new infections by 2015.  If successful, the increase in testing combined with an increase in recommendations for early ART would expand the market for antiviral medications substantially.

A few aspects of the April 2009 report on NA-ACCORD raise worries about whether it should be the basis for broad-based policy.  First, people who deferred therapy were observed very briefly (median 1.3 years, many of them for only 6 months), so any advantage to early therapy appears to refer to the period immediately post onset of therapy.  That’s important because toxicity and/or resistance might not be evident right away.  Second, looking only at people with an initial CD4 count above 500 and holding constant self-reported history of drug injection, there was only weak evidence for a slight effect of early treatment on mortality (the relative mortality hazard was 1.28 (95% confidence interval 0.85 to 1.83)).  Drug users had a higher mortality risk, and this finding—on which the authors of the New England Journal paper do not comment—suggests that early ART did not reduce the hazard of death for drug users.

Also, the authors of the NEJM paper could not possibly account for some of the hard-to-regiment aspects of HIV infection.  These would include variations in cause of death, treatment adherence, and monitoring of treatment effects — all of which would either not be evident in a cohort study or could not be controlled in a secondary analysis.

Finally, the authors are slightly cagey about the effect of drug-injection history in the above-500-CD4-count group, reporting a twofold increase in death hazard for those who delay ART after excluding people with a drug-injection history – but never reporting information on the effect of ART delay among drug injectors alone.

Most important, observations on people who transitioned to the next-lower CD4 compartment (i.e., from above 500 to <500, or from 351-500 to <350) were censored after 6 months if the individual had not yet initiated ART.  Therefore, the real comparison the NEJM authors are making is between immediate-onset ART while CD4 count remains in the same CD4 compartment vs. immediate-onset ART after CD4 count has dropped to the next lower compartment.  It’s not really a study of immediate versus delayed onset ART.

There’s plenty of reason (including the 2009 NEJM paper) to think that suppressing HIV early rather than late should be helpful, and some reason to think that the reduction in viral load produced by ART will lower infectivity in a way that makes transmission to uninfected sexual or drug-sharing partners less likely.  That in turn could be of public-health value.

Of course, nobody is being forced to start ART before he or she wants to, no matter the policy recommendation. Still, it’s worth wondering whether the expansion of testing and extension of early treatment will substantially improve the public’s health in a way that makes the cost, and self-evident advantages to pharmaceutical (and test-kit) manufacturers, worthwhile.

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?

Megan was an exemplar.  She was director for community health at Montefiore Medical Center’s School Health Program, had established lead poisoning prevention programs in Bronx communities, was a founding member of the NY City Coalition to End Lead Poisoning, added a school-based education component to the Hunts Point Asthma Initiative, organized community gardens and helped develop the clean-up of the Bronx River, among many, many other neighborhood health initiatives.  She and her husband Richie were recognized recently by the Rotary Club for taking in three children who had come to the Bronx for heart surgery.

Bronx News Network posted a short obituary, paying tribute to Megan’s community spirit.

Everything Megan did seemed to be about serving, in the most personal of ways:  making people’s lives a little better, reducing suffering a little, making the neighborhood a little less dangerous, cheering people up.  For me, she exemplified what public health could be about:  caring, first of all and most of all; reducing suffering; making an impact among friends and neighbors; and hoping others might be similarly influential.

Megan wasn’t known as a public health “expert.”  She wasn’t a maker of big policy.  She was a maker of many small differences.  That seems precious.  She’s irreplaceable.  It’s a terrible loss.

And there has been new talk about the usual issues:  The  perpetual vexation about tenure.  The problem of safety on campuses.   The question, now customary, of whether a shooter’s  writing offers any clues to her or his psyche.

But there hasn’t been much discussion about the victims.  Two of the three who were killed, Maria Ragland Davis and Adriel D. Johnson, Sr., were African American professors.  All three of the deceased — the other, Prof. Gopi Podila, was department chair — were known for their support of students, according to obituaries published by the Chronicle of Higher Education.   This in itself is both laudable and rare enough, in a field increasingly driven by the quest for research grants, to deserve mention.  But the sudden death of two science professors who were themselves black Americans and who devoted themselves to educating black students in the sciences is a particularly profound loss to higher education.

That Dr. Ragland Davis was a black woman, one of the rarest of beings in the scientific professoriate, makes the loss particularly poignant.

Statistics are no solace, of course.  But the silence about the loss of two black American professors who died by gunfire is part of the greater, even more stunning, silence about the great many black Americans who die by gunfire every year.

In 2006, the last year for which complete data have been posted by the National Center for Health Statistics (see table 18), 30,896 Americans died by gunshot.  Almost half, 12,791, were murders.  That’s 35 firearm murders per day, on average.   About one every 40 minutes.

Black Americans are over twice as likely to die by gunshot than are white Americans (see table 19 at the link above).  The gunshot death rates are roughly 22 deaths per 100,000 per year and roughly 9 per 100,000 per year, respectively.  Those risks have been remarkably constant, even as deaths from Americans’ main form of deadly mishap, vehicle crashes, have declined.

This is not a plea for gun control.  Better gun control laws would allow a lot of people to live longer, and improve the public’s health — but we hear such pleas every time  a multiple shooting makes the news.  That’s not the point here.

The point is the problem of giving chances to people who haven’t had them.  Or, to put it more bluntly, the point is race.

In particular, the impossibility, still, of talking about how science should be done by people who have not historically been included in shaping it and defining it.  By people other than the ones who, at least until recently, made all the decisions about what’s worth studying and what’s worth changing.  By women, by black Americans, by people who grew up poor, by people who did not attend elite universities on the east coast or in California.

Universities — the elite ones and the many non-elite ones — are indispensable in the endeavor to change science, for all sorts of reasons.  Maybe the best reason is the presence of professors who support and encourage students who aren’t drawn from the usual class of people.

The deaths at UAH should be an occasion for great mourning, not only for professors who died doing their work, but for the project of changing science.  If the silence over the Huntsville victims were the silence of grief, it wouldn’t seem so bad.  But I think it’s the silence of not really caring, or of not wanting to face a shameful truth.  Compared to talking about the links among race, science, and education… well, it’s less taxing to wonder about the shooter’s unpublished novel.

As New Scientist points out, the GMC’s finding removes any impediment to charging Wakefield and two of his colleagues with misconduct.  GMC may rule on that score in a few months, according to the BBC.

By and large, the talk about the verdict hasn’t been about the substance of the contentious vaccine-autism link.  At Autism Science Foundation, Alison Singer (the group’s president) writes that

Anti vaccine autism advocates continue to see Wakefield as a hero who remains willing to take on the establishment and fight for their children.  In the meantime, Wakefield’s actions have had a lasting negative effect on children’s health in that some people are still afraid of immunizations. In some cases, the younger siblings of children with autism are being denied life saving vaccines. This population of baby siblings, already at higher risk for developing autism, is now also being placed at risk for life threatening, vaccine preventable disease, despite mountains of scientific evidence indicating no link between vaccines and autism. This is the Wakefield legacy.

On the other side, Generation Rescue writes in support of Wakefield at Age of Autism.  GR isn’t as cogent as Singer, but brings up the point that tends to complicate this and most discussions of autism:    “Do you think pharmaceutical companies have too much influence in the laws, policies, and regulations of our government?  We do.”

Liz Ditz provides a great service, compiling blog posts pro-Wakefield and, separately, those criticizing Wakefield and/or supporting the GMC’s decision.  (As of today, the Wakefield critics seem to have been more prolific.)

Thursday’s BBC report concludes with a graphic showing a decline in MMR coverage in the UK between 1996-97, when it stood at around 90%, and 2004, when it bottomed at around 80%.  Superimposed is the number of measles cases, which increased from a few dozen in 2005 to over 1200 in 2008.  The implication is that Wakefield’s report was somehow responsible for the drop in coverage in the late ’90s and that that decline led to a sharp uptick in measles incidence.  The graphic also implies that after Lancet retracted the original paper in 2004, public acceptance of MMR vaccine improved after Wakefield had been repudiated — but too late to prevent the measles upsurge.

Without supporting Wakefield’s methods, it’s still worth asking whether his 1998 paper should be held accountable for the decline in vaccine acceptability.  As early as February 1998, England’s Communicable Disease Surveillance Centre was reporting on the drop in MMR coverage from 1996 and ’97 data and BMJ reported in 2003 that the British trend was consonant with declines in MMR uptake in Europe generally:

[T]he experts say that coverage is substandard across Europe owing to a surprising lack of political will to implement an effective disease prevention programme, given the region’s stated goal to eliminate measles by 2007.

A decline in nationwide vaccine coverage to 80%  is probably less important as an explanation for increasing measles incidence in the U.K. than two other factors:  locally deficient MMR coverage and immigration from countries with lower vaccination rates.  In fact, measles increases in the UK seem to have been attributable to outbreaks in the northern part of the country and to high incidences among very young children in London, according the UK’s Health Protection Agency.

What’s to be learned from the Wakefield mess?

1. The role of pharmaceutical companies (including vaccine makers) in setting scientific agendas and moving policy remains an issue for many people.  Defenders of Big Public Health, like Mark Honigsbaum who writes an interesting piece in The Guardian today, tend to be dismissive of allegations that public health has become a game for technocrats in which corporations have too much sway.  But the defenders misunderstand those critiques.  The critics are not saying that government predictions are wrong where they should be right, nor that officials are on the take; the critique is this:  the relationship between profit makers and public agencies is sometimes awfully cozy and the attentiveness to real suffering is remarkably slight.

2. The pre-eminence of ethics boards, like Britain’s GMC, doesn’t always sit well.  With the Wakefield case, the MMR-autism controversy steps onto the slippery terrain of moral decision making in regard to research.  Many people don’t feel perfectly reassured about the ethics of medical practice when the overseers are themselves physicians, and the moral reasoning often seems restricted to “did the physician follow the rules?”

3. The stance of official agencies on autism doesn’t inspire confidence.  Vaccination is hard to exonerate as a cause of autism as long as the official approach is that autism is a disease, and by implication preventable — rather than a disability, which might or might not have a cause but whose sufferers, in either case, can be afforded decent lives.  To make matters worse, official agencies’ stance doesn’t defuse the controversy.  In the U.S. and U.K., they respond to anti-immunization claims with assertions about the safety of MMR in particular.  But they don’t seem to want to support the research that would test whether some children might be susceptible to damage incurred cumulatively by undergoing the numerous vaccinations that are scheduled for children today.  It’s unlikely that the scrutiny of immunization, or the controversy, is going to go away unless officials soften that stance.

We’ll probably hear more on this if the GMC rules to disbar Wakefield from practicing medicine.

Federal agencies are already scrambling to spin the disaster as a victory.  “From our point of view, this looks very successful,” CDC spokesman Richard Quartarone tells Stobbe.  Despite the fact (also noted in the AP story) that vaccine uptake was barely better among the flu-vulnerable groups who were the focus of the immunization effort:  22 percent of personnel at health care facilities, 38 percent of pregnant women.  Some success.

Apparently, New York State Health Commissioner Daines doesn’t want to be left off the victory train.  He announced on Friday that the law requiring immunization of staff of health care facilities would be enforced — even though a restraining order was issued by state Supreme Court Justice Thomas McNamara in October prohibiting enforcement.

(A federal district court judge in San Diego ruled this week in favor of the Rady Children’s Hospital’s union of nurses and technicians, according to San Diego CityBeat.  The union had requested arbitration of the hospital’s mandatory flu-immunization policy which, they claim, violates their collective-bargaining agreement.)

Health officials’ pandemic-flu-disaster story was flimsy from the get-go.  The evidence for a serious flu outbreak was slim, despite the attempts by officials and some reporters to make the situation look dire.  But through autumn 2009, at least there were some hospitalizations and deaths that served to maintain the sense of impending catastrophe that the disaster story sought to achieve.  Now, though, with flu activity in the U.S. less than usual for this time of year and no widespread occurrence of H1N1 flu reported, officials are playing with the numbers in their desperate attempt to peddle vaccine.

In her talk at Hunter College, for instance, Secretary Sibelius noted that “over a thousand” infants and children had died from H1N1 flu.  The CDC’s latest flu update counts 300 pediatric flu deaths from April 2009 through the beginning of the new year.  And it notes that about a third of the 236 pediatric flu deaths in the current season had bacteria cultured from sterile sites — suggesting the question of whether more timely medical care, rather than immunization, might have saved many of those kids.  Where the remaining 700 of Secretary Sibelius’s thousand pediatric flu deaths are to be found remains a mystery.

What’s happening here?  The federal government ordered 250 million doses of swine-flu vaccine last year.   Vaccine makers were looking at terrific earnings from this outbreak.  But they are now worried about losses in the anticipated $7.6 billion worth of global sales — because so much vaccine has gone unused.  Western European countries are stopping their orders and seeking to off-load existing stocks.  Americans don’t want the vaccine, at least not when swine flu seems to be less damaging than regular, seasonal flu and they aren’t feeling reassured about the safety of the rapidly produced vaccine.

Federal and state officials won’t let go, though.  It’s dispiriting.

The disaster in Haiti put the spotlight on suffering this past week.   Not just the tremendous death and damage from the event itself, but the penury and misery in which many Haitians lived even before they had to live with, or die in, the earthquake.  And the earthquake should have reminded anyone who was watching — which is to say, nearly everyone — to be appalled at the amount and degree of suffering in the world, even on days when there are no natural disasters making the news.

The disquieting thing, especially this week, is that people who are in a position to devote themselves to alleviating illness and dispelling misery — health officials, I mean — are preoccupied with covering up for their mistakes on flu and satisfying the needs of the pharmaceutical companies.  Instead of looking at the suffering in our midst.

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!”

At The Great Beyond, Daniel Cressey notes that Dr. Gerberding, while at CDC, was accused of promoting the Bush Administration’s agendas at the cost of scientific accuracy.  Naturally, now that she is heading for Merck, many are concerned about what looks like a cozy relationship between official agencies and pharmaceutical companies.

Merck says that its vaccine arm is worth $5 billion.  It “markets vaccines for 12 of the 17 diseases for which the U.S. Advisory Committee for Immunization Practices currently recommends vaccines,” according to the company’s press release.

Dr. Gerberding was close to the vaccine world as head of CDC. In fact, during her tenure there CDC’s   Advisory Committee on Immunization Practices (ACIP) called for the implementation of immunization against human papillomavirus and varicella zoster (chicken pox) virus and the agency pushed for expanded immunization against seasonal flu; within 10 months of her (January ’09) departure from CDC, the ACIP had issued recommendations for the use of anthrax vaccine and Cervarix and Gardasil vaccines against HPV.  Gardasil  is a Merck product.

But the problem is more than the “revolving door” metaphor implies.  To have a door there must be a wall — a clear demarcation between inside and out.   As if corporations (pharmaceutical companies among them) were outside of the official system, eager to get the ear of those inside.

Whereas it seems that there isn’t really much of a wall between official health agencies and big business at all.  To be an official today means taking a veritable oath of loyalty to corporate solutions.  The official has to deal in risk.  She has to be ready to sell risk as a kind of debt:  people should want to avoid risk, just as they avoid debt; but if their behaviors put them “at risk,” they can relieve it through “lifestyle” correction.  You can refinance if you know how.

The correction that allegedly relieves risk usually involves the use of better products. Cut out trans fats,  lower your cholesterol, elevate your mood, hop on a treadmill, lose weight, drink responsibly, get seasonal flu vaccine, get swine flu vaccine, wait patiently while the full-body scanners are used at the airport, eat more vegetables, wear sunblock, use hand sanitizer.  Health officials’ job is to get the means for personal risk reduction to the sorry at-risk population.  Have hand-sanitizer dispensers installed in public buildings.  Distribute condoms.  Publish recipes for healthy meals.

Notably, health officials are not supposed to argue for any of the things that would actually make a difference to the public’s overall health:  redress wealth disparities, provide excellent primary care for everyone (including immigrants), or build more decent and affordable housing.  When was the last time you heard a health official call for a campaign against poverty?

The official has to pitch personal risk reduction, in other words.  She has to be ready to support high-cost, individualized approaches to improving the public’s health — or well-being, which, Dr. Michael Fitzpatrick astutely notes at Spiked!, has replaced health as the main objective of modern Good Works .

Health officials keep faith with the dogma of risk avoidance.  Corporations preach risk reduction and peddle the wares by which people can restructure their lives — and avoid risk.  The wall separating government policy makers from corporate solutions gets more and more flimsy.

Nutty, but not so terrible, perhaps.  The policy is a transparent attempt by a not-so-wealthy university to seem au courant and curry favor with donors, who might like the idea that the school is addressing obesity — which the public health industry keeps insisting is a terrible problem facing young people.

Really, the obese-student policy at Lincoln doesn’t demand much.  Some students have to work out for a few hours a week (it’s a 1-credit course).  Not how they want to spend their time, probably pointless in terms of their health, but not the end of the world.

But pay attention to the commentary.

The director of another university’s center on higher-education law and policy voices concern — not over Lincoln’s feeble gesture at controlling fatness , but over medical confidentiality.  “Being put in a class with other ‘at-risk’ BMI’s walks a little close to disclosure,” he told the Chronicle.

The implication here is that obesity is an illness, and therefore only a physician should be allowed to know that you have it.  Certainly, your classmates shouldn’t.

How can obesity, of all things, be thought of as a secret that would only be revealed if you got into gym shorts and showed up on the treadmill in the fat-students’ class?

There’s a clue in the use of the term “at risk”:  obesity is like sleeping around without using condoms, driving drunk, or smoking near your kids  — it’s supposed to be both dangerous and shameful.  You would only admit being “at risk” to your doctor (who would, we have to assume, dutifully dissuade you from following your naughty instincts).

At the NYT blog The Choice, Rebecca Ruiz notes that the Lincoln faculty will be discussing the problem tomorrow.  So far, there’s been plenty of skepticism there, but a few defenders of the fat-class policy.  And most of the comments responding to Ruiz have been supportive of the idea that a university might require physical exercise.

What isn’t getting mentioned is race.  Is the policy popular because Lincoln is one of only two HBCUs in Pennsylvania, and some of the much-discussed “adverse outcomes” of obesity are conditions that are common among African Americans?  Do people feel  relieved that a predominantly African-American university is addressing a problem that seems somehow racial?  Do we feel reassured that a college that  doesn’t serve America’s traditional wealthy elite is taking on a problem that seems to be a threat to the elite — and a threat that seems born of the bad habits of the poor, especially the dark-and-poor?

Obesity is more common among people who identify themselves as African Americans — even at colleges, as a recently published study showed.  Here, and worldwide, obesity is mostly a problem of poverty.

Doesn’t obesity’s taint stem, at least partly, from the way it reminds Americans of poor people — and the dark-skinned poor in particular?

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

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

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

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

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

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

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

We think not.

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

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

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

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

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

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

Read the full post here.

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.

This month’s American Journal of Public Health brings us a primer (abstract here; subscription required for full text), written by lawyers supported by the Robert Wood Johnson Foundation, teaching “policymakers to avoid potential constitutional problems in the formation of obesity prevention policy.”

The article isn’t exactly a Steal This Book for the anti-obesity crusaders, but the authors’ stated aim is to help those crusaders skirt legal challenges to statutes that might, for instance, ban fast foods or require the posting of accurate calorie counts on restaurant menus:  “This primer is meant not to deter obesity prevention efforts but to foster them,” the authors adumbrate.

Of course, the anti-obesity crusade is well on its way to using the law to tighten the control of behavior already.  And the failure of restaurant calorie counts to show any effect on eating patterns isn’t dampening enthusiasm, it seems.

Brian Elbel of NYU and colleagues just reported in Health Affairs that the calorie counts now posted by law in New York (another piece of legislation backed by our bluenose mayor) don’t affect how much people eat,  based on a study of over a thousand New Yorkers from minority neighborhoods (abstract here, full article here).  At Freakonomics, Stephen Dubner surmises that this sort of program only helps people “who are already the most vigilant about their health and well-being.”  But it’s hard to find anyone in public health who is opposed.

They should be.   The public health industry, which likes to claim its main interest is human dignity, should be lobbying for less regulation of human appetites, not more.

But public health is often the pre-eminent paradigm of control in our society. Rename the acts or traits you find morally repugnant as diseases, and you can hand them to the health sector for management.   Once you say you’ve got an epidemic on your hands, you can count on the public health industry to respond.  Alcoholism, addiction, smoking, obesity, social anxiety… there seems to be a big supply of epidemics that used to be moral offenses or threats to the social order and are now opportunities for your doctor or your health commissioner — not your clergyman — to tell you how to act.

The neat thing about the control exercised through public health is that you never have to sermonize, read Bible verses, or prophesy Apocalypse.  The rhetoric of risk is a lot easier for the self-professed progressives in public health to swallow than religious sermonizing would be.  Even when the sermon and the risk rhetoric have the identical goal: wiping out the moral offense.

From Junkfood Science, we learn that

Employers will now perform random tests of employees for evidence that they’ve smoked outside of work and will weigh employees in the workplace and report their BMIs to the state. Employees deemed noncompliant with the State Health Plan’s employer wellness initiative, will pay one-third-more for health insurance. Employers believed that eliminating smokers and fat people would lower health costs.

And from WSJ Health Blog, that the CEO of pharmaceutical corporation Schering-Plough agreed (at a meeting at the Cleveland Clinic) that people with unhealthy behavior should pay more for health insurance.  Sure — you certainly wouldn’t want the wealthy to pay more.

That’s not the only problem with the public health industry’s vigorous embrace of behavioral control, but it’s a big one.  Start classifying people based on how they behave, and you begin discriminating against the ones who don’t act right.  But the ones who you think don’t act right are almost always the ones society was already discriminating against — the poor, most of all.

And even when the poor aren’t getting shafted in the crusade against the unhealthy, inquiry about how a just society should work is going down the tubes.  The profound moral-philosophical questions of what is the right way to live a life, the right way to raise children, the nature of liberty, and so forth, are surrendered in the public health paradigm – replaced with the simple dichotomy:  healthy vs. not-healthy.

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.