Schafer is arguing for a precautionary-principle approach:  why would you take the chance of exposing a lot of people to a vaccine too new to allow its long-term effects to be known perfectly?  Especially, we might add, when the flu outbreak you are confronting is very mild, thus far?

Not everyone finds this satisfying, though.  In fact, some people feel there’s a duty to protect the public against the eventuality of widespread virulent flu. (Two facts should trouble this argument:  the historical fact that such a flu outbreak has happened exactly once in history, and the ancillary fact that, even in 1918, before flu immunization existed, the outbreak spared over 99% of the American public. But they don’t.  We’ll ignore them for now, just as most people do.).

Of course, if you really think there’s a duty to protect then you make immunization mandatory.  There’s precedent, and it’s been upheld by the nation’s highest court of law — in Jacobson v. Massachusetts (1905).  Justice Harlan, writing for the majority, held that the state of Massachusetts was within its rights to require Henning Jacobson to undergo smallpox vaccination when an outbreak threatened the city of Cambridge, and to fine him $5 for his refusal to be immunized.

The Jacobson case is taught in schools of public health as a prime assertion of the police power, i.e., the right of states to make laws to protect the public’s health.  And to validate the reach of such laws, even to mild intrusions on individual liberty. Harlan writes that “the liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint.”

But the nuances of Justice Harlan’s decision are instructive.  He made the point that the state’s legislature deemed smallpox vaccination to be effective and of minimal harm, and allowed the city to require vaccination only when a properly constituted board of health determined that that was necessary for public health.  In other words, the police power allows a state to limit liberty in the name of public health, but not for just any excuse, by any means, or without considering consequences.

And, we note, Harlan’s decision hinged on the legislative power.  That is, mandatory vaccination wasn’t  okay just because a board of health had said so; it was okay because the legislature had passed a law allowing the board to make such a decision, and the law was reasonable and sound.

Harlan’s basic standard was the “necessity of the case.”   Cambridge could make Mr. Jacobson undergo vaccination because the state law gave the board of health the power to decide when universal vaccination was necessary, in view of the situation.  And the board had looked at the situation, and decided that vaccination was indeed necessary

What should we make of that today?  In view of the current swine flu situation, should we then stand with Schafer, and argue that the most basic of the tenets — necessity — on which the police power is predicated has not yet been met?

Or should we say that the potential for a severe flu outbreak — a possibility not yet realized but, well, possible — creates a necessity to vaccinate?

Or is Jacobson simply out of date?

“We all want to believe that a pill or potion that comes from sea coral or from the Amazon jungle will cure that pain for which little else has worked,” Verghese writes.  The “flip side,” he says, “is that we are extraordinarily sensitive to any suggestion that someone is taking away something we think is good for our health.”

And magical thinking’s influence isn’t limited to cruising the natural supplements aisle or reading the ads in a health magazine.  Sometimes it’s part of expert opinion — and so it becomes part of widespread belief.

Consider how the flu experts talk about the possibility of swine flu’s return this fall. In Monday’s Washington Post, the experts’ words wax electric.  Dr. William Schaffner, chair of Preventive Medicine at Vanderbilt U.’s medical school, asserts that “The virus is still around and ready to explode…. We’re potentially looking at a very big mess.” And Dr. Arnold Monto, a physician epidemiologist at U. Michigan’s School of Public Health, worries “about our ability to handle a surge of severe cases.”

So, even as H5N1 reports that an article in The Independent finds scientists skeptical as to whether there will be a so-called second wave of serious flu outbreaks in the northern hemisphere this fall, we’ve got American scientists suggesting — in high-voltage terms — that something awful is going to happen.

They’re not wrong: something bad might happen.  That’s always true.

But language matters.  And language coming from so-called experts matters a lot.  It has magic.

Vigorous metaphors promote popular fears.  The last time swine flu came around, in early 1976, respected virologist Edwin Kilbourne published an influential op-ed piece in the NY Times (13 Feb 1976), called “Flu to the Starboard! Man the Harpoons! Fill with Vaccine! Get the Captain! Hurry!” Kilbourne urged officials to prepare for an “imminent natural disaster.” Fair enough:  a serious H1N1 flu might have happened in ’76 (it didn’t) — but his whaling metaphor appealed to more than just preparation.  It was about power and authority (“get the captain!”).  Presumably, the authority of science, industry, and government.

And so with other metaphors that are meant to be calls to arms.  There were the warfare metaphors about the alleged threat of bioterrorism, and the plague metaphors about AIDS.  Now, there are explosive metaphors about obesity.

Last year, acting U.S. Surgeon General Dr. Steven Galson called childhood obesity a “national catastrophe,” for instance.  And Dr. Risa Lavizzo-Mourey, president of the Robert Wood Johnson Foundation, warned of obesity’s “corrosive” effects, which, she asserted, imperil a generation of America’s youth.  According to Dr. Matthew Gillman of Harvard “You build [obesity] up over generations” — like an electrical charge in a capacitor, like explosive potential, the reader has to presume.

Talking about childhood obesity, Dr. Eric Hoffman of Stanford told the Washington Post that “we have taught our children how to kill themselves.”

Invoking metaphors to create magical thinking isn’t just an American habit.  Childhood obesity is a “time bomb,” according to physician Howard Stoate, chair of Britain’s All-Parliamentary Group on Primary Care and Public Health.

Verghese’s right.  People can be afraid to let go of what they believe they need for their health — however magically.  And magical thinking is inside the way our experts talk to us about health.  That sort of magic can run deep.

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.

Often, we do think about this – but usually by considering what the risks are and how to avoid them.  That means, we ask whether we can make life less harmful by changing something, and then we ask what change to make (and what it will cost).

Rarely do we ask: what sort of health do we expect – especially if we also have to accord that level of health to everyone?

There’s something about the risk question that goes against the concept of health for all.  Almost always, the risk we talk about pertains to us:  what can we affluent, educated people in the U.S. do to make sure we don’t get sick (or die) tomorrow? It’s not very often that we ask about risks for people who can’t get the recommended exercise or eat the recommended fruits and vegetables because they have kids and no job.  Not too often that we are concerned about the risks of medicating adolescents (see below) for people who can’t make such assessments because their kids are incarcerated.  When health = avoidance of risk, we mean “health for people like us.”

Not that the risk question is frivolous.  It gets particularly poignant when it comes to children.  For instance, Liz Borkowski posted a valuable note at The Pump Handle last week about the use of antipsychotic drugs for children.  She was commenting on a post by Alison Bass that was concerned with “shilling for Big Pharma,” about the death of a 12-year-old Florida boy who was on several medications.

Whether the world we’ve made is dangerous to our kids is a question that can’t be ignored.  But we also have to remember that it’s only one side of the story, and it’s only part of that one side (the part that pertains to people like us).

Often, we hear a plea for a deeper conversation about health.  It’s what we are hearing when parents of autistic children ask about vaccine safety, or others ask whether the prominence of the autism epidemic is going to translate into better treatment for autistic adults (as Karl Taro Greenfeld did in “Growing Old With Autism” in the NY Times, 23 May).

It’s what we are hearing when parents of troubled children allege that pediatric bipolar disorder is underdiagnosed or when others argue that it’s overdiagnosed.

These voices aren’t talking about risk; they’re speaking in a different register.  They’re talking about suffering, and the alleviation of suffering, and asking what sort of responsibility the society (or the state) is going to take.

Too often, we can only hear the risk part, not the alleviation-of-suffering part.  We react to the allegations that vaccines cause autism, for instance.  Some people are attracted by the lure of an easy-to-blame culprit (vaccines or other products of Big Pharma, immunization guidelines or other policies of Big Medicine) and join the bandwagon; others are repelled by the anti-immunizationists’ failure to venerate Big Science, and ridicule the parents who don’t want their kids vaccinated.  But not too many people interpret what they’re hearing as a cry for more caring, rather than a demand to identify risks.

In the health professions, we’re especially given to hearing such claims in terms of risk, rather than health-vs.-suffering.  For instance, we take notice when (as Sarah Rubinstein points out at WSJ Health Blog), the pharmaceutical industry talks about having a role in the conversation over the costs of health care  as the WSJ reported on 26 May.

But the reason we’re interested is often because we want to debate how to structure the healthcare industry rather than because we really want to discuss how much caring there should be in healthcare.

This isn’t a matter of idealism or some kind of touchy-feely hippie alternative to industrialized medicine.  It’s a real, and realistic question.  No rational person wants to give up effective medication for people who are suffering, or wants our society to stop doing research that would tell us if certain drugs might be harmful.  But to think only about the risks and not about the suffering part is to blind ourselves to the more difficult – and more essentially human – questions about health.

We learned that veterinarians from the Wildlife Health Center do rounds for all animals in NYC’s zoos and aquarium; animals needing special care are brought to the center.  Health records for all animals in zoos are electronic and are maintained with common software – making it straightforward for health records to be transferred whenever the animal is transferred from zoo to zoo, anywhere in the world, and of course facilitating research.

Animal health seems far removed from human health – not only in that it’s much harder for caregivers to see any person’s prior health records than it is for vets to see an animal’s.  We think of wildlife health as distinct from our own.  Even when an event like the 2001 foot-and-mouth disease outbreak in Britain causes us economic distress and affords people the ghastly sight of piles of cow carcasses piled up in farm fields, we don’t see the connections easily.

Increasingly, it’s becoming apparent that the health of human populations depends on equilibria in the wider world.  We have our military-style campaigns to defend Fortress Humanity from microbial invaders:  we use antibiotics, vaccination, and close monitoring of routes of ingress via food and water.  They work, at least up to a point.  But the evidence of MRSA, antibiotic-resistant TB, avian flu, S. Saintpaul in jalapeño peppers, and the new swine flu is that those measures aren’t perfect.  There’s not going to be any Conquest of Contagion (as Charles E.-A. Winslow put it in 1943),  and so-called victories such as the use of immunization to eradicate smallpox and control polio won’t be repeatable for every germ.

In the long run, as the One World, One Health movement suggests, we’ll have to shift to a much broader view of the planet as a system – in which we humans are co-resident with other species.  We might manage to ward off a serious flu outbreak with vaccine (the jury’s still out on whether the current swine flu strain can become highly damaging or not, but it’s reasonable to think that some flu strain might).  And we should improve food-safety systems to guard against outbreaks of salmonellosis and the like.  But we have to move toward a more complex understanding of how human health, animal health, environmental conditions, and international transfers of food, animals, goods, and people interact, especially with respect to the movements of microbes.

In that regard, it’s  troubling to learn from DemFromCT’s post at DailyKos yesterday that Sen. Max Baucus says that a new healthcare plan in the U.S. will not cover undocumented immigrants. It’s cruel, of course, to deny care to immigrants.  But it’s also shortsighted.

If we continue to have a huge, frequently mobile proletariat of migrant workers  forced by economic duress to travel from country to country in search of a living wage and we also make it impossible for them to get care, we’re harming ourselves.  Even those who aren’t moved by the humanitarian aim of ensuring all individuals a decent life should be moved by self-interest.  Creating a means by which disease and disability can move around with the people who suffer from them will undermine whatever arrangements we make for health.

One Health means we have to think about the interactions of many species – and it’s ridiculous to exclude some members of our own.

Nobody knows how dangerous this flu strain might become, of course, but you can’t argue with revere’s logic from a contagion-control standpoint.  But is this really a matter of contagion control?  No, it’s not.

The Queens and Brooklyn school closings were announced amidst a political battle being fought on what, in New York, is always the bitterest of ground:  public schools.  The mayor took control of the public school system when he took office, but he needs legislation now to maintain that control  Parents are up in arms about the school system’s incapacity to provide seats in local schools for children as young as 5 years old.  The mayor can’t risk alienating any more parents — it would only take one child contracting flu in school and dying of it to provide fodder that could be fatal to the mayor’s effort to retain control of the schools.

Plus, the mayor is up for re-election.   Plus plus, the mayor is bringing in a new health commissioner (Dr. Thomas Farley) on short notice — one who is strongly allied with outgoing commissioner Frieden’s view that a good health official is a moralistic meddler in people’s lives.  Bloomberg needs to make sure everyone believes that the flu situation is dire so that his decision to forego a careful search and precipitately appoint as commissioner a Frieden colleague will seem wise.

By closing schools, Bloomberg resolves two legitimation crises, the disgruntled parents of mistreated grade-school children are deprived of one weapon to use against him, and — since the flu is mild and as summer is coming it will undoubtedly retreat soon anyway — Bloomberg is going to come out of this looking smart and proactive.

So be careful about interpreting the NYC school closings as a public health measure.  Politics and publicity are still the bottom line.  Welcome to Bloomberg’s New York.

Frieden tried hard to reconfigure the role of the health official in 21st-century America.  He seemed to have recognized that health is on the main stage now in the policy theater.  And he’s been searching for a new role for the public-health physician.  As DemFromCT points out in yesterday’s DailyKos, Frieden handled the swine flu crisis well.  All good.

Still, it’s hard to applaud Frieden for his work during his tenure as commissioner here in NY.  Perhaps he couldn’t stand in the way of the moral juggernaut driven by mayor Mike Bloomberg.  Or maybe Frieden’s medical focus makes him share some of Bloomberg’s fervid disdain for the nasty bits of urban life — the smoking, the quick noshes, the hook-ups — even if not the bluenose moralism.  What can’t be denied is that Dr. Frieden and Mayor Bloomberg together promoted the myth that bad health is purely a matter of bad behavior.

The myth was an alarming break with the reality of the real causes of poor health, but it played well.  There was the ban on smoking in bars, the ban on serving trans fats, the constant hectoring about what we eat and how much of it, and the finger wagging about AIDS “complacency” and our failure to use condoms.  There were the restaurant closings on account of violating the health code (that was after the City’s health department had been embarrassed by media reports of rats in a number of food establishments).  Those were aspects of the stagecraft that has characterized the Bloomberg reign in NYC, but none of them had much impact on the city’s health.

What there wasn’t, under Bloomberg-Frieden, was any discussion of how to improve health through providing better housing – and Dr. Frieden seems to have raised no objection to the mayor’s new plan to charge homeless people rent for staying in city shelters. In fact, housing was off the health agenda entirely – although it has always been on Bloomberg’s, usually in the form of deals that would sell to developers middle-income housing or the land it stands on — even though decent housing would arguably have made more difference to the health of more people than trans fats ever would.

Neither did Dr. Frieden ever publicly argue for funding for public schools or prep-for-college programs on the grounds that education translates into better health.   Great opportunities for real change were passed up in favor of preserving the myth of behavioral risk.

In the recent crisis over swine flu, Frieden was statesmanlike – and we have to hope he’ll show similar circumspection and gravitas as CDC Director.   At Effect Measure, revere points out the need for good management at CDC.  But we also have to hope that, once free of Bloomberg, Dr. Frieden doesn’t bring the same moralistic sermonizing to the matter of disease control.