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.

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.

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?

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.

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!”

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.

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?

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?

Alex Jones reports that the proposal was ratified early this month, over the objection of the NY State Nurses’ Association.

Word on the street is that NYC’s Department of Health and Mental Hygiene is now getting into mandatory vaccination in a big way.  It is strong-arming medical centers into forcing their staff to undergo flu vaccination, telling administrators, we hear, that they would be required to fire employees who refuse to undergo flu immunization.   And the mandate would extend beyond direct-care personnel, to include general staff — anyone who might come into contact with a patient.

Since specific vaccine against H1N1 flu is not yet ready, the current plans are said to be for mandatory vaccination against seasonal flu; presumably swine flu vaccine would be added if it becomes available.

No official substantiation yet of the NYC officials’ actions — in fact, we really hope we’re wrong on this.  But we notice that requiring universal vaccination for health care workers would not be out of line with the city’s Pandemic Influenza Preparedness and Response Plan — especially chapter 7, “Vaccine Management.”

Clearly, a plan to require immunization of all health care workers — in a city whose health care workforce numbers in the hundreds of thousands — could be a boon to the vaccine makers.

Would it help the public?   If this coming flu season is mild, universal immunization of medical-center staff will be at least partly superfluous.

If there’s a widespread outbreak of virulent flu, the effectiveness of mandatory vaccination in health care centers would depend on the current level of flu-immunization coverage among med-center staff.   As many caregivers routinely undergo seasonal-flu immunization anyway, it isn’t clear that mandatory immunization orders would add any public health value to the current situation.

So far, there hasn’t been much outcry from the public health profession. Perhaps that will change as we get into autumn.

“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.

Last Tuesday, a post by Revere at Effect Measure highlighted the effect that cultural anxieties have on the production of scientific knowledge — specifically with regard to modes of contagion.   In the 1920s, a time of worry about immigrants and socialists, public health “concentrate[d] on society’s most marginal people, in keeping with the Zeitgeist.”  Thus Typhoid Mary, and other concerns about germ carriers.  By contrast, when the environment is of most concern, people worry about transmission via objects — fomites in our odd epidemiology jargon (from Latin fomes:  touchwood or tinder).  There are reminders to wash hands after touching the subway handholds, not to handle other kids’ toys, to think about doorknobs.

On Thursday, “Swine flu this fall:  turbulence ahead” took the time to work through the results of mathematical modeling — a highly readable post which explains why some modeling results suggest a rationale for the belief that swine flu might spread intensely in the northern hemisphere this fall.  Revere does the favor of reminding the reader that models are not always good predictors of what will happen.

History shows that the metaphors that guide scientists’ focus in tracking contagion aren’t always perfectly either/or.   They don’t alternate neatly between people-directed or environment-directed, that is — more typically, many myths and metaphors compete for attention, with certain ones winning out at any given moment.  Now, the alleged toxicity of the environment seems very compelling to some people, and there are also contagion concepts based on fears of foreigners, suspicions of supposedy nefarious corporations, worries about open borders, anxieties about public education, concerns that governments keep secrets, and so forth.

The guiding metaphors for contagion breathe life into moral, political, or profit-making campaigns.  The magic-bullet concept remains compelling, for instance, and perhaps accounts for some of the interest not only in Tamiflu but in whether or not flu strains are resistant to it, and whether or not it will be made available,  to whom, and at what cost.  There’s a post at H5N1 on this today.

But there’s an overarching truth about swine flu:  our society can’t seem to leave it alone.  No matter how small the tally of confirmed H1N1 flu deaths (WHO counted 1154 as of the end of July, the European Centre for Disease Prevention and Control‘s report today puts the number of deaths at 1645 — but even the higher number yields an exceptionally low case-fatality ratio:  under 0.1%, roughly on the order of seasonal flu.  So this remains a far-reaching but so-far mild outbreak.

Yet the question of whether or not it will become more severe — more virulent, more deadly — remains front and center for public health people, and stays alive as a media story.

Okay, yes, it’s important to be prepared.  It would be shameful if there were deaths that would have been preventable with a little forethought and planning.

That accounts for the assiduous tracking by serious public-health people.  But what accounts for the prominence of this rather mild outbreak in the public consciousness?

This is an era of epidemics.  Which is to say, it is an era of fear.  There must be something wrong, it is so easy to think.  This is not just the work of media (although they help, and it doesn’t hurt that playing on fear sells).  It runs deeper than that.  Our modern civilization seems, sometimes, deeply uncomfortable with the world we’ve created.

Last Thursday, for instance, the  New York Times ran a story featuring a study that claimed TV viewing is linked to blood pressure increases in kids.  It’s a story of toxicity in the constructed environment — of the ways contemporary arrangements are inherently and latently harmful (yes, latently:  TV isn’t causing kids to shoot other kids, at least not in this story; it is allegedly causing them to develop a so-called risk factor for later harm).

How do we keep an eye on flu, or other outbreaks, and seek ways to protect everyone from harm as best we can, but avoid hysteria about contaminated toys, subway riding, TV viewing, processed foods, and so forth?  This is a challenge.  It means examining what makes us anxious, and it means understanding that life has risks that can’t be avoided.

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.

“Declaring a pandemic has more to do with politics than with medicine or helping you to stay safer. In fact, responses to fears about a pandemic are far more frightening and dangerous than the flu itself,” Junkfood Science points out.

At Effect Measure, a post by revere on 6 June voices skepticism over the utility of the W.H.O.’s pandemic threat alert system.  revere writes, “The WHO pandemic alert system, which was instituted in 2003 and had never been seriously tested until this outbreak, immediately met a pandemic it couldn’t handle, not because it was so severe but because it wasn’t severe enough. “  revere finds the threat alert system to be “more of a problem than a help.”

A report out this month on “Pandemic Flu” from the Trust for America’s Health, asserts that “Investments in pandemic planning and stockpiling antiviral medications paid off,” but “even with a mild outbreak, the health care delivery system was overwhelmed.”  Still, this report noted that the “WHO pandemic alert phases caused confusion.”  This is reassuringly un-martial talk for a group whose report is subtitled “Lessons from the Frontlines” and which is partially funded by the Center for Biosecurity.

We agree that the pandemic alert causes confusion – and, we’ll add, consternation – and concur with Junkfood that the alert is about politics.  But W.H.O. gets an overly bum rap.  The agency has been trying to leverage its clunky threat-alert barometer to help health officials in poor countries to plead their case for more funding or better programs, and to get us in the rich countries to notice that it’s the poor who suffer when a disease spreads globally.

The pandemic barometer as constructed is too crude an instrument for that.  As revere points out at Effect Measure, the system could be “scrap[ped]… in favor of an up-to-date information system.”

But the important point will be to shift the focus.  The medical and public health industries have to stop thinking about flu (and other contagions of world importance) as a problem only when Americans’ health is threatened.  The health sector has to start paying much more attention to the conditions under which viruses become epidemic (i.e., human disease) problems:  the many ways that humans and animals interact, especially through markets for wild-animal meat, and the interactions of wild with domesticated animals; economic conditions in poor countries that make it impossible for people to stay out of the way of virus traffic; and the poverty, crowding, and compromised health that make it easy for some viruses to spread once they start adapting to humans.

Instead of worrying about airplane passengers landing at U.S. airports, the focus should be on the real conditions that most of the world – and its viruses – lives in.

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

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

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