Philip Alcabes discusses myths of health, disease and risk.

Cholera: A Shame, Not a Whodunit

Titling Maggie Fox’s article on the source of the Haitian cholera outbreak “Whodunnit?,” Reuters makes distraction the main attraction.

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

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

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

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

Here’s the segment of The Takeaway:

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

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

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

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

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

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

Media Culture: Beyond Fat and Salt?

Over at Media, Culture & Health, Steven Gorelick notes that a story on salt and the food industry, which appeared on page A1 of the print NY Times on Sunday, would not have made the front page in the past.

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.

Fear and Flu

Kudos to Revere, for two enlightening posts on flu — which bear on an important issue in the health realm today.

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.

Risk, Opportunity, and Care

We’re off this evening to Ukraine and Poland, for a trip involving family heritage and some literary-historical exploration (as well as visiting with friends).

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.

How to Cover a Health Crisis – or Make One

A post by revere at Effect Measure reminded us that the pandemic preparedness initiative had an intrinsic ineptitude to it.  “CDC had been training state labs to make the differentiation between the two seasonal flu subtypes, H1N1 and H3N2, and bird flu, H5N1, so the capability to do seasonal subtyping already existed outside of CDC. But neither the reagents nor the proficiency for the new swine virus did.”

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.