Philip Alcabes discusses myths of health, disease and risk.

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.

Cookie Crisis: Toxic Food Environment or World Food Shortage

One by one, the foods that seem most American are turning out to cause illness.  Last year, people got sick from Salmonella St. Paul in fast-food tacos (the jalapeño peppers were contaminated) and then others from Salmonella typhimurium in peanut butter (back in 2006-7 there had also been an outbreak of salmonellosis associated with eating peanut butter).

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.