Philip Alcabes discusses myths of health, disease and risk.

Pandemics, politics, poverty

At Junkfood Science yesterday, Sandy Szwarc exploded some of the myths about the swine flu outbreak.  Although much is made of the fact that the hospitalizations and deaths associated with H1N1 flu infection have predominantly been among children and young adults, Junkfood notes that those numbers are no higher than in past flu seasons.  Her post quotes Dr. Anne Schuchat of CDC, who reminded the media at a May 28th briefing that seasonal flu generally comprises a mixture of H1N1, H3N2, and B influenza strains – and that H1N1 strains tend to cause relatively more illness among the young.

“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.

Does Health Mean More Than Avoiding Risk?

If our society is going to be  healthy population it will mean making everyone healthy.  Self-evidently we’ll also have to think about what it means to be healthy.

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

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

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

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

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

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

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

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

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

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

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

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

It isn’t health if it isn’t for everyone

A couple of weeks ago we toured the Wildlife Health Center at the Bronx Zoo with Dr. William Karesh, director of the field veterinary program for the Wildlife Conservation Society and VP for WCS’s Global Health Program.

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

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

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

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

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

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

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