Philip Alcabes discusses myths of health, disease and risk.

W.H.O. and the Medical Industry

At EP-ology, Carl Phillips has a new post on the World Health Organization’s failure to care about suffering.   It’s worth reading — especially if you (still) believe that the WHO’s main aim is promoting health.

Phillips’s focus in that post is on a new WHO Atlas on headaches

and the problem that headaches cause people to stay home from work, or work less productively.   The agency estimates that Europe-wide, the lost productivity from migraines alone is worth 155 billion euros each year.  It isn’t that you feel crummy when your head hurts, and that chronic headache makes your life miserable.  It’s that you might not perform your expected per-capita service to the expansion of wealth.

Here’s how EP-ology assesses the agency:

The WHO is not the humanitarian organization that many people might think it is.  It is a special-interest medical-industry-oriented organization with an emphasis on the interests of governments, not people.  Its emphasis on productivity in looking at headaches … ignores people’s welfare…

Now, I can’t agree with Phillips’s analysis that the WHO’s ethical system is either “communist” or “fascist.”  For self-described public health agencies like the WHO to be concerned primarily with productivity and the generation of wealth — and only secondarily, if at all, with suffering — has been a hallmark of capitalism since the British Parliament passed the world’s first Public Health Act in 1848.

In fact, the laws institutionalizing public health in Britain in the late 1840s were passed by the Whig (liberal, more or less) government of Lord John Russell.  Public health was a legacy of efforts not by the nascent socialist and communist movements, but by radical capitalists — who sought to secure a moderately hale labor force to serve British industry with little cost to the factory owners.  And aimed to blame individuals for their own misery.

But it’s impossible to disagree with the main point of Phillips’s post:  WHO’s aim is to serve industry.

As further evidence, consider this follow-up note on Tamiflu by Helen Epstein, published in the May 26th issue of NY Review of Books (I discussed Epstein’s main article in a post last month).  It seems more and more apparent that potential dangers of Tamiflu (oseltamivir) in children were ignored.  Epstein reports that

the risks of delirium and unconscious episodes were indeed significantly elevated in children who took Tamiflu, especially if they took the drug during the first day or so after influenza symptoms appeared….  If these results are confirmed, they are especially worrying, since the World Health Organization and the US Centers for Disease Control both recommend that Tamiflu be taken as soon as possible after symptoms appear.

I was not the only one unaware of this important study; neither, apparently, were the World Health Organization, the US Food and Drug Administration, and the US Centers for Disease Control. When I contacted these agencies in January and February 2011, their spokespeople assured me that there was no evidence that Tamiflu causes neuropsychiatric side effects in children. [emphasis added]

In the rush to move taxpayer monies into the hands of wealthy private corporations, the WHO (with CDC and other agencies) proclaimed a flu emergency in 2009.  And ignored evidence on possible dangers of the products they were touting as part of the “preparedness” response.

Profiting from Preparedness

Don’t miss Helen Epstein’s brilliant exposé in the latest issue of The New York Review of Books. She shows how the profit motive shapes the “preparedness” industry — worth $10 billion worldwide in 2009 (the year of the Flu Pandemic That Wasn’t).

I’ve covered the profit-motivated thinking behind vaccine recommendations generally and specifically with regard to flu immunization.  Epstein’s main interest is in the role of pharmaceutical companies in promoting oseltamivir (Tamiflu®) and other neuraminidase inhibitors as public health responses to flu fears.  Her story features the brilliant work of Tom Jefferson and colleagues, and the shady behavior of the global biotech firm Roche in trying to block Jefferson et al.’s efforts to investigate the safety of neuraminidase-blocking agents.

Jefferson was lead author on the Cochrane Collaborations’ main paper on neuraminidase inhibitors for flu prevention and treatment.   But when reports of adverse effects of these drugs emerged and he and colleagues tried to re-assess the underlying reports on which the effectiveness of oseltamivir and similar drugs was based, Jefferson was stymied.  His colleague, Peter Doshi, related the story in BMJ.   The journal’s editor-in-chief, Fiona Godlee, along with Cochrane director Mike Clarke, wrote in an accompanying editorial:

The review and a linked investigation undertaken jointly by the BMJ and Channel 4 News cast doubt not only on the effectiveness and safety of oseltamivir (Tamiflu) but on the system by which drugs are evaluated, regulated, and promoted.

The take-home message is that while there is evidence that Tamiflu can be effective in treating flu, the evidence is shakier than it seems, and troubling reports point to potentially serious adverse effects.

How does a questionable medication get to be the basis (or part of the basis) for public health policy?  The answer is that the policy makers and the money makers work hand in hand.

Maryann Napoli at Center for Medical Consumers tried to point out the troubling links between WHO and big pharma last year, and Steven Novella at Science-Based Medicine brought it up around the same time.

But most of the coverage focuses on the involvement of individual scientists and/or physicians who are receiving payments or other forms of remuneration directly from drug companies.  It’s not hard to police such straightforward conflicts — and so it was easy for Margaret Chan, WHO Director-General, to say last year that “at no time, not for one second, did commercial interests enter my decision-making.”

Epstein’s great contribution is in showing that obvious conflicts of interest aren’t the main way that for-profit companies influence policy.  It’s done through stonewalling, as Jefferson encountered when he tried to examine Roche’s data.  It’s done through widely accepted collusions.

For instance, the CDC Foundation — “Helping CDC Do More, Faster” is its motto — is a nonprofit organization, created by the U.S. Congress, whose job is to

connect the Centers for Disease Control and Prevention (CDC) with private-sector organizations and individuals to build public health programs that make our world healthier and safer.

Of course, calling them “private-sector organizations” suggests that these are not-for-profits — and some, like the District of Columbia Department of Health, the Medical College of South Carolina, and UNICEF, really are.  But most of the private-sector collaborators who are linked with CDC’s policy makers by the CDC Foundation are big corporations.  They include all the giants of Pharma world:  Merck, Pfizer, Roche, Sanofi-Pasteur, etc.  (They also include some who are just giants:  Google, Dell, YUM! Brands, and IBM, to name a few.)

So when CDC’s updated flu response plan now recommends antiviral (i.e., neuraminidase-inhibitor) treatment “as soon as possible,” it’s worth asking whether this is because it has any public health value (answer:  no) or just because CDC is cozy with companies that make money when people get sick.

Nuclear Energy and Risk

Elizabeth Kolbert is a fine science writer.  Her explanations of the complicated mechanisms — geothermal, marine chemical, atmospheric, and so forth — underlying climate change are clear and compelling.

But I confess I’m no fan of her work.  Kolbert’s sky-is-falling! rhetoric is a little too florid, and her criticism of people who don’t act environmentally a little too pointed.

Yet, her short piece in this week’s New Yorker, “The Nuclear Risk,” is terrific.  It’s worth reading.   She gets at a central lesson of the radioactivity crisis that followed on the earthquake + tsunami disaster:  you can only plan for the disasters you’re able to conceive of.  The Japanese catastrophe, she writes

illustrates, so starkly and so tragically, [that] people have a hard time planning for events that they don’t want to imagine happening. But these are precisely the events that must be taken into account in a realistic assessment of risk. We’ve more or less pretended that our nuclear plants are safe, and so far we have got away with it. The Japanese have not.

That the nuclear crisis is supposedly under control now, or might be under control if some new problems are dealt with, doesn’t change the planning problem (and have a look at this blog post by Evan Osnos for a worrying take on what happens to people who are facing such a triplex disaster scenario).

Kolbert relates the problem of nuclear planning in the U.S. to corporate interference with regulatory agencies, quoting the Government Accountability Office’s finding that the Nuclear Regulatory Commission has based its policies

on what the industry considered reasonable and feasible to defend against rather than on an assessment of the terrorist threat itself.

It’s disturbing that industry and regulators are on intimate terms, but it isn’t exactly news — not in regard to energy policy, nor health policy (for example, consider the CDC’s Advisory Committee on Immunization Practices, which I wrote about a year ago).   The comfortable collusion between corporations and government agencies is an issue — but it’s not the most troubling lesson of the Japanese crisis.

Rather, the main event is the inevitability of unforeseen and unforeseeable disasters.  And the simple impossibility of making plans to avoid what can’t be imagined.

Which is where I part company with Kolbert.   Would better planning (or stricter regulation of industry) have avoided the near-catastrophic radioactive release at Daichii?  Yes, perhaps.  But nobody could have foreseen an earthquake of this magnitude, or infrastructure so destabilized by a tsunami as fast-moving and destructive as this one, or the double-punch effect occurring where it did and how it did.  There’s only so much you can plan because there’s only so much you can envisage.

And that’s the problem with the idea of planning to reduce risk.  You plan for what you know. Maybe you plan for something a little worse than what you’ve seen before — but even that is basically what you know, with a little juicing to make it livelier.   Even the pure-fantasy regulatory agency — the one with firewall immunity from influence by industry, perfectly competent engineering of its plans, and state-of-the-art technology — can’t foresee every eventuality.  Therefore, even the best planning won’t eliminate risk.

In the end, the question isn’t just how to keep the energy industry away from the regulators.   It’s how to live in a universe that isn’t completely predictable, no matter how good you think your “science” is.   And is ruled by random, implacable, and sometimes highly destructive nature.

Why Vaccinate Children Against Flu?

Scientists shill for vaccine manufacturers in doing routine research.  This week, HealthDay reports that University of Rochester researchers found lower flu-immunization coverage in states with less Medicaid coverage for vaccination.   Instead of asking whether pediatric flu immunization has any public health value, research like this assumes that flu immunization is useful.  It helps make sure the vaccine manufacturers sell more flu vaccine.

What is the value of mass immunization of children against flu?

CDC claims that flu is dangerous for children and recommends immunization.  This claim seems to be based on the 50 to 150 pediatric deaths attributed to flu each year.  Preventing children’s deaths is a good reason to immunize those who might get very sick were they to be exposed to influenza.

But to translate a small number of possibly preventable deaths into a national policy of mass immunization?  That takes a special relationship with the vaccine manufacturers (see here and here and here and here for my comments on the collusion of officials with pharmaceutical interests).

The evidence that flu vaccine is effective in children is shaky, as Dr. Tom Jefferson’s exhaustive scrutiny of study data reveals.  Immunization of children seems to be weakly effective at reducing influenza-like illnesses in a general population, as Ritzwoller et al. showed in a study published in Pediatrics in 2005.  Partial immunization was ineffective — an issue worth considering if more than a single dose is required.

A few studies suggest that mass immunization of children is a way to prevent flu among young adults.

A community trial of immunization of children against flu, published in Vaccine in 2005, showed the ineffectiveness of immunizing children:  there was no reduction in acute respiratory illnesses among children in the concurrent or subsequent flu seasons, compared to communities where kids were not immunized.  There were slight reductions in ARI incidences among adults in the community where children were immunized — but this study wasn’t designed to show whether it was the immunizing of kids that protected the adults, or something else.

Similarly, a 2000 study published in JAMA by Hurwitz et al. showed that flu immunization of children in day care had the effect of reducing acute febrile illnesses among household contacts, compared to household contacts of daycare attenders who were not immunized (abstract here, full article requires subscription).  So immunizing children in daycare might help their parents to avoid getting sick.

In general, there’s suggestive evidence that mass immunization of small children against flu lessens the impact of flu outbreaks among young adults.

But few young adults die of flu.  It’s an annoying and sometimes serious illness.  The reason the public health authorities are interested in preventing flu among young adults isn’t to reduce suffering; it’s to keep them from staying out of work.  Should we immunize children so that the nation’s economic machine doesn’t slow down?

To put it a little differently:  should we shift large amounts of taxpayer money into the hands of pharmaceutical and vaccine manufacturers for the purchase of flu vaccine for children, basically in order to spare employers the loss in profits that would arise when workers stay home?

The news from ProPublica this week, that they and associated journalists found many cases of physicians taking money from big pharmaceutical companies, is alarming but comes as no surprise.  ProPublica’s new searchable database shows that the seven pharmaceutical companies (collectively accounting for 36% of market share) that provided data together made $257.8 million in payments to physicians.

What’s more alarming is that pharmaceutical companies often don’t even have to bother paying to push their products.  That’s especially true when the product is a vaccine.  Even flu vaccine, despite its limited and highly variable effectiveness.  Policy decisions made by the Advisory Committee on Immunization Practices and CDC, practice decisions by medical organizations, research-grant funding, and so on are thoroughly organized around immunization.  Despite the evidence.

Public Health Priorities: Follow the Money

Thanks to Crof at H5N1 for bringing to our attention a strong editorial in yesterday’s Bangkok Post.   The editorialists note that H1N1 preparedness efforts were not always successful and that WHO, fresh from announcing that the H1N1 pandemic is over, is now promoting fears of renewed outbreaks of H5N1 (avian) flu.  The editorial continues:

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.