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.

Public Health Crisis or Publicity Crisis?

At Effect Measure today, revere draws a valuable distinction between the position of CDC and that of New York’s municipal government regarding the closing of schools to prevent the spread of flu.  Pointing out that “it’s a strain to which there is no natural immunity in the school population of students or staff,” revere notes that  CDC’s “first instincts were sound, and to their credit they have not engaged in the tendency to minimize the seriousness of the situation that [Mayor] Bloomberg and [Health Commissioner] Frieden have yielded to.”

Nobody knows how dangerous this flu strain might become, of course, but you can’t argue with revere’s logic from a contagion-control standpoint.  But is this really a matter of contagion control?  No, it’s not.

The Queens and Brooklyn school closings were announced amidst a political battle being fought on what, in New York, is always the bitterest of ground:  public schools.  The mayor took control of the public school system when he took office, but he needs legislation now to maintain that control  Parents are up in arms about the school system’s incapacity to provide seats in local schools for children as young as 5 years old.  The mayor can’t risk alienating any more parents — it would only take one child contracting flu in school and dying of it to provide fodder that could be fatal to the mayor’s effort to retain control of the schools.

Plus, the mayor is up for re-election.   Plus plus, the mayor is bringing in a new health commissioner (Dr. Thomas Farley) on short notice — one who is strongly allied with outgoing commissioner Frieden’s view that a good health official is a moralistic meddler in people’s lives.  Bloomberg needs to make sure everyone believes that the flu situation is dire so that his decision to forego a careful search and precipitately appoint as commissioner a Frieden colleague will seem wise.

By closing schools, Bloomberg resolves two legitimation crises, the disgruntled parents of mistreated grade-school children are deprived of one weapon to use against him, and — since the flu is mild and as summer is coming it will undoubtedly retreat soon anyway — Bloomberg is going to come out of this looking smart and proactive.

So be careful about interpreting the NYC school closings as a public health measure.  Politics and publicity are still the bottom line.  Welcome to Bloomberg’s New York.