Map of life expectancy at birth from Global Education Project.

Wednesday, June 10, 2009

The Real Harm from H1N1 Influenza

Lawrence Gostin in the new JAMA -- subscription only I am pained to say -- takes the occasion of the recent H1N1 flu brouhaha to discuss pandemic preparedness. You are permitted to read the first few words here, Influenza A(H1N1) and Pandemic Preparedness Under the Rule of International Law, for what it's worth.

Let me say right up front that although Gostin acknowledges the possibility that this strain of virus could somehow mutate to become more dangerous, there was never any particular reason to expect that, and since he wrote experts have developed further understanding of this particular strain which makes it appear even less likely. The fact is that were it not for the enhanced surveillance systems and viral genome testing capacity put in place recently, largely in response to the H5N1 bird flu scare, we would never have known that anything was happening at all regarding H1N1 influenza. We would have observed nothing out of the ordinary, and there would have been no story. As of now, we would simply have an essentially normal end to the flu season in the northern hemisphere, and a normal beginning to the season in the south. For all practical purposes, that is the situation in fact, but we are burdened with widespread and damaging overreaction to this non-event.

Gostin calls for an international regime with greater enforcement powers in anticipation that something more significant might occur some day, and he also calls for more coercive authority on the part of our domestic CDC. I will return to these issues later, but first I must say that the real events he describes constitute a narrative, not of ineffectiveness or excessively cautious response, but rather of overreaction and a response which exclusively did harm, and no good whatsoever. He writes:

On April 29, WHO raised the pandemic alert level to 5, the second highest level . . . . The alert system is based on geographic distribution of sustained spread among humans without due regard to the actual health threat because it could entail relatively mild disease. The threat level, moreover, could heighten fears and cause the public to overreact.*

Indeed. And while the director-general can issue recommendations, she "did not recommend travel or trade restrictions, screenings, or examinations." Well, there is no reason why she should have; there was no scientific evidence that any such measures would have done more good than harm. Gostin notes that nonetheless:

  1. China and Hong Kong quarantined travelers from North America, including 22 Canadian students with no symptoms, 300 guests and employees who happened to be in a hotel where a Mexican man was isolated, and everybody in Singapore who happend to have visited Mexico was quarantined.

  2. "Social distancing" measures included closure of 700 schools in the U.S., disrupting the education of 245,000 children, although the CDC reversed its recommendation regarding school closure after 4 days. (Of course, it never should have made it in the first place.)

  3. Numerous countries restricted travel to and from Mexico and banned meat from North America, causing economic damage. In fact Mexico's GNP declined by up to .5% in a few weeks.

  4. Egypt culled 400,000 pigs, an act of irrational discrimination against the country's Christian minority

As Gostin writes, "epidemics often bring out irrational fears and discriminatory behaviors among individuals and governments." It is obvious that these irrational and harmful responses were driven largely by the grotesque overreaction to this event on the part of the corporate media, an overreaction echoed and reinforced on putatively liberal blogs and web sites such as the Huffington Post and Daily Kos. For weeks, the exclusive public health-related focus of these sites was this perfectly ordinary, non-threatening non-event. Regardless of the exact content, excessive coverage inevitably creates the impression that the issue is extremely important, urgent, and ought to preoccupy us. That impression was false, misleading, and damaging.

Let me just conclude by noting that Gostin says that the CDC's legal authority "to prevent the introduction, transmission, or spread of communicable diseases into or within the United States" has "limited applicability" and would be challenged should it try to exercise it. I'm not entirely sure what he means -- the pandemic flu plan is available here and as you can see it presumes very broad powers that would no doubt surprise most people and perhaps strike some as undemocratic. CDC has submitted revised regulations which Gostin considers more effective, but which are as yet in limbo.

I do not personally object to the government having emergency authority in case of dangerous infectious disease outbreaks or epidemics, but I do feel that this ought to be subject to a full democratic airing which it has not had. I have gotten a couple of e-mails from readers who have stumbled across the facts about this authority and become all worked up about totalitarianism and concentration camps. I've tried to talk them down but obviously we have a failure here of democratic process and perhaps of adequate legal checks and balances.

Finally, Gostin makes one observation which I heartily endorse:

Federal and state legislatures have also allocated inadequate resources to the CDC and state and local health departments. As the cost of health care has soared, only about 2.5% of health spending has been allocated to prevention and public health.

We can certainly do better than that, without running off yelling that the sky is falling.

*In the elided section he notes that the alert does not trigger any actual powers or require any action, which of course makes it utterly pointless.


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This is rare because had a time when we were heated by Influenza, it was really rare because now we don't hear anything about it, I'd like to know why it happened.m10m

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