Map of life expectancy at birth from Global Education Project.

Tuesday, November 03, 2009

Why we really, really need to stop talking about the #&*!@ flu.

I have written quite a lot about how inappropriate and misleading is the massive media obsession with the "novel" (not really) H1N1 influenza strain that's going around. It's misleading because influenza, even if we are having a somewhat worse flu season than average, is just not a very important cause of morbidity and mortality in the United States; but it's even more misleading and damaging to the political discourse because it drives out discussion of what is really important in public health, which is inequality, poverty, and political power. Flu is largely apolitical, and the more we talk about it, the less we talk about issues that really matter.

Regarding morbidity and mortality, the vast majority of people who get the flu get over it in a few days and then they are perfectly fine. The National Center for Vital and Health Statistics attributes around 36,000 deaths each year to influenza, which is way down the list of causes; and that will be true even if the absolutely worst case predictions come true this year (which at this point it is clear they will not) and we have 3 times the usual number. And most of those attributions are questionable anyway. What's more this will be over in a few months, whereas our other problems are still with us.

Approximately 6,650 Americans die every day. More than 1,700 of those deaths are attributed to heart disease, the number one cause, with cancer not far behind. About 122,000 Americans die of unintentional injuries every year. But in fact the actual, underlying causes of these deaths are largely social determinants subject to political responses: tobacco marketing, poverty, environmental contaminants, social stress, inadequate mass transit, you name it.

For example, there is the epidemic of obesity, which is associated with all sorts of major chronic illness and disability including diabetes, heart disease, cancer, blindness, loss of limbs, and kidney failure. And yes, it's affecting children more and more. And it's a political issue. The average child in the United States sees 15 television food ads every day, that is 5,500 per year. Food companies also market their products in schools and on the Internet, and they place products in TV shows, movies, video games and music. More than 98% of TV food ads seen by children are for high-calorie, low nutrition foods -- full of fat and sugar. There is consistent, direct evidence that TV food advertising causes kids to eat the advertised foods. Our agricultural policy, that subsidizes corn and its sugar that find its way into most of that junk food, either directly or by fattening up chickens and cattle, makes toxic junk food cheap compared to fruits and vegetables. This is not a failure of personal responsibility or even a cultural failing. It is a political issue. It is a public health crisis caused by corporate greed.

In fact, social inequality is by far the leading cause of premature death and disability. If death rates were equalized between Black and white Americans, there would be almost 84,000 fewer deaths in the United States each year. That's far more than influenza will ever cause. And yes, these premature, preventable, politically and socially determined deaths include more deaths of children than influenza will ever cause -- children are far more likely to be murdered than they are to die of the novel H1N1 influenza.

And of course, taking a global perspective, it's even less important. While we have been obsessing about influenza, pneumonia unrelated to flu has been killing a little kid every fifteen seconds. The new issue of Health Affairs gives us lots of information about the real burden of infectious disease in the world -- and no, it doesn't even mention influenza. There's HIV (sorry, abstract only to non-subscribers) which today infects more than 30 million people, with 4.1 million new infections every year, and only 1.3 million more people getting treatment -- in other words, we're falling farther and farther behind. And there are innumerable infectious diseases you probably never heard of -- 50 million people get dengue fever every year, 12 million are currently living with Leishmaniasis, 128 million people have lymphatic filariasis, 807 million have ascariasis, 37 million people are infected with onchocerciasis and nearly a million are totally blind or visually impaired as a result. I could go on and on but you get the idea.

And these diseases are not limited to poor countries. They are right here in the U.S. The prevalence of HIV in the District of Columbia -- yes, the capital city of the United States, in the shadow of our greatest symbols of national power -- is more than 3% among adults -- comparable to Nigeria and Angola. And the prevalence in black men is more than 6%. Poor people -- Black and Latino and rural white -- in the United States, are infected with some of those diseases you never heard of. As many as 4 million people, mostly African Americans in the south, are infected with ascariasis, which causes stunted growth and cognitive impairment. Toxocariasis may infect as many as 2.8 million Americans, again mostly African Americans. Latinos are subject to Cysticercosis, Chagas disease, and Dengue fever.

So why do we hear about nothing but the flu? Because it can affect rich white people, that's why. Because it has nothing to do with justice, or inequality, or politics. Because it's a convenient diversion to stop anybody from talking or thinking or doing anything about issues that really matter.

Time for it to stop.

Update: Just for the heck of it:

[I]t can't be denied that in most cases, the infection has run an astonishingly mild course. And the question of whether the WHO overreacted will only become more pressing. Some experts expressed criticism early on, saying that before declaring phase six, the WHO quickly modified its own definition of a pandemic. The organization simply disregarded the criterion that stipulates a very high mortality rate must first be present, and changed passages accordingly in the pandemic definition on its Web site. If the virus turns out not to be nearly as new as first believed, that begs a further question -- what, then, actually makes swine flu a true pandemic?

Some virologists already had doubts when the WHO first announced the existence of a new flu in late April. Top health officials were indeed talking about a "new subtype" of the influenza virus, one feature required by the US Centers for Disease Control and Prevention to meet its definition of a pandemic. But "new subtype," it turns out, was an inaccurate description -- the pathogen behind swine flu is in truth only a new strain of an old subtype. And as influenza expert Hans-Dieter Klenk at Marburg University's Virology Institute explains, "such strains are more closely related to each other than subtypes are." . . .

No one knows how swine flu's course will run. But in the end, British molecular biologist Derek Gatherer may prove to have been right all along. Gatherer declared his suspicions back in the beginning of July, that humankind is facing only a "pseudo-pandemic," one that "may be insufficiently virulent ultimately to enter the annals of major pandemics."

Chicken Little, anyone?


Anonymous said...

No arguments here. Good points, Cervantes.


gribley said...

I don't disagree with any of this, but my analysis is almost orthogonal: We hear about the flu because it has the potential to be a major train wreck, and the media likes a train wreck. That's why it was such a big deal in the spring -- it unfolded rapidly and dramatically -- and that's why people are concerned now. That's also why there were years of fear following 9/11, which killed fewer Americans than died in car crashes in the same month. There is a nonzero chance of H1N1 turning into something much bigger than seasonal flu. And, yes, it has the potential to affect everyone, nearly randomly, and thereby shakes the houses of the wealthiest, and that helps gain attention.

Your argument is perfectly apt for seasonal flu, but I think you're missing the point for a high-mortality pandemic. Which this is not... quite... yet.

Cervantes said...

But y'know what gribley? Even if it had turned out to be worst case scenario, everything in my post would still be true.

And, the concern about a worst case scenario was overblown in the first place -- it was highly improbable, not based on any real evidence about this particular flu strain, and pretty much designed to scare people in order to increase the prestige and funding of people who study influenza.

Anonymous said...

The local Switz. minister of health (although no such position exists, I’m transposing) said that it was expected there would be between 100 and 1000 deaths at the most, less than from the ordinary flu.

CH bought 13 million doses of vaccines (pop 7 million plus) as frontiers here are most pesky, it is ‘regions’ that count, and CH was ready to vaccinate Italians, the French, Austrians and Germans.
The guidelines for getting vaccinated have been all over the press and the TV. Vacc is free, and optional.

Briefly, all health personnel; others in touch with the larger public on a daily basis (eg. teachers, police, bus drivers down the line); children after 6 months to 12 or 15? ; pregnant women, anyone ‘at risk’ - to be appreciated (that is judged) by family doc, e.g. elderly, auto-immune disease, aids, etc. All family members of anyone at high risk. Making a long story short...

Optional? That means none of this is deemed serious in any way and the public has to be reassured.


Anonymous said...

I think you've made something of a classic error in judgment about public health when you talk about how we pour resources and attention in to the flu, even though it only accounts for ~36, 000 deaths per year. What you could just as easily say is that "even though we pour vast amounts of money in to flu research and control efforts, it still accounts for ~36000 deaths every year". What would happen if we diverted those resources elsewhere?

You are correct when you say that worldwide rates of infection of the horrible (and, incidentally, all parasitic) diseases you discussed accounting for a much larger burden of disease and disability, and death. And that in our own country the determinants of health can be used to demonstrate inequalities in health. But none of these facts are incongruous with the fact that influenza has the potential for huge amounts of death yearly, as well as horrible pandemics. It deserves our attention.

Cervantes said...

Flu deserves some attention, but not the obsessive, overwhelming, exclusive attention it is getting.

Also, that 36,000 deaths a year is highly misleading. Most of them are people who are already very sick and have a limited life expectancy. Some of those deaths, in fact, are merciful. Furthermore, almost none of them are actually confirmed to be from influenza, and the majority of people who have flu like illnesses don't have flu at all.

It just isn't important. It's a very minor issue in public health, and it gets far too much attention.

RayPublicHealth said...

FYI, I'm going to copy this post and share it with some public health friends and colleagues here. Will send the link to your blog too, of course.