September 27th, 2009
Public health is bedeviled by the public’s lack of understanding of uncertainty. Public health policy deals with potential future events. Decisions about policy have to be made with often inadequate data. If, as often happens, bad scenarios don’t unfold, policy-makers may well have made make decisions that turn out to be wrong in the sense that the preventive efforts were taken that turned out not to be needed.
We see this in the case of the current H1N1 swine flu pandemic. Skeptics are using the initial concerns about worst case scenarios, which turned out to be wrong when more data was available, to encourage skepticism about current plans to cope with a looming pandemic. We see this reasoning in a recent Alternet article by Joshua Holland – H1N1 Just Isn’t That Scary: Why There’s No Reason to Go Overboard with Swine Flu Hysteria — which claims that swine flu fears are more dangerous than the swine flu itself. [Holland's article received a furious rebuttal -- More crappy flu journalism, this time Alternet [rant alert!] — from revere at Effect Measure with which I strongly concur. My comments complement revere’s.]
Holland refers to comments last spring abut the potential danger:
In April, Homeland Security Chief Janet Napolitano called a press conference and declared a public-health emergency. In August, officials for the Centers for Disease Control warned that H1N1 could infect half of the U.S. population and kill 90,000 Americans by year’s end. CDC officials estimated that 1 in 10 New Yorkers had contracted the virus this spring.
Holland refers to these estimates as “grist for their [the media's] sensationalist mills.” He, however, makes no argument that the data available in spring 2009 were not consistent with these warnings. We had a highly contagious, fast-spreading pandemic flu strain to which no one under 52 had any apparent immunity. Those most affected by the pandemic were the young. We had reports of many deaths in Mexico, and we had the awareness that influenza has the ability to rapidly mutate. There were a number of deaths of young patients, which is atypical for the seasonal flu.
To not take action, issue warnings, consider school closings, and start a vaccine development program would have been highly negligent. Had the pandemic developed differently, as could well have occurred, likely, many of the same people now criticizing the “hysteria” would soon be screaming at the incompetence or corruption of a public health policy establishment that failed to respond to a looming crisis.
In any case, Holland and similar writers fail to understand that, even with the relatively low severity of the swine flu at this point, the overall risk is greater because of the lack of immunity in the population. Thus, a much larger percentage of the population is likely be become infected. If even a small proportion of the infected become very ill and require hospitalization, our emergency medical system, already operating under great continuous strain, will face much greater strain. Large numbers of severely ill people may be turned away from ERs, to take their chances at home. revere explains the problem:
Our big city emergency rooms periodically and routinely go “on diversion,” meaning that they divert the ambulance that’s on its way their hospital to another hospital. The main reason is not the already ludicrous long waits in the ER but the shortage of critical care beds, the ones with the ventilators and skilled nursing that Holland thinks will now save people seriously ill with flu. It’s a common mistake. But it’s a mistake.
In a healthcare system from which most excess capacity has been wrung by budget cuts, even a mild pandemic can cause severe disruption. If the vaccination program only avoided this eventuality, it would be worth it, contra Holland. But, like the seasonal flu vaccine it is likely to reduce many forms of illness-caused social disruption and save lives. Likely thousands. Possibly many more.
Holland, however, recommends that the non-health professionals among us just ignore swine flu:
The take-away from all this is that the best cure for swine flu hysteria may be a healthy dose of salt….
Public-health officials, epidemiologists and clinicians have to worry about H1N1. As things stand, you really don’t.
In these statements Holland uses the common commentator’s trick to pose the options as “hysteria” or forgetting about it, as if those are the only options. Of course, hysteria is never useful. But cautious alertness often is.
Additionally, public health policy to deal with a situation like the swine flu pandemic requires the allocation of public resources and the development of plans and the carrying out of preparatory measures by many in a multitude of systems throughout society. Both resource allocation and preparedness planning cannot successfully be carried out without public involvement and an informed citizenry.
Holland, however, fails the primary task of both journalists and the public heath community of helping people understand the uncertainties and complexities of the situation, developing preparations for potential bad scenarios, and helping people cope, no matter how events unfold. Accurate knowledge and understanding, including knowledge of uncertainties and limits to our information, are among the most effective public heath tools. Unfortunately, Holland’s article is no help in developing these tools.