Cautionary note on avian flu and tsunami

The following cautionary note appeared in the Flu in China and Flu Information website. It is authored by Michael Olesin and Henry L. Niman:

A comment on monitoring of aid workers for avian influenza
-----------------------------------------------
The terrible disaster affecting southeast Asia will certainly create a number of public health challenges in the immediately affected areas. However, there is the possibility that these events may lead to a much larger pandemic influenza problem. The relief effort has brought a number of people from around the globe to a region not only affected by the tsunami but also affected by avian influenza. It is possible that the [local] population in the area might have some innate immunity due to repeated exposure to avian influenza. However, with the influx of immune-naive foreign aid workers, there seems to be a potential for spread into people who may be much more susceptible. It is a safe assumption that hygienic conditions in the area are going to be lacking for some time. In addition, many of these workers might almost suspect that they will come down with an illness because of the circumstances, and may simply shrug off the 1st signs and symptoms. As they return to their countries of origin, they may unwittingly depart during the prodromal phase of illness only to act as the index cases of pandemic flu in their countries.

It would be prudent for federal, state, and provincial public health departments to set up surveillance systems to monitor the health of individuals who traveled to help with the tsunami recovery efforts

Published: Jan 1, 2005 9:26 AM (China time)
By Michael Olesen, Henry L. Niman
Special to ProMedMail

Lakoff - IV: Complex metaphors

[Preamble: This is one of a series of posts about the relevance of the work of George Lakoff for public health. First a disclaimer. My aim here is not an explication of all of Lakoff, or where he stands in cognitive science versus analytic philosophy, or whether there is a "there, there" as Gertrude Stein once wondered about Oakland (where Lakoff is now situated at UC Berkeley). It is rather to take some elements of Lakoff's writings (and I think genuine insights), and see how they might illuminate a central problem in public health, having a Central Problem. Posts will be relatively short, as befits the medium. PF is Lakoff's book, Philosophy in the Flesh (1999). MP is Moral Politics (2002)]

Summarizing to this point: Lakoff is a cognitive scientist who has studied two kinds of mental constructs, categories and conceptual metaphors. He views both as "embodied," i.e., realized by neural structures in the brain. Neural structures serve the survival of our species. They are thus not "free" to assume any form whatsoever, but are conditioned by our existence as evolved biological organisms. These structures process information from our environment and perform computations. We refer to some of these computations as "inferences" when they involve reasoning, but Lakoff points out that a great deal of things that could properly be called inferences are unconscious, i.e., we are not aware of them and do not have conscious access to them. In particular, our sensorimotor system also performs conputations. Many of our primary concepts are metaphors for these embodied "inferences" (examples: higher = more, as in "a higher price", which comes from seeing piles of objects get higher as more are piled on).

Lakoff views complex metaphors as built of the primary components, like molecules are built from atoms (PF, chapter 5). To these are added commonplace knowledge like cultural models, folk theories or familiarity with everyday objects or appliances, like a car. It is the primary metaphors that are grounded directly in experience. The more complex metaphor constructed from them and glued together by items of everyday knowledge is not. Complex metaphors derive their "grounding" in the experiential elements of their constituents. Lakoff gives several detailed examples of complex metaphors, such as "Love is a Journey." Such metaphors allow us to use words and reasoning about travel to talk and reason about love ("our relationship is going nowhere; we are spinning our wheels."). We habitually employ many complex metaphors, each with many variations.

Lakoff has analyzed a number of important conceptual systems, such as morality and causation, using this framework. He was engaged in work on moral metaphors during the election of 1994 that swept conservatives into power in Congress. This started him thinking about the different kinds of reasoning used by political liberals and conservatives. More in the next post.

First post here. Previous post here. Next post here.

Social Security Reform: Watch the birdie

I don't usually comment on health care finance issues. But an interesting post by Angry Bear (an economist) prompts this observation.

First, the post points out convincingly that the alleged Social Security crisis is just that, alleged, and the case isn't very convincing (but read the post and decide for yourself).

Second, Social Security is a public insurance scheme. Private insurance companies aren't really "insurance companies," they are banks. They take in a great deal of money in premiums for one purpose only, to invest it and make more money. In phraseology I used earlier about chemicals, an insurance policy is a dollar's way of making another dollar.

Third, the hullaballoo about Social Security is about something that might happen in fifty years. As Angry Bear observes:

Of course, in 50 years, we'll all have personal flying devices and robot vacuum cleaners. In the meantime, there are real problems to worry about: nuclear proliferation, global terrorism, the declining dollar, jobs, and the massive general fund deficits.

The infamous Republican pollster/spinmeister Frank Luntz advised his patrons, "Your plan must be put in terms of the future, not the present."

This seems especially pertinent when the present looks like this present. (Hat tip, Al, for Angry Bear post; and Environmental Working Group for Luntz memo).

What if it wasn't "just another lie"?

Sunday (1/2/05) the Fear Monger's cable channel, FX, will broadcast a 2002 BBC "docudrama" about a fictional smallpox epidemic. Ross at Public Health Press has the details in an excellent summary. Whether or not you watch it, here is something to think about:

It was an open secret in the public health community that prior to the onset of the war (and even preceding 9/11) Cheney's office was pressuring reluctant public health experts to get moving on a smallpox vaccination program. Did Cheney really believe Saddam might have the smallpox virus or was this (as widely assumed) another lie to coax us into a war? If he lied, nothing much changes. If, on the other hand, he and the DoD vulcans thought this was a real possibility, the picture is quite horrifying. For as much as a lying Cheney could be considered just another lying bastard in a den of lying bastards, a believing Cheney would be a monster whose recklessness goes beyond what even his most aggressive critics allow.

Here's why. Knowledgeable public health experts knew that smallpox vaccination could not be deployed quickly and widely enough, even in the United States, to stop the rapid spread of a highly contagious disease - a disease that kills one third of its victims and leaves 60 – 90% of those “lucky” enough to survive blinded or horribly disfigured. But the evil kernel of the policy is that the Administration was indifferent to the obvious fact that smallpox would not stop at our borders or even arrive here first. This plague, against which the human species is no longer protected by prior exposure or vaccination, would have spread around the globe like a supersized tsunami, possibly killing more than a billion people. Those most likely to die would be those unprotected by vaccination, i.e., the world's poor and those for whom a live virus vaccine is too dangerous because their immune systems are compromised. Thus the poor in HIV-ravaged Africa and Asia would have been left to the mercy of a killer that shows no mercy.

The smallpox “plan” grew out of concern that Saddam would invoke the so-called “Samson option,” whereby an attack he knows has no other purpose than to eliminate him would push him to take the temple down around everyone’s ears. The Administration seems to have concluded that if there were sufficient vaccine to protect the American military and some of its population, that was sufficienct. No significance seems to have been given to the global devastation even a “limited” military action could unleash. Even a nuclear exchange might pale in comparison to what could happen if smallpox was loosed on the planet again. If Cheney wasn't lying, it means the Bush-Cheney Administration was willing to take the chance of poking the hornet's nest with a sharp stick. Fortunately there were no hornet's within.

A crime against humanity may not be easy to define, but provoking a global smallpox epidemic would certainly qualify. Unfortunately many of us wouldn't have lived to see the trial.

A risky experiment

According to an excellent news report by Helen Branswell, CDC is about to embark on a risky, but probably necessary, experiment. With the potential for a catastrophic pandemic with influenza A(H5N1) ("bird flu"), certain basic questions need to be answered, chief among them, how easily can the avian virus exchange genes with influenza strains already circulating in human populations. In a recent post we worried about the danger of this happening in the thousands of workers engaged in culling infected birds across southeast and east asia as a result of co-infection with both viruses. In the CDC experiment, a 2004 influenza A(H5N1) strain will be intentionally mixed with currently circulating human influenza A strains, H3N2 and H1N1. The work is designed to test the ease with which reassortment can happen and also test various constructed gene combinations from both viruses to see if they can produce the feared human-adapted virus that retains high pathogenicity.

If this sounds risky, it is. The work will be done in an "enhanced BSL3" laboratory--not the highest security but close to it. Viral particles will be tested in animals for disease causing potential and transmissibility. While stringent laboratory procedures will be specified, it is not clear exactly what precautions will be taken with laboratory workers potentially exposed to the virus, e.g., will they be kept under observation and allowed only limited contact with the public during and for a short time after their work with live virus?

The objective is to obtain some quantitative information on risk. According to WHO's Klaus Stohr, "It will give us an opportunity to predict the probability because we will have an understanding on the number of reassortment viruses which are viable, the percentage of those that are viable which are then transmissible - and also on the percentage of those which are viable, transmissible and pathogenic. And how pathogenic they are."

Branswell's news article also contained the somewhat disquieting information that CDC has already done some work on H5N1 hybrids:

CDC researchers have already made hybrid viruses with H5N1, using versions of the virus isolated after it first caused human infections in 1997 in Hong Kong.

"Some gene combinations could be produced and others were not," is all [CDC scientist Nancy Cox] will reveal of that as-yet unpublished work.

It seems to this observer that reliable scientific information on this topic is of such urgency it should be released on a continuing basis, not wait for the usual peer-review process to unfold. The scientific community can do its own peer-review if sufficient technical details of the experiment are released at the same time. We urge CDC to provide all information on these experiments on an expedited basis.

Defending science

In November of 2004, just days after the election, the American Public Health Association (APHA), the American professional association of public health workers, passed a resolution opposing legislation or administrative policies that attempt "to define the characteristics of valid public health science, or dictate prescriptive scientific methodologies." What was behind this resolution was industry's all out assault on the integrity of the scientific process in advisory matters, within the courts and in the regulatory system.

The exploitation of new formulations of what is considered "correct" scientific evidence by industry started much earlier, during the Clinton administration, with the skillful use of the Supreme Court's 1993 decision in Daubert v. Merrell Dow Pharmaceuticals, Inc. This decision, which made the trial court the "gatekeeper" of what was "relevant and reliable" scientific evidence, effectively substituted the judgment of one layperson, the judge (who may have chosen the law precisely because of a lack of aptitude for science), for the judgment of 12 other laypeople (the jury) about what was "proper" scientific method. So successful was this tactic of preventing the jury from hearing scientific evidence vital to proving the claims of a plaintiff in a personal injury tort action, that now we are seeing attempts to introduce "Daubert-like" criteria into the regulatory process. At the same time that sanctimonious statements about "sound science" are made in the regulatory arena, the Bush Administration has become notorious in the scientific community for its attempts to tamper with a scientific advisory process that, while not perfect, has at least functioned with some moderate credibility.

What the APHA resolution does is enable the country's leading public health association to file "friend of the court briefs that address the problem inherent in the adoption of Daubert and Daubert-like court rulings, the application of Daubert in regulatory proceedings, and when judges misinterpret scientific evidence in their implementation of the Daubert ruling." This is a forward looking policy that recommends itself to other scientific associations that wish to defend science against those who deform it when its findings are uncomfortable, inconvenient or inconsistent with political ideology.

Lakoff - III: Embodied concepts

[Preamble: This is one of a series of posts about the relevance of the work of George Lakoff for public health. First a disclaimer. My aim here is not an explication of all of Lakoff, or where he stands in cognitive science versus analytic philosophy, or whether there is a "there, there" as Gertrude Stein once wondered about Oakland (where Lakoff is now situated at UC Berkeley). It is rather to take some elements of Lakoff's writings (and I think genuine insights), and see how they might illuminate a central problem in public health, having a Central Problem. Posts will be relatively short, as befits the medium. PF is Lakoff's book, Philosophy in the Flesh (1999). MP is Moral Politics (2002)]

There is still more to say about Lakoff's contention that the mind is inherently "embodied" because it lies at the foundation of all that comes later. The embodiment is a consequence of our biological existence. Both we and lower animals react to their surroundings by altering our behavior and changing our environment to optimize our chances of survival as a species. Individuals may be more or less successful, but it is the population that survives, not the individual. In the course of evolution neural mechanisms arose in multicellular organisms to accomplish many important tasks. These mechanisms perform computations or inferences. For example, when temperature nerve endings in the fingers are stimulated an action is initiated to pull your hand away from a hot stove. Configurations that contributed to population success propagated.

For Lakoff, "embodied concepts" are neural structures that make use of the sensorimotor mechanisms of our body. An essential element is the use of these structures to categorize elements in our surroundings: "hot stove" becomes not just a particular object but a class or category of objects which we need to distinguish efficiently if we are to survive. Categorizing is largely subconscious. It is difficult to imagine functioning in the world without it. Our bodies not only determine that we categorize, but also largely determine the categories we use. For many important subconscious concepts this is not an "add on" but a built-in function, controlling and constraining the possibilities (which usually depends to some extent on our environment). The result is certain basic level concepts, for Lakoff, the highest levels for which a single mental image can represent the entire category. His example (PF Ch. 3) is a "car." The concept of a car is more general than the concept of a particular Chevrolet but can still be conceived of as a single mental image. It is not as encompassing as a "generalized vehicle," which we have a great deal of forming a mental image of. These basic concepts are categories that allow us to function in the world and they exist for Lakoff as neural structures. Similarly, spatial-temporal relations exist as basic concepts (for example, "in front of," "after," etc.) because they enable reactions ("inferences") necessary for survival.

Spatial and sensorimotor experiences and inferences in turn can become associated with other experiences, like being nurtured, being threatened or being happy. These give rise to "primary metaphors," metaphorical inferences that associate experiences like being nurtured, fed or frightened with spatial-temporal or sensorimotor concepts. Examples Lakoff gives: More is Up ("prices are high"); Intimacy is Closeness ("We've been close for years but now we are drifting apart"); Affection is Warmth ("He greeted me warmly, but she was cold to me"); etc. [PF, ch. 4]. Theories as to how these primary metaphors arise might be that during infancy, when being held by your mother, you associate the sensorimotor concept "warmth" with the affective concept of being nurtured or loved. As biological beings we all carry an enormous number of these primary metaphors around with us. While not all are universal, there are hundreds that are the same in many cultures. We will be particularly interested in those that are widespread in our own culture.

The next step is to bundle the primary metaphors into complex metaphors. This is where "reframing" will enter the picture.

First post here. Previous post here. Next post here.

Bird flu danger signal from Japan

In an earlier post I wrote finis to the cases of avian influenza in workers involved in a massive chicken cull in Japan last February. Five people were found to have immunologic evidence of H5N1 infection after the fact, and one worker, for whom paired sera were available, showed a greater than four-fold rise in antibody titer. The only reported symptoms were a sore throat in one worker. Because of the close contact with infected birds there was no evidence that the virus had changed character with respect to person-to-person transmission. It was also an event that occurred ten months ago. But an editorial in the Japanese daily Yomiuri Shimbun (Tokyo) has made me rethink this easy dismissal and prompted one last comment. It is not a happy one.

The Editorial raises the (excellent) question of why it took from February until mid-December to report on these cases. It also claims these five workers (four farm employees and a Kyoto prefectural employee who inspected the farm) wore no "flu masks", protective clothing and took no antivirals, contradicting earlier reports that all had worn personal protection and were treated prophylactally with oseltamavir, an antiviral. Even more troubling is this:

The [Health, Labor and Welfare Ministry] said it took a long time to convince the employees to allow blood samples to be taken and to develop a fool-proof method of detecting the virus. In total, about 7,000 people were engaged in containing the epidemic, but only 58 of them were tested for the disease.

This indicates that 10% of the tested workers were infected but less than 1% were tested. Even if we assume there was no serious illness among the unexamined 99%, if their infection rate were the same as those tested we would expect infections in about 700 and symptoms in over 100. There is thus the potential that a certain number of these could also be co-infected with a human-adapted strain of influenza A, increasing the danger of producing a dangerous recombinant with an H5 protein adapted to person-to-person transmissibility.

These data underscore the importance of providing personal protective equipment to workers engaged in the mass culling of infected birds in southeast asia where the disease is spreading and also treating them prophylactically with effective antivirals. When a vaccine becomes available they should be the first vaccinated.

Upon further reflection this case raises serious questions about the safety of efforts to contain the disease before it reaches the human population. It would indeed be a heavy irony if this were the pathway to a global pandemic.

Let them eat sushi

Christmas Eve marked one year since Japan banned US beef imports because of fears the US beef supply was not sufficiently protected against Bovine Spongiform Encephalopathy (BSE or "Mad Cow Disease"). At issue is the US refusal to test all beef entering the food supply for BSE, regardless of age. All domestic cattle bound for the table are tested in Japan. A tentative compromise wherein all cattle older than 21 months would be tested seems to have been stalled. Japanese opinion polls have shown that consumers there are unwilling to trust the US beef supply and do not want their own country to relax its stringent regulations (story, Newsday). Apparently Japanese Prime Minister Junichiro Koizumi, an ardent supporter of Bush's Iraq debacle, will eat American shit but not American beef.

For those readers addicted to the red state/blue state formulation of politics, it is worth noting the irony that one of the beef industry's friends and most ardent opponents of stringent regulations was Texas Democrat (and cattleman) Charles Stenholm. Stenholm was redistricted to election defeat by Republican House Leader and Chief Scumbag Tom Delay, ending 17 inglorious years as a member of the Agriculture Committee helping to make the US food supply unsafe. It could have been worse. We could have lost a real Democrat. Good riddance.

Meanwhile in Japan, the food industry worries that the beef ban will have long-term effects. A spokesman for industry warned that "while Australian and Chinese beef imports have tried to fill the gap, they do not fulfill the same niche as U.S. beef, and a long-term ban could turn the Japanese off beef all together. . . . There is a chance that the consumers here will eventually be turned off by beef as a whole."

Wouldn't that be a shame.

Bush Administration declares war too costly, cuts back

The War on World Hunger, that is.

In one of the first signs of the effects of the ever tightening federal budget, in the past two months the Bush administration has reduced its contributions to global food aid programs aimed at helping millions of people climb out of poverty.

With the budget deficit growing and President Bush promising to reduce spending, the administration has told representatives of several charities that it was unable to honor some earlier promises and would have money to pay for food only in emergency crises like that in Darfur, in western Sudan. The cutbacks, estimated by some charities at up to $100 million, come at a time when the number of hungry in the world is rising for the first time in years and all food programs are being stretched.

As a result, Save the Children, Catholic Relief Services and other charities have suspended or eliminated programs that were intended to help the poor feed themselves through improvements in farming, education and health. (New York Times via Talk Left).

The cutbacks in November and December amounted to about $100 million in food aid (1/2,000 of the cost of the Iraq escapade).

Merry Christmas, World.

The future diseases of occupation

Yet more heartache in store for a suffering country and its people. A story in the Christian Science Monitor reminds us of the continuing environmental degradation of occupied Iraq. Bullets and bombs are not the only airborne threats. According to the UN Environment Program (UNEP) hundreds of environmental "hot spots" from huge burning landfills, chemicals spills, oil trench fires and much more are contaminating the soil and its crops, the water and the air. Major tributaries of the Euphrates are reported unable to support biological life in many areas. Depleted uranium from ordnance litters the landscape.

Given the struggle to exist each day, protecting the land, air and water takes a back seat to survival. But in the long run there will be a price to pay. The war and the occupation will exact its toll from generations not yet born.

Lakoff - II: Preliminaries

[Preamble to this series: This is one of a series of posts about the relevance of the work of George Lakoff for public health. First a disclaimer. My aim here is not an explication of all of Lakoff, or where he stands in cognitive science versus analytic philosophy, or whether there is a "there, there" as Gertrude Stein once wondered about Oakland (where Lakoff is now situated at UC Berkeley). It is rather to take some elements of Lakoff's writings (and I think genuine insights), and see how they might illuminate a central problem in public health, having a Central Problem. Posts will be relatively short, as befits the medium. PF is Lakoff's book, Philosophy in the Flesh (1999). MP is Moral Politics (2002)]

It is necessary to approach Lakoff not from his current destination (the "reframing" project) but from where he starts. Those who only know him from his latest elephants book, which is a summary of the tactical aspects of a longer book, Moral Politics, may wonder how he arrives at some of his formulations. There is undeniably a "rabbit out of the hat" feeling about them but they become more understandable (and evaluable) when the underlying theoretical machinery is revealed.

Lakoff didn't arrive at his latest views on politics by starting with an interest in the political implications of cognitive science. Before Moral Politics he had written widely on a bewildering variety of topics. But throughout there are certain underlying themes. The three most important I set out in the previous post. The first of these was that the mind is inherently embodied and the second, that most thought is unconscious (I will consider the third, important from a political standpoint, later).

First, mind is embodied. In Lakoff's view all our mental processes, the small portion that are conscious and the vast majority that are not, are shaped by the fact we are evolved, biological entities. To survive we have developed mechanisms to sense our environment, categorize it and react to it, as have all organisms. In "higher" organisms this involves using neural structures that enable us to perceive, move and manipulate. These structures "have been shaped by both evolution and experience." (PF, ch. 3).

This leads naturally to the second point, that most thought is unconscious. On a trivial level most of what we do to get along in the world is unconscious (I don't think about how to chew or walk), but Lakoff's more radical contention is that "higher functions" like reasoning and forming and manipulating concepts use the same neural circuitry and also involve constraints dictated by sensing, categorizing and manipulating the world. Reasoning is thus just as "sensorimotor" as breathing or walking. For Lakoff it is wrong to separate "reflexes" like pulling your hand from a hot stove and "reasoning." Both are versions of "sensorimotor inference." This holds true also for philosophical concepts like "causation" and "morality."

This also implies that "reason" is universal with all living things, not just "human" ones. We are on a continuum with other animals. People are not in conscious control of most of their reasoning nor do they have access to the operation of most of their thinking. These are findings Lakoff takes as established by modern cognitive science and he uses this machinery to construct a wide ranging theory. One product is his much discussed "reframing" formulation of political action. Of which, more to come.

Previous post here. Nest post here.

Small minds thinking tiny

Leadership in public health in this country comes in sizes: small, smaller, tiny, miniscule, absent. How would you grade the Arizona Department of Health Services? Consider this.

The Arizona Republic reports that there is lead in some Mexican candy being sold in the state but the state of Arizona is doing nothing to stop it, saying it is the job of the Federal Government. The state also has no plans to conduct tests to see which candies are involved. The implicated sweets, made with chili powder and tamarind, are popular with Latino children. Not to worry, says the Arizona Department of Health Services:

... the primary source of lead poisoning [in children] is not candy, but lead-based paint found in older housing. Children are poisoned when they eat the paint chips or inhale lead dust. Other sources are folk remedies that contain lead and cooking with pottery with lead-based glazes, she said.

"At this time, we haven't found Mexican candy to be the primary source of lead poisoning."

Question: have they looked? Not too hard, it turns out.

Trying to ban the treats in Arizona isn't the solution, said Will Humble, chief of epidemiology and disease control for the DHS.

Most of the questionable candy is flavored with chili powder or chili paste that sometimes gets contaminated in the manufacturing process, he said.

"So it's the spicy candies that are the problem, but it's not all," Humble said. "There are some spicy candies with chili powder in them that are absolutely fine. That's what is really tough about this. You can't just say, 'Well, all the candy made in Mexico with chili powder in it is bad.' You can't make that kind of a statement because it's not true."

Although extensive testing has been done in California, Arizona public health officials have not tested candy from Mexico or tried keeping it off the shelves. Humble believes that's the federal government's responsibility.

Yeah, just like protecting the environment is the federal government's responsibility. Just like keeping an eye on predatory energy companies is the federal government's responsibility. Just like keeping us from getting ripped off by pharmaceutical companies selling unsafe drugs at exorbitant prices is the federal government's responsibility. Just like . . .

You have one unheard message

A four year study from 12 research groups in seven countries, funded by the European Union (EU) and released on December 19, suggests that radiofrequency electromagnetic radiation from cell phones is capable of altering cellular DNA, that the changes are heritable by progeny cells and that they occur at a rate faster than cellular DNA repair can accommodate (see story in Wired).

Everyone queried in the story was at pains to say the demonstrated biological changes do not establish a health risk and that more research is needed. . . .Duh.

There has been substantial concern in local communities about EMF exposures from cell phone towers, towers often situated stupidly with respect to schools, day care centers and other facilities. Over the years I have been asked to examine the exposure estimates from some of these facilities and in most instances felt the emf exposures were not sufficient to constitute a hazard, even to persons relatively close to the transmitters. But that's just part of the story. And it is the rest of the story that makes me concerned about the cell phone towers.

My main concerns relate to emf exposure from the transmitter you hold in your hand when you use a cell phone, not the base station tower that has received the most attention. In most cases the transmitting antenna is right up against the cranium, leading to radiation hot spots within the skull (see a figure here in the section "Absorption of RFR from a Mobile Phone"). The EU study indicates that biological effects from emf of this frequency and power density are demonstrable. There has been almost no informative epidemiology done on the problem, so human data are largely lacking.

Which brings me to my concern about the cell phone towers. What they do is create a need for cell phones. Many people now use their "cells" preferentially over land lines and have come to depend on them. What will we do if down the road we discover these devices present a risk to their users? Even if the risks are very small, say one in a million per year (not detectable by any conceivable epidemiological study), with tens or hundreds of millions exposed people the bodies would add up.

This seems another case of rushing headlong into a technology without adequate demonstration of safety, or lacking that, responsible inquiry. . . . Hey, I didn't say it was a news story.

Lakoff - I. Who is George Lakoff?

[Preamble to this series: This is one of a series of posts about the relevance of the work of George Lakoff for public health. First a disclaimer. While I have read Lakoff, I am not a "Lakoff scholar." My aim here is not an explication of all of Lakoff, or where he stands in cognitive science versus analytic philosophy, or whether there is a "there, there" as Gertrude Stein once wondered about Oakland (where Lakoff is now situated at UC Berkeley). It is rather to take some elements of Lakoff's writings (and I think genuine insights), and see how they might illuminate a central problem in public health, having a Central Problem. I will try to keep the posts short (above the fold), as befitting the medium, although I might not always succeed.]

Who is George Lakoff? I first met him after reading some of his writing but knowing there was a great deal more I hadn't read. I was glad to see he really existed and not a printing press or a consortium of graduate students. He is real, unlike the avatar, Revere, who writes this. His PhD is in linguistics from Indiana University (1966) and he stopped at a variety of institutions before coming to rest at Berkeley in 1972. He is short and plump and no shrinking violet in demeanor. Surprisingly, he is not particularly well-tuned to how his arguments are received by others, but he is open to criticism and not at all defensive. I like him. You can read his official bios at the Rockridge Institute website which he founded to put his theories into political practice ("Rockridge Institute: Rethinking Progressive Politics. Reframing Public Debate. Changing Public Policy.") Lakoff himself is a genuine progressive. In 1991 he was among a few academics to get on the internet to try to rally his colleagues against the first Bush misadventure.

He describes himself as a cognitive scientist. This self-identification is essential to his intentions. Lakoff believes that modern scientific studies of "the mind" have settled, and in most cases, "swept away" millenia of a priori speculation about human reason and the boundaries of knowledge. His project almost overwhelms you with its breathtaking ambition: to reconstruct all of Western Philosophy on the basis of the new scientific discoveries from cognitive science (see his Philosophy in the Flesh, written with Mark Johnson, for more along this line; hereafter abbreviated, PF).

Here, in his own words (PF), are the three major "findings" of cognitive science Lakoff gives as the basis for his reconstruction of philosophy:

• The mind is inherently embodied
• Thought is mostly unconscious
• Abstract concepts are largely metaphorical.

The first item is characterisitc: Lakoff is a thoroughgoing materialist. Second, Lakoff believes the unconscious plays a dominant role in how we think and how we reason. Third, metaphors are the currency of abstract thought.

It is the latter two, especially the third, that has drawn the most attention in the political realm and which we will look to for implications regarding public health. More about that in coming installments.

The point I want to make is that Lakoff is about a good deal more than "reframing" messages. The reframing part, in fact, is just the tip of an iceberg that supports a "naturalized epistemology" much more radical than most current adherents of that philosophical position ever dreamt.

Enough for now. Next post, here.

How long can you hold your breath?

A recent issue of Nature (16 December 2004) contains an important article by Mills, Robins and Lipsitch on the 1918 influenza pandemic (the "Spanish flu"). By fitting parameters in a mathematical model (technically called a SEIR deterministic model, a system of ordinary differential equations) by using mortality data from 45 cities they estimated a median reproductive number of less than four. The reproductive number ("R naught," usually written R₀) is the average number of additional cases each infected case produces. If R₀ drops below one, the disease dies out. The 1918 flu estimate of less than four is not large compared to other contagious diseases [cf. measles (13 - 14), pertussis (16 - 18) or polio (8 - 12) (data from Anderson and Mays, Infectious Diseases of Humans, Oxford U. Press, 1991)], there is reasonable expectation that vigorous control measures might quickly shorten a pandemic.

But two characteristics of the 1918 pandemic are not so encouraging. One is the extremely rapid spread, with a doubling time of only 3 days, attributable to the short serial interval, the average time between a primary case and the secondary cases it produces. The other is the high case fatality, roughly ten times that of previous influenza pandemics. The likely explanation for the latter is the absence of any effective population immunity to influenza A(H1N1) in 1918. We are faced with a similar situation if H5N1 were to get loose by mutating to a form where person-to-person transmission becomes possible. In this context, the rather low R₀ of the 1918 flu sounds more ominous: it shows the virus does not have to mutate to a super-contagious form to have catastrophic effects.

Given the speed of transmission and the essential lack of enough antivirals or a vaccine against this virus, Mills et al. suggest the most effective control measures at the start of such an epidemic would be to limit person-to-person contact. This could be done through quarantine, cancellation of public meetings and gatherings and possibly shut-down of public transport. The economic costs, of course, would be enormous. But as they point out:

Increased passenger travel relative to 1918 will facilitate the spread of a new virus across the globe. It is imperative that real-time surveillance information be shared freely, and that preventive measures be taken very early in a new pandemic. Therefore, while the relatively modest reproductive number estimated for 1918 pandemic influenza suggests the feasibility of controlling a similar future pandemic, significant planning and investment will be required to facilitate a rapid and effective response.

So, once again, I ask what preparations are being made for an immediate response should surveillance data suggest that a match has lit the tinder? Do we have in place measures that would reduce person-to-person contact? Or are we going to make it up as we go along, too little, too late and "holding our breath" the while?

Environmental Health News: Important resource

The information in the post about perchlorate came via Environmental Health News, an important resource for those interested in environmental health. See their site here (also in the links list in left sidebar).

Perchlorate shenanigans: Same ol', same ol'

In a detailed article the (Riverside, CA) Press-Enterprise today sets out the tortured and unhappy story of how the perchlorate industry used hired-gun scientists to interfere with and delay needed regulations of a water contaminant whose prevalence in water supplies is becoming widespread. The article is too long to do justice to here, so read it yourself (you will have to endure a fairly invasive "free registration" process; you can make up a name, email and address if you wish). The article also has links to scans of some original documents. It is a superb job of reporting. Kudos to Douglas Beeman and David Danelski.

Perchlorate is an oxidizer used in military rockets, fireworks and road flares. Ninety-percent is used by the military, according to the Press-Enterprise. Health concerns have centered on effects on thyroid metabolism, particularly in the fetus. Thyroid function is important to neurological development. Severely hypothyroid infants with accompanying mental and physical retardation are known as cretins. The concern is that lesser degrees of interference with thyroid function will result in altered development. There is no dispute that high levels of perchlorate affect the thyroid. The question is what level in the water could be considered "safe."

The Press-Enterprise presents a detailed history of attempts to regulate this chemical, which is now being discovered in more and more water supplies. In 1992 EPA tentatively proposed a limit of 3.5 parts per billion in drinking water. The industry trade group countered, based on their own scientific studies, that 42,000 ppb was safe. In 2002, based on additional scientific evidence, the EPA lowered the reference dose to 1 ppb. There followed a tale of furious lobbying, attacks on one of the few independent scientists to weigh in on the issue and ultimately insinuation of industry influence directly into the Office of Management and Budget. One of the arguments used was that the 1 ppb limit would "interfere with national security." The result was the increasingly common EPA practice of kicking the hot-potato over to the National Academy. A Committee there is scheduled to report next month.

In an accompanying article, The Press-Enterprise reveals how the respected journal Environmental Health Perspectives allowed an industry scientist to redact and edit a news article on perchlorates in the journal. A link to a .pdf of the invoice of the scientist for his "services" to the trade group is included with the article.

Jeez.

Smokers don't think elephants (or anything else, apparently)

Many of us were dismayed when polls indicated a substantial portion of the American public continued to believe that WMDs were found in Iraq despite widespread reporting to the contrary. Well public healthniks, prepare to be dismayed again.

A survey in Nicotine and Tobacco Research's December 2004 issue (and reported by Reuters Health) found that 94% of smokers consider themselves well informed about the risks of smoking, but halfof those did not know the risk of heart attack was higher among smokers. One third agreed with the statement, "Cigarettes still have not been proven to cause cancer." The study authors point out this indicates the tobacco industry defense that most smokers are making a well-informed personal choice is false. But that's not what I want to talk about here.

Putting dismay aside (a pretty tall order, but try it), what do these results mean? I can't think of a simple explanation. Stupidity is too facile and condescending. Not everyone is the sharpest knife in the drawer, but the prevalence of these mistaken beliefs is too high and is repeated in too many other areas where ignorance remains in the face of a wide consensus on the facts. Any other possibilities? Addiction, surely, but it doesn't explain the mistaken beliefs, unless addiction has additional features not usually attributed to it.

This finding reminded me that George Lakoff, the cognitive scientist whose ideas on the importance of linguistic framing are au courant these days, likes to say that "facts don't matter" when they conflict with a subject's strongly held cognitive frame. Lakoff's ideas are much debated because he has applied them to politics (see his books Moral Politics and recent don't think of an elephant!). But it strikes me they might be useful in public health independently of their validity in politics (for the record, I know Lakoff and am impressed with the explanatory power of his ideas in the political realm, but their appropriateness and applicability there seems to me a separate question). Lakoff's elephants book is his most accessible (punchy and short). If you are not enamored of his political persuasion put that aside and translate the political to a public health context.

The importance of the Lakoff perspective, in my mind, is that it directs our attention, also, to the"frame" we use in crafting public health messages, which in turn requires us to consider the implicit values of public health. Lakoff reminds us that it is not only the cognitive frame of the receiver of the message but also the frame of the sender that matters.

Suspect cases of H5N1 in Kyoto, Japan

Kyodo (Japan) News is reporting suspected influenza H5N1 cases in five persons who had worked in February to cull 240,000 infected chickens and 20 million eggs on a Japanese farm near the town of Tamba in Kyoto Prefecture. The five had fever and tests showed the presence of antibodies against the virus in their blood, indicating a prior infection, but not the virus itself. None are reported in serious condition. They were among 60 farm employees, firefighters and government workers who worked on the operations. If confirmed (tests at the National Institute of Infections Diseases in Tokyo are continuing), these will be the first human cases of avian influenza in Japan.

At this time I have no information as to the protective measures taken by the four farm workers. The firefighter is reported to have taken the antiviral oseltamavir (tradename Tamiflu) prophylactically and to have worn a protective suit with hood, goggles and a mask. This kind of personal protective equipment needs to be fitted properly, and it would seem that if this is indeed a case of infection some breach occurred.

The fairly heavy exposures likely in this setting indicate that if disease transmission did in fact occur it does not signal the feared change in the virus that would make person to person transmission more likely. I have been following this case for a day or so, but it now appears to have made at least one wire service (Reuters Alertnet) so I thought I would post my take on it for those who follow the avian flu issue via this site.

Update 12/18/04: This story is now on the Asian wire services, although with little new information. Mainichi Interactive (Japan) reports that all the workers took antivirals and wore protective clothing and "surgical masks." These masks provide little protection. All the suspect cases are said to have recovered. Reading between the lines it sounds as if the symptoms may have occurred shortly after the cleaning in February and the government is only now releasing findings that these five individuals had antibody rises suggesting infection on retrospective analysis. Why this is being reported at this late date after exposure is unclear. I will only update this if there is something significant to say about it.

Added note, 12/18/04: China Daily confirms my suspicion that these were studies done in March and April of last spring. There are some additional details there for those who are interested. I will not report further on this unless there are significant new developments. Human infections from poultry are possible in a setting of heavy exposures.

Update/conclusion, 12/23/04: The Ministry of Health, Labour and Welfare of Japan is reporting the results of their investigation on their website (in Japanese). A rough translation has been made available by Dr. Akira Goto via ProMed-Mail. In essence, it reports that a serological investigation of 48 clean-up workers culling avian influenza infected chickens last February revealed five with antibodies to the Kyoto strain H5N1. For only one of the five was there a paired sample, so that is the only case classified as "confirmed." However the titers of four more workers make it highly likely they, too, were infected. Only one had symptoms (sore throat). None had fevers, as was earlier (erroneously) reported. This suggests that people may be asymptomatic for infection, which would be consistent with many other virus infections.

Progressive health care/policy blog debuts

It's good not to be the absolute newest game in town and even better to have more good company. Progressive public health blogs Confined Space and Public Health Press were here before me. Now we are joined by the health care/policy blog, Health Care Renewal:

Health Care Renewal is dedicated to the open discussion of health care's current dysfunction with the hopes of generating its cures. The core values of health care are under siege. Patients and physicians are caught in cross-fires between conflicting interests, and subject to perverse incentives. Free speech and academic freedom are threatened. Pseudo-science and anti-science are gaining ground. Power in health care is increasingly concentrated and abused. Some of these issues have been discussed only in whispers. We will directly address them.

This is a group blog, some (all?) of whom are at Brown University's Center for Primary Care and Prevention. I assume they speak with their own voice, not the University's. Welcome to our tiny corner of the blogosphere.

Clarification: Since not everyone reads the Comments sections of Posts, I'll repeat here the clarification from the bloggers at Health Care Renewal:

We appreciate the welcome. The current group of bloggers comes not from a single institution or location, but from around the US, and we hope to enlarge it, and if possible include other countries. Our introduction is as stated above, and we welcome your readership and your comments.

Blogosophy: Listening (but still with my Left ear)

In a thought provoking interview veteran technology columnist Dan Gillmor discusses his difficult decision to leave print newspapers and launch a new venture in citizen-journalism. You should read it for yourself, but one point caught my attention: we don't talk to each other enough. Here's the relevant part of the interview:

Your comparison of journalism-as-a-lecture model vs. journalism-as-conversation is fascinating. How would you like to implement this in your new media startup? [NB the interview was conducted after a talk by Gillmor at Harvard's Berkman Center where he made this comparison]

What I've been doing personally on the blog for some time now has been all about that. The only way you can have a conversation is if you listen. That's the first rule of conversation. And I've had a wonderful time listening, even when they attack me (laughter). I typically learn more from those who think I'm wrong than from people who think I'm right. Especially when they tell me why I'm wrong.

And then once you learn how to listen -- which is something journalists need to do better -- then we can then say that with the tools being created ... "Don't just respond to us but let's all talk together"...

This seems to me pretty good advice. The danger of speaking in an echo chamber is especially acute as progressives struggle with discouragement and a perception of living in a hostile environment (leading us to build a safe cocoon around ourselves). The left-right and blue state-red state formulation is a trap (and I say that as a committed person of the Left who intends to remain that way). We all spend a lot of time wondering why the "other side" doesn't "get it." We ought to spend some of our time asking ourselves just what it is we don't get. And clearly not everything we think is correct (sorry). So listening seems like a good idea.

Here's a modest start. There is a blog that frequently links to me, isemmelweis (for those who don't catch the reference, Semmelweis was a pioneering doctor who helped conquer childbed fever--"Doctors, wash your hands"). I have never linked to him/her (isn't it nice that on the internet we aren't burdened by knowing irrelevant things like a person's age, sex, race, class?), nor (until now) put the site on my blog roll. Some of this was laziness, but most of it was because the issues that seemed to exercise him/her seemed far from my own. More importantly, perhaps, in comments made here, isemmelweis early on self-dentified as a free marketeer and I have a reflexive distrust of "market forces" in public health and medicine. So I wasn't motivated to listen. I'm not sure my mind is open about this, but there's no harm in listening. And potentially some good. So toddle on over to isemmelweis and other medically oriented blogs and have a listen. Let me know what you hear and what you think about it. I'll do the same.

Another case of crying Wolfowitz

Here's more on the anthrax vaccination issue. As noted in a previous post, Deputy Defense Secretary Paul Wolfowitz has requested that the Secretary of DHHS declare an emergency to allow resumption of the controversial mandatory anthrax vaccination of military personnel. The program was suspended by a federal judge in October as a result of a lawsuit by six anonymous plaintiffs alleging that the vaccine was not approved for DoD's intended use, has not been shown effective against pulmonary as opposed to cutaneous anthrax, and has led to adverse health effects in some. The judge's order vacated a December 2003 FDA ruling that the vaccine was safe and effective for all routes of exposure. In a story that broke on 12/15/04, Chris Stroem at GovExec.com quotes the judge's opinion:

"Unless and until FDA properly classifies AVA as a safe and effective drug for its intended use, an injunction shall remain in effect prohibiting [the military's] use of AVA on the basis that the vaccine is either a drug unapproved for its intended use or an investigational new drug...Accordingly, the involuntary anthrax vaccination program, as applied to all persons, is rendered illegal absent informed consent or a presidential waiver."

Stroem also has seen Wolfowitz's memo, which claims that

"... there is a significant potential for a military emergency involving a heightened risk to United States military forces of attack with anthrax."

"In making this determination I have considered a classified November 2004 Intelligence Community assessment of the anthrax threat. This heightened risk has been and continues to be the basis for the DoD program of vaccinating personnel serving in the areas of the Central Command [Iraq and Afghanistan] and Korea."

Lawyers for the plaintiffs in the lawsuit say that an emergency cannot be declared by a Deputy Secretary (only the Secretary) and moreover, neither DHHS nor DoD has authority to grant a waiver. That must come from the President himself.

The military's anthrax program seems as poorly thought out as their occupation of Iraq. Both have put US troops into unnecessary danger and pigheadedness is keeping them there.

Good summary of bird flu H5N1

For those who wish a concise technical summary of avian influenza A(H5N1) I recommend this from the Center for Infectious Disease Research & Policy (CIDRAP) at the University of Minnesota .

Anthrax

The same day scientists at Johns Hopkins School of Public Health (alias the "Bloomberg School"; good thing Tampax didn't give the money) announced the best way to prevent anthrax cases after an intentional exposure of weaponized material would be to use antibiotics, Deputy Defense Secretary Paul Wolfowitz sent the Department of Health and Human Services (DHHS) a memo asking it to initiate the process of resuming anthrax vaccination for military personnel, suspended since October 27, 2004 under a court order by DC circuit Judge Emmet Sullivan. The mandatory vaccinations, which have been blamed for a variety of adverse health effects by some soldiers, have been subject of much controversy within and outside the services and are the subject of a lawsuit. The existing vaccine is used by veterinarians as protection against the cutaneous form of the disease and in its current form is a crude preparation, administered over 18 months in six separate applications. It is not approved as a preventive for pulmonary anthrax, DoD's intended use.

The Hopkins work suggests that 70% of cases could be prevented by rapid (within 6 days) distribution of antibiotics. Concommitant use of vaccine and antibiotics might reduce the length of time antiobiotics are needed, but providing protection for the entire population by pre exposure vaccination is not considered practical. Anthrax is not a contagious disease and there is no way to predict where it would be used as a weapon. The only people who should be vaccinated, therefore, are those who are or have a high likelihood of being exposed.

In related news, the government has let a $877.5 million contract to a California biotech company to manufacture 75 million doses of a new recombinant version, allegedly for use in the civilian population in the event of a mass exposure. It would require "only" three applications.

Which leads to two questions:

• Why is DoD pushing this when they could easily distribute antibiotics to troops they knew were exposed? The unlicensed mandatory use amounts to a large population experiment;
• Why did the government order 75 million doses of a vaccine they only need for a post-exposure scenario? This is enough for 25 million exposed persons. There is no plausible scenario where 25 million people will be exposed to weaponized anthrax in a short period of time. And if it happens, the Hopkins results indicate the best course of action would be rapid mass prophylaxis with antibiotics.

They can pay a small company $877.5 million for a superabundance of anthrax vaccine but can't get the population protected against influenza, a disease that kills 36,000 Americans in a "normal" year? What am I missing, here?

Public stealth leadership

It's nice to now at least one state governor recognizes that when federal leadership fails to respond adequately to a threat it is time to take matters in our own hands. It's just too bad he's got the wrong threat.

Massachusetts Republican Governor Mitt Romney leads a national working group on "safeguarding the nation." On Tuesday he told homeland security officials that state and local agencies and private businesses (like Halliburton?) need to gather their own intelligence on terrorists rather than just relying on federal efforts (New York Times). According to Romney:

"Meter readers, E.M.S. drivers, law enforcement, private sector personnel need to be on the lookout for information which may be as useful."

Meanwhile, the Trust for America's Health reports that Romney's own state ranks dead last in developing effective state plans for emergency preparedness despite an infusion of $20 - $30 million of federal funds for the purpose. One of the major reasons, according to the Report, is that the state cut its public health budgets between Fiscal Year 2003 and 2004.

Maybe meter readers in Massachusetts can also do outbreak investigations and test environmental samples for nerve agents after they are done reading meters or maybe turning in highschoolers for reading the Koran (or even reading about the Koran).

Preparing for bird flu: time to reboot?

Computer viruses have certainly affected "real life" (assuming that what many of us do passes for a life). Now the Information Technology research and analysis company, The Gartner Group, is warning that biological viruses can also affect your online life.

In TechWeb News:

"Include the possibility of an avian flu pandemic in your business continuity planning and crisis management preparations," wrote a pair of analysts at Gartner in a briefing posted on the research firm's Web site. "A pandemic would not affect IT systems directly, but would likely cause considerable economic disruption through its impact on the workforce and on business activity."

Gartner analysts Dion Wiggins and Steve Bittinger point to the major economic disruptions from the few hundred SARS deaths in 2003. Planning for a possible bird flu pandemic is needed because "many business continuity plans rely on IT to keep business running even when travel restrictions, quarantines, or vendor problems develop because of a disease, or the fear of a disease."

Recommendations included

"re-assessing business continuity plans, establishing policies for employees working from home (as well as providing them with the means to do so, such as VPN access), and coordinating crisis management plans with workers."

[...]

"IT managers should ensure that their enterprises plan, from the boardroom on down, for a likely future outbreak whose course and consequences are unpredictable..."

Oh, and by the way:

"Do not wait for an outbreak before reviewing or establishing contingency plans. Many strategies take time to set up."

So here's my IT plan for DHHS: Ctl-alt-delete.

Pedal edema from congestive thought failure

Question: What should New Yorkers fear most? Stumped? Too many possibilities? It's the bike, stupid. The final word from "public health expert" Elizabeth Whelan, President of the wingnuttery, American Council on Science and Health:

We New Yorkers are more obsessed, even more than other Americans, about hypothetical or phantom health risks. We are constantly anxious about trace-level exposure to the dry cleaning chemical "perc," PCBs in the Hudson River, dioxin traces in paper towels, pesticide residues in produce and whatever the other scares du jour happen to be. The city just passed laws requiring all of us to have carbon monoxide detectors, even in high-rise apartments, where the risk of injury or death is totally theoretical.

That is why it is particularly astounding that we are so tolerant of real risks, including this one: the risk of death and injury to pedestrians posed by out-of-control bicyclists.

Not convinced? Why not do an epidemiological study (Design by Whelan)?:

Ask 10 of your friends, work colleagues and relatives if they have recently been hit by a bike in New York - or, more likely, almost hit - and I predict that most will say yes.

Time to become an activist:

Let your political representatives know that it is time to make bike riders obey the law by prosecuting violators. But to protect ourselves, we must be cautious and constantly on the lookout for speeding bikes, whether it's when we're crossing the street or getting out of a cab.

As a society, we should not tolerate such real risks to life and health while our representatives and regulators constantly (and expensively) seek to protect us from parts per billion of some chemical they fear, primarily because they cannot pronounce its name.

Is this the first reported case of cerebral pedal edema?

CDC Director's missing vertebrae

A Pacific News Service story, "Iranians say they're harrassed by U.S. security agencies" is of particular interest here because it recounts the case of NIOSH employees Aliakbar Afshari and Shahla Azadi, an Iranian couple recently fired without explanation and allowed no appeal. According to the Pacific News Service story,

Afshari and Azadi have been permanent residents for 17 years and NIOSH employees in [the NIOSH facility] in Morgantown [West Virginia] for seven. In May they were told, to their surprise, that they failed a background check and were escorted from the premises. Each had passed a previous check. They were told documentation of the recent check was classified.

Their attorney, Allan Karlin, resorted to the Freedom of Information Act, but the FBI said it had no related documents in Washington and are looking in other places. He says the government made no attempt to interview the couple’s co-employees and superiors. He learned that the Department of Homeland Security ordered the background check on individuals from “threat countries to the United States,” which includes Iran.

Karlin obtained 20 letters from diverse sources testifying to the couple’s upstanding characters.

We have become so inured to a federal terror bureaucracy run amok we forget to ask, "Why is the head of NIOSH's parent agency, CDC, letting this happen without a peep?" CDC Director Julie Gerberding has an obligation to defend and protect the many dedicated public servants at NIOSH from this kind of Kafkaesque crap. At the very least, she could have publicly insisted on due process.

Diagnosis: Absent spinal column.
Treatment plan: Backbone transplant.

Update, 12/17/04: For some follow-up and additional commentary see Jordan Barab's Confined Space site. Excellent (as usual).

"Earth to DHHS. Earth to DHHS. Come in, please..."

As noted in earlier posts (here and here) China is stepping up plans to deal with a possible human version of bird flu. Now we learn that the UK is also drawing up plans, to include providing antivirals for key health and emergency services workers, closing down schools and public places like movie theaters, and quarantining victims' families.

Dr Douglas Fleming, Director of the Royal College of [General Practitioners'] Birmingham Research Unit said: "The idea that an outbreak may happen this year, next year, or in the next 10 years, is speculative.

"But we should all welcome the fact the government is planning in case it does happen.

"I believe our best hope as far as pandemic management is concerned is to stockpile anti-virals.

"The prospect of a vaccine becoming available, in sufficient time and sufficient quantity to curtail a pandemic, seems much less likely."

Meanwhile, the US is. . . doing what, exactly?

According the Executive Summary of a Draft Pandemic Influenza Preparedness and Response Plan from the Department of Health and Human Services dated August 2004 (4 months ago),

The Department of Health and Human Services (HHS) continues to make progress in preparing to effectively respond to an influenza pandemic. This has been done through programs specific for influenza and those focused more generally on increasing preparedness for bioterrorism and other emerging infectious disease health threats. Substantial resources have been allocated to assure and expand influenza vaccine production capacity; increase influenza vaccination use; stockpile influenza antiviral drugs in the Strategic National Stockpile (SNS); enhance U.S. and global disease detection and surveillance infrastructures; expand influenza-related research; support public health planning and laboratory; and improve health care system readiness at the community level.

Excuse me?

Substantial resources have been allocated to assure and expand influenza vaccine production capacity; increase influenza vaccination use; stockpile influenza antiviral drugs in the Strategic National Stockpile (SNS); ... and improve health care system readiness at the community level.

Maybe I can be forgiven If I have my doubts. Resources allocated to assuring and expanding influenza vaccine production capacity? Sure, and they just let a contract to Chiron Corporation to do human trials of a new H5N1 vaccine. Chiron is the company that sent half the US vaccine source down the toilet. Stockpile antivirals? Yeah, enough oseltamivir for a couple percent of the US population, compared to one third or more for the UK and still climbing. Improved the health care system readiness at the community level?

"Earth to DHHS, Earth to DHHS. Come in, please!"

The DHHS document gets one thing right:

Characteristics of an influenza pandemic that must be considered in preparedness and response planning include: 1) simultaneous impacts in communities across the U.S., limiting the ability of any jurisdiction to provide support and assistance to other areas; 2) an overwhelming burden of ill persons requiring hospitalization or outpatient medical care; 3) likely shortages and delays in the availability of vaccines and antiviral drugs; 4) disruption of national and community infrastructures including transportation, commerce, utilities and public safety; and 5) global spread of infection with outbreaks throughout the world.

At least they know how bad it will be.

Socially redeeming or obscene?

While we are on the subject of flu vaccine (which we always seem to be here) a reader alerted me to an interesting piece from the New York Times magazine on a proposal to make vaccines "good business." Market-oriented economists Michael Kremer at Harvard and Rachel Glennerster at M.I.T., suggest in their book Strong Medicine: Creating Incentives for Pharmaceutical Research on Neglected Diseases that

Western governments and foundations should make a legally binding promise to pharmaceutical and biotech companies: if you invent a safe and effective vaccine for malaria, tuberculosis or H.I.V., we'll buy the first (say) 200 million doses at a respectable profit-guaranteeing price. One great virtue of this scheme, the authors suggest, is that the public would pay for only a successful product. If a company invests millions in research but fails to develop a vaccine that meets the contract's specifications, no money would change hands.

Allegedly the Gates Foundation is interested and may try to assemble a roster of private donors.

My reaction? I certainly agree with the wry comment of the NYT writer, David Glenn, that "you might prefer an alternative world in which pharmaceutical companies make fatal diseases their primary concern and pour money into cures for impotence only when offered large prizes by eccentric software moguls." But for the rest of it, I'm no economist. So I ran it by a colleague who really is an economist. His reaction was equally wry (for an economist, anyway). An interesting idea, he averred, because it would test the proposition whether big pharma would settle for anything less than a really obscene profit. Anyone want to place a bet? (Tip of the hat to JGarrow for the alert).

Update, 12/14/04: The Bill & Melinda Gates Foundation has pledged $42.6 million to the first nonprofit US drug company, the Institute for OneWorld Health. Working in partnership with UC-Berkeley and Amyris Biotechnologies, OneWorld will seek to produce via biotechnology, the very effective natural anti-malarial, artemisinin.

Malaria has become increasingly resistant to front-line medications, but combination drugs containing artemisinin show nearly 100 percent effectiveness after a short three-day regimen. Yet, at a price of $2.40 per adult course for artemisinin combination therapies provided through the World Health Organization, these drugs are still beyond the reach of millions of the world’s poorest people. Artemisinin is in short supply, and producing it currently is labor-intensive and relatively expensive.

[...]

Each year, between 300 and 500 million people, most of them poor, become infected with malaria, and at least 1.5 million die, primarily children in Africa and Asia.

[...]

To ensure affordability, UC Berkeley has issued a royalty-free license to both OneWorld Health and Amyris, of Albany, Calif., to develop the technology for malaria treatments. In exchange, Amyris will produce the drugs at cost, and OneWorld Health will perform the detailed non-clinical regulatory work that will be required by United States and other global agencies to allow the low-cost, microbially-based product to be substituted for plant-based product by manufacturers of combination drugs containing artemisinin. (From eBioBlogger)

UC-Berkeley, Amyris and the Institute for OneWorld Health should be commended for this effort as should the Gates Foundation for supporting it. We will keep an eye on it.

Bird flu: "Holding our breath"

I would like to stand back and take a sober look at the current situation regarding "bird flu."

Here's what we don't know at this moment:

• if H5N1 influenza A ("bird flu") will make the transition from rare and sporadic bird-to-human transmissibility to full-fledged human-to-human transmissibilty;


• if it does, whether it will retain the virulence seen in the human cases thus far;


• if these things happen, whether an avian influenza pandemic will be this year, next year or never.

Here's what we do know:

• all the ingredients are in the soup;


• if it happens we aren't ready.

The ingredients:

(a) A bird influenza virus, designated H5N1 for its surface antigens and to which the human population has no effective immunity, crossed over to humans in Hong Kong in 1997. There were 18 cases, of whom 6 died. Since January of this year (2004) there have been 44 cases in Viet Nam and Thailand, of whom 32 have died, an unusually high case fatality rate;

(b) The virus has changed since 1997, persisting longer in wildlife and the environment and has been found in new hosts, including mammals (large and small cats and mice, the latter in the laboratory) and wild and domesticated ducks, wild herons, ostriches and other birds, including, of course, chickens. Ducks excrete large amounts of the virus but appear unharmed by it. The 2004 strain is not identical to the 1997 strain. H5N1 seems to mutate with facility and speed;

(c) Southern China and Southeast Asia where H5N1 is now endemic is like a huge incubator for influenza viruses. Here people and their livestock, including chickens, ducks and pigs, live in close proximity. Pigs can be infected with human strains of influenza A virus. If humans or pigs are simultaneously infected with H5N1 there is the possibility of the kind of genetic reassortment that could produce an H5N1 adapted to human transmissibility. While most such reassortments will not be problematic,those that can use humans as hosts will be selected for in an evolutionary sense. Random genetic changes in the virus could produce the same result, without co-infection. For a virus, a host of any kind is merely a way to make another virus;

(d) We live in an era of unprecedented population mobility. Commercial air travel can deliver infected individuals around the globe within the incubation period of influenza A. At the same time many urban areas are disastrously overcrowded, and civil and national wars are resulting in population displacements that are difficult to impossible to control (e.g., Darfur, Congo):

'No man is an island,' said John Oxford, professor of virology at Queen Mary Westfield school of medicine, London. 'It doesn't matter where it starts -it will be on our doorstep within 12 hours. You can't argue that it isn't our problem.' (quoted in The Guardian Online).

Containment will be impossible.

(e) If the human species does not suffer a major population crash under conditions of overpopulation, overcrowding and a deteriorating environment, it will be unlike almost any other species known to natural history. Unlike other species, however, we have non-biological tools like technology and culture to help us. Will we use them properly?

We aren't ready:

If H5N1 pokes its head above water in the human population, we will not be able to stop it with our current medical measures of immunization and prophylactic medication.

Two large pharmaceutical companies are about to begin clinical trials of an H5N1 vaccine (see post), but its effectiveness, timing and access for most of the world's population are unknown at this time. There are few antiviral drugs that seem effective. Oseltamivir (trade name Tamiflu) has been approved by the US FDA for preventive use and may have some effectiveness against H5N1. Older antivirals that have generic versions like amantadine appear not to work for avian influenza in humans.

The use of vaccine and antivirals might buy some valuable time while civil societies prepare and then try to cope with the consequences of a serious influenza epidemic. Neither will prevent a pandemic hitting with considerable force. But stretching out the epidemic curve can be important.

If and when that happens, most authorities feel the US is less well prepared than other countries. An excellent in-depth story by The Observer/Guardian Online (same link as above) compares the US to the UK:

The UK ... has been in negotiations with Roche [manufacturer of Tamiflu] for months. Even if Britain buys enough doses only to cover between 10 to 20 per cent of its population, that bill will still come to millions of pounds...

Britain also has a strong network of public health groups and is well placed to implement the plans that it is currently working on for dealing with the emergence of a flu pandemic.

By contrast, the United States looks ill-prepared and has bought antivirals to treat only one million of its 300 million citizens. 'We're all holding our breath,' said Julie Gerberding, head of the Centres for Disease Control and Prevention. Australia and the Netherlands have stockpiles that meet the demands of around one-third of their populations.

"Holding our breath" might work to prevent inhaling some influenza virus from your neighbor's sneeze, but our nation can't hold its breath. As a strategy it doesn't cut it. Our federal and state health establishment still has not gotten its act together. In a future post I will explore what needs to be done and suggest ways to get it done in the absence of effective public health leadership.

Trying to count future flu deaths

By now many of you will have seen a variety of predictions about the death toll an influenza pandemic might exact, whether from "bird flu" or other strain to which the world's population has little immunity (discussions on this site here and here). WHO, after sounding the alarm that included death estimates from 7 million to more than 100 million, "clarified" their position in a prepared statement: "While it is impossible to accurately forecast the magnitude of the next pandemic, we do know that much of the world is unprepared for a pandemic of any size." But then WHO added that a pandemic virus could "affect between 20-50% of the total population."

The difficulty of making these predictions is well discussed in a news story from the The Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota. CIDRAP's Director, Michael Osterholm, has himself said a pandemic could kill 1.7 million in the US and as many as 177 million globally. The CIDRAP story notes that a Pittsburgh medical researcher and critic of WHO, Henry L. Niman, has said the global toll could even reach 1 billion, assuming the 72% mortality of recent avian influenza cases held.

Much depends, it appears, on the likely proportion of the world's population that would become infected by a highly contagious disease like influenza, the distribution of severity of disease among those infected, and the mortality rate for those with severe disease. These are three critical unknowns, making it understandable that predictions might differ. Trying to bound the estimates for these factors on the basis of past pandemics is a chancy enterprise. The world is not only very different now than in 1918 but also different than 1957 and 1968 when the last pandemics struck. But if a mutated strain of H5N1 allowed as efficient human-to-human transmission as currently circulating strains with the virulence seen in the bird-to-human cases, the higher estimates could not only be plausible, but even plausible underestimates. Consider the worst case, where half the globe's population is infected (3.2 billion people) and half of those are serious cases with 70% mortality. Niman's estimate of 1 billion would actually be 10% too small. If 20% of the US population were infected (50 million people) and half were severe cases (25 million), in order to get as low as Osterholm's 1.7 million US deaths, the mortality rate would have to be only 7%. Even with excellent medical care this would likely not be attainable with a virulent strain and epidemic conditions.

So while it is not suprising, given the uncertainties, that estimates might differ widely, I am surprised that by simply putting together the component parts, it is so easy to get numbers much higher than any of them.

In related news, Reuters is reporting that big pharma companies Aventis-Pasteur and Chiron Corporation will shortly begin human trials of an H5N1 vaccine. Having an effective vaccine would not prevent a pandemic, but it could slow its spread and lessen its impact if widespread vaccination could be accomplished. Cutting a death toll of 150 million people by a third would save 50 million lives. We do not know at this point the licensing conditions of these vaccines. Simple self-interest would dictate that these companies be required to license the vaccines gratis to allow production at multiple sites around the world and the vaccine should be provided at cost by any manufacturer. This is something that should be settled in advance rather than when a crisis is upon us.

Rearranging the deck chairs on the Queen Mary

The obesity problem in the US is big and getting bigger. From the weekly news magazine The Week:

[T]he Queen Mary 2 had to replace most of its deck chairs because overweight Americans were breaking them. “We do have many large passengers,” said a crew member. “And we do have 10 restaurants on the ship, so if they are big when they get on, they tend to be bigger when they get off.”

Is a dollar alive?

To emphasize this is a space where "outside the box" (desperate?) thinking is encouraged, let me try to pry the argument about whether "safety pays" away from monetizing costs and benefits (previously discussed here and here) this way. I'll start from a very strange direction by asking: Is a dollar alive?

Take a virus. While there is some reason to say that a virus isn't alive, we traditionally speak of a "live virus" because it has almost all the characteristics of other microbiological agents we generally deem as living. It is true a virus must hijack the host's cellular machinery to reproduce itself, but this is a typical commensal or parasitic relationship similar to other organisms and their hosts. In fact a computer virus has every bit as much claim to be "alive." It hijacks the host computer to reproduce itself and employs the network to spread to other hosts. There seems little about either a biological or computer virus that disqualifies it as a living organism.

Which brings me to the "dollar" (or similar unit used as a means of exchange). If we adopt the perspective of a greenback that wants to reproduce itself, getting humans to invest it in a production process like chemical manufacture is one way it could do so. Dollars in, more dollars out. Those dollars then need to be invested again, where they produce still more dollars. The chemical is the dollar's way of making another dollar. True, a dollar has no "intention" of reproducing. But neither does a virus or a bacterium. Like a virus, the dollar just works that way in a particular physical/social environment.

From this point of view (the dollar's), the object is to find the most efficient way to reproduce and survive. The firm and the people who run it are the host machinery it uses. In some sense they are irrelevant. The good employer and the bad employer are just different kinds of mechanisms. The dollar itself must evolve and adapt to different environments.

So the task at hand (for us) is to contour the environment so that when the dollar reproduces itself it does as little harm to the host machinery and its parts as possible. That is where regulation and other societal mechanisms come into play. In cohabiting with humans and other organisms, the dollar can reproduce itself in benign or malignant ways (just like other organisms). We, like other organisms, have the opportunity through our own defense and adaptive mechanisms to coexist as peacefully as possible.

This formulation is admittedly unorthodox, if not weird. And by treating workers and bosses in the same way it seems to ignore power and political relationships in the dollar's human hosts. These relationships become central when we discuss how to recontour the landscape (the environment the dollar negotiates in its quest to make another dollar). What the change in perspective attempts is to effect a subtle shift away from an argument about the best (cheapest, most efficient, safest) way to make a chemical or a table saw, to another question, what's the safest way for a dollar to make another dollar.

Taking up some threads

Before moving on, let me take up some threads.

In the short time this site has been up, several interesting threads have started. Here are three:

1. "Prevention pays/safety pays" and the possible perils of cost-benefit analysis;
2. Influenza versus bioterrorism: zero-sum game versus taking advantage of an opportunity;
3. Missing leadership in public health.

I plan to address (2) and (3) in future posts. But let's make a start here on (1).

To do a cost-benefit analysis you need a common yardstick. The usual solution is to monetize all the costs and benefits. Jgarrow suggests that the choice of "money" as the yardstick is just a matter of convenience so that we can be discussing the same thing. But the point is not a "common conversation" between ourselves as suggested in jgarrow's comment (although it is important we refer to the same thing) but that there be commensurable units for all costs and benefits so they can be added up and compared. Since monetizing these items is the essence of almost all cost-benefit analysis this puts us immediately on specific terrain, that of accounting and net profits. I am not opposed to using "public good" as a yardstick, but you'll need to tell me how to measure it for all the different kinds of costs and benefits so I can make the comparison.

I suggested that a more favorable terrain for public health is that of the human costs to the worker and his family in terms of pain, suffering and quality of life. To do a cost-benefit analysis of this you would need to monetize these things and compare them with costs to industry in dollar terms (where I will allow you to internalize things that are now external costs). I was asking this: suppose that the costs, when totaled up, showed it was cheaper to cut off some fingers than pay to prevent them from being cut off. Would we or should we acquiesce to this?

LB chimes in that the costs feel different to the worker, who may or may not, depending on various factors including perceived risk or special dread, decide to protect themselves or demand protection. She suggests that because some employers don't care, they must be made to care via societal mechanisms like regulation, criminal sanctions or costly litigation. I tended to agree. JQA remarks on the challenge to public health leadership: do we negotiate with them on their terms or do we opt for force through societal mechanisms?

In the next post I will try to get us off this very classical formulation by making a radical shift in landscape and perspective.