Tuesday, January 24, 2006

Excuse me while I interrupt

I thought I'd stick my nose, uninvited, into another conversation. Over at Scienceblogs there is a small forth and back between nosenada's Kevin Vranes and Aetiology's Tara Smith regarding the "crying wolf" syndrome and bird flu. I'll say at the outset my sentiments are completely with Tara, but the topic is important, so we will revisit it (see here, here and here) briefly. This is also an encouragement for all to head over to the new scienceblogs one stop shopping address where some of the blogosphere's premier science bloggers have set up new shingles. Aetiology is also up for a Koufax Best New Blog Award. For me it's a toss up between Aetiology and The Next Hurrah, the terrific political blog where my Flu Wiki colleague DemFromCT holds forth. The Wampum folks have wisely held off voting so we can actually take the time to peruse the nominees, so I'll do that before committing myself further.

Anyway, back to the topic at hand. It was precipitated by a post on Aetiology bemoaning a particularly ignorant piece at Huffington Post on why bird flu was just another BushCo scaremongering tactic. Written by Bill Robinson, who by the looks of his background and the content of his post wouldn't know a virus from a worm (I'm talking biological species here). It was a really dumb post and Tara was right to take him down.

Kevin still has a problem, though. It is the old "scarce resources" problem, competing needs, etc. Why bird flu, he asks, and not climate change or obesity or many other human and environmental needs?
But compounding the "many supplicants" problem for the infectious disease community is that this community is beset with a recent history of crying wolf. That's fine for a scientist who has no problem with the constant "corrections in understanding" inherent to science, but this kind of record drives a policymaker crazy. Policymaking is a system of taking in expert information from many quarters and coming up with the most tractable solution, which primarily must be politically tenable, if not practically and scientifically tenable (in that order).
Kevin's bio indicates he has a PhD in geophysics and has worked as a Senate staffer. Which explains some of his perspective. As a scientist he had to struggle with choices in a complicated environment where everyone wants something and they all have convincing arguments. Fair enough. This can give rise to genuine dilemmas.

But bird flu isn't one of them. Scientists are pretty much agreed about the possible magnitude of the threat although wary of making exact predictions. But this isn't one of the extremely low probability high consequence problems any more. For most who follow this situation closely, this is a borderline low to medium probability high consequence event. And that is a public policy emergency.

Kevin avers that there have been infectious disease false alarms in the recent past, and he cites West Nile and SARS. Neither were false alarms. West Nile, validating our fears, has become endemic throughout the US and is now one of the most serious vectorborne encephalititides. It has behaved just as predicted. SARS was considered a possible pandemic disease, true. It is fortunate it didn't turn out that way. But it very easily could have and constant vigiliance is required to prevent it actually becoming so. I don't think anything done in response to SARS was at all inappropriate, and if Kevin thinks so, he should say what it was. It did cost a lot of money, but that money was in lost revenue, not expenditures. Nor did policy makers do much about it. So there weren't major policy decisions at stake.

Kevin also seems to (mistakenly) think that there is an influential "infectious disease commnity" responsible for sounding the alarm. For the record, I am a chronic disease epidemiologist. My specialty is cancer. But like many of my public health colleagues I am extremely worried about the effects of a serious influenza pandemic because the consequences of a possible 30% to 40% absenteeism would ripple throughout society in very damaging ways if we don't plan for them. And because of this I am a strong advocate of thinking through the consequences in advance and preparing for them with effective workarounds. You can't do that if you don't think about them ahead of time. And you won't bother to do that unless you move it up the priority scale.

The approach we have advocated (and the one that is behind The Flu Wiki) is to strengthen the public health and social services infrastructure so that our society can be sufficiently resilient to withstand the shock of a pandemic with minimal damage. Any investments made to that end are multi-use and will pay off in many ways. We need to work on tools that allow neighbor to help neighbor. Trying to solve the pandemic problem by throwing money at vaccines and antivirals alone is both fruitless and barren with respect to the other important needs Kevin points to. But the policy makers with their hands on the levers of power aren't interested. they would rather spend money than mobilize the community.

So finally, I'd like to take a gratuitous swipe at today's policy makers. Kevin's version is of rational people beseiged by conflicting and competing demands. What's a poor CongressThing to do? But of course that's not how the system works -- or at least that's not how it's working. Whether we address or don't address bird flu versus energy, say, isn't about crying wolf or fear mongering or even choices. Sometimes it's about money. Sometimes it's about bribes. Sometimes it's about mistaken notions or helping a constituent. Sometimes it's hard to know what it's about.

But it certainly isn't a game played by the rules of logic's predicate calculus.