Thursday, May 18, 2006

Fixing the public health roof

My Flu Wiki partner DemFromCT has a characteristically well-informed and sensible post up over at his blog, The Next Hurrah. It summarizes the Indonesian cluster at this point. The situation there remains unclear, with conflicting news reports saying either that human to human spread has been ruled out, that it remains under suspicion or that this seems to be another example of a familial cluster with human to human spread but no further spread. Indonesian authorities are also issuing mixed messages. On the one hand, they say there is no proof of human to human spread and that infected poultry or livestock are being investigated as the source. On the other hand, they admit there is no proof of an animal source and that human to human spread has not been eliminated.

Available information suggests that the originally reported timeline showing a gap of more than a week between the index case (who was buried prior to laboratory confirmation could be obtained) and subsequent cases is too long to make a common source a reasonable explanation. The possibilities then are multiple animal to human transmission or human to human. Henry Niman has repeatedly argued that limited human to human transmission has been occurring for some time in Indonesia and elsewhere, and I think the evidence suggests he is correct. This still leaves several questions, such as why there is not more secondary spread or more transmission to unrelated caregivers like health care workers., but not having an answer to those questions doesn't mean the proposition is wrong. I think the weight of the evidence is on Niman's side.

Henry and I have sparred here on occasion, but I have always been more than willing to give credit where credit is due and this is another such case. There remains a significant difference in style between us that is partly traceable to our different professional disciplines but also matters of individual temperament. Henry has been right, often (at least I think so) but not right, often, as well. That's not a fatal flaw. I am reminded that Babe Ruth hit more home runs than anyone else but he also struck out more often. There is a great deal of judgment involved in interpreting fragmentary and disparate data and Henry has systematic (but usually defensible) proclivities to move in one direction rather than another. He is in many ways the antipode of another figure with whom I have engaged in much more contentious battle here, Marc Siegel. I have sometimes thought we might solve the world's energy problem by putting Niman and Siegel together in one room and using their temperature difference as an energy source (or maybe like having a proton encountering an anti-proton, each annihilating the other with a burst of gamma rays).

For most of us, if and when this virus evolves into a pandemic strain (and it might never do this), we will have time. Maybe not a lot of time, but it won't be in our midst instantaneously. That is important to remember because even though every day we don't strengthen our public health and social services infrastructures to manage the consequences of a pandemic is a precious day lost, the appearance of the real thing will still have the wonderful ability to concentrate the mind -- if we can keep our minds clear and not clouded by an irrational panic.

Panic can be rational, but only when we are faced by a mortal threat for which there is no other response. Currently the threat may be a mortal one, but there are many ways to respond. If people can fill sandbags in the face of an impending flood, they can most certainly find numerous public health and social service sandbags to fill. The Indonesian cluster is a reminder we need to stay concerned and focused.

Here's another metaphor. It's like fixing the roof of your house. You want it to be intact at any time, not just when you think a storm is coming. Time to fix the roof, storm or no storm.