Thursday, March 23, 2006

Unhelpful commentary

Debate, skepticism and different perspectives are usually a good thing. So I'm not going to complain too much about another piece of Commentary from Harvard graduate student Peter Doshi in this week's Christian Science Monitor, even though I think it is completely wrong-headed. I know people who think that about me, too. But it is wrong headed.

First, what did he say? He starts with what I consider a straw man argument. The media, aided by politicians out to gain advantage, are spreading unwarranted fear about bird flu which is distorting priorities and creating public anxiety. Doshi had an earlier piece in the British Medical Journal implying that the CDC estimates for flu-related deaths are grossly inflated. There was a good response from one of NIH's best flu epidemiologists, Dr. Lone Simonsen, whose specialty is understanding and interpreting flu statistics. Doshi just didn't understand the system or the basis for the estimates. Moreover if one really counted non-respiatory flu-associated deaths the figure could easily be a gross underestimate.

Doshi also rehashes Dr. Peter Palese's reservations about H5N1 again. I have discussed Peter Palese's views here before. I know Peter, like him a lot, and respect his authority as a ldeading flu virologist. But the data he cites in the Shortridge paper of 1992 contains nothing specifically on H5N1 and there are reasons to believe the H5 data summarized may not be accurate because of the condition of the samples and the method used at that time. The highest seroprevalence reported for H5 in that paper is 7% and for most areas it is 0%. This is not evidence of widespread immunity. I will concede that I myself have been of the opinion that there has probably been a lot of mild and inapparent infection with this virus, but seroprevalence data now coming out seems to indicate otherwise and I now believe I was wrong (see the entry at The Flu Wiki and this from ProMed). This means that the case fatality is not as underestimated as we have assumed. That's bad. It also means that Doshi's comparisons with the 1968 pandemic are not particularly appropriate. 1968 was an unusually mild pandemic, as Doshi knows.

The question is not whether the virus as it currently is constituted is a pandemic threat but whether it will become one. There are many reasons to think this can happen and happen soon. When and i it does, there will be no time to prepare, so waiting to do so is not prudent, although that is what Doshi is advocating. As we have emphasized here many times, and will do again, the way to prepare for an influenza pandemic is to strengthen a community's social service and public health infrastructure. Concentrating on vaccines and antivirals is not a useful way to prepare because if there is no pandemic (we should be so lucky) it would be wasted and the use of either requires an infrastructure to distribute them. Instead the task before us is one of community mobilization but requires a proper appreciation for the nature of the threat.

Doshi's view is very unhelpful in that regard, but not because he objects to scaring people as a tactic. I consider it a bad tactic,too. It is unhelpful because it doesn't do what it should: provide people with a sane appreciation of the risk so they can start to develop the kinds of relationships, structures and orientations that will respond to widespread community illness by encouraging and allowing neighbor to help neighbor.