Monday, April 03, 2006

Fear, fear of fear, fear of (fear of fear) . . .

There has been a lot of loose talk about the high cost of instilling fear about bird flu in people, loose talk that itself borders on panic or at least fear-mongering -- the fear of fear. Some even use the intentionally evocative -- and misleading term -- an epidemic of fear. Pretty much the talk about the cost of frightening people is conjectural, speculative or couched in generalities. It rarely, if ever, considers the benefits of educating the public to a sane appreciation of the risk.

Evaluating that risk is where many of these arguments begin, but that's not their genesis. They really begin at the destination: the proposition that what public health authorities are saying about bird flu is creating a harmful and irrational panic by fostering policies that are wasteful and unlikely to be very helpful in a pandemic (e.g., stockpiling antivirals); or by diverting energy that could better be directed at more real and tangible health problems, like seasonal influenza, or some other public health goal, or even rebuilding the entire public health infrastructure. For spice, there may be an insinuation that those raising the alarm are doing it for reputation, research grants or actual money. None of these are arguments about the likelihood of a pandemic. For the argument's destination, however, it is important a pandemic of avian influenza not be too probable or even probable at all. It can threaten birds, but not people. A good example of this is a recent opinion piece in the British Medical Journal.

To work, these arguments must start with risk. They have a characteristic structure, something like this. H5N1 is a bad virus, but mainly bad for birds. Humans have a tough time catching it (variants: the historical and environmental conditions to allow this virus to evolve into one where it is easy for humans to catch don't exist now or we can treat the disease now with modern medicine, etc.). Compared to other risks (choose your favorites) it is trivial. Moreover, many other risks touted as apocalyptic turned out to be anything but (multiply drug resistant HIV, airborne Ebola, etc.) and the fear of them was itself harmful (swine flu). Since people's perception of risk is out of all proportion to reality and is based on irrational fear, they do irrational things.

The BMJ piece follows this pattern closely. And interestingly, it doesn't present any direct arguments a pandemic is unlikely. It can't, because we don't know how to predict the likelihood of a pandemic. Instead it rests on the fact that in its current form H5N1 is not a pandemic strain. These pieces usually pay lip service to the fact that flu viruses mutate with alacrity but fail to mention the amount of genetic change necessary to produce markedly different biological characteristics may be small. The biological arguments are almost all based on the virus as it is, not as it might be (or for that matter, as it was in 1996, before it caused the first human cases in 1997).

No one can deny that fear can lead to clouded judgment and irrational behavior. It can also concentrate the mind. Fear is an instinctual reaction whose proverbial components are "fight or flight." We do one or the other according to our ability to fight versus our perception that flight is the only recourse. So like everything it's a balancing act. If people are properly prepared, they will fight. If not, flight is the reaction.

But public health officials are deathly afraid of inducing fear (although you wouldn't know this from what is written about how they are fear mongering). I have seen this repeatedly up close for almost forty years as a public health profesional. They are adept at imagining all sorts of untoward effects of giving the public a fair warning.

Fair warning is not the same as fear mongering and it rarely (if ever) causes "an epidemic of fear." It is prudent and empowering. People rarely panic when they have adequate information and trust the information-giver. To trust the information-giver, the information has to be given honestly. Too often public health officials suppress what they actually believe because they don't want to "induce panic." But in the case of bird flu the problem is not panic, but getting people to pay attention. Attention to what? That there is a potential freight train headed down the tracks. It may stop before it gets to us, but we don't know that now. We can see it coming and it is getting closer by the day (unless you are deaf and blind). And it's not just any train or even a hypothetical train. One like it passed through before and we know what it did. And this train looks a lot like the last one.

H5N1 isn't just any bug. It's an influenza virus. It can exact the same global toll as AIDS, malaria or schistosomiasis but do it in a couple of months. This dynamic makes it very different than those other major killers in terms of how it can tear the social fabric. This doesn't diminish the importance and burdens of those other diseases but does suggest why influenza has attained a special importance among that select group. As with the others, it is the poor and vulnerable who will suffer most.

The noted flu virologist Robert Webster appeared on ABC News recently saying that people weren't ready for an outcome where half the population might die. Having myself been on shows like that (Nova, 60 minutes, NPR, etc.) I know how this can happen. I suspect if he had it to do over again he would do it differently. He has issued a clarification letter that amounts to an indirect retraction, in that it does not mention the earlier mortality estimate, but does reiterate that the result of a pandemic, whose likelihood no one can predict, could be very serious. Preparing for it would be prudent. Despite his network misstep, nothing untoward of consequence occurred as far as I know. The sky didn't fall because he issued a scary scenario.

There doesn't have to be a conflict here. The preferred outcomes of the flu-deniers (and let's be clear; that's what they are) are not different in kind, character or quality from the mainstream of the public health community who remain deeply concerned. It's easy to trade accusations about motives. Both sides have done it. But it isn't necessary since we agree on what needs to be done: strengthen the social service and public health infrastructures of all our communities and avoid wasteful expenditures and false hopes such as stockpiling antivirals as the main means to fight a pandemic. Intensive effort and investment in vaccine technology is wise measure, as it also addresses other infectious diseases. Reliance on private enterprise to do it is probably a bad idea. It isn't profitable. An alternative, such as national or international vaccine institutes would be better.

Most importantly, however, we need to be talking publicly about this, getting people used to the idea that a pandemic might happen, what we can do about it 9and there is a great deal), and assuring them that we are leveling with them. Right now there is a job to do: hardening our communities against the shock of a pandemic. That has to be a cooperative effort. We aren't helped by arguing a pandemic is unlikely and that openly and honestly talking about a pandemic is harmful.

Mistakes will be made in that discussion. That's a given. But for those of us who think that there is a substantial chance (let's say for the sake of argument 5 - 10%) a serious pandemic could happen, there is no choice but to talk about it in a way that encourages people to prepare for it. We have argued here that the preparation should be multi-use so that if a pandemic doesn't occur, we will still have enormous net benefit.

It would be great to close the argument about fear. But I fear it isn't closed.