Public health: The benefits of freaking out
Beyond over-reactions in the media, let's get to the core of the issue: Did the WHO, the Centers for Disease Control (CDC) and the government of Mexico overreact, or did they (gasp) do the right thing? Taking the flu seriously had benefits, says David Fidler of Indiana University. "Some think there is cause to blame public health authorities for overreacting, but the reason we have so much epidemiological and scientific information about H1NI is because the public health authorities went on alert, became more vigilant, and investigated possible cases. Now we have this ironic situation, we can step back from the crisis, but only because we went on high alert, and had this transparent flow of information, from the scientific makeup of virus to the extent of global spread."
According to Science, the pace of scientific progress has been astounding, with scientists from across the globe contributing their expertise. "'I'm amazed at the capacity we have with the information and communication technologies," says epidemiologist Mirta Roses Periago, head of the Pan American Health Organization. During the past few weeks, she notes, scientists have rapidly shared sequences of the viruses, digital images of patient X-rays, and electron micrographs of the new H1N1. "At this point in history, this is the best surveillance we've ever had," said Keiji Fukuda, one of WHO's assistant director generals."
Already, this information is being used to formulate a vaccine against H1N1.
Telling it like it is
Beyond the scientific effort, public health folks have also mounted a new, refined effort to inform the public without causing panic. Notably, the official pronouncements offered no blanket reassurances that the epidemic could be controlled. Instead, WHO and CDC statements pursued this type of realistic tone: "We're doing what we can, but we have many unanswered questions about this virus: Where it came from, how deadly it is, how fast it is spreading. The best thing is to follow guidance from local authorities, and not panic. Prompt action can save lives, but stay tuned: We cannot know in advance how bad this will get."
That cautious tone reflects a global effort to discuss epidemics and pandemics with the public that is encapsulated in WHO's 2005 "Outbreak Communication Guidelines. The new style emphasizes building trust, promptly releasing new information, and admitting when questions cannot be answered. (In 2005, WHO also promulgated the International Health Regulations, as a basis for the global response to crises like H1N1.)
When no treatment is available, public health authorities must rely on prevention. The goal is to get healthy people to change their behavior by raising the level of concern -- making them worry, but not panic. This approach is inherently difficult, says LeeAnn Kahlor, an assistant professor of advertising at the University of Texas. "People don't tolerate uncertainty well. They want concrete answers. Am I at risk? Will I get this flu? How many people will die?"
None of these answers can be known when a new flu virus strikes, notes Kahlor, who studies risk communication during epidemics. "It takes time to take the measure of a new strain. I'm not sure how you get around that in the short term."
Did somebody panic?
There was some panic during the H1N1 episode -- witness the London tabs -- but Kahlor says that in Texas, which borders Mexico and had the first American death from H1N1, "I have been really impressed with how institutions -- like the University of Texas and various Texas school districts -- have responded. They have provided people with helpful information (using email and newsletters), explained their decisions to stay open (or close), and responded in a timely manner. This builds confidence that when the 'big one' hits, there are people who know how to respond."
One sign of panic may be the widespread use of face masks, which are not particularly effective at blocking influenza viruses. But the alarms also sparked an increase in frequent hand washing, which does reduce transmission of flu and other respiratory diseases.
The warnings to date are a mild version of what we would hear during a truly dangerous pandemic. If a virus like 1918 broke out, we would be advised to stay home to avoid infection. We hope the planners have figured out how to prevent panic while preserving services like water, electricity, sewers, police and food distribution in these circumstances...
Given influenza's ability to mutate into dangerous new forms, a killer epidemic may be only a matter of time, which explained the alarm over avian flu. But even in a milder case like H1N1, communication would be eased if the public knew more about science, Kahlor says. "If people had a basic understanding of viruses, of how they can mutate, of how personal actions reduce threats, and how science is a process, tolerance for uncertainty in the short term may increase. I think we have allowed the public to build unrealistic expectations for what scientists and the medical community can know; people don't understand the process and the uncertainty that is a real part of science."
Amen.
A good word for Mexico
The response to this year's outbreak was shaped by the deadly SARS epidemic in 2003, which China prolonged with a "see-no-evil, speak-no-evil" policy that obstructed scientists trying to investigate the outbreak. By most accounts, Mexico did much better: it reported what it was finding, and promptly sent tissue samples to labs the United States and Canada where the new virus was identified.
In a great blog at Science magazine, writer Jon Cohen quoted Ira Longini, an epidemiologist at the University of Washington: "I think the Mexicans did all that was possible with a virtually impossible situation."
Mexico has taken the biggest economic hit from the pandemic, with a meltdown of tourist income combined with a shutdown of gatherings, sporting events and restaurants designed to contain the epidemic. These costs, combined with discrimination against Mexican citizens, has caused some finger pointing, says Fidler. People want someone to blame, "and the general thesis" is that the blame should go "to public health authorities and WHO, which went from phase 3 to phase 5 [its second-highest level of alert], or the CDC, which declared a national public health emergency, and issued guidelines on closing schools after finding one case."
Public health: an impossible job?
Such blame-gaming is only possible after an impending epidemic has been averted, but public health authorities must be judged based on what they knew at the time, Fidler says. "We are already forgetting that the initial report from Mexico concerned a disease with a fairly severe impact. Public health authorities have to take action on basis of the best available data, it's always a circumstance where I'm damned if do and damned if I don't. The virus had not been seen before. There was some evidence that it had a fairly high morbidity and mortality in a young, otherwise healthy population. These are all bad signs, and I don't think public health overreacted at the global or national level."
Indeed, as we go to press, we learn that the Mexican state of Jalisco has again banned public events after three new deaths were linked to H1N1.
To repeat, influenza is a tricky, fast-spreading virus, and some believe health authorities responded too sluggishly. Yi Guan, a Hong Kong University virologist who identified the SARS virus in 2003, noted that by April 24 WHO knew that the virus was moving from person to person in Mexico, and that the United States had three cases. "I was still optimistic we could contain H1N1," Yi told Science. Then nothing happened all weekend. ... We missed the golden period to contain the virus. Several hours could be another couple hundred cases. Every second was valuable at that time. We made a huge mistake. From then on it was countdown to the pandemic."
We may eventually learn whether the mild outbreak reflects the inherent nature of the virus, or the human response to it, or both. But asking whether public health folks went overboard raises a good point: Will warnings be heeded next time, when a truly dangerous virus is afoot?
Cry wolf too many times, and everybody goes to sleep. It's the same hazard that stymies efforts to forecast earthquakes and volcanoes, and to some extent, hurricanes.
How it's supposed to work
If we cannot know whether people will respond appropriately to the next influenza warning, the "they-cried-wolf" crowd must confront an equally tough question: Would H1N1 have been more destructive if the warnings had been less alarmist? Would anybody have responded to a message from the WHO that "another mild flu has been detected in Mexico?"
Historians have jargon for efforts to describe trains of events that did not occur: They use "counterfactual history" to explore, for example, what would have happened if Japan had not attacked Pearl Harbor in 1941 and brought the United States into the world war. A counterfactual history of H1N1 would try to describe what would have followed mild warnings about H1N1.
When public health is working right, we don't see the disasters. We see the warnings, we get concerned (if not scared). We change our behavior, the white-coats work late, and then we breathe a sigh of relief and start to blame the experts for crying wolf.
Like it or not, that's how public health is supposed to work -- at least, until the blame-gaming step....
