H1N1: The Rant

On June 11, 2009 Dr. Margaret Chan, Director General of the World Health Organization (WHO) held a press briefing at the WHO’s headquarters in Geneva to announce that in response to surveillance data regarding the new strain of the H1N1 virus that was first detected in April, “I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6.” This is rather like when the Secretary of Homeland Security raises the National Threat Level from Orange (High) to Red (Severe). Except that the Secretary of Homeland Security’s announcement does not receive saturation coverage from international media, is not carried live by major networks around the world, and does not lead reporting in most print, broadcast and electronic media outlets.

Dr. Chan’s remarks and the media frenzy around them disturb me for two reasons. First, I think a more appropriate venue for her remarks might have been a conference call among health ministers or a conference of epidemiologists. Her remarks offered directives for national and international agencies, as well as drug companies. They had to do, primarily, with ramping up prevention efforts on a macro scale. Of course I believe that developing an effective vaccine and ensuring that adequate distribution mechanisms are in place are vital. But do I believe that those efforts were advanced by Wolf Blitzer bloviating immediately after Dr. Chan finished speaking ? Or by the coverage provided by Al Jazeera, the People’s Daily, the BBC or the Newark Star-Ledger? No. And I say that even though most media outlets offered responsible coverage (although People’s Daily got a little snarky with the British in later stories on vaccine development and distribution).

A more specialized audience might not have been given to widespread confusion over the concept of a “pandemic.” Until fairly recently I had no idea the term pandemic did not reference severity of impact. Number of reported cases and number of deaths? Not of interest to pandemic adjudicators. For instance if 700,000 people die of a virus in Indonesia, but the virus is contained to Indonesia, then there’s no pandemic merely a lowly epidemic. Bad week for the Indonesians perhaps, but the WHO has bigger fish to fry. Now, if a dozen people in each of 11 countries come down with the very same virus, yee-ha ma!, crank up the fund raising machine ‘cause we got ourselves a pandemic! I believe it was a reported case in the Netherlands that lead our strain of H1N1 to the promised land.

A posting by The Mayo Foundation for Medical Education and Research (MFMER) on the Mayo Clinic website points out that the phase 6 classification does not even reflect the severity of individual infections. So a virus doesn’t even have to make people very sick to achieve the coveted pandemic status?

My point is not that statistical modeling is without value, my point is that because the public’s (public=me) understanding and the public’s concerns are so different (life, death, human suffering in a non-abstract way) that the terms of art of the public health establishment are not useful in communicating with the public. Since pandemic apparently doesn’t mean lots of people will get very sick and many will die, which is, I believe, the understanding of much of the public it is probably a term that confuses more than it clarifies.

In short, a pandemic is like pornography. No one can define it but everyone knows it when he or she sees it. Lest you think I’m being glib, until the week after Dr. Chan’s memorable press briefing the WHO had a definition on its web site saying that a pandemic flu causes "enormous numbers of deaths and illness." When this was brought to WHO’s attention by CNN, a WHO spokeswoman told CNN that the definition was in error and had been yanked. She explained, "It was put up a while ago and paints a rather bleak picture and could be very scary.”

That explanation is particularly startling given the statement that denoted the high water mark of Dr. Chan’s press briefing. Threading her way between fear mongering and reassurance, Dr. Chan finally came down firmly on the side of fear mongering, "After all, it really is all of humanity that is under threat during a pandemic." I’m going to repeat that for those who are experiencing for the first time my slack-jawed astonishment. The woman said:: "After all, it really is all of humanity that is under threat during a pandemic." To which I can only respond, no. That is a lie. A simple, unadorned lie. A lie.

No war, no weapon, no incident-of-widespread-serious-contagious-illness-with-a-high-mortality-rate-that-we-may-or-may-not-call-a-pandemic has ever been a threat to “all of humanity.” It’s just a ridiculous thing to say. From the Director General of the World Health Organization in the context of an international press briefing, it’s a good deal more pernicious.

Starting in the 1330’s Europe, North Africa, the Middle East and much of Asia endured the ravages of the Bubonic Plague. Scholars offer estimates ranging from one-third to one-half to as high as 60% of the population of Europe perished in 5 horrific years. The Chinese province of Hubei was said to have lost 90% of its population in a single year, 1334, at the start of this pandemic. At any point in the Fourteenth Century was “all of humanity” at risk? Emphatically not.

As World War I drew to a close in 1918, the world was struck with an influenza pandemic that killed somewhere between 20 and 40 million, or 50 million, or 100 million people worldwide in a year or less. (This is what is meant by scholarship – “you say something and I’ll say something different and we’ll both have work for a decade.”) An article in Fortune magazine called “Viruses of Mass Destruction" offered the vivid vignette of mass graves being dug by steam shovel for bodies being buried without coffins. Was “all of humanity” ever at risk? Not for one single second.

From 2003-2005 the WHO worked nights and weekends to gin up a crisis for the Avian Flu Pandemic. It was the next big thing in public health. Worse luck that it was so hard to find someone who hadn’t spent 8-10 hours a day standing waist deep in chicken refuse, or hadn’t swilled the blood of a recently deceased fowl (very big at weddings), or who wasn’t a family member or intimate of one of the former who would appear to be infected. Heading to a conference in Vietnam in 2003 a WHO official worried that an Avian Flu global pandemic could kill “millions.” He went on to add that the world is “now overdue” for an influenza pandemic, since mass epidemics have occurred every 20 to 30 years and it had been nearly 40 years since the last one.

Avian Flu is known among its associates as H5N1. Since the initial cases were reported in Southeast Asia in 2003, the WHO has been forced to concede that the total number of cases, worldwide has only reached 281, with 169 fatalities. Vietnam, the epicenter of the H5N1 pandemic, reported 93 cases, with 42 deaths through 2005. And none since.

After such a disappointment, one can see why the folks at WHO would be pulling for a threat to “all of humanity” to cover lost ground.

But there’s another reason, for WHO, for member governments and big international donors, for drug companies and the better off citizens of industrialized nations. Something new, something headline grabbing, something the Director General of the World Health Organization can get up on the bar and really twirl her tassels over will distract all of the above from the seemingly intractable problems of hunger and disease and clean drinking water and sanitation that do not lend themselves to the quick and profitable fix of this year’s vaccine and a still patented antiviral or anti-bacterial medication.

The United Nations’ Millennium Development Goal is to reduce the 1990 child mortality level by two-thirds by 2015. The most recent progress report was issued in 2006. Looking at deaths among children under five worldwide, the figure in 1990 was 12.7 million and in 2006 it was 9.7. In Sub-Saharan Africa, 4.1 million children under five died in 1990 and 4.8 million children under five died in 2006. The hard number increased substantially, but the relative change is almost incomprehensible. Did I mention these are children? Under five?

That a sustained effort on the part of the United Nations cannot get the children of sub-Saharan Africa the assistance, simple, basic assistance - wells , sewers, food assistance, common antibiotics – to advance their very survival suggests to me that “all of humanity” is under threat in very profound ways. And if those children remaining, who have been denied so much and have seen such horrors ever come to have my access to anger it will be the greatest threat that “all of humanity” has ever faced.

Even counting Legionnaires’ Disease.

Since I started with H1N1, I want to come full circle. I leave the final word to the U.S. Centers for Disease Control and Prevention (CDC): “Most people who have become ill with this new virus have recovered without requiring medical treatment.”