An Epidemic of Overreaction /The scare Scenario / The Fear Epidemic

Thu, 27 Oct 2005

Dr. Marc Siegel,  a practicing internist and an associate professor of medicine at New York University School of Medicine, and a subscriber to the AHRP Infomails, forwarded 3 recent Op Ed articles he has published–in The Nation, the Los Angeles Times, and USA Today. Dr. Siegel puts the Avian flu in perspective and assures the public that at this point the Avian flu poses primarily an epidemic of fear generated by overreaction.

“If Americans are afraid of avian flu now, imagine what will happen if a single scrawny, flu-ridden migratory bird somehow manages to reach our shores. This is how fear works, how the fear epidemic – as opposed to a flu pandemic – spreads. Fear is supposed to be our warning system against imminent dangers, but as a deep-rooted emotion, it interferes with our ability to make sound judgments. And if anything is contagious right now, it’s judgment clouded by fear. Immediate government overreaction creates this cycle of fear: The public reacts and calls for action. Health officials, hearing the public and media cries, look to quiet these generated fears with knee-jerk health policy (such as stockpiling a product with a relatively short shelf life: Both Tamiflu and bird flu vaccines are perishable and will have to be discarded if not used in three years).”

“Most human influenzas begin as bird flus, but many bird flus never change to a form that can harm us. Though flu pandemics occur on the average of three times per century, and we are clearly overdue (the last was in 1968), there is absolutely no indication that the transformation to mass human killer is about to happen. The threat is theoretical. Unfortunately, the attention it has received makes it feel like something terrible is inevitable. Why the overreaction? For one thing, direct comparisons to the Spanish flu of 1918, a scourge that killed more than 50 million people worldwide, has alarmed the public unnecessarily”

“But there are many differences between 1918 and now. Many of the 1918 flu victims died of pneumonia because of a lack of antibiotics, which we now have in ample supply. There were also no flu vaccines or antiviral drugs back then, and people lived (and died) in wartime conditions of deprivation and sometimes squalor.”

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October 24, 2005
THE NATION
The Scare Scenario
Dr. Marc Siegel

When I see the posters for the soon-to-be released Chicken Little movie, I have to wonder what the lead character would have to say about the current bird flu craze. Would he say the sky is about to fall on him? Or would he come to his senses and understand that even as an American chicken, he is more likely to be killed by panic than by the flu?

The American public is profiting the least from the ongoing hysteria surrounding avian influenza. The drug manufacturer Roche is suddenly in great demand for its antiviral drug Tamiflu, which has only been tested against bird flu in the test tube and has no current use, because the virus has not mutated to a form that can easily be transmitted among humans. A common misconception–that Tamiflu is some kind of a bird flu vaccine rather than an antiviral that at best decreases symptoms of infection–has led to a lot of impulse buying. As with the antibiotic Cipro, prescribed to treat anthrax back in 2001, Tamiflu is becoming a treatment for the fear of a virus rather than the virus itself.

Another main profiteer of the bird flu panic is our federal government. Driven to avoid another disaster debacle like Hurricane Katrina, the Bush Administration is galloping to the rescue in advance of anything happening. The President’s recent suggestion that he might use the military to control an influenza pandemic reminds us how quickly civil liberties can be sacrificed in an emergency. But more than that, it is a hysterical suggestion. Pandemics infiltrate a community person by person. A show of military force would likely cause a panic that would spread a virus more quickly.

Most bird flus don’t mutate sufficiently to pass to humans. And those that do are usually responsible for our yearly influenza outbreak. On the average of three times per century, a mutated avian influenza is a bad enough bug to cause a pandemic. The bird flu of current concern, A(H5N1), is a big killer among birds but is still several mutations away from being able to routinely infect us. The estimated sixty-five people who have died of it over the past two years did so because of their close and repeated contact with birds, not because of casual contact. Cooking a chicken kills the influenza virus.

So why all the panic over a potential threat? In part the public hysteria is due to the fact that basic information about this potential pandemic has been misconstrued or ignored about this potential pandemic, much in the way previous health threats in the news–anthrax, smallpox, West Nile virus, mad cow disease–were all magnified beyond their ability to do great harm.

In each case there is a doomsday scenario that is packaged and sold to the public by the media, which consequently makes some undeserving manufacturer rich or collects votes for an undeserving leader.

In the case of bird flu, direct comparisons to the scourge of 1918 may well be overblown. Many people died of pneumonia during that outbreak of the Spanish flu because there were no antibiotics to treat it. There were also no vaccines, no antivirals and little in the way of public health or the sanitary conditions Americans take for granted today. We also have our top scientists and epidemiologists tracking this avian flu, which was not the case in 1918 prior to the essential mutation.

Fear leads to a diversion of resources; our fear of bird flu is being translated into a proposal for massive stockpiles of perishable drugs and vaccines. Congress could calmly and rationally designate funds to upgrade our flu vaccine manufacturing capacity using the genetic technology we already use routinely for other vaccines. Instead, our government allows pharmaceutical companies to use an outdated chicken-egg medium that requires three to six months to develop a vaccine against a particular strain. This slow process is then a justification for panicked stockpiles.

Bird flu is better studied in the laboratory than in a news conference. This virus deserves public attention only insomuch as it motivates our government to improve emergency services while bringing methods of vaccine manufacturing into the twenty-first century.

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LOS ANGELES TIMES
An epidemic of overreaction
10-11-05
By Marc Siegel, MARC SIEGEL is an internist and associate professor at the New York University School of Medicine. He is the author of “False Alarm: The Truth about the Epidemic of Fear” (Wiley, 2005).

THIS PAST WEEK, my patients seemed more nervous than usual. In addition to concerns about chest pain, coughs and fevers, there were also the sudden, uneasy questions about bird flu.

“Should I be taking Tamiflu?” several asked. “Can you prescribe it so I have a supply on hand just in case?”

My answer was always the same. “No. Tamiflu is an antiviral drug that has not yet been proved effective against bird flu. And even if it worked, there’s still no bird flu to treat.”

The difficulty with informing the public about a potential pandemic is that the uncertainty about when or if it could occur breeds fear. Scared people over-personalize the news, and their worries increase. Fear is a warning system intended to alert us to impending danger. The bird flu, though a potential large-scale danger, is not impending.

The facts are these: The current H5N1 avian influenza virus has not mutated into a form that can easily infect humans, and the 60 people in the world who have died of this bird flu have done so not because this bug is on the road to mutation but because millions of birds throughout Asia have been infected, and the more birds that have it, the more likely that an occasional human bird handler will be infected.

Most human influenzas begin as bird flus, but many bird flus never change to a form that can harm us. Though flu pandemics occur on the average of three times per century, and we are clearly overdue (the last was in 1968), there is absolutely no indication that the transformation to mass human killer is about to happen. The threat is theoretical. Unfortunately, the attention it has received makes it feel like something terrible is inevitable.

Why the overreaction? For one thing, direct comparisons to the Spanish flu of 1918, a scourge that killed more than 50 million people worldwide, has alarmed the public unnecessarily. In fact, there are many scenarios in which the current bird flu won’t mutate into a form as deadly as the 1918 virus.

And even if we accept the Spanish flu scenario, health conditions in 1918 were far worse in most of the world than they are now. Many people lived in squalor; 17 million influenza deaths occurred in India, versus about half a million deaths in the U.S. There were no flu vaccinations, no antiviral drugs, and containment by isolating infected individuals wasn’t effective, largely because of poor information and poor compliance. Today’s media reach could be a useful tool to aid compliance. Of course, the concern that air travel can spread viral infections faster may be valid, but infected migratory birds were sufficient in 1918.

Unfortunately, public health alarms are sounded too often and too soon. SARS was broadcast as a new global killer to which we had zero immunity, and yet it petered out long before it killed a single person in the United States. SARS was something to be taken seriously, but the real lessons of SARS, smallpox, West Nile virus, anthrax and mad cow disease weren’t learned by our leaders – that potential health threats are more effectively examined in the laboratory than at a news conference.

With bird flu, scientists have been working on the structure of the viruses in an attempt to protect us. Studies published in the journals Nature and Science over the last six years have given scientists a road map with which to track the current bird flu and alert health officials if it mutates further. It is reasonable to try to control the bird flu while it remains in the bird population. There is great value in improving our emergency health response system and upgrading our vaccine-making capacity. Government subsidies in these areas could make the public safer.

But, right now, there is no value in scaring the public with Hitchcockian bird flu scenarios. The public must be kept in the loop, but potential threats should be put into context. The worst case is not the only case.

USA TODAY
Alive and well: The fear epidemic
By Marc Siegel
10-19-05

A 50-year-old asthmatic patient who came to my office recently asked for Tamiflu as a protection against bird flu.

“Bird flu may get us all this year,” he wheezed anxiously.

“There is no bird flu here,” I said.

The greatest problem among my patients right now isn’t bird flu; it is fear of bird flu. The greatest risk of an epidemic is of a fear epidemic.

The hyperventilating has reached well beyond my practice. The U.S. Centers for Disease Control and Prevention has been deluged with phone calls and questions. Among them: “Is it safe to keep a bird feeder in the yard?” The answer: Yes!

Bird flu scares us because it is a mindless microbe that has choked off the breathing of millions of birds. But a species barrier protects us from this virus unless there are several more mutations to the viral DNA.

So why are people scared out of proportion to the risk, which is currently close to zero for anyone except bird handlers?

All eyes on 1918

For one thing, comparisons to the terrible scourge of 1918 – when another bird flu mutated and passed human to human – have dilated the sense of danger. But there are many differences between 1918 and now. Many of the 1918 flu victims died of pneumonia because of a lack of antibiotics, which we now have in ample supply. There were also no flu vaccines or antiviral drugs back then, and people lived (and died) in wartime conditions of deprivation and sometimes squalor.

If Americans are afraid of avian flu now, imagine what will happen if a single scrawny, flu-ridden migratory bird somehow manages to reach our shores.

This is how fear works, how the fear epidemic – as opposed to a flu pandemic – spreads. Fear is supposed to be our warning system against imminent dangers, but as a deep-rooted emotion, it interferes with our ability to make sound judgments. And if anything is contagious right now, it’s judgment clouded by fear.

Immediate government overreaction creates this cycle of fear: The public reacts and calls for action. Health officials, hearing the public and media cries, look to quiet these generated fears with knee-jerk health policy (such as stockpiling a product with a relatively short shelf life: Both Tamiflu and bird flu vaccines are perishable and will have to be discarded if not used in three years).

Right and wrong approach

So what’s the right approach?

Modern-day scientists are tracking the current bird flu and comparing its structure with influenzas of the past. This should comfort us. Laboratory science and careful epidemiological study are the best kind of preparation.

But PR is inevitably part of the game. That’s where calls for vaccine stockpiles and “fact-finding” missions come in. U.S. Health and Human Services Secretary Mike Leavitt just wrapped up such a trip to Asia over the weekend. His fear-provoking conclusion: Preventing the start of a global pandemic is just about impossible.

We’ve heard this all before.

First it was anthrax, then smallpox, followed by West Nile virus and SARS, then human influenza, and now the animal variety. The public-health batting average has been quite low.

It is true that AIDS taught us that we need to look seriously at emerging threats before they spread. But AIDS still kills nearly 3 million people every year in the world, tuberculosis nearly 2 million and malaria about 1 million. We would be far better off using our personal fear radar against these diseases than against a bird disease that’s still off in the distance.

Marc Siegel is an associate professor of medicine at NYU School of Medicine. His new book is False Alarm: The Truth About the Epidemic of Fear

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