Emotional Epidemiology

This, from The New England Journal of Medicine, sounds familiar:

This is the story line for most headline-grabbing illnesses — HIV, Ebola virus, SARS, typhoid. These diseases capture our imagination and ignite our fears in ways that more prosaic illnesses do not. These dramatic stakes lend themselves quite naturally to thriller books and movies; Dustin Hoffman hasn't starred in any blockbusters about emphysema or dysentery.

When the inoculum of dramatic illness is first introduced into society, the public psyche rapidly becomes infected. Almost like an IgE-mediated histamine release, there is an immediate flooding of fear, even if the illness — like Ebola — is infinitely less likely to cause death than, say, a run-in with the Second Avenue bus. This immediate fear of the unknown was what had all my patients demanding the as-yet-unproduced H1N1 vaccine last spring.

As the novel disease establishes itself within society, a certain amount of emotional tolerance is created. H1N1 infection waxed and waned over the summer, and my patients grew less anxious. There was, of course, no medical basis for this decreased vigilance. Unusual risk groups and atypical seasonality should, in fact, have raised concern. By late summer, the perceived mysteriousness of H1N1 had receded, and the number of messages on my clinic phone followed suit.

But emotional epidemiology does not remain static. As autumn rolled around, I sensed a peeved expectation from my patients that this swine flu problem should have been solved already. The fact that it wasn't "solved," that the medical profession seemed somehow to be dithering, created an uneasy void. Not knowing whether to succumb to panic or to indifference, patients instead grew suspicious.

Posted on December 9, 2009 at 6:43 AM • 20 Comments


JeroenDecember 9, 2009 8:44 AM

Given that some countries sport HIV infection rates in the double digits (Wikipedia reports >26% for Lesotho, topping the list), it seems unfair to include HIV in this list.

Old Prof. OtterDecember 9, 2009 9:53 AM

What they are missing is any notice of what goes on in talk radio. There was a show done that stated that the last swine flu type disease killed maybe 50 and the vaccine killed/crippled maybe 1000. So, simple, if this is not the 1918, then keep away from the vaccine. (numbers are per a lousy memory, but good enough to convey the core information.)

Steven HooberDecember 9, 2009 11:08 AM

> then keep away from the vaccine

Isn't all this thinking falling into the same trap. All I've heard from (non-panicky) health professionals is that there is a new flu every year. Every year they create a new vaccine, and test it the same way as always.

This doesn't vary except for the panic factor (some induced by the government response, yes). The uniqueness of the danger of the Novel H1N is /slightly/ elevated, and the uniqueness of the danger of the vaccine is nil.

Not that there is zero danger from any of these factors, just that the absolute uniqueness of the danger is quite low, and the perceived danger is very high for entirely sociological, psychological, cultural reasons.

Petréa MitchellDecember 9, 2009 11:36 AM

When a co-worker said he didn't want his kids getting the H1N1 vaccine because it was too new and "they haven't tested it enough", I blurted out something like, "So you'd rather test a new and poorly understood virus on them instead?"

I'm not entirely proud of fighting vague and irrational fear of the unknown by invoking vague and irrational fear of the unknown, but I think it did make an impression.

ChuckDecember 9, 2009 11:59 AM

What will happen in the next years?
H1N1 becomes probably one of the more dominant strains of flu and replaces one or two of the previous years prevalent strains. It will be included in the standard mixture of strains for the 'ordinary' flu vaccine (which is updated yearly and is a vaccine againt ~3 main strains).
and nobody will make a fuzz about it -- but just gets the 'ordinary' flu vaccacine. A few thousand unvaccinated weak/erlderly will die (as during each season) and so on...

Probably a vaccination against pneumonia (i.e. pneumococcus bacteria) is much more important, since most people do not die just because of flu but of pneumonia *after* one was soften up by flu.

Dr. PhilDecember 9, 2009 2:34 PM

@Petréa Mitchell:
There's a relatively small chance that he'd end up testing the new virus on his kids. Maybe he'd rather take the 0.1% chance that his kids get the disease than the 100% chance they get the vaccine.

Petréa MitchellDecember 9, 2009 3:44 PM

Dr. Phil:

You're missing the point. I wasn't making a rational argument based on statistics, and neither was he.

Clive RobinsonDecember 9, 2009 6:20 PM

One thing that has come out of the H1N1 pandemic (yup it is "officialy one") is that Roche may have been playing fast and lose with data about Tamiflu efficacy.

It might actually be statisiticaly less effective than a placebo.

As the UK has spent something like 500 millon USD equivalent on it (acording to the various news items) it might prove interesting...

RobertDecember 9, 2009 6:40 PM

My greatest concern is the incompetent way the vaccine thing has been handled at county, state, and federal levels. It's a miserable response to the risk at hand, admitting though that the risk is limited rather than the overblown hysteria found in the mass media.

There have been vaccine shortages for years. This isn't good at all. My impression is that skewed economics - possibly created by government interference - mean that vaccines aren't terribly profitable. In turn, quick response for new vaccines isn't profitable either. And since there's no non-profit manufacturing vaccines, a Russian-style-bread-shortage ensues. I believe the federal government to be at fault for this one.

In the case that you believe there simply wasn't time to grow enough vaccine, because it wasn't easy to incubate using decades old technology, I can still make the case that the various states, excluding Minnesota - coincidence Bruce? I think not - dealt with the situation poorly. They failed to approach vaccine distribution based on the aggregate risk to the population, ie making sure the highest risk people got both vaccines first to reduce chances of outbreak, and instead gave it out willy-nilly.

The flu kills plenty of people every year. The only real difference is that there were two strains this year (H1N1 2009 and H1N1 2007) where one (the former) was more resilient and more communicable. How much press the former got then sent material portions of the public into a dither, including educated clinicians/medical practitioners and government officials who should know better and are paid to know better resulting in greater risk to the general population.

Bruce ClementDecember 9, 2009 8:40 PM

@Petréa Mitchell

Brilliant comment. Hope you don't mind, but that has been temporarily made into my email signature & permanently added to my list of memorable quotes (With attribution, of course)

GregDecember 10, 2009 6:57 AM

There is a strong case for vaccinations... except for influenza. The data is just not clear that anything makes any difference over nothing. Experts* have arguments about this all the time.

* Medical experts, that often get help from our math group on statistics. These guys really don't understand anything about statistics.

BF SkinnerDecember 10, 2009 7:57 AM

@ Bruce Clement @Petrea Mitchell - ditto!

@Gerrit "Storm in a ..."

Not so true. The anti-vacinate movement is growing here in the US. I see it as part of the general anti-intellectualism that got us our former president and feeds some of the political unrest here now.

People are responding emotionally to risk based on stories rather than facts. They seem to be trying to stop trusting science and scientists. Everyone knows about the washington redskins cheerleader no one knows the actual stats are yes some guilleme-barre are known to be a result of the vacine (less than 2 in how many million doses?)

DavidDecember 10, 2009 9:03 AM

Dr. Phil: The chance of getting the flu, if not vaccinated, is significantly higher than one in a thousand. I used to routinely catch it, which is one reason I always get a flu shot when available. Call it about 50% for me, and I'm not in a job where I'm particularly exposed.

Even if it were one in a thousand, the H1N1 virus has been killing maybe one person in two hundred affected, so that would be one person in two hundred thousand killed by H1N1. That's more dangerous than the vaccine.

Now, add to that the fact that H1N1 has been killing healthy young people in considerably larger numbers than most flu viruses, which tend to kill off the old and sickly, and you will understand why my child is getting the shot when available.

CalebDecember 10, 2009 2:41 PM

My wife and I watched H1N1 closely since she was pregnant with our 3rd (born Nov. 7th), we have two kids 5 or under, and I have asthma--placing us in the high-risk category. I caught a nasty strain of type-A influenza (not H1N1 variant) back in September but managed not to spread it to anyone else.

When my wife asked her doctor about vaccine safety, he started to get defensive. She reassured him that she just wants the facts from him and not anyone outside the medical industry and he calmed down. Apparently, he had to deal with a lot of people bringing misconceptions about vaccines and some with various conspiracy theories.

averrosDecember 10, 2009 4:55 PM

@BF Skinner

"The anti-vacinate movement is growing ... part of the general anti-intellectualism"

No, this is part of growing recognition that coalition of government, big business, and academia (who gets grants from the previous two) are lying too often for the benefit of themselves at the expense of general public.

There's nothing anti-intellectual in being sceptical about scares de jour. In fact, uncritically believing what the "experts" are telling us *is* against the reason - simply because it is based on faith.

There's a name for this faith - it is called "scientism". Look it up.

RogerDecember 11, 2009 2:36 AM

I don't know if things are different in the US, or if these doctors have a biased sample (more than an average number of hypochondriacs.) But my personal experience is that this report is completely wrong: there is no initial phase where "the public psyche rapidly becomes infected."

Rather, people have for more than a decade been bored out of their brains with medical scare stories, and now ignore nearly all of them.

RayDecember 11, 2009 1:37 PM

@Petréa Mitchell

Your comment just got cut and pasted into an email to some of my snarkier friends. You totally made my day with that, and I just thought you should know.

AlexDecember 15, 2009 6:02 AM

Well ... in Germany, the number of deaths officially attributed to swine flu is below 100 (!), with about 5% of the population vaccinated. This is waaaay below the "normal flu" numbers. I guess someone made real big bucks here ...

Clive RobinsonDecember 15, 2009 7:37 AM

@ Alex,

"Well ... in Germany, the number of deaths officially attributed to swine flu is below 100 (!), with about 5% of the population vaccinated. This is waaaay below the "normal flu" numbers."

Hmm I don't know about Germany but the "flu season" has not yet started in the UK due to the fact of unseasonal weather conditions, nor are the figures yet in on shortend life expectancy for those who have been infected.

That being said, apparently the results from autopsies show that the H1N1 effects are very similar (ie attacks the lungs) to those from the 1918 pandemic that killled more people than WWI.

However medical science has moved on a significant amount since 1918, for instance at the very least we have anti-biotics that will help fight the secondary infections (which may have contributed to the high 1918 and onwards death toll).

Also in many respects our populations are far healtier (lung wise) than in 1918 due to a number of factors including having heating for homes that does not produce micro particulats in the air that cause significant "pea souper's" like the one that killed many thousands in London and the UK in the 1950's.

Our populations also tend to smoke less and we eat more healthaly.

So there are many many differences that may account for the sofar low death rate.

"I guess someone made real big bucks here ..."

Yes one of which is Roche with "Tamiflu" that appears to have significant questions hanging over the clinical trials information that gave rise to it being bought in very large quantities (the UK is estimated to have spent over €600,000).

All that being said H1N1 has not yet run it's course at a "flu season weather" time where it would be expected to cause most infections.

We will probably have to wait untill June 2010 before we can say "we are out of the woods" yet.

Personaly (and I've no financial interest other than as a tax payer and user of the UK NHS) I think the spending was justified based on the information available at the time the purchase decision had to be made (if with hind sight it is not, is an altogether different issue, afterall we can all get the correct lotto numbers after the draw).

Will it turn out to be a waste of money. Probably not even if H1N1 is not a problem in the long run.

Now the capacity is available in the drugs industry they will want to see a good return on their investment in new plant etc. Therefore I expect that those with the appropriate buying power (Gov's) will re-negotiate the pricing on drugs that will use the extra capacity (they have paid for).

And with a little luck that new capacity will also give benifit to those in other nations that cannot currently afford the sort of health care we see in the UK and Germany.

With health care the cost / benift is very difficult to gauge due to the number of causes and the many effects each cause has, and the time over which benifits are expected to be realised.

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