One Flu Over the Cuckoo’s Nest…and met Nurse Ratched

One Flu Over the Cuckoo’s Nest
Thursday, December 21, 2006
By Steven Milloy

Flu fearmongers must be quite depressed these days. Seasonal flu is late. Bird flu – despite all the headlines – hasn’t gained much traction among humans. And we haven’t had pandemic flu in 36 years.

Well, I would suggest that Mr Milloy contact the Alabama hospitals.  See the post below this one for a run-down of what this year’s early and severe flu season is doing to some of Alabama’s children.

The good news is so good (for the rest of us, that is) that the flu lobby seems to be resorting to manufacturing fantasy flu statistics.

A new study published this week in the medical journal The Lancet (Dec. 23/30) estimates that a global pandemic flu could result in 62 million deaths worldwide, mostly in poor nations. The researchers naturally conclude that “prudence” requires “focusing on practical and affordable strategies for low-income countries where the pandemic will have the biggest effect.”

But the study is yet another example of how out-of-touch with the real world some public health researchers can be.

First, the researchers’ estimate of 62 million deaths has far more shock-value than credibility. It’s guesswork derived from other (cherry-picked) guesswork.

The 62 million-death sound-bite is the product of statistical modeling that uses worst-case death rate estimates from the 1918-1920 pandemic influenza – an epidemic that medical historians believe killed somewhere between 20 million to 100 million people.

Well, he won’t get an argument out of me about it being all guess work, because, that is precisely what it is.  The sad fact is, our ignorance appears to know no bounds when it comes to pandemic influenza.  A case in point is the September 2006 WHO report:

Influenza Research at the Human and Animal Interface plainly, and depressingly, points out.

Determinants of virulence and transmissibility.

A mutation in the PB2 gene, at position 627, has been shown to influence pathogenicity in mice, but that finding has not consistently correlated with severity of infection among viruses isolated from patients in Indonesia and Viet Nam. Investigation of the role of internal polymerase genes is continuing. It appears clear, however, that the external HA and NA genes are not the sole drivers of disease severity.  likewise, transmissibility of the virus may ultimately prove to be a genetically complex trait. One especially important question that was discussed is whether the H5N1 virus is likely to retain its present high lethality should it acquire an ability to spread easily from person to person, and thus start a pandemic. Should the virus improve its transmissibility by acquiring, through a reassortment event, internal human genes, then the lethality of the virus would most likely be reduced. However, should the virus improve its transmissibility through adaptation as a wholly avian virus, then the present high lethality could be maintained during a pandemic.

We do not entirely understand what makes an influenza virus easily transmissible from person to person or what makes it a killer of unimaginable efficiency or a strain so mild as to barely register on the medical radar.  We just don’t know.  Experts can hazard reasonable guesses and estimations, but at the end of the day, they are still guesses.

Back to Mr. Milloy…

In addition to the obvious uncertainty surrounding the actual death toll from the 1918 flu pandemic, the researchers ignored several key (not to mention glaring) differences between 1918 and 2006.

First, while there’s no sure-fire cure or preventative measure for the flu, modern medical care and public health practices have dramatically improved since 1918. So any flu epidemic is likely to be far less severe – a point we’ll come back to in a moment.

This, while a true statement for the first pandemic strain victims (assuming a moderate to severe strain), those marvelously advanced and improved health care practices will be reduced to the exact same palliative care victims received in 1918 once the health care system is overwhelmed and supplies run out.  Supplies like ventilators, which are in a decidedly finite, and limited, supply.

Next, a great proportion of the deaths in 1918 was probably due to secondary bacterial infections that followed the initial viral infections. Today, antibiotics would be used to treat bacterial infections.

Hummmm…..well, it seems to me that Mr. Milloy is guessing when he states, rather authoritatively I might add, that "a great proportion of the deaths were due to bacterial infections", what we now term secondary infections.  What he fails to consider is that one of H5N1’s primary killing mechanisms is viral pneumonia for which antibiotics would do no good, thus it doesn’t matter whether we have them or not, we will be in the same medical ballgame as they were in 1918.  Not to mention that as of this date most victims of H5N1 don’t live long enough to get those secondary bacterial infections.

And let’s not forget that during 1918-1920, much of the world was still recovering from the strains of World War I. Poverty, hunger, unsanitary living conditions and stress likely made much of the global population ripe for a killer flu pandemic.

None of these considerations were factored into the researchers’ estimate of 62 million deaths.

Actually, they were.  In fact, they were so heavily factored in that the researchers arrived at the conclusion that 96% of the deaths would occur in third-world countries.

But, don’t misunderstand, I take great exception to the research paper as well, only for vastly different reasons than Mr. Milloy

But perhaps the researchers’ choice that most reveals their apparent desire to come up with a scary – rather than a realistic – death toll from pandemic flu is their decision to use the 1918 pandemic flu data in the first place. There were, after all, two other more recent and, in all likelihood, more relevant pandemic flu outbreaks in the 20th century.

There was the 1957-58 Asian flu pandemic that killed somewhere between 1 million to 4 million people. The 1968-1969 Hong Kong flu killed an estimated 750,000 people.

Now if one wanted to estimate a death toll from a hypothetical pandemic flu in today’s world, it seems as though data from the Asian and Hong Kong flu pandemics would be much better starting points than the far more uncertain data from a chaotic period almost 90 years ago. That presumes, of course, that one is interested in more realistic (albeit smaller) estimates that better reflect modern conditions as opposed to overblown numbers aimed at producing scary headlines.

While there is reason to speculate that there have been 10 pandemics in the last three hundred years only the last three, 1918, 1957 and 1968 are documented with any reasonableness, and only the last two would meet any sort of scientific standards.  But, the 1918 was caused by an entirely Avian Influenza virus, while the last two were a reassortment with human adapted influenza viruses.  The resulting severity is like comparing the proverbial apples and oranges, as is clearly stated in the above WHO quote.

No reasonable person discounts that H5N1 could present as a mild strain if and when it makes the leap to human transmissibility, what reasonable people are saying is that it doesn’t have to be mild, it doesn’t even have to weaken at all.  And that, whether Mr. Milloy is aware of it or not, is what makes the prospect of a pandemic H5N1 truly nightmare stuff.

What this sort of study reveals is how public health researchers can put more stock in frightening the public than informing it. It’s as though they assume that we’re too stupid to work with facts and must be terrified into action.

If Mr. Milloy thinks this research paper is frightening he should take the time to read the world’s leading Influenza Virologists.

And then, what is the action that the researchers desire? In this case, they want more money allocated to pandemic flu preparedness. While this may sound reasonable at face value, let’s consider several key realities.

First, pandemic flu is quite rare and we ought to be cautious not to over-allocate scarce public resources to events that seldom happen and that seem to be getting less severe when they do occur.

Yes, we are fortunate that Influenza pandemics are rare events.  But rare doesn’t mean non-existent.  And, should a severe pandemic strike, even what Mr. Milloy labels as misdirected and excessive spending will be deemed criminally insufficient.

Next, millions of people in the developing world die every year from preventable diseases, such as mosquito-borne malaria and diarrheal diseases caused by unsafe food and water. Why not spend available resources on saving people from those deadly diseases that are taking lives right now rather than on over-preparation for a hypothetical epidemic that is highly uncertain.

Moreover, by tackling these other ongoing diseases, populations will be made less vulnerable to pandemic flu should it occur.

At last, something that I find reasonable.

Finally, pandemic flu frenzy is also a problem in the U.S. The federal government has already spent $600 million in local and state government preparedness planning for a pandemic flu that may or may not happen any time soon, according to a report this week in the Chicago Tribune. That “preparedness” includes stockpiling vaccines – a stockpile that could very well prove entirely useless since no one can be certain that the vaccines will be effective against a specific strain of flu virus from which pandemic flu might actually develop.

Useless preparation may be worse than no preparation because it means that precious public health resources, efforts and time have been wasted.

A half-truth at best.  Yes, a pre-pandemic strain of vaccine was produced on a limited basis.  There were good reasons for doing so.  The nomenclature had to be tested and certified.  Real problems were identified and addressed because of this.  Human trials were conducted, and valuable information was garnered because of it.  And, lastly, the Federal government contracted for several million doses under the reasonable assumption that even a poorly matched vaccine would be better than no vaccine and there are folk that will need to be protected at the earliest possible moment, sooner than a perfectly matched vaccine would allow.

If we can’t expect truthfulness and clear-thinking from public health researchers and officials in a time of relative calm, how much confidence can we have in them should a public health emergency develop?

Yep, I fully agree with this statement!  Although for diametrically opposed reasons.  We need truth about exactly how bad it could be, not best case scenarios presented as worst case.  And, that is exactly what our public officials are doing should H5N1 go pandemic as an entirely novel avian virus.