Opinion Piece, Lancet. Moral Panic and Pandemics

Laidback Al · May 30, 2010

The Lancet, Volume 375, Issue 9729, Pages 1866 - 1867, 29 May 2010
doi:10.1016/S0140-6736(10)60862-8

Moral Panic and Pandemics

Sander L Gilman

On May 21, 2009, WHO's Director-General, Margaret Chan decided that influenza A (H1N1) was not going to become a pandemic. Not because of any epidemiological rationale but because the very term ?pandemic? was feared to trigger global panic. ?Swine flu? would have become a stage six pandemic on that date. But Chan observed that ?I know that you have given me a lot of trust and flexibility, and this is not an easy task. I need to balance how science should play a role and not to forget about the people.? Not ?science? but public response was the key to the rethinking of what our present outbreak of H1N1 should be labelled. By June 11, 2009, H1N1 was a designated pandemic. This too had its political dimension with medical consequences. . . .

full text at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60862-8/fulltext

hat tip to Jane at FW

Shannon Bennett · May 31, 2010

Re: Opinion Piece, Lancet. Moral Panic and Pandemics

The debate boils down to what is the most ethical choice of action. Do we downplay the possible outcome of a pandemic? What are the ramifications if that choice is made? Hesitating means a slow response to both the manufacture and acceptance by the public of a vaccine. On the other hand if the pandemic is a relatively mild one people feel duped into getting an otherwise unnecessary jab. They also feel tricked into an unnecessary fear. We also are left with the expense of vaccine that remains unused-who will cover that cost? But the argument as to the right choice goes further than when we declare a pandemic - it means defining a pandemic before one occurs.

Do we highlight the possibility of infection and the sometimes chronic illness or even death resulting from the infection? Or, do we suggest because of the fears of those who actually do get sick they will certainly recover ignoring the possibility of a negative outcome? There are pitfalls regardless of which choice is made. If this were polio, there would be far less debate. Polio was seen as a child killer and crippler. It wasn't something that was passed through the community every winter. A perfectly healthy child could suddenly and very unexpectedly succumb. We accept the loss of life of influenza as a matter of course. Influenza deaths while unfortunate are accepted as a perfectly understandable culling of the human herd because of the perceived vulnerability of those who die. Thirty thousand deaths every year only affect the very old or infants unlucky enough to catch it or those who are chronically ill anyway and were probably going to die early in any event. Flu doesn't affect the otherwise healthy. In the case of a novel influenza it most certainly does wreck havoc even, and sometimes because of, the most robust immune systems. This is the dichotomy we face.

Ignorance, economic ramifications, as well as a lack of vaccine all influence a clearly defined and timely use of the word pandemic. What world leaders and international medical organizations need to do is to educate the public. Because although the H1N1 virus is still circulating and may still become a hideous killer, it may not as well. But that does not mean that an even bigger killer may be on the horizon. If we do not educate now, it will mean an even slower response to a mass killer. That result will without a doubt destabilize economics as well as governments. So, which is better? Which is the most ethical choice? Or, are we looking at the problem from the wrong direction entirely?

JJackson · Jun 1, 2010

Re: Opinion Piece, Lancet. Moral Panic and Pandemics

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ffice:smarttags" name="place"></o:smarttagtype> What are the messages and why has the communication of key facts been such a problem. There are three main problems, as I see it, the message, delivery and credibility.
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What is the absolute minimum information required to make an informed decision?
If we start with the term Pandemic. To me this implies the emergence, or re-emergence, of an infectious disease spreading over a wide geographical area. More interestingly it does not say anything about the reproductive number, generation time or severity, nor does it say anything about the epidemiology, latency or causative agent. It fact it says little apart form there is a disease which is currently gaining the upper hand over us.
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The problem with pandemic communication is that the WHO’s 1 to 6 scale seemed to be viewed as stages leading up to some kind of catastrophic blast off. Why was it so difficult to explain that
'Phase 6 means the disease is now into the phase where it will spread freely. We will also be letting you know how quickly it is spreading, the range of severity being reported, the range of symptoms, typical course of the illness etc. None of these are implied in going to phase 6. Pandemics, and epidemics, can be of a very mild disease or cause mass fatalities. They can have long latency periods, like HIV, so take decades to build up or infection, incubation and infection of the next host can occur in a few days as in flu.'
All of this was well know as was the fact that viral influenza can cause massive fatalities in all age groups, as it did in 1918, or be an inconvenience to the young and fit. That it could also come as a disease, like HP H5N1, killing half of those that caught it was a major shock to all and is the reason that so many countries had pandemic plans in place. Anyone who could legitimately be called a flu expert, and most of the regulars here prior to the H1N1 pandemic, were well aware that other flu serotypes were just as likely to go pandemic as H5N1. SARS and HIV had also made it clear novel disease, as well as novel strains of old disease, had to be considered. However H5N1, due to its extreme case fatality rate, was far more likely to result in a global catastrophe.
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The next communication problem was with the epidemiology. The seasonal flu has a typical symptom set, for the fit, and although it causes many fatalities annually these are heavily concentrated in the very elderly (90% of deaths in the over 65s – US data). The 1918 flu was noted for attacking the young and fit, the group generally best able to fend off infectious disease. H1N1(2009), once enough data was available to see a pattern, caused lots of mild, or asymptomatic, illness with a small amount of very severe respiratory illness. Again the age profile was nothing like seasonal flu with nearly half of the fatalities falling in the 25 to 50 age group and very few over 65s. The message here is that the total numbers of fatalities may not be very different to previous years but those dying are young adults rather than their grandparents and great-grandparents.
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The other communication problem is in being believed and not crying wolf. The message is the same as for any other natural disaster. We need to prepare for Hurricanes, Earthquakes and Pandemics. Fortunately they are not all of the worst category and just because most of us got a gentle shaking this time it does not mean we will next time. At all times we need to have a contingency plan for the full range of events and preparations for the range of likely events. H5N1 is still out there and there is no reason to believe that there has to be a prescribed gap between flu pandemics, or pandemics of any other disease. I thought the scientists did an excellent job at their briefings, clear and factual. The problem was that most people did not watch briefings what they got was news stories. The sad truth is that all the key communication points could be explained in half a page of A4 text but it is not possible to get everyone to read half a page of text.
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I am not sure the question <st1

lace>Shannon</st1

lace> raises is real, in the sense I do not thing there is a need to spin in any direction. The truth is not that complicated and the public should be capable of understanding that a disease can be fatal for some and mild for most. If the illness develops in such a way as to cause the patient breathing difficulties then a trip to casualty, without delay, is needed else the usual - rest, lots of fluids and time - remedy is fine.

As to response, prepare for and initiate a response for a severe pandemic until it becomes evident that it is not, at which point scale back. Again I do not see this as hard to sell. It may lead to production of excess vaccine but we need to have the public debate over vaccine technology and capacity. Do we pay for a transition to quicker production methods and the maintenance of a surge capacity, so we can cope with flu pandemics, or if not are we clear that the downside is massive loss of life should a virulent strain go pandemic. We, collectively, may decide the risk is acceptable and that the money could be better spent elsewhere but we should at least have the discussion based on the facts.

Opinion Piece, Lancet. Moral Panic and Pandemics

Laidback Al

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Shannon Bennett

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JJackson

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