Telling more than you know

"Everyone is entitled to their opinion, but not all opinions are equally valid."

That may be the only thing I remember from one particular college class many years ago. But it's a valuable truism to keep in mind whether you're talking religion or politics or infectious disease. Who's doing the talking and on what do they base their comments?

The speaker may be quite intelligent, but talking outside their specific field of knowledge. If they're obviously outside their field, it may be easy to detect. But if they're talking about something that's sort of in their field - a teacher talking about education or a medical person talking about health care - well, you assume they know what they're talking about. But they may not.

A similar problem comes from placing total trust in the news media or in government officials. Those sources may not always be accurate, either. But that's a separate conversation for another day.

The possible motives for spreading misinformation are a separate conversation, too. In the cases below, I don't think there's any ulterior motive; it's just unrestrained ignorance.

The problem is amplified, of course, when the speaker uses a "megaphone" - in the form of a speech ... or Letter to the Editor ... or blog ... or comment in an online forum ... or call-in radio talk show. From such platforms, you can quickly mislead a much larger number of people. Two cases in point....

Pediatrician's Letter to the Editor

First is a Letter to the Editor of USA Today from pediatrician Dr. David Safir of Los Gatos, California - "Dire predictions are rampant — even though bird flu isn't." Dr. Safir believes the leaders of three U.S. federal agencies were out of place on Monday, March 20, 2006 in talking about "the predicted bird flu pandemic." (For the record, the officials did not predict a bird flu pandemic. They did say they expect the U.S. to see bird flu in birds this year. For more on the confusion between bird flu in birds and "bird flu" in humans, see my post here.)

To justify his concerns, Dr. Safir cites three past cases of what he considers exaggeration, hysteria, and hyperbole about supposed pandemics-in-the-making - the 1976 swine flu vaccination program, Legionnaire's disease in 1976, and the 2003 SARS outbreak. In similar vein, he says, we are now "bombarded" daily about a bird flu pandemic, adding:

Let me be clear. I don't have any problem with responsible health officials looking into such possibilities and working on vaccines. But the climate surrounding this issue can be described only as hysterical.

Everyone seems to compare this possible pandemic to the 1918 flu epidemic. But consider: Then, antibiotics were more than 20 years from being discovered, critical care was in its infant stages, and health facilities were fairly inadequate to care for large numbers of people with pneumonia and respiratory failure. So all of these current dire predictions are really very unscientific because they are based upon a comparison with a 90-year-old event in a different period of medical history.

Do you see any problems with Dr. Safir's contentions? Rather than respond separately now, I'll comment on the second case (below) which basically expresses the same thoughts. Both doctors - DOCTORS - think the bird flu risk is being hyped, and both offer as evidence the differences they think they see between now and 1918.

"We will never see another 1918"

Seeing Dr. Safir's letter reminded me of this second example which is perhaps worse and which I inwardly stewed about a few months ago. A medical doctor (a kidney researcher named Patrick Cunningham) emailed a comment October 17, 2005 to the popular blog Instapundit.com expressly making "a gentle but sincere plea to the blogosphere to calm down this flu hysteria just a bit" and adding:

The main way that flu kills is by predisposing its victims to "superinfection" by bacterial illnesses - in 1918, we had no antibiotics for these superimposed infections, but now we have plenty. Such superinfections, and the transmittal of flu itself, were aided tremendously by the crowded conditions and poor sanitation of the early 20th century - these are currently vastly improved as well. Flu hits the elderly the hardest, but the "elderly" today are healthier, stronger, and better nourished than ever before. Our medical infrastructure is vastly better off, ranging from simple things like oxygen and sterile i.v. fluids, not readily available in 1918, to complex technologies such as respirators and dialysis. Should we be concerned? Sure, better safe than sorry, and concerns about publishing the sequence are worth discussing. Should we panic? No - my apologies to the fearmongers, but we will never see another 1918.

Sounds good. And from a medical doctor, no less. You feel reassured. Now you can flip over to the sports section and get on with your life, right?

Before you leave ....

For one thing, I'm struck that this doctor seems to picture the rest of the world as being just like his neighborhood. (He works at the University of Chicago.)

Aside from that myopic view, almost every sentence he wrote is questionable.

Dr. Cunningham says: "The main way that flu kills is by predisposing its victims to 'superinfection' by bacterial illnesses" and we now have antibiotics to treat bacterial illnesses. REALITY: Laurie Garrett, Senior Fellow for Global Health at the Council on Foreign Relations points out in the July/August 2005 Foreign Affairs magazine, "Most strains of the flu do not kill people directly; rather, death is caused by bacteria, which surge into the embattled lungs of the victim. But the Spanish flu that circulated in 1918-19 was a direct killer. ... Had antibiotics existed, they may not have been much help." And the World Health Organization (WHO) recently noted, "So far, most fatal pneumonia seen in cases of H5N1 infection has resulted from the effects of the virus, and cannot be treated with antibiotics."

Dr. Cunningham says: "Crowded conditions" were a compounding factor in 1918, as if crowded conditions don't exist any more. (There are a few billion more people now than in 1918 and we have 425+ population centers of one million or more.) REALITY: Dr. Michael Osterholm, Director of the Center for Infectious Disease Research and Policy (CIDRAP), wrote in the same issue of Foreign Affairs, "H5N1 continues to evolve in the virtual genetic reassortment laboratory provided by the unprecedented number of people, pigs, and poultry in Asia. The population explosion in China and other Asian countries has created an incredible mixing vessel for the virus [H5N1]. Consider this sobering information: the most recent influenza pandemic, of 1968-69, emerged in China, when its population was 790 million; today it is 1.3 billion. In 1968, the number of pigs in China was 5.2 million; today it is 508 million. The number of poultry in China in 1968 was 12.3 million; today it is 13 billion. Changes in other Asian countries are similar."

Dr. Cunningham says: "Flu hits the elderly the hardest, but the 'elderly' today are healthier, stronger, and better nourished than ever before." REALITY: Yes, normal seasonal flu typically hits the elderly the hardest. But, as the WHO and others have repeatedly noted, that wasn't the case with the 1918 pandemic flu....

Deaths from influenza, whether during seasonal epidemics or pandemics, usually occur at the extremes of the lifespan – in the very young or very old. "Spanish flu" preferred the prime of life, causing most deaths in young and healthy persons in the age range of 15 to 35 years. In a complete reversal of previous patterns, 99% of deaths occurred in people younger than 65 years.

And with respect to the current cases of bird-to-human H5N1 infections, the WHO says:

Most cases have occurred in previously healthy children and young adults.

Dr. Cunningham says: "Our medical infrastructure is vastly better off, [including] complex technologies such as respirators and dialysis." REALITY: But we don't have infinite supplies of these resources. And in a major pandemic, we'll know it. Again quoting Dr. Osterholm of CIDRAP, "....many countries would not have the ability to meet the surge in the demand for health-care supplies and services that are normally taken for granted. In the United States, for example, there are 105,000 mechanical ventilaors, 75,000 to 80,000 of which are in use at any given time for everyday medical care. During a routine influenza season, the number of ventilators being used shoots up to 100,000. In an influenza pandemic, the United States may need as many as several hundred thousand additional ventilators."

So the second thing that strikes me about Dr. Cunningham is that, despite his good intentions in his InstaPundit.com comment, he simply hasn't done his homework - he hasn't read what highly-visible authorities in medicine, public health, and public policy are saying. Yet he's comfortable to speak up in a public forum to tell the flu "fearmongers" that "we will never see another 1918."

I hope we don't see another 1918, either. But I've concluded Dr. Cunningham's opinion is not equally valid with the World Health Organization. I don't care if he is a doctor. If I can't believe any of his other contentions, why should I believe his contention that we won't see another 1918?

Oh, yeah, back to our Dr. Safir. He's as off-base as Dr. Cunningham, basically for all the same reasons, as you can see.

Like so many other people, neither of these doctors is grasping (1) how different a major pandemic flu would be from a normal seasonal flu and (2) the impact of the event simply in terms of the overwhelming number of people who might be affected. What stumps me is how a doctor, of all people, can't grasp that.

And by not accepting any real possibility of a pandemic, such observers never move to the next level - understanding that half of a pandemic's problems will come from the non-medical indirect impacts.

Do your homework before delivering your lecture

As I've said before, I'm not an alarmist.

I'm just doing what you're doing ... trying to synthesize many observations made by many people about avian flu - looking at their credentials, their evidence, their reasoning and trying to decide who makes the most sense. Then I'm posting my thoughts here. You weigh the evidence (I give links to source material) and draw your own conclusions. Take responsibility. Whatever you decide, at least don't ignore the topic. And don't believe everything you hear. Too much may be at stake. If your conclusions lead you to make some added preparations, prepare early.

By the way, the trail of misinformation includes misinformed who defend other misinformed - in this case, portraying our Dr. Cunningham above as the accurate, reliable, level-headed one in the conversation. (If you click over to the linked post, be advised that "MSM" means "main stream media," I think. The blogger doesn't bother to define the acronym.)

Then there's one of the well-reasoned commenters at The Huffington Post blog (Chuck Simmins) who is helping the world understand that, "In truth, the entire affair is primarily motivated by the competition for research dollars." Uh-huh. Tell that to the relatives of the 105 people killed by H5N1, thusfar, and to the poor (now poorer) owners of tens of millions of culled birds. Yeah, bird flu isn't real; it's just some boogeyman tale intended to scare up some research funds.

There's an endless stream of such misinformed people who are ready to tell you what they think. If only they knew what they were talking about.

My parting plea: If you're going to think about H5N1 at all, please be a deep thinker and not a shallow thinker. Or, at least, if you're going to be a shallow thinker, please keep your thoughts to yourself. OK? Otherwise, your misinformation may harm other people. And I know you don't intend to harm others.

5-3-06 UPDATE: A leading insurance risk modeling company has completed a probabilistic model which indicates the 1918 Spanish Flu pandemic was not a worst case. In fact, the model suggests there's a 20% chance we could see a pandemic more severe than 1918.