Off-Topic Friendly Message on Swine Flu

I submitted this for the AMA-MSS conference as a Scientific Issues Committee member. I thought I'd share it here for anyone interested, even though it has nothing to do with running.

Swine Flu: Pork or Peril? - Samuel Mackenzie, CSI


"Even though it killed at least 40 million people in less than a year, the 1918 influenza pandemic's most alarming feature may have been that it nearly extinguished the basic humanitarian impulses that bind civil society together."

The quotation is from John Barry, author of The Great Influenza: The Epic Story of the Deadliest Plague in History.1 It's an account of death and suffering by infectious cause that may strike today's physicians as near fiction by virtue of the sheer enormity of the epidemic. At this writing, basic humanitarian impulses are intact, but another strain of the influenza virus has come knocking at civil society's door. On April 27, 2009 the World Health Organization raised its global alert level regarding the spread of swine flu to Phase 4.2 While reminiscent of a color-coated U.S. Homeland Security Terror Alert level, the Phase 4 label is indeed grounded in science, as it indicates the virus's capability of sustained human-to-human transmission.3 More recent community infections of H1N1, a reassorted swine flu strain of Influenza A virus, put the virus's potential a mere phase away from a pandemic by WHO standards, at Phase 5.

That said, in an age in which 250,000 people in the world die from AIDS every month and over 2 billion are infected with M. tuberculosis,4 is swine flu such a public health nightmare that it warrants upwards of $3 billion in prevention and containment?5 (President Obama requested one and a half billion dollars of that sum for the development of a vaccine.) And as large as $3 billion sounds, the expenses associated with local, state, and federal programs likely pale in comparison to those more hidden costs: School and work closures, misguided bans on pork trade, and limits on travel to and from infected countries. Swine flu, or the more porcine-friendly H1N1, has taken the lives of 117 people to date--97 from Mexico, 17 from the U.S., 2 from Canada, and 1 from Costa Rica.6 For reference, 35,000 die from different strains of flu in the average year.7

Looking at these numbers, it would seem on the surface that our spending is a misappropriation of resources. However, stopping the story there ignores two key facts in the swine-flu story: First, transmission of H1N1 is occurring in the warmer months. Since it's confined to North America at this point, it's not a stretch to expect an increased incidence as we move into the fall and winter. Second, we may not have seen this virus in its most deadly form. When two RNA viruses trade their segmented parts upon coinfection of a cell, we call the process reassortment. This is the mechanism by which this particular virus was born in its swine host, and it could now just as easily take place in infected human cells leading to increased virulence and easier transmissibility. If that happened, we just might have another Great Influenza on our hands.

So the question remains: Are the measures we're taking truly worth it or is fear driving our decision-making on the policy level? Taking a utilitarian cost-benefit approach to global health, I consulted the 2008 Copenhagen Consensus Report.8 Each year, eight renowned economists (five of whom were Nobel laureates last year) prioritize several proposals related to the ten biggest global challenges (e.g. malnutrition, diseases, education, air pollution, etc.). To be fair, swine flu was not submitted for consideration, but the top three recommendations for efficacious global spending were 1) vitamin A and zinc supplements for children, 2) the Doha development agenda, and 3) iron and salt iodization. TB case finding and treatment came in at number 13.

What's frustrating about epidemic prevention is that it's impossible to evaluate the value of a good program since its goal will always be to maintain the status quo. If our programs fail, on the other hand, we'll know it. Maybe then, swine-flu will make the top-ten list.

1 Barry, J. (2004) The Great Influenza: The Epic Story of the Deadliest Plague in History. Viking Press, New York.

2 World Health Organization. (2009) Statement by WHO Director-General Margaret Chan: Swine Influenza. [http://www.who.int/mediacentre/news/statements/2009/
h1n1_20090427/en/index.html] Accessed: 29 April 2009.

3 World Health Organization. Current WHO phase of pandemic alert. (2009)
[http://www.who.int/csr/disease/avian_influenza/phase/en/index.html] Accessed: 29 April 2009.

4 CDC. (2007) Extensively drug-resistant tuberculosis—United States, 1993–2006. MMWR, 56: 250-253.

5 AP. (2009) Swine Flu Costs Ohio $44,000 Per Day. Columbus Dispatch. 11 May 2009.

6 AP. (2009) Mexico's Death Toll Reaches 97. Deccan Hearald. 30 May 2009. [http://www.deccanherald.com/content/5269/mexicos-swine-flu-death-toll.html] Accessed: 30 May 2009.

7 Rugman, J. (2009) New Yorkers Resist Swine Flu Panic, For Now. [http://blogs.channel4.com/snowblog/2009/04/29/new-yorkers-resist-swine-flu-panic-for-now/] Accessed: 30 May 2009.

8 Copenhagen Consensus. (2008) [http://www.copenhagenconsensus.com/
Home.aspx] Accessed: 30 May 2009.