Influenza, Terrorism, and Pediatrics

\"animal20farm20graphic20-20big20pig20close20mouth-713368\"Before you get too \”conspiracy theory\” on me, let me assure you that I am not going to talk about how the influenza virus pandemic is the work of terrorists (unless the Napoleon and Snowball are trying to take over our farm).   I am also not suggesting that children are terrorists (although some do raise my suspicion).
The virus that brought such worry and even panic seems now to be \”fizzling out\” and people are now questioning if the authorities and the press overreacted to the threat.  Will this be a replay of the \”boy who cried wolf\” and have us complacent when a real threat comes?  One writer questioned if the flu \”overreaction\” was \”more costly as the virus itself.\”  Another article cites an Austrailian professor (of what, the article did not say) who stated that \”the country would be better off declaring a pandemic of some the real health problems it has, like diabetes and obesity.\”

The real din, however is in the countless letters to the editor and calls to radio talk-show hosts mocking the \”alarmism\” put forth by the WHO and others about this flu.  This does appear to be in the minority, as one poll said that 83% of Americans were satisfied with the management of the outbreak by public authorities.  Still, I suspect the volume of the dissent and sniping at the non-serious nature of the pandemic so far will only increase over time.  The number of people who know better than public health officials will multiply.

This pandemic is a catch-22 for public health officials, as an excellent article on the subject states:

The irony is that the overreaction backlash will be more severe the more successful the public health measures are. If, for example, the virus peters out this spring because transmission was interrupted long enough for environmental conditions (whatever they are) to tip the balance against viral spread, CDC and local health officials will be accused of over reacting.

Which brings me to the connection to terrorism.  If public authorities somehow thought there was a 10% chance that New York City would be hit with another major terrorist attack, how big should their reaction be?  If they suspected that there was a reasonable probablity, say 5%, that the subways would be flooded with sarin gas, should they shut them down?  I would certainly hope they wouldn\’t leave that many people open to the chance of death.

And what is the best outcome?  The best outcome is that this is an overreaction.  The best outcome is that the terrorists, in fact, have reformed and are instead joining the Professional Bowling tour.  I would welcome this outcome (not to mention the exciting infusion of young talent to the tour).  The problem is, the officials have no idea how it will play itself out.  Truth be told, since 9/11, there have not been any major terrorist attacks in the US.  Does this mean that the money spent on the department of homeland security has been wasted?

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As a pediatrician, I am very accustomed to overreaction.  If you bring in your 20 day-old child to my office with a fever of 102, I will do the following:

  1. Admit them immediately to the hospital
  2. Draw blood tests looking for serious infection
  3. Check a urinalysis to make sure there isn\’t an infection (using a catheter to get the sample)
  4. Start IV antibiotics as soon as possible
  5. Perform a spinal tap to rule out meningitis.

This seems a little over-the-top, doesn\’t it?  The child just has a fever!  The problem is that children this age with a fever caused by a virus look identical to those who have meningitis.  By the time their appearance differentiates, it is too late.  This forces me to do the full work-up on every infant with fever and treat each one as if they have meningitis or some other serious infection.  I do this despite the fact that the cases of meningitis are far outnumbered by that of less serious problems.

If this is your child, don\’t you want me to do that?

Knowing what we know about pandemics, the same caution was, in my opinion, absolutely the right thing to do.  If the virus turns out to be nothing serious, hallelujah.  I don\’t want my patients (or family members) dying at the rate that some of the previous H1N1 viruses caused.  I want this to be a lot of worry for \”nothing.\”  Please let it be so.

But I still don\’t think it is time to relax.  As one commenter on an earlier post I wrote about this pandemic stated:

It’s still a bit early to relax. The 1918 flu went around first in the spring and was very mild – kinda like this. Then it came back in the fall after incubating and mutating and was a killer.

I think the CDC and WHO probably will be concerned about this until next year, at least. Just to be on the safe side.

Remember that that flu, which was mild in the spring, went on to kill 20-100 million people.

For this reason, I hope the voices of reason win out over the armchair quarterbacks that don\’t have to make these decisions that could mean the life or death of millions.  Will you tell me that evacuating the NY subways wouldn\’t be a good thing on the threat of Sarin gas?  Would you criticize me for \”overreacting\” if your infant with a fever turned out to just have an upper respiratory infection?  I hope not.

If you would, then that gives us ample reason to ignore your opinions on how this flu was handled.

[poll id=\”20\”]

32 thoughts on “Influenza, Terrorism, and Pediatrics”

  1. Better to be safe. That’s how we stay healthy. There have been some confirmed cases near where I live, but no panic. I haven’t even seen anyone wearing masks. Stay home if you’re sick, wash your hands…
    There’s a difference between panic and sensible precautions. When someone in Mexico phones you and says that eleven people in his city have died of the flu, and that the city is under quarantine, it is sensible to cancel your plane ticket to visit that person – postpone the trip for a year. Panic would be wiping down the phone with alcohol after said call (to avoid all the germs that might have flown through the telephone lines), then begging your doctor for tamiflu 🙂

    Think back to mad cow and the reaction of a certain island nation’s government. They didn’t want to lose money so they lied, said beef products were safe, and ultimately made things worse. I’ll go way out on a limb here and speculate that Mexico is doing the same thing right now with the flu. They don’t like losing tourist dollars, so they’re hiding the facts. What happens to the economy if you quarantine entire cities? I hope I’m wrong, but I think the problem is worse than they’re letting on.

  2. Better to be safe. That’s how we stay healthy. There have been some confirmed cases near where I live, but no panic. I haven’t even seen anyone wearing masks. Stay home if you’re sick, wash your hands…
    There’s a difference between panic and sensible precautions. When someone in Mexico phones you and says that eleven people in his city have died of the flu, and that the city is under quarantine, it is sensible to cancel your plane ticket to visit that person – postpone the trip for a year. Panic would be wiping down the phone with alcohol after said call (to avoid all the germs that might have flown through the telephone lines), then begging your doctor for tamiflu 🙂

    Think back to mad cow and the reaction of a certain island nation’s government. They didn’t want to lose money so they lied, said beef products were safe, and ultimately made things worse. I’ll go way out on a limb here and speculate that Mexico is doing the same thing right now with the flu. They don’t like losing tourist dollars, so they’re hiding the facts. What happens to the economy if you quarantine entire cities? I hope I’m wrong, but I think the problem is worse than they’re letting on.

  3. Unusually for me, I’m not completing the poll. This is because it’s a “radio button” single choice poll, and I think that “Not time to relax” and “Probably won’t end up being much” are both correct answers.
    I refer you to both the 1918 outbreak (although IMO that would have been less severe 3 or 4 years later, when more people would have had stronger immune systems) and the seemingly low mortality of this outbreak.

    Against this, the World has changed since 1918 in that we have a much more mobile (and more quickly mobile when they are mobile) population, and a higher proportion of geriatrics in that population.

  4. Unusually for me, I’m not completing the poll. This is because it’s a “radio button” single choice poll, and I think that “Not time to relax” and “Probably won’t end up being much” are both correct answers.
    I refer you to both the 1918 outbreak (although IMO that would have been less severe 3 or 4 years later, when more people would have had stronger immune systems) and the seemingly low mortality of this outbreak.

    Against this, the World has changed since 1918 in that we have a much more mobile (and more quickly mobile when they are mobile) population, and a higher proportion of geriatrics in that population.

  5. We are more quickly mobile than in 1918 but I don’t know about being more mobile overall. There were 42,243,214 soldiers mobilized in WWI. And they were living cramped and in conditions of dubious hygeine in military camps and in the trenches. Perfect conditions for spreading the flu.

  6. We are more quickly mobile than in 1918 but I don’t know about being more mobile overall. There were 42,243,214 soldiers mobilized in WWI. And they were living cramped and in conditions of dubious hygeine in military camps and in the trenches. Perfect conditions for spreading the flu.

  7. Whoops! That 42,243,214 figure refers only to the Allied personnel. Counting both sides, the figure is over 70 million.

    1. I see where you’re coming from, and yes that’s a factor I’d not considered. However, its effects on the overall epidemiology would depend on when and how quickly troops “in theatre” were demobilised. I don’t have the figures for WW1, but the figures I do have for WW2 suggest that demobbing the British and US and their allies, and repatriation of (German alliance) PoWs would have taken over a year, with the first demobs being 6 months or so after the surrender. Can anyone fill in the gaps?

    2. The numbers stateside (without considering the troops) were staggering. Here’s an interesting timeline from PBS about the illness and its spread. While I do think the soldiers had an influence, the very small number of people actually traveling compared to now is definitely worth noting.
      The situation is probably ripe for quicker spread, but the information spreads faster as well, making a legitimate defense against the illness. Are we at risk of repeating 1918? I doubt it could be to that level, but the only way to assure that is to act as if it were still a possibility.

      1. Thanks for that Rob. I’d never seen a 1918 timeline before.
        There are, I think, 2 big points to note there:-
        1) We’ve got very much better anti-flu drugs now than we did in 1918.
        2) From the timeline, it doesn’t really look like a travelling population was a major factor in the spread.

        Which looks like I’m back to my original position that this could well be a big nothing, but we’d better be ready to deal in case it isn’t, simply because the travelling population is so much larger. For example, pretty much every reported case of H1N1 in Scotland so far is either someone who’s been to Mexico, or someone who’s been in direct contact with someone who’s been there.

  8. Whoops! That 42,243,214 figure refers only to the Allied personnel. Counting both sides, the figure is over 70 million.

    1. I see where you’re coming from, and yes that’s a factor I’d not considered. However, its effects on the overall epidemiology would depend on when and how quickly troops “in theatre” were demobilised. I don’t have the figures for WW1, but the figures I do have for WW2 suggest that demobbing the British and US and their allies, and repatriation of (German alliance) PoWs would have taken over a year, with the first demobs being 6 months or so after the surrender. Can anyone fill in the gaps?

    2. The numbers stateside (without considering the troops) were staggering. Here’s an interesting timeline from PBS about the illness and its spread. While I do think the soldiers had an influence, the very small number of people actually traveling compared to now is definitely worth noting.
      The situation is probably ripe for quicker spread, but the information spreads faster as well, making a legitimate defense against the illness. Are we at risk of repeating 1918? I doubt it could be to that level, but the only way to assure that is to act as if it were still a possibility.

      1. Thanks for that Rob. I’d never seen a 1918 timeline before.
        There are, I think, 2 big points to note there:-
        1) We’ve got very much better anti-flu drugs now than we did in 1918.
        2) From the timeline, it doesn’t really look like a travelling population was a major factor in the spread.

        Which looks like I’m back to my original position that this could well be a big nothing, but we’d better be ready to deal in case it isn’t, simply because the travelling population is so much larger. For example, pretty much every reported case of H1N1 in Scotland so far is either someone who’s been to Mexico, or someone who’s been in direct contact with someone who’s been there.

  9. We need to look separately at the response of public health officials and the response of the media. I believe public health officials acted responsibly. The media, however, did not. They could have dedicated 5 minutes of ever hour to the issues, instead of 24/7. I think the real winner in all of this is those who hold stock in Purell!

    1. Agree. But would you rather have 24/7 on OJ or Joey Buttafuco? The press is just trying to make a buck. What better thing to make money off of than people’s fear?

      1. I was watching a DVD of the 1980s British comedy show “Yes Prime Minister” (season 2, episode 1 or 2 if you have it) last night.The PM was having lunch with the editor (UK usage – The person who decides which stories to run, in which order etc) of a newspaper which had recently published a story about the PM.
        PM – “Do you think there is anything to speak of in this story?”
        Editor – “Not as such, but we sold an extra hundred thousand copies by running it!”

        Enough said about the real motivations of the press I think!

  10. We need to look separately at the response of public health officials and the response of the media. I believe public health officials acted responsibly. The media, however, did not. They could have dedicated 5 minutes of ever hour to the issues, instead of 24/7. I think the real winner in all of this is those who hold stock in Purell!

    1. Agree. But would you rather have 24/7 on OJ or Joey Buttafuco? The press is just trying to make a buck. What better thing to make money off of than people’s fear?

      1. I was watching a DVD of the 1980s British comedy show “Yes Prime Minister” (season 2, episode 1 or 2 if you have it) last night.The PM was having lunch with the editor (UK usage – The person who decides which stories to run, in which order etc) of a newspaper which had recently published a story about the PM.
        PM – “Do you think there is anything to speak of in this story?”
        Editor – “Not as such, but we sold an extra hundred thousand copies by running it!”

        Enough said about the real motivations of the press I think!

  11. Jason Ritenour

    A very well-written article and very valid points concerning the health-related scares.
    I must, however, very strongly object to combining some amount of valid overreaction to a health threat and overreactions to terrorism which are much more likely to be taken way too far. I don’t even disagree with the examples given in this article. I would much rather be inconvenienced by the shutting down of a mass transit system which we believe may be under threat of attack and have it be nothing than see it go through. However there is a lot of danger in saying that an overreaction is warranted if it prevents further attacks. Closing down a subway for some amount of shaky intelligence that turns out to lead nowhere is one thing. Imprisoning an innocent man for years on end due to shaky intelligence that turns out to lead nowhere is a completely different thing, especially if over those years the man is harshly interrogated (I am intentionally leaving torture out of the discussion here).

    You are making a good point about the flu reaction, please do not sully it by bringing the specter of terrorism into the picture which is far more dangerous to treat the same way.

    1. I am in no way equating this with WMD or torture. The analogy made sense in that people were truly terrorized by the flu threat. It is an unknown thing that could cause you harm – which is what terrorism is. Politics aside, the terrorists win by causing fear – which is what I saw in the exam room when this was just starting. People wanted reassurance, but I had no idea how bad it would be and didn’t want to give information I couldn’t back up.
      The unfortunate thing about terrorism is that we have become inhumane in our battle against it, which takes away our moral high ground.

      1. If you want an example of a fear/greed reaction to H1N1, there are people over here paying 6 times market cost for a course of Tamiflu!

  12. Jason Ritenour

    A very well-written article and very valid points concerning the health-related scares.
    I must, however, very strongly object to combining some amount of valid overreaction to a health threat and overreactions to terrorism which are much more likely to be taken way too far. I don’t even disagree with the examples given in this article. I would much rather be inconvenienced by the shutting down of a mass transit system which we believe may be under threat of attack and have it be nothing than see it go through. However there is a lot of danger in saying that an overreaction is warranted if it prevents further attacks. Closing down a subway for some amount of shaky intelligence that turns out to lead nowhere is one thing. Imprisoning an innocent man for years on end due to shaky intelligence that turns out to lead nowhere is a completely different thing, especially if over those years the man is harshly interrogated (I am intentionally leaving torture out of the discussion here).

    You are making a good point about the flu reaction, please do not sully it by bringing the specter of terrorism into the picture which is far more dangerous to treat the same way.

    1. I am in no way equating this with WMD or torture. The analogy made sense in that people were truly terrorized by the flu threat. It is an unknown thing that could cause you harm – which is what terrorism is. Politics aside, the terrorists win by causing fear – which is what I saw in the exam room when this was just starting. People wanted reassurance, but I had no idea how bad it would be and didn’t want to give information I couldn’t back up.
      The unfortunate thing about terrorism is that we have become inhumane in our battle against it, which takes away our moral high ground.

      1. If you want an example of a fear/greed reaction to H1N1, there are people over here paying 6 times market cost for a course of Tamiflu!

  13. Doc Rob & all your readers–
    I live in the San Francisco Bay Area. We WILL experience a…life changing, catastrophic earthquake, we just don’t know where the epicenter will be, or when the quake will strike.

    Here’s the deal — WHEN it happens, most folks will be without power and water for a significant period of time (3-7 days). The 1989 Loma Prieta quake left my household w/o power for 4 days. The earthquake will also likely disrupt the supply chain — of groceries, of other necessary supplies such as (say) medication, gas and diapers.

    One of the adages I’ve learned in the last two weeks is this: “If public health services function properly, nothing happens.

    The truth of that adage makes it hard to sell public health….

  14. Doc Rob & all your readers–
    I live in the San Francisco Bay Area. We WILL experience a…life changing, catastrophic earthquake, we just don’t know where the epicenter will be, or when the quake will strike.

    Here’s the deal — WHEN it happens, most folks will be without power and water for a significant period of time (3-7 days). The 1989 Loma Prieta quake left my household w/o power for 4 days. The earthquake will also likely disrupt the supply chain — of groceries, of other necessary supplies such as (say) medication, gas and diapers.

    One of the adages I’ve learned in the last two weeks is this: “If public health services function properly, nothing happens.

    The truth of that adage makes it hard to sell public health….

  15. What exactly does “the Spanish Flu was mild in the spring” mean? Compared to 20 – 100 million deaths, 1 million during the spring outbreak might be considered “mild”. Besides, the number that matters is the mortality rate.
    “I don’t want my patients (or family members) dying at the rate that some of the previous H1N1 viruses caused.”

    Wasn’t the Spanish Flu the only previous deadly H1N1 outbreak? Besides, the all-cause associated mortality of the novel H1N1 in the US has been lower than that of the normal seasonal strains.

    With something as mild as the novel influenza A / H1N1, it is important to not raise excessive alarm. Why? In the case of an outbreak serious enough to merit an all-out response, the public will be sufficiently numb to the alarm. There will be a “boy who cried wolf” mentality towards the situation.

    I just saw a patient whose only understanding of H1N1 was that “it was killing lots of people all over the place”. However, she had no understanding about techniques for prevention.

    There needs to be balance in how the media presents the spread of the virus. Instead of fear mongering and focusing on every death (of which there have been few), they should be educating the public on how to act during a serious outbreak. While everyone is paying attention to influenza A/H1N1, they will be much more receptive to learning about how to contain the spread of disease.

    1. Look at the timeline I posted in comment #6. It gives a good recount of the year. The vast majority of deaths happened in November and December.
      The Russian flu, other outbreaks of swine flu, and avian flu are all H1N1, and all have their degree of lethality. “Normal” flu is deadly, so it is dangerous to say only the 1918 variety was deadly. The problem with pandemics is that they affect young and old alike – with the majority of deaths from this pandemic mirroring the previous ones with a very high % of deaths being in the young and healthy.

      Sure the press went nuts. But they do so for much dumber things compared to this virus that still has the potential to kill off a significant % of our population.

  16. What exactly does “the Spanish Flu was mild in the spring” mean? Compared to 20 – 100 million deaths, 1 million during the spring outbreak might be considered “mild”. Besides, the number that matters is the mortality rate.
    “I don’t want my patients (or family members) dying at the rate that some of the previous H1N1 viruses caused.”

    Wasn’t the Spanish Flu the only previous deadly H1N1 outbreak? Besides, the all-cause associated mortality of the novel H1N1 in the US has been lower than that of the normal seasonal strains.

    With something as mild as the novel influenza A / H1N1, it is important to not raise excessive alarm. Why? In the case of an outbreak serious enough to merit an all-out response, the public will be sufficiently numb to the alarm. There will be a “boy who cried wolf” mentality towards the situation.

    I just saw a patient whose only understanding of H1N1 was that “it was killing lots of people all over the place”. However, she had no understanding about techniques for prevention.

    There needs to be balance in how the media presents the spread of the virus. Instead of fear mongering and focusing on every death (of which there have been few), they should be educating the public on how to act during a serious outbreak. While everyone is paying attention to influenza A/H1N1, they will be much more receptive to learning about how to contain the spread of disease.

    1. Look at the timeline I posted in comment #6. It gives a good recount of the year. The vast majority of deaths happened in November and December.
      The Russian flu, other outbreaks of swine flu, and avian flu are all H1N1, and all have their degree of lethality. “Normal” flu is deadly, so it is dangerous to say only the 1918 variety was deadly. The problem with pandemics is that they affect young and old alike – with the majority of deaths from this pandemic mirroring the previous ones with a very high % of deaths being in the young and healthy.

      Sure the press went nuts. But they do so for much dumber things compared to this virus that still has the potential to kill off a significant % of our population.

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