05/11/2009 - 09:07

Stirring up "swine flu" hysteria

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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All disease crises begin with some level of chaos and confusion, particularly when a novel microbe is involved. The current influenza A (H1N1) crisis--referred to by the media as "swine flu"--isn't an exception. The notable difference is the level of hysteria it inspired.

Here is what we know: The flu virus began spreading sometime in mid-March as Mexican health officials received reports of influenza-like illnesses in several areas of the country. Surveillance efforts throughout Mexico didn't intensify, however, until April 17 when a case of atypical pneumonia was reported in Oaxaca State. And even then, the enhanced surveillance focused on severely ill, hospitalized patients who, most likely, spuriously raised the mortality rate.

Worse yet, because surveillance focused on this specific set of patients, the entire clinical spectrum of the disease, including very mild cases and those who did not seek medical attention, wasn't reported. (See "Poverty, Tendency to Self-Medicate Help Drive Up Flu Deaths in Mexico.") These high, but inaccurate, early reports from Mexico were the first contributor to the global hysteria, as panic grew that this outbreak might be the next global killer.

In late April, when the first cases of the H1N1 virus were reported in the United States, Margaret Chan, the World Health Organization's director-general, declared a "public health emergency of international concern" under the rules of the WHO's new International Health Regulations.

The WHO and the Global Outbreak Alert and Response Network then sent a team of experts to Mexico to investigate the crisis with local authorities. On April 29, Chan raised the pandemic level from phase 4 to 5, which many countries took as a cue to put in place large-scale pandemic preparedness efforts. Take, for example, China's remarkably fast and transparent response--all the more impressive given that it hadn't confirmed a single H1N1 case. Chinese health officials clad in biohazard suits boarded planes arriving from Mexico and the United States and led Mexican passport holders into forced quarantine. Many detainees were kept at the Guo Men Hotel, located on the outskirts of Beijing. Hong Kong was similarly aggressive with quarantine and isolation. Its health officials isolated one Mexican tourist, a 25-year-old man, who subsequently became ill with the flu virus. To date, they haven't reported any additional cases.

Reason number two for the "swine flu" hysteria had to do with the fact that everyone was erroneously and ignorantly referring to it as the "swine flu." Here, public health officials have no one to blame but themselves as they misnamed the outbreak from the start. Nonetheless, there isn't any evidence that the virus came from pigs. In fact, the flu's genome contained some swine, avian, and human components. The WHO stopped using the name after Egypt began slaughtering 300,000 pigs, despite the fact there wasn't a single case of the flu in the country. Likewise, Iraqi officials decided to kill three wild boars in a Baghdad zoo to ward off the virus. Other countries--including Russia and Ukraine--banned imported pork products from Mexico and the United States.

It's worth noting that these mistakes are somewhat understandable given that the appropriate response to avian influenza is to slaughter poultry in order to decrease the risk of spread from birds to people. Egypt, for example, has been dealing with an outbreak of avian flu simultaneous to this global H1N1 crisis. However, eliminating herds of pigs is a wholly inappropriate response. The H1N1 virus was already spreading rapidly from person-to-person without animal involvement, and the only case of the virus appearing in pigs occurred when a Canadian farmer, who had recently returned from a trip to Mexico, inadvertently infected a herd. So in this case, humans infected pigs, not the other way around.

As a step toward minimizing similar responses, the World Animal Health Organization continues to advise countries not to cull swine herds and that pork consumption doesn't pose a risk to human health.

The last reason for the global hysteria over H1N1 is the media, which needs to accept responsibility for generating fear and hype. While there are many benefits to real-time reporting, today's media sometimes blurs news with entertainment when looking for the next disaster to highlight. This ambiguity is amplified when public health professionals aren't able to provide clear answers at the start of a crisis. Plus, online social media services such as Twitter and Facebook provide individuals opportunities to communicate rumors, personal opinions, or unsubstantiated facts during disease crises that can misinform others.

Our interconnected global community will certainly confront another disease crisis; therefore, we must learn from the response to the current H1N1 crisis to do a better job in the future. During the initial stages of any outbreak, public health professionals and the media must be cautious when providing numbers on how many people are infected and how many have died. A country's disease reporting capability is only as good as its medical and public health infrastructures. Therefore, we must assume that the numbers from countries with poorly integrated medical and public health infrastructures and large numbers of uninsured will be inaccurate.

And we must not forget that the name of the disease matters. By using the name "swine flu," health officials inadvertently tied the disease to pigs even though there was no evidence that pigs were involved. The name led to some countries inappropriately slaughtering their healthy swine herds or banning pork products. They should have used the name "influenza A (H1N1)" from the start. In future outbreaks, health officials should only refer to a pathogen by its scientific name, taking care to avoid naming the causative pathogen after an animal, location, or subgroup of people to avoid inadvertently placing blame or scapegoating.

Finally, the individuals who run social media services such as Facebook and Twitter have a responsibility to aid in the spread of accurate information. They should state on their homepage that any discussions about the latest disease crisis are unofficial and point users to official WHO and Centers for Disease Control and Prevention (CDC) information. Even if official websites typically reflect the previous day's reported cases, the information posted will be the best available. At the same time, social media users need to be educated about the fact that the WHO and CDC websites have official outbreak updates that can benefit their informal, networked communities. In short, both the users and providers of these services need to work together to share accurate, useful information. The internet and instant messaging will be an increasingly important mode of crisis communication in the decades ahead, so government officials would do well to make it a major part of their crisis response efforts. Indeed, CDC has started a Twitter following called "CDCemergency."

Government officials, the media, and the public share the responsibility of making sure that future disease crises do not generate global hysteria. Hysteria contributes to inappropriate actions and can cause needless suffering and harm to those who might have nothing to do with the crisis at hand. There will be a "next" disease crisis, and we must respond better next time.