Has the Response to Swine Flu Been Too Feverish?Published: May 13, 2009 in Knowledge@Wharton
When news first broke out in mid-April that a new strain of the so-called "swine flu" had possibly killed dozens of patients in Mexico and spread to individuals in the United States, public health officials and the media jumped immediately into a red-siren state of high alert.
Dire warnings from agencies such as the World Health Organization (WHO) -- which called the new H1N1 influenza a likely pandemic -- were given almost limitless attention on cable news outlets like CNN and MSNBC. Indeed, concern about the potential of a swine flu pandemic peaked before scientists could learn one of the most important facts about the H1N1 virus -- that the strain was, in fact, relatively mild, no more lethal than the seasonal flu that Americans typically combat each winter. By then, the swine flu scare had already made a large global economic impact by curtailing travel and tourism, especially to Mexico, which could lose at least $2 billion in business in the coming months.
But, for the most part, the feverish pitch of official warnings and media coverage was not overblown, according to experts at the University of Pennsylvania and Wharton. The highly publicized health warnings may have helped to slow the spread of the H1N1 virus. A more casual approach to the initial reports could have proved deadly if the strain had been more serious, they say.
"From a business perspective, the costs of a false negative are so much bigger than the costs of a false positive," says Wharton health care management and economics professor David A. Asch. In other words, a lackadaisical response to a flu outbreak that went on to cause worldwide death and illness would have toppled stock markets and removed trillions of dollars from the economy, a far worse scenario than the cancelled vacations and business trips that resulted from the warnings.
"We have to tolerate a large number of false alarms to protect the public health," says Asch. "I don't think that's easily understood and conveyed by the media. It's a funny paradox," he notes, adding that anyone complaining about the amount of news coverage this time would be much more upset if there had been an outbreak like the 1918 influenza that killed as many as 100 million people worldwide.
"On the whole, I think if you have a new strain of the flu, you should be yelling about it," agreed Arthur Caplan, director of Penn's Center for Bioethics, who has for the most part praised the aggressive response by public health authorities. "I find it irresponsible for people to say it was overhyped or that people didn't react in a responsible manner."
Indeed, many experts believe that the relatively rapid response of health authorities at the Centers for Disease Control as well as the international agencies may have helped slow the spread of the H1N1 virus -- through speedy communications and the ability to issue simple and widely disseminated instructions about frequent hand washing and cough covering in public spaces.
Not Over Yet
Even now, the virus continues to spread and is expected to migrate to the southern hemisphere, where autumn will soon yield to winter, the flu's favorite season. As long as the virus remains active, health officials warn, it threatens to mutate into something more deadly.
Despite growing evidence that the swine flu outbreak has -- so far -- not been nearly as deadly as the 1918 Spanish flu pandemic, it has clearly been a significant health event. New cases continue to pop up in the United States, where there have been more than 2,500 reported infections in at least 44 states, including three deaths, in addition to at least 48 deaths in Mexico.
But the world has changed dramatically since 1918 and even since 1976, when another swine flu epidemic caused U.S. officials to launch a widespread and controversial vaccination program. With today's sharp rise in air travel and the steady increase in worldwide commerce, the recent bird flu outbreaks in Asia and now the H1N1 event centered in Mexico are fueling an ongoing debate about the implications of economic globalization.
Health experts worry that globalization has created an environment for the evolution and more rapid spread of new strains of contagious diseases, such as influenza. In particular, they have focused attention on Southeast Asia, where urbanization and dietary changes, especially greater meat consumption, have increased the opportunities for viruses to spread between humans, livestock and poultry.
"[Consumption of] animal protein is an early sign of economic development," according to Asch. "People move away from rice and they want animal protein, but there are not a lot of roads, so animals have to be close to the city," increasing the opportunities for viruses or bacteria to move from animals to humans. In Mexico, experts investigated the role of a large farm operated by a subsidiary of the American pork producer Smithfield Farms that has been the target of past pollution complaints and is located close to one of the earliest flu victims -- but the results have been inconclusive. Smithfield Farms has denied that the facility played any role.
There is no doubt that the flurry of communication among world health officials led to warnings that slowed down segments of the broader economy. The United States and other nations cautioned citizens in April to avoid non-essential travel to Mexico, and airline bookings and other tourism related activity plunged. In fact, government officials in Mexico are working on an economic stimulus package to offset an estimated $2.2 billion loss due to cancellations and other business interruptions when schools and other facilities shut down.
Because the H1N1 strain proved to be relatively mild and outbreaks outside of Mexico were not widespread, its economic impact has been relatively contained. But experts note that epidemics have the potential to pack an economic wallop: The 2003 Asian epidemic of SARS -- severe acute respiratory syndrome -- wreaked much greater havoc on that region, with losses calculated at $30 billion mostly due to curtailed travel.
Erwann Michel-Kerjan, managing director of the Risk Management and Decision Processes Center at Wharton, says the 2009 swine flu event drove home a lesson that should have become clear after the SARS episode: Large businesses as well as governments need more extensive risk management plans to deal with the fact that a pandemic can spread quickly in the 21st century, and the ability to adjust to rapidly changing circumstances is critical. One recent study found that only one in four companies had a plan to deal with a large number of employee absences all at once.
"You have to protect your own employees first, and that's what most companies have been doing," Michel-Kerjan says, noting that he is concerned that not enough businesses -- let alone nations and other institutions -- have updated their risk management plans and assessments for a possible global pandemic. "SARS was the wake-up call." Every medical crisis has different characteristics that require business and government leaders to remain flexible, he adds. In the swine flu outbreak, for example, U.S. health officials initially told schools with confirmed cases of the virus to close for two weeks, but they reversed that policy in early May as the flu was found to be mild and because it was determined that school closings would not alter the risks to the wider community.
While he agrees that the modern global economy can contribute to the emergence of pandemics, Michel-Kerjan argues that the modern workplace -- with employees much more able to perform jobs from home because of the Internet and teleconferencing -- plays a counterbalancing role. Still, he notes, "human resources and risk managers need to work hand-in-hand to make sure that if an employee doesn't need to travel, he or she won't."
Fast Action Helped
Thankfully, say observers at Wharton and Penn, the implications for Mexico's economy were not on the minds of that country's health officials when they first became aware of the outbreak in mid-March. The initial reports -- later revised downward -- told them that the illness had killed 100 or more adult patients. They did not at first know if the deaths occurred among 100 cases or 10,000. Marjorie Bowman, the director of the Center for Public Health Initiatives at Penn's Medical School, says Mexican authorities were wise not to wait for all the details before alerting the public. Caplan suggests that the world ultimately owes a debt of gratitude to Mexico for its success in preventing the wildfire spread of the virus domestically and to other nations.
Growing access to technology -- such as equipment to speed analysis of the new strain, and the ability to share that information globally via the Internet -- also helped slow the spread of the disease, according to Bowman. Google's mapping applications, she says, were particularly useful for pinpointing outbreaks and helping epidemiologists to spot patterns in the spread of the illness.
Several experts, including Bowman, say the way the World Health Organization classifies influenza outbreaks may have caused some undo alarm in the first few days after its discovery. The WHO raised the global pandemic alert to the fifth of six escalating levels of danger, suggesting a pandemic is "imminent" because the epidemic had met a specific standard: human-to-human transmission of the H1N1 virus in at least two countries. But this standard does not weigh the severity of the strain, according to Bowman. "We may need two pieces for the rating," one indicating severity and one for the rate of transmission, "because for the consumer, it's fairly anxiety producing," Bowman says.
Harvey Rubin, director of Penn's Institute for Strategic Threat Analysis and Response (ISTAR), notes that for the most part, he found the actions and statements by leading health officials -- as well as President Barack Obama, who cautioned Americans to be concerned about the swine flu outbreak but not "alarmed" -- to be quite successful in reassuring the public. Richard Besser, acting head of the federal Centers for Disease Control, "was out in front of this thing. He was calm, he gave the right answer when he knew things -- and when he didn't know, he said he didn't know," Rubin says.
While the constant repetition of the story on cable TV news might have alarmed some people, experts agreed that the good information offered by the media -- even the common sense tips about frequent hand-washing -- greatly outweighed the bad. Bowman notes that because so many television commentators reported that face masks did very little to prevent the spread of the virus, very few Americans rushed out to buy them. In addition, the television coverage greatly increased awareness of the seasonal flu, which kills as many as 36,000 U.S. citizens every year with little fanfare. Some experts speculate that flu shots will increase next year because of the publicity.
Another important message, Caplan notes, was for flu victims to stay home from work or school. The Internet allows an ever-increasing number of people to perform their work tasks from home -- an option that was not available during the 1918 and 1976 epidemics. The surge in global travel associated with combat toward the end of World War I may be what made the 1918 outbreak so severe, especially among previously healthy young males, according to Caplan. In 2009, "I think the messaging was very good, and very effective."
Still, Asch worries that as appropriate as it has been, all the attention paid to this outbreak of a relatively mild flu strain could cause people to discount the danger of the next epidemic. There may be many false alarms of a global pandemic before there is one real, lethal outbreak.
In fact, health officials are worried that the public is already too jaded about the current H1N1 outbreak, even as additional cases continue to be reported. New flu strains often return with a second wave that can be more virulent than the first, especially if the virus mingles with other infections and has an opportunity to mutate. Indeed, that was exactly the pattern followed in the deadly 1918 pandemic, which involved a different strain of the same type of virus.
Regardless of how this swine flu saga plays out, says Rubin, it has presented a rare teachable moment about the health risks that exist in the 21st century as well as the relatively simple precautions that people can take to slow the spread of viruses. "I think the public learned a lot of science because it was new and novel, and the news needs the new and novel," he says. "When the public learns science, that's always a good thing."