H1N1: The Mildest Pandemic?
The media, as well as experts, have had us scrambling to get vaccinated against the H1N1 influenza virus, but experts are now saying that the pandemic may not be as severe as originally predicted. Rob Stein of the Washington Post explains:
Experts warn that the flu is notoriously unpredictable, but several recent analyses, including one released late Monday, indicate that the death toll is likely to be far lower than the number of fatalities caused by past pandemics.
Historically, flu pandemics have killed tens of thousands, the worst being the Spanish Influenza pandemic of 1918 with a death toll of between 20 and 50 million worldwide. Experts say that the best estimate of deaths from the 2009 H1N1 outbreak will fall between 10,000 and 15,000.
Have we finally realized that preventative measures are worth investing in? Or is the virus simply less vicious than previous outbreaks? I am inclined to side with the former. While I do believe many people overreacted, it seems that the general paranoia was enough to prompt governments worldwide to take preventative action and vaccinate as many people as possible. But is there a better way to instigate this sort of change than scare tactics?
Good questions, Sarah. I think that it is slowly becoming commonly understood that prevention is another, equally important, method of treatment. I’ve read in a couple other blogs that the swine scare has increased handwashing practices in impoverished communities in Latin America, which just confirms what you’re saying here.
The paranoia of governments intrigues me. It begs the question: why don’t governments shake in their boots when they see numbers on AIDS, a much more devastating issue than the flu? I think one answer could be capability. Governments, especially rich ones, can address a flu epidemic a lot easier than an AIDS epidemic, all they have to do is tell people to wash their hands and provide them with vaccines much cheaper than any AIDS treatment. So I think another important question to ask along with the scare tactics one is: how do we make governments more capable in addressing bigger, scarier problems, like HIV/AIDS?
I agree with you about the hand-washing, Dev- we saw that personally on our visits to clinics and health promoter trainings in Nicaragua. And I also agree that there is somewhat of a taboo on the topic of HIV/AIDS, which I would argue is due not only to the difficulty of the treatment, but also to the method of transmission. In many countries, even if sex and drug use are talked about, the government is too careful to avoid appearing to condone certain lifestyle choices that they don’t provide adequate information and/or resources to prevent the transmission of HIV/AIDS. This is especially true of the US, and US-supported programs like PEPFAR that advocate abstinence-only prevention. However, there is also a problem with the affordability of ARVs, and the difficulties of procuring reliable treatment for patients who cannot afford the medication… in short, HIV/AIDS is not only scarier, but way more complicated.
Sarah, Dev, and Carolyn, it does seem reasonable that increased hand washing is resulting in better health outcomes. Time did an article a while ago on the benefits of the H1N1 scare in Bolivia. It appears that all of the hand washing has also decreased the incidence of diarrheal diseases.
Of course there are limitations to the improvements resulting from the “wash your hands a lot” approach. In particular, the lack of easy access to water in many regions hinders the effectiveness of this approach and highlights the need for even more basic health interventions than “wash your hands a lot” ad campaigns. Previous data (also referred to in the Time article) also suggests that hand washing habits are not sustained over time, limiting the long-term effectiveness of outbreak-specific campaigns. None of this is to say that such hand-washing campaigns should not be done (even temporary reductions in mortality and/or morbidity are an improvement), but should instead serve as a reminder that prevention should include much more than hand-washing campaigns and vaccinations — basic health and sanitation infrastructure must also be considered part of disease prevention and should be given due time and funding.
As for governments apparently worrying more about flu than AIDS despite the high number of AIDS deaths, I can think of three reasons:
1) Because flu is spread by casual contact, it is MUCH harder to control the spread of flu than of HIV (it may be politically easier for governments to have flu prevention campaigns than HIV/AIDS prevention campaigns, but actually preventing the spread of the disease is much harder for flu than HIV). The difficulty and uncertainty (and pure lack of control over the situation) in preventing the spread of flu is certainly the cause of much of the paranoia. If HIV could be spread by an infected person’s sneeze, you can be sure that flu wouldn’t even be in the same league as HIV in terms of government action/paranoia.
2) In some (many? most?) countries outside of sub-Saharan Africa, regular old seasonal flu kills more people than HIV/AIDS. The CDC has estimated that 36,000 people die from seasonal flu every year in the US, whereas there were an estimated 14,000-17,000 deaths from AIDS each year in the US between 2003 and 2007. Before the severity of H1N1 was known, it was not unreasonable to think that the death toll from H1N1 could have been much higher than that for seasonal flu. Say 5% of the US population became infected with H1N1 (300 million * 0.5 = 15 million [the CDC estimates that between 5% and 20% of Americans are infected with seasonal flu each year, hence the 5% estimate here]) and the mortality rate was 2.5% (the 1918 flu mortality rate has been estimated to be 2.5%), then we have 375,000 deaths in the US alone from the current H1N1 pandemic — much higher than the number of deaths from HIV/AIDS in the US. Even with a more modest 1% mortality rate, there would have been 150,000 deaths — still an order of magnitude higher than HIV/AIDS deaths. And if the current H1N1 virus had spread like the 1918 virus, infecting, say, 20-50% of people instead of 5%, then the death tolls would have been even higher. With those numbers, I think a little (initial) paranoia was justified.
3) Government officials are themselves more afraid of getting flu than HIV. This gets back to (1) with the lack of control over the situation. Officials know how to avoid getting HIV (or should), but there is no way for them to be certain that they can prevent themselves from getting flu. The focus on flu could very well have a bit of self-interest at heart.
Regarding governments’ capabilities for combating HIV/AIDS, there are a number of people who believe that there are already too many resources devoted to HIV/AIDS relative to its actual disease burden. According to a BMJ piece by Roger England, HIV/AIDS accounts for 3.7% of mortality but 25% of international health care aid. Over at OpenForum, David Hudacek points out the disparities in media attention and funding between HIV/AIDS and respiratory illnesses. I personally think that HIV/AIDS receives more money and attention than it is due (at least in a relative sense). It would be great if we could provide ARVs to everyone with HIV, but it makes no sense to make that a top budgetary priority when so many people are dying from other easily preventable/treatable diseases. HIV/AIDS is terrible, but we should not forget about other causes of death, even if they are not so high profile.
That said, there is still a tremendous amount of work that governments should be doing to fight HIV/AIDS. Carolyn mentioned the abstinence-only provisions of PEPFAR — it is provisions like this, and provisions preventing the use of funds for needle exchanges, that need to be fixed. If we could fix the politics surrounding HIV/AIDS, progress could be made without devoting additional (monetary) resources to the epidemic. Governments need to be capable of supporting effective policies; throwing more money at the problem will not stop the HIV/AIDS epidemic if we keep pouring money into programs with such limited effectiveness.