Should we leave it to experts to worry about disease epidemics?

‘Virologists spend a lot of time telling each other about potential outbreaks and developments in infectious diseases, but not a lot of time telling the public.’ So said John Oxford at the ‘Plagues of the future?’ public event, organised by spiked at the Dana Centre in London, on 8 December 2004.

Oxford wanted to correct what he saw as an unsatisfactory situation. He commented upon the media interest that the event and this spiked-debate have attracted recently, explaining that he had been contacted to appear on BBC News and the popular TV show Richard and Judy as a consequence.

Increasing public awareness about the dangers of diseases – particularly diseases which many people ‘take lightly’, such as influenza – is a good thing, according to Oxford. The World Health Organisation has suggested that we currently have a diminishing window of opportunity to stop the first massive outbreak of influenza in the twenty-first Century.

Oxford explained that until volunteering for the Royal Naval Air Force in 1914, his father had never left Poole in Dorset, and upon his return after the First World War he never left Poole again. Oxford‘s point was that societies in 1914 were a lot more static than today. One event of mobility, the armistice of 1918, put nine million people on the move – the ‘Great Gate’ at Waterloo being the location of discharge, for all those British soldiers who survived. The virus that caused the great influenza epidemic of 1918 had already emerged towards the end of the war, but it was the armistice that brought people back to their families, and spread the virus.

Oxford reminded us that today’s world is not static, but rather is always on the move. Five million people a day fly by aeroplane. With increased mobility, and increased pressure upon natural resources due to population size, the ability of diseases to mutate and jump species barriers increases. Regardless of how HIV emerged as a disease, it’s clear that the jet engine is a cause of its global reach.

Oxford cited the Elizabethan poet John Donne’s 1624 poem ‘For Whom the Bell Tolls’, telling us that ‘no man is an island, entire of itself; every man is a piece of the continent, a part of the main’. Whether Oxford meant this as a positive or a negative statement was left ambiguous, but his meaning was perhaps clarified when he cited another line from the poem: ‘Any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.’

‘Severe respiratory distress: it could be due to influenza or it could be bubonic plague.’ Dr Michael Fitzpatrick began his presentation by citing the Health Protection Agency publication New Diseases New Threats, issued to every GP in the UK – the most recent ‘desk intervention’ from the government, regarding the threat of contagious diseases. Fitzpatrick continued reading: ‘Skin lesions may be just a common boil, or it may be coetaneous anthrax.’ Under the heading ‘Some things you may not have seen’, the publication listed mustard gas poisoning.

Fitzpatrick summed up this publication as a remarkable piece of propaganda, which tells us more about the government’s concern to ensure that citizens know them to be worried about the threat of disease – especially in the context of bioterror – than it does about any desire to do anything substantial about the numerous serious diseases out there. Fitzpatrick conceded that in the case of SARS, the disease was only dealt with so rapidly because of a close watch and cooperation between science and public administration. He also said that he ‘sleeps well at night’, knowing that people like Oxford are working so hard on these public health threats.

Contingency planning is important, argued Fitzpatrick, but the government has dressed up a series of political stunts as effective contingency planning – for example, the recent mock bioterror attack on the London Underground. ‘How useful is it to stage such an event for a mixture of mass public spectacle, reassurance and alarm?’, he asked.

Malaria, leishmaniasis, and cholera are all easily preventable diseases, said Fitzpatrick, and yet millions of people around the world are dying from them. Meanwhile, millions are being spent upon vaccines for anthrax – a disease which is not regarded as a credible threat, by most virologists and security experts – in the name of security. What we actually produce through these public reassurance and engagement exercises, he argued, is anxiety far out of proportion to the actual threat.

Fitzpatrick then turned to his second ‘vignette’, a recent book entitled The Return of the Black Death: The World’s Greatest Serial Killer, by social historian Susan Scott and epidemiologist Christopher Duncan. The book is developed from an earlier academic study by these two authors, entitled Biology of Plagues: Evidence from Historical Populations, published in 2001. The academics were amazed by the media interest that this earlier study received, and so wrote an investigation of the subject for a popular audience.

Fitzpatrick commented that the studies that occupy the earlier parts of the book are but a warmup for the final chapters, ‘Return of the Black Death’ and ‘Is there something more terrible than the Black Death?’ He explained how this type of fantastical disaster writing, which is more creative than scientific, brings out the prejudices in people. The authors’ apocalyptic vision contains gruesome details of how pubs, clubs and football matches will be the epicentres of the spreading disease. How wonderful, Fitzpatrick noted dryly, that opera houses, tea rooms, the Cheltenham Gold Cup, and the Henley Royal Regatta will all escape unscathed.

Fitzpatrick argued that the popularity of these doomsday visions, and the resonance of these types of disaster scenarios, point toward a level of cultural distress in society. These visions are a peculiarly modern apocalypse, an ongoing state of affairs rather than a terminal event. Citing Susan Sontag’s 1988 book AIDS and its Metaphors, Fitzpatrick explained that this is not so much a case of ‘apocalypse now’ as ‘apocalypse from now on’, with ‘an unparalleled violence that is being done to our sense of reality, our humanity’.

It’s not so surprising that an expert virologist such as Oxford should have accepted the thesis of a society at risk, given that risk and the probability of outbreaks are a virologist’s bread and butter. What was surprising, however, was his apparent enthusiasm to discuss the imminent dangers of influenza on daytime television. According to Oxford, ‘in a world where people like to know, with people conscious of risk and the Richter scale of risk, this needs to be talked about on Richard and Judy‘.

Oxford‘s ‘take-home message’ seemed to be that we treat influenza too lightly, and that the government needs to wake up to the danger. As an example, he suggested that if in a restaurant someone got on their chair, announced that they had influenza, and then left, no one would think twice. However, if someone were to do the same but announcing that they had SARS, then in all likelihood, panic would break out. And yet when comparing incubation periods to the number of people affected, influenza is much more serious than SARS. SARS has an incubation period of 12 days, and only infects one person on average; whereas with the three-day incubation period of influenza, the number of people likely to be infected is 12.

Oxford highlighted a recent newspaper article, in which Gordon Brown promised to put £200million into AIDS vaccine research over 10 years. Oxford called this a ‘sick joke’, given that a private company often puts a minimum of £800million into researching a single drug. The comparison showed the difference between a political gesture, and the real will necessary to combat infectious diseases.

When eight people died of anthrax in the USA, out of a population of three million, there was a massive panic, with citizens buying up entire stocks of vaccines. A genuine influenza epidemic, which Oxford claimed was a credible short-term prediction, would affect many millions. And if the vaccines weren’t ready to supply the need, then there would be many worried and sick people. Ultimately, said Oxford, we need preparation and not panic.

Fitzpatrick agreed with Oxford that the case of SARS showed the potential for new diseases to emerge, and the importance of an efficient response. However, he pointed out that there was an enormous panic around SARS, as a consequence of the public awareness campaigns. These campaigns led to an irrational rather than a rational framework for dealing with the disease, with sales of useless paper masks booming, Asian economies shutting down, and Toronto brought to a standstill.

Echoing Sontag’s sentiment regarding the violence done to our sense of reality, Fitzpatrick asked whether people can really live their lives thinking ‘maybe tomorrow will be the great flu epidemic’. It is necessary for a small group of people to live in this way, as it comes with the territory of being a virologist. But Fitzpatrick was suspicious of government attempts to engage the public in an understanding of the threat of disease, and he was equally suspicious of an appearance by a virologist on daytime TV.

We’ve come far enough to be able to treat a disease like influenza lightly, reflecting our emancipation from the fear of disease – something which our predecessors didn’t have, and which Fitzpatrick is willing to defend. Addressing an audience remark on the effectiveness of the AIDS campaign in the 1980s, Fitzpatrick suggested that the aim of this campaign was not to inform the gay scene – which, by that time, had already begun to change its attitudes and behaviour – but was rather intended to scare the heterosexual community.

Fitzpatrick argued that today’s so-called Chlamydia epidemic suggests that our sexual behaviour was not in fact altered, and that the safe sex campaign was not a ‘good lie’, as an audience member had suggested. These strategies are illegitimate, because they reinforce a framework of addressing challenges to public health without reference to adult and rational lines of argument.

Using fear to regulate behaviour may produce some short-term victories, as in the case of SARS. But in the long term, it’s a damaging strategy which misuses and ultimately undermines the most valuable resource we have – individual autonomy and the capacity to think.

Oxford suggested that the World Health Organisation has only just woken up to the fact that it has an immense amount of power, and that in the case of SARS, it was able to literally shut down parts of the world by stopping mobility. The question remains as to whether such an interventionist strategy can be effective in the long term. Ultimately, Oxford‘s warning to governments was to stockpile influenza vaccines – a warning which many are not taking seriously.

I’d like to follow Dr Michael Fitzpatrick‘s advice that, seeing how John Oxford is working so hard on this issue, the rest of us can relax.

Anthony Stavrianakis, UK