Apocalypse looms – again
Before you fall for the scare about antibiotic-resistant plagues, just consider how insanely wrong the authorities were about swine flu.
Dr Michael Fitzpatrick
Just when we thought it was safe to take off our face masks, another plague threatens the survival of humanity.
Last week, on the very day that the World Health Organisation officially declared the swine flu pandemic over, microbiologists launched a new alert – over multi-drug resistant bacteria. Professor Tim Walsh, co-author of a report in the Lancet Infectious Diseases, strikes the now-familiar note of impending doom: ‘In many ways, this is it. This is potentially the end. There are no antibiotics in the pipeline that have activity against NDM 1-producing Enterobacteriaceae.’ (1)
Here we go again. Only 12 months since the great summer alarum of 2009, when England’s chief medical officer Liam Donaldson raised the spectre of 65,000 deaths from swine flu (the total fell short of 500, far fewer than the annual toll from seasonal flu), we are faced with another nightmare scenario. If the flu doesn’t get us, the New Delhi Metallo-beta-lactamase 1– positive bacteria spreading among ‘medical tourists’ travelling to India for cosmetic surgery will do instead, ravaging the population back home in Britain in defiance of any existing antibiotic.
Or, more likely, it will not. The spectre of antibiotic-resistant microbes is as old as antibiotics. Over the past decade we have already survived Methicillin-Resistant Staphylococcus Aureus (MRSA), multi-drug resistant Tuberculosis, and highly resistant strains of HIV. The lesson of the swine flu scare is that the public should exercise a degree of scepticism over the doomsday warnings issued by leading figures in microbiology and public health.
According to the declaration of the end of the pandemic issued by WHO last week, it was ‘pure good luck’ that swine flu fell so far short of the apocalyptic potential so eagerly proclaimed by its promoters in the spring and summer of 2009. It was ‘pure good luck’ that the H1N1 virus did not mutate into a more virulent strain, ‘pure good luck’ that it did not become resistant to the drugs distributed with such abandon by the staff of the national pandemic phoneline in the UK, ‘pure good luck’ that the swine flu vaccine turned out to be effective and safe. Indeed, it was good fortune that WHO managed to assemble its top brass to call off the pandemic: an earlier meeting was disrupted by the cloud of ash from the Icelandic volcano.
There is a remarkable contrast between the benign operation of fate and the gloomy prognostications of public health authorities: over SARS, bird flu and swine flu, warnings of global Armageddon have been rapidly falsified by events. Yet the same authorities are falling over themselves to congratulate one another on their handling of these minor outbreaks of infectious diseases.
The independent review of the UK response to the 2009 pandemic carried out by the former Welsh chief medical officer, Dame Deirdre Hine, concludes that ‘overall the UK response was highly satisfactory’: ‘The planning for the pandemic was well developed, the personnel involved were fully prepared, the scientific advice provided was expert, communication was excellent, the NHS and public health services right across the UK and their suppliers responded splendidly and the public response was calm and collaborative.’ (2)
Splendid! After spending an estimated £1.2 billion, we were left with 30million unused vaccines (less than a quarter of those eligible took up the jab); 2.7million phoned the pandemic phoneline (most of these also called GPs’ surgeries); 1.2million people received anti-viral medications (though the vast majority probably did not have swine flu); and several people misdiagnosed by the pandemic phoneline died of other conditions. When Dame Deirdre refers to this as a ‘world class’ performance, perhaps she means this in the same sense as that of the England football team in South Africa.
In a retrospective commentary, former Times science editor Nigel Hawkes accused authorities of going ‘over the top’ as ‘predictions of the severity of the pandemic consistently exaggerated its likely impact’ (3). Though projections by leading public health officials of rates of disease and death from pandemic flu on a catastrophic scale created enormous public anxiety and caused major disruption to primary health care, there is little evidence that they had any protective value. Given the rapid spread of the virus, it appears than none of the measures taken in the early ‘containment’ phase of the outbreak, such as more assiduous hand-washing, face masks, social distancing measures (school closures, etc) and the provision of prophylactic anti-virals to contacts, had an appreciable effect on its dissemination.
It soon emerged that early reports from Mexico provided unreliable figures for deaths resulting from swine flu and an uncertain number of cases of infection to use as a denominator with which to calculate the mortality rate. In the judgement of the Hine Report, commissioned by the Cabinet Office and published earlier this year, ministers and officials placed excessive faith in mathematical modelling. They had come to regard this as ‘hard, quantitative science’ that could provide ‘easily understandable figures’ which had the aura of appearing ‘scientifically very robust’. Though the mathematicians warned, at the first pandemic planning meeting in April, that in the absence of reliable data their modelling capability was low, they were under pressure from the politicians to ‘produce forecasts’. The high level of uncertainty surrounding these projections does not seem to have deterred the modellers from producing them or the politicians from projecting them into the public realm.
The nearest the Hine Report comes to a criticism of official conduct is the observation that the ‘English chief medical officer’s citing of the “reasonable worst-case” planning assumption of 65,000 fatalities on 16 July 2009 was widely reported in headlines in somewhat alarmist terms’. How else could such an alarmist figure be reported? British authorities chose to promote such gloomy projections at a time when other prominent health figures had already declared such figures improbable. A month earlier, on the occasion of declaring the swine flu outbreak a global pandemic, WHO chief Margaret Chan had already acknowledged that most cases were mild and that she did not expect to see a sudden and dramatic jump in severe or fatal infections.
The alarmist response to the swine flu outbreak reflects the wider trend of the past decade in which ‘crying wolf’ has emerged as the appropriate official response to diverse real and imaginary threats, from the millennium bug to bioterrorism, obesity to global warming (4). For the authorities, the overriding principle is to avoid blame for unforeseen disasters, by always proclaiming the worst-case scenario and repeating the mantra ‘prepare for the worst, hope for the best’. From this perspective, rational contingency planning gives way to scaremongering. Instead of making discreet preparations for probable, predictable, emergencies, the authorities engage in speculation about the grimmest possible eventualities with the aim of promoting more responsible behaviour and healthier lifestyles (5).
Rather than communicating realistic assessments of risk to the public, the authorities engage in sharing their anxieties and promoting fears. Instead of guiding practical professional interventions in response to real health and social problems, politicians and public health officials engage in dramatic posturing and sloganeering.
Many commentators have drawn attention to the wider cost of the pandemic in terms of the damage to confidence in public health authorities. The erosion of trust fosters a climate of cynicism that is increasingly responsive to allegations of corruption and conspiracy theories, even if these cannot be substantiated. The poor uptake for the swine flu vaccine – among health service professionals as well as among vulnerable patients – reveals the corrosive effects of the pandemic for the health service. The culture of fear promoted by pandemic scares fosters a climate of pessimism and victimhood, sapping the faith of human beings in their own capacities (6). Fear, according to philosopher Lars Svendsen, robs us of our freedom and undermines our ontological security.
In her defence of the mathematicians who were cajoled by the politicians into providing projections of the swine flu pandemic on the basis of inadequate data, Dame Deirdre protests that ‘modellers are not court astrologers’. From the perspective of the US critic of public health, Philip Alcabes, the dame doth protest too much. He depicts today’s public health officials as ‘wizards’ and ‘soothsayers’. He argues that they have turned public health policy into ‘a magic show, the official engaging in legerdemain and the public – the conjurer’s audience – agreeing to believe that the official has succeeded in pulling off an inexplicable trick’. Whereas in the past authorities recommended protective measures against outbreaks of infectious diseases, now they identify imaginary dangers (such as bioterrorism) and prescribe preventive measures, which do nothing to make us safer (but which legitimate the authorities even if the threat fails to materialise).
Politicians and scientists keep identifying new epidemics (of social problems such as binge-drinking and internet stalking, as well as of viral infections). Their incessant exhortations to be aware and vigilant and to curb risky behaviours are amplified by the media, fostering public anxieties. The result is a climate responsive to the promotion of a new brand of piety, in which everyone is supposed to worship at the altar of ‘healthy lifestyle choices’.
The scaremongering over swine flu and drug-resistant bacteria brings to mind a story told by the Sufi writer Idries Shah (and retold by the psychoanalyst Adam Phillips) (7). Mulla Nasrudin is standing one morning in the yard outside his house throwing corn. A man who is passing stops and looks at him, extremely puzzled.
‘Mulla Nasrudin, ‘ he asks, ‘why are you throwing this corn around?’
‘Because it keeps the tigers away’, the mulla replies.
‘But there aren’t any tigers here.’
‘Well, it works then, doesn’t it?’ the mulla says.