Maclean's Interview: Philip Alcabes

Epidemiologist Philip Alcabes talks with Kate Fillion about swine flu, fear, and the folly of too much preparedness

Maclean's Interview: Philip AlcabesQ: In your new book Dread, you look at the ways fear and fantasy have fuelled epidemics throughout history, and point out that the last time North Americans worried about swine flu, in 1976, the “cure” turned out to be far worse than the disease.

A: It was a public health fiasco. Some soldiers at a base in New Jersey got sick, one of them died, and it turned out he had a strain of flu from the same family as the 1918 strain, which killed 40 million people. U.S. federal officials jumped far ahead of the facts and promoted a nationwide immunization program. They started in the fall and immunized 45 million people, but by November they had to stop, because they started to see cases of this neurological condition, Guillain-Barré syndrome. Later studies suggested very strongly that at least half the cases—there were about a thousand—were vaccine-associated, and 32 people died. You might say, “Well, you have to break some eggs to make an omelette, you have to protect the public”—but there was no swine flu outbreak after all! And the U.S. government spent $93 million after the fact to remunerate people who had lost loved ones.

Q: It’s surprising that the scientific community promoted fear.

A: I’m not going to impute that agenda to scientists, but I do think there were scientists claiming that another 1918 could happen any minute, which is why they needed more funding for flu research, and they were suddenly heeded. What happens in the ’70s is that there are advances in laboratory methods and techniques that allow people to study viruses a lot better, which is a good thing, and there’s also an expansion of funding for benchtop research. The federal authorities that provide grant funding insist, not unreasonably, that researchers show their research will be useful in some way. And that creates an incentive for scientists to imagine what might happen: “What if 1918 happens again? Maybe with this research, we could fight it better.”

Q: What do you think of Obama’s “no cause for alarm” message on swine flu?

A: It’s the right message. He’s saying, “We’ve got a sound public health system, we’ve been planning for infectious disease problems for a long time and we have experience that goes back even longer, and there’s no need to see this as an extraordinary crisis.”

Q: But the World Health Organization is warning this could be a pandemic.

A: The WHO has been saying that a pandemic is inevitable for the past few years. I don’t know what it’s like to work for the WHO, but I imagine you see that the health agencies in the member nations are concerned, and you can’t do much, so you go out and crank the thermometer from level three to level four. I don’t make much of that.

Q: What does it do to us, psychologically, to be warned of an epidemic or pandemic?

A: It arouses fear. The rhetoric of the last few years about the possibility of a reprise of 1918 has fertilized people’s imaginations. And then when something real happens, it’s kind of like a match being thrown on dry tinder. We’ve been ready to get worried, and oh, now there are actually flu cases, it really is a new strain! And that seems to validate our fears, not just of illness or foreigners or germs, but our fears of social disruption, that something fundamental is going to change and life as we know it isn’t going to go on.

Q: You say that we create stories about epidemics as an outlet for our dread. What dread, exactly?

A: I think we’re deeply ambivalent about the society we’ve created. We like the advanced technology, the comfort, the fact that we no longer have to share a mud hut with our 12 children and the family goat. On the other hand, we really worry that we’ve gone too far, in some way tempted fate, and therefore bad things are going to happen. The idea that punishment will take the form of a disease epidemic is ancient. It’s in the Bible. And in fact, the response to the Black Death in the 1340s represented a similar kind of anxiety about modern times. A lot of people were still living with the family goat, but they were worried that they weren’t worshipping the way that their grandparents had, the church was changing, there was a new middle class and people were leading different lives. Anxieties about modernity got swept up and attached to the specific fear of that plague. This anxiety about modernity stays with us, it’s just that modernity gets updated. What has changed is that we’ve established public health systems. Now we actually have something to fall back on and feel confidence in.

Q: During the avian flu scare a few years ago, there was endless talk about “preparedness,” stockpiling food and Tamiflu and so forth. You’re anti-preparedness. Why?

A: I’m not anti-planning. I’m a public health promoter; I think we should plan for reasonable eventualities and put the processes into action when the facts warrant it. But I don’t see the utility of getting people worried that anything might happen, because we put ourselves in a position to respond to nothing.

Q: How did the “preparedness” movement gain so much momentum over the past decade?

A: The Bush administration was very adept at channelling people’s fears into the creation of threats that were based on little or no evidence, and using that as a kind of manipulation to get the public to agree to more surveillance and fewer civil liberties. Bioterrorism was essentially chimeric. There was almost no chance that any person was going to take germs and create a widespread epidemic disease disaster, but we were told that was going to happen and therefore we should duct tape our windows and so on. It’s part of what I call a personalization of risk.

Q: How does bioterror feel more personal than any other risk?

A: After the World Trade Center disaster, I was really struck by how fatalistic New Yorkers were about the collapse of the towers and the deaths of thousands of neighbours, friends, family members. On the other hand, there was the postal anthrax outbreak a few weeks later, and five people died. Now, that’s sad, but the reaction to that was people were ironing and microwaving their mail, buildings got evacuated every time somebody thought they saw white powder, there was near-hysteria.We recognize that terrible things happen in the world, but when it seems like “there’s something I should be doing to protect myself,” it resonates in a different way. We ask ourselves, “Did I do something wrong? Should I be protecting my own health by not indulging in some behaviour or by adopting some new behaviour?” In the past quarter-century or so, we’ve personalized risk much more dramatically.

Q: What factors contributed to that change?

A: I think AIDS is the big one. I don’t mean HIV per se, but the AIDS epidemic, which is to say the story we’ve told ourselves about what AIDS means. The premier explanation for AIDS, that’s been adduced at least in North America and Europe, has been moralistic: “It’s about behaviour, people doing something wrong.” It’s not just: “Infections happen”; or, “Here’s yet another example of a contagious microbe spreading through the population.”

Q: What story do we tell ourselves about the Spanish flu?

A: “Something is going to creep up and invade us”—which is ironic, because in fact the 1918 flu very likely began in the U.S. But we call it the Spanish flu because at the time, newspapers were censored in the countries that were at war. So in the U.S., England, France and Germany, though people were sick and dying, there was literally no mention of the flu. Spain, however, was neutral in World War One, so the Spanish newspapers carried reports of this epidemic, and the story is that people started calling it the Spanish flu because that’s where it was reported.

Q: What story could we tell ourselves about the swine flu? “People shouldn’t vacation in Mexico?”

A: I worry that if we allow ourselves to exaggerate our fears about what this—so far—quite small outbreak of a new strain of flu means, we’re going to start hearing from the anti-immigration people who want to make the fences between the U.S. and Mexico higher. We’re going to hear from the ideologues who want to blame it either on capitalism or on what they claim is Obama’s socialist agenda. It’ll bring out the crusaders.

Q: You say that old-fashioned public health measures are the best ways to deal with a flu outbreak. Why is it so difficult for people to believe in tried and true responses?

A: The methods already in place in Mexico City—closing schools, temporary bans on public gatherings, travel restrictions—have been used for hundreds of years, and they seem to be working so far. But we have this double-edged sword of knowledge: we’ve got access to so much information now that we can know in a few instants what’s happening anywhere in the world. That could be reassuring if we wanted it to be, but we have these fantasies about a terrible pandemic with millions of deaths, and it’s very easy to interpret the wealth of information that’s available at the click of a mouse as validating our fears. I want to be clear: it’s still possible that something really bad will happen. But at this point, a week into our awareness of the outbreak centred in Mexico, we’re not looking at a very bad flu outbreak.

Q: When the hype of an epidemic—like the avian flu epidemic a few years ago—isn’t borne out, does it create an incentive for the media to ratchet up the threat level the next time in order to get people’s attention?

A: I think we’re always worried. We carry anxieties with us, and the stories that public health people and the media tell simply fuel those fears. I don’t see that it’s ever been hard to sell us on the idea that we should be worried about some new thing: the obesity epidemic, the ADHD epidemic, the restless leg syndrome epidemic. But it’s a two-way street: if we didn’t want to read those stories, they wouldn’t be published or broadcast. We want to hear about epidemics, in part because they seem to tell us something about this anxiety we have about what’s wrong with modern life. The obesity epidemic seems to talk to us about the addictiveness of modern life, or about the toxicity of the food supply. It’s interesting because actually, we’re pretty safe. Compare North America to Africa or other developing countries: our kids aren’t dying of diarrhea or malaria. Yet we’re fascinated by epidemics. At least we no longer, as they did in the 14th century, burn Jews when an epidemic comes. Civilization has made some progress.

Q: But we still have trouble keeping something like the flu in perspective.

A: Exactly. There have been 149 deaths in Mexico as of this morning. Let’s say all are attributable to this flu, which we don’t know yet. Well, that’s one bad weekend on the roads in the U.S. But no one thinks of auto accidents in terms of a public health crisis.

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