How much should we worry about pandemics?

Brett Stephens isn't that worried:

In other words, despite all the processes of globalization that are
said to be leading us toward nature's great comeuppance, trend lines
indicate we are better equipped than ever to minimize the effects of a
pandemic.

Why? Because wealthier people tend to be healthier people, and
because wealthier societies have more to invest in medicine and
research, and because a higher standard of living tends to correlate
with more personal space. Also, because globalization means information
sharing across boundaries, and rapid adoption of best practices, and
greater transparency.

I say think probabilistically, a concept not prominent in his piece.  A one percent chance of one hundred million deaths is, in expected value terms, one million deaths and that is a big deal.  Probably the United States is less vulnerable than it was in 1918, but how many people would die in China, India and many other locales?  How much disruption to trade, travel, and the world economy would take place?  Even in the United States, our public health systems would break down quickly and render many modern medical advances useless (e.g., when would the Tamiflu run out?).  Having lots of living space is wonderful, but it pays off only if people stay home from work and that means dealing with massive absenteeism.  Not pretty.  Better safe than sorry.

Oddly Stephens never mentions that we are living in a raging epidemic now, namely AIDS, which has run for several decades.  For all the virtues of retrovirals, the modern world was quite slow in combating or even checking the disease and still many people, including U.S. citizens, engage in very risky behavior.  Our collective response was not terribly impressive.  Greater wealth does help, but greater wealth also means we should spend more to limit the problem.

Going back to the flu, I was struck by this passage:

In each of the four major pandemics since 1889, a spring wave of
relatively mild illness was followed by a second wave, a few months
later, of a much more virulent disease. This was true in 1889, 1957,
1968 and in the catastrophic flu outbreak of 1918, which sickened an
estimated third of the world's population and killed, conservatively,
50 million people.

I should add that we're not yet "out of the woods" on this wave, since there is a reasonable probability of sustained human-to-human transmission starting in at least one country.  And a virus which lives in many people is a virus which can mutate.

The main thing we should do — invest in public health infrastructure — is in any case a good idea with many possible payoffs, whether a pandemic comes or not.  It is a better investment of money than pursuing the ideal of universal health insurance coverage.  I might add that one of the better arguments for universal coverage is simply that it could lead to better monitoring of some public health issues.

Comments

So four of the last flu epidemics and 116 of the last non-epidemics were preceded by a mild spring flu season. In other words, a mild spring flu season predicted 120 of the last four flu epidemics.

Asher, this is a quite new strain, different from most other years. Besides, it happening 4 times out of 120 is still quite something to worry about.

Ahhh... one more thing...

[Given a large number of deaths of poor people around the world] "How much disruption to trade, travel, and the *world economy* would take place?"

Morals aside and focusing purely on the economics, that they are poorer is indicative that their marginal contribution to the global economy is proportionally smaller so the disruption will be less.

Lacking actual numbers, it seems not unreasonable to me to believe that interruptions to trade among the wealthier to combat the possibility of infecting the poorer (e.g., by encouraging everyone to not ride a plane even though the chance of death in a wealthy society is quite low) could easily have a greater impact on the global economy than the impact from the deaths of the poorer people around the world.

Thus to maximize the growth in the world economy, it may well be preferable for the wealthier societies to worry less instead of worry more.

Wouldn't massive investment in public health infrastructure make health cheaper anyway, moving us towards the goal of universal coverage? (If the infrastructure's in place, universal coverage seems like it would also help prevent deaths in case of an epidemic - people would get treated without worrying about having to pay.) Not to ignore their relative importances, but it seems like health infrastructure investment and universal coverage are complementary goals.

In each of the four major pandemics since 1889, a spring wave of relatively mild illness was followed by a second wave, a few months later, of a much more virulent disease.

Well that's odd -- because as I understand it, that's not the way pathogens evolve. When they first jump from other species, they may 'accidentally' kill their new human hosts, but from the pathogen's perspective, this is a bad mistake (because dead people can't support or transmit the pathogens). Even seriously ill people aren't very useful to pathogens, since seriously ill people don't go out and interact with other potential hosts. So the evolution is in the direction of viruses becoming more easily transmissible but less lethal. But I suppose 'virulent' can refer to either transmissibility or severity.

Still, I'm less worried that I was because the fatality rate now seems much lower than originally believed and will drop over time as the virus evolves.

Tyler, I'd take Asher's point to be that the "mild spring flu season" is not causally connected to "severe epidemic".

I'd take issue with "greater wealth also means we should spend more to limit the problem." Greater wealth means we CAN spend more, but we can also spend that money teaching deaf-mute New Guinea tribesmen about Shakespeare's sonnets, or providing psychotherapy to disturbed wombats. "Can" doesn't mean "should".

There are several simple factors at work here as well. The industrialized world is much more robust in terms of respiratory health, body mass, nutrition, and hygiene. Heavier people with fewer lung issues (less heavy particulate pollution, less smoking, etc.) simply live through diseases at higher rates.

Slocum,

Pathogens can evolve either for increased or decreased virulence depending on the method of transmission. The classic case is cholera, which has evolved to extreme virulence in third-world settings because it can most easily infect caregivers that way. In the USA, it has evolved to such low virulance that it was endemic to the Gulf Coast areas of TX and LA for decades before health officials noticed it.

http://jama.ama-assn.org/cgi/content/abstract/247/11/1598
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=202726

In short, pathogen evolution supports the contention that wealth=health.

"Better safe than sorry" is such a lame slogan! True, one might end up sorry for not having taken effective precautions, but how about being sorry for having incurred the cost of useless precautions?

Yglesias's article simply made the point that public health authorities may have acted properly even if the swine flu turns out to be less virulent than they originally expected, since they had to act initially on quite scanty information. But he just assumes, without evidence, that their actions were in fact appropriate, given their initial information.

isn't one major factor missing in your analogy, namely that you can spread the flu by coughing or sneezing near someone, whereas AIDS involves behavior that by-and-large (outside of Africa/lack of blood transfusion testing elsewhere) is voluntary. After the initial realizations about the methods of accidental transmission (eg, blood transfusions) the risk of its spread was largely a matter of education of the public and an exercise in self-control and self-maintenance (via regular testing, full disclosure to partners, etc).

The comparison of the two as diseases of similar "pandemic" potential seems pretty flawed.

Wouldn't universal health care spending by default improve public health infrastructure (even accounting for waste and rent seeking)?

"Better safe than sorry" is such a lame slogan! True, one might end up sorry for not having taken effective precautions, but how about being sorry for having incurred the cost of useless precautions?

This is just a framing issue and it's a failure of public education and public relations if the point doesn't get through to enough people. When you renew your car insurance every six months, after having spent the term of the insurance accident-free, do you reflect on how purchasing the insurance was a "useless precaution"?

What counts as a useless precaution is pretty relative, also. In many countries, washing your hands after using the toilet or waiting for traffic to clear up before crossing the street are considered by locals to be useless precautions. In the U.S. and other countries, public health and safety officials have changed attitudes enough to get people to rid their minds of this way of thinking.

Some recent research has been conducted on the economic effects of shocks such as stock market crashes and flue on consumption and GDP growth:
http://www.hoover.org/pubaffairs/dailyreport/archive/44358832.html

Now that we've two of those in the mix together, it's certainly some cocktail!

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