Posted: October 21, 2007
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Read “FAFfing About”
if you need some motivation

CIDRAP Business Source website, July 17, 2007
logo, link to CIDRAP Source

Whenever my commitment to pandemic preparedness starts to flag, I read something wrongheaded by an opponent of preparedness. Here’s my take on an example from a major medical journal.

Controversies breed extremists

We’ve got some on our side. Certain blogs, for example, assert knowingly that an H5N1 pandemic has already started and that the news is being suppressed by corporate lackeys at the World Health Organization and the US Centers for Disease Control and Prevention. Blogs by “flu survivalists” debate not just how much food, water, and toilet paper they’ll need to be self-sufficient for a year or more, but also how much ammunition they should stock.

As a more moderate advocate of pandemic preparedness, I often find it discouraging to read what the extremists on my side have to say. Their errors, exaggerations, lapses in logic, and occasional paranoia make me want to protest.

Reading the other side’s extremists, on the other hand, helps rekindle my commitment to pandemic preparedness. For this purpose I have long recommended the work of Marc Siegel (a New York City internist), Michael Fumento (a syndicated columnist), and Sherri Tenpenny (an Ohio osteopath and alternative medicine advocate). Their errors, exaggerations, lapses in logic, and occasional paranoia give me energy.

Now I can add Tony Delamothe, deputy editor of BMJ (formerly British Medical Journal). His editorial in the Jun 30 issue, titled “FAFfing About,” certainly got my blood going again and may do the same for you. It begins this way:

Somewhere, I imagine, there’s a small group of people proud to be counted among the Friends of Avian Flu, or FAF for short. I suspect they have a catchy mission statement, such as “Keeping the nightmare alive” and lapel badges of vaguely bird-like shape.

“Faff,” by the way, is a British colloquial verb meaning dither, futz, diddle, potter about uselessly. “I spent the day faffing about in my room.” That’s pretty much what Delamothe thinks we’re doing.

Here are some “highlights” of Delamothe’s six-paragraph editorial.

Taking the short view

The piece presents an insupportable claim that since the H5N1 virus hasn’t yet hit on a mutation that lets it transmit easily from human to human, it obviously hasn’t got what it takes:

Their challenge is to keep bird flu forever in the public eye. This should be getting harder, as influenza H5N1 is proving particularly resistant to undergoing the killer mutation that would allow efficient human to human transmission of the virus.

Keeping people’s attention is getting harder, but not because H5N1 has proved a dud. It’s getting harder in large measure because so many people share Delamothe’s impatient assumption that a disaster that takes its time isn’t coming. The truth is we’ve never before watched a potentially pre-pandemic flu virus in action. We simply don’t know how many years previous pandemic viruses spent faffing about before they went pandemic.

Waiting till it’s too late

The editorial absurdly implies that it’s unwise to worry about a risk until it materializes full-scale:

Ten years after the strain first appeared in humans, it has killed just 191 people.... Although these deaths are a tragedy for the victims and their families, it’s as well to remember that a similar number of people die on the roads world wide every 84 minutes.

As those with firsthand experience with 9/11, Katrina, HIV, or even seatbelts keep trying to tell us, the time for preparedness is before it’s too late. Perplexingly, Delamothe himself makes this point about HIV:

For AIDS, however, it really is apocalypse now. [Skeptics] used to point out that there were more papers on AIDS than people with the condition, but that was a very long time ago. Sixty million people have now been infected with HIV and another [14,000] are acquiring the infection every day.

Without a doubt, AIDS has infected far more people than H5N1; H5N1 is still in the “more papers than cases” stage. There’s also little doubt that if H5N1 does launch a pandemic, the virus will infect a lot more than 60 million people. (One third of the world’s population is a generally accepted rule of thumb, and that means more than 2 billion people would be infected.) And there’s no doubt at all that much more early action on HIV/AIDS, back when there were more AIDS papers than cases, would have been a wise investment.

Importantly, it would have been a wise investment even if the AIDS pandemic had never materialized and the investment had been wasted. Preparedness is always about hedging. You prepare for a pandemic the way you buy a fire insurance policy, hoping you won’t ever need it and thinking you probably won’t need it this year. You buy it anyway.

Missing the point

The editorial accuses preparedness proponents of committing a bait-and-switch fraud by oscillating between an obsession with H5N1 and the more general warning that sooner or later some flu strain will launch a pandemic:

H5N1 had been groomed for stardom, but now it can be any influenza strain that becomes pandemic, further details unknown. As influenza pandemics occurred in 1918, 1957, and 1968, another one is likely. But why should we be any more worried in 2007 than in 1997 or 2017?

Four things are all true:

H5N1 still looks especially scary to most experts. It is unprecedentedly widespread in the bird population; it is unprecedentedly deadly to both birds and humans; it has already proved capable of occasional bird-to-human and human-to-human transmission.
Even if H5N1 fizzles, history says one or another flu strain goes pandemic at a rate of roughly three per century.
The emergence of H5N1 has provided a teachable moment, a chance to inspire more pandemic preparedness than was feasible in 1997, and perhaps more than will be feasible in 2017.
Preparedness for an H5N1 pandemic is also in large measure preparedness for any influenza pandemic (not to mention other emergencies).

If it were possible, it would be cost-efficient to wait to prepare until shortly before the next pandemic. But since nobody knows when that will be, the choice is to prepare prematurely or to be unprepared when the need is greatest. The only sort of “pandemic timing” that’s feasible is to focus your preparedness efforts when there’s a novel influenza strain like H5N1 that both experts and the public are eyeing worriedly.

A call for less transparency

The editorial advances the dangerous suggestion that pandemic preparedness should be undertaken secretly:

Couldn’t those responsible for planning for the next pandemic do their planning less publicly and put the frighteners on the rest of us at the appropriate time?

The suggestion is grounded in two fundamental risk communication flaws. First, the assumption that we Friends of Avian Flu are scaring the stuffing out of people is false – false in that most people are barely aware of the pandemic threat, and false in that most people are capable of absorbing new fears, integrating them into their list of fears, acting on them, and then relegating them to a secondary role, all without breaking a sweat, much less going berserk. (See “Scaring people is scary” and “Get your slice of the ‘fearfulness’ pie.”)

The second flaw is the wrongheaded notion that it’s possible to prepare for a pandemic without bringing the public along with you. Some aspects of this claim are patently absurd. How can you secretly get stockpiles into people’s homes? How can you secretly prepare employees for their pandemic “emergency duty station”? But even the sorts of pandemic preparedness that corporate and government leaders might imagine they could undertake on their own are profoundly unlikely to work unless the people you’re hoping to help know what you’re up to and have had some input. And in a democracy it’s hard to sustain momentum on an expensive project unless you have built a constituency. (See “Why talk now? The case for communicating with employees before the pandemic arrives.”)

Turmoil over terminology

The editorial carries a weird charge that calling pandemic flu “pandemic flu” is less honest than calling it “avian flu”:

Some of the observations [at a recent conference] were familiar: the inevitability of the pandemic and the possibility of drug resistance. But others were relatively new: the terminological mutation from “avian flu” to “pandemic flu,” in recognition of H5N1’s failure to mutate genetically.

Letting the label “avian flu” (or “bird flu”) get applied to the future pandemic virus was a monumental mistake. It has led people to expect that a pandemic will arrive, if it does, on the wings of sick birds – and thus to feel safe as long as local birds are healthy. We haven’t made much progress in correcting that mistake and helping people see the distinctions among the following:

  • Bird flu in birds (a big, current veterinary problem)
  • Bird flu in humans (a small, current public health problem)
  • Pandemic flu in humans (a big, potential public health problem).

Teaching people the phrase “pandemic flu” would be a major step forward. (See “The four faces of bird flu.”)

Lamenting the limelight

The editorial reveals its author’s extraordinary perception that we Friends of Avian Flu are actually winning the war of words:

FAF knows that the best way to generate column inches is high profile scientific conferences with well oiled media machines....

At the moment, newspaper column inches and television minutes on pandemic preparedness are, frankly, in the toilet. We FAFfers are either doggedly plugging along or dejectedly waiting for the next teachable moment. Those of us in the public sector are having a hard time hanging on to politicians’ attention. Those of us in the private sector are having a hard time hanging on to top management’s interest. Entrancing the media and the general public is pretty much beyond us right now.

The upside

If you need your pandemic preparedness engines recharged, read “FAFfing About.” Then read the appended “Rapid Responses,” nearly all of them from pandemic preparedness supporters who were wonderfully revved up by Delamothe’s editorial. Thanks. We needed that.

Copyright © 2007 Regents of the University of Minnesota. Originally published on
the CIDRAP Business Source website, July 17, 2007. Reproduced with permission.

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