Tuesday, May 04, 2010

When Words Fail Us



# 4545



Note: I’m having ISP connectivity problems this morning, and have just managed to get online.  Hopefully the problem is now resolved.



A hat tip to Crof at Crofsblog, who picked up a story I missed last night, featuring CIDRAP’s Michael Osterholm.   It appears in Medscape News, and is entitled Lessons Learned From the H1N1 Pandemic Are Meager.


A small excerpt, but as Crof says, you’ll want to read the whole article, there’s a lot there to take in.



Lessons Learned From the H1N1 Pandemic Are Meager

Bob Roehr



"We have been our own worst enemy, continuing to say there have been 36,000 deaths every year from seasonal flu, and then we put numbers out that say there have been 12,000 deaths" this year from H1N1.


"We have not done the job to describe the impact on society," said Dr. Osterholm, who is now with the University of Minnesota, Minneapolis, and is a former Minnesota state public health official. 


"The current mild, moderate, severe measurement system is outdated, antiquated, and should be thrown away," asserted Dr Osterholm. "It is fine to talk about cases that way," but the system does not work when dealing with a broader public health event. 


(Continue . . .)



As a blogger who has penned more than 1500 essays over the past 12 months, I’ve struggled with the most accurate and appropriate way to describe this pandemic on a daily basis.  


And to be honest, I haven’t always succeeded.


The words we use are important and more powerful than we realize, and I’ve often found myself agonizing over which ones to choose.


Very early on it was apparent that novel H1N1 wasn’t a 1918-like pandemic, although it always retained the potential to intensify.  I felt it was imperative not to `oversell’ this threat with hyperbole, but I also did not want to minimize it either.


So over last summer and fall, I used terms such as `moderate, `mild’, and `less severe than’ to describe this pandemic, although I was never really satisfied with any those terms.


Last June, for lack of a better term, I began to call it a High Morbidity-Low Mortality pandemic.


One that sickened many, but killed relatively few


Clumsy, but somewhat descriptive.   But even that didn’t tell the whole story.


In fact, I never managed to come up with a term, or even a phrase, that I felt adequately described this pandemic.   Instead I relied on lengthy passages such as this one from last July, written about 6 weeks into the pandemic:


The apparent `mildness’ (a relative term) of this first wave of H1N1 is heartening news, and we may find that the pandemic of 2009-2010 turns out to be far less serious than first feared.  But influenza viruses are unpredictable, and we’ve a long way to go before the final chapter of this pandemic play is written.


The impacts, particularly in the health care delivery field, are likely to be significant even in a low fatality pandemic.   And if it is you, or a loved one that is severely hit by the virus, you won’t think of this pandemic as having been `mild or moderate’.


Okay, so it isn’t Hemmingway


Complicating matters has been the spotty surveillance and reporting from around the world.  We really have no idea how many people have died as a result of the H1N1 virus, and probably never will.


Numbers, such as the ones released by the WHO (World Health Organization) are so far from reality as to be useless (not their fault, btw, since they are reliant upon reports submitted to them). 


They have, however, been used to great effect by pandemic deniers who point to them and demand, `why all the fuss?’.


Last August, in Apples, Oranges, And Influenza Death Tolls, I wrote of the problems involved in trying to assess and compare the impact of the pandemic.  That blog ran over 1700 words. 


Not exactly the makings of a meme.


A month later, as I watched the growing age-shift of cases (and fatalities), I wrote a blog entitled Numbers Don’t Tell The Whole Story.  


And here, finally, I was getting closer to describing the real impact of the pandemic (and no, this wasn’t some epiphany or giant mental leap on my part. I was writing about the concerns that many public health officials were openly expressing). 


In the case of novel H1N1, most of the infections and 90% of the deaths we’ve seen have been UNDER 65.


This is the opposite of what we would normally expect from seasonal influenza, and much harder for a society to accept. We are talking relatively young adults and children dying from a disease that normally kills the elderly.


One could easily argue that the death of a child is 10 times (or perhaps a 1000 times) more tragic, and costly to society, than the death of an 90-year-old in a nursing home. 




While we obsess over the numbers, and try to quantify the importance and severity of this pandemic, the truth is the numbers don’t tell the whole story.

That would require equating the death of a 10 year-old child or a 30 year-old pregnant woman, to that of a 90-year old nursing home resident.


And while it may sound insensitive, from a societal standpoint, they are worlds apart in terms of impact.



Alas, brevity is the soul of public communications.   


And long and nuanced discourses, such as the ones above, don’t filter through well to the public.  For that, you really need a short, simple sound bite.


But pandemics aren’t simple.  They are incredibly complex, and they defy a one word, or even one sentence description. 



For every impeccably researched and thoughtful news story on this pandemic by the likes of Helen Branswell, Maggie Fox, Jason Gale, Mayrn McKenna et al., there have been a hundred editorials, blogs, or offhand comments by cable news talking heads that described H1N1 as `mild’, `overblown’, or a `non-event’.


One word descriptions that people can easily latch on to.


Which is why the public perception of this pandemic differs from what many doctors and public health officials saw and experienced. 


Last March, we saw the first attempt to quantify this pandemic’s impact in terms of Years of Life Lost (YLL), a metric that I believe more accurately reflects the severity of a pandemic.  This study, of which Michael Osterholm co-authored, helps put the pandemic of 2009 into perspective.


Simply put, if an 80 year-old dies from a flu-related illness, statistically they were deprived of but a handful of years.


If a 40 year-old succumbs to the flu, they lost decades of life.


In terms of YLL, the death of a 40 year-old probably has a ten-fold greater impact than the death of an 80 year-old.


And when you take the estimated number of deaths, and and correct for the age-shift, it turns out that the H1N1 pandemic of 2009 has probably matched, or perhaps even exceeded, the number of years of life lost due to the 1968 pandemic.



Preliminary Estimates of Mortality and Years of Life Lost Associated with the 2009 A/H1N1 Pandemic in the US and Comparison with Past Influenza Seasons

By Cecile Viboud, Mark Miller, Don Olson, Michael Osterholm et al (5 authors)




Although it is important to get all of this right from a historical and scientific standpoint, how we view this pandemic also impacts the way we will react to the next one. 


Far too many people have come away from this experience with the false belief that it was all hype, overblown to benefit vaccine manufacturers, and just another in a long line of `scare stories’ perpetrated by the media to garner ratings.


Granted, we got lucky.


This pandemic didn’t turn into a repeat of 1918, and for that we can all be thankful.  But we do great damage to any future public response by trivializing its true impact. 


Communicating clearly, concisely, and accurately to the public in a crisis can save lives. And that becomes all the more important when a long-term event like a pandemic is in progress, since advice may change over time, or vary by region.


And anything you say has to cut through the `noise’ issued forth by competing interests. 


But to do that, we have to find the right words


Words that will resonate with the public, cut through the nonsense and malarkey, and that will inform, but not inflame.


And so far, finding them hasn’t proven to be easy.

No comments: