SWINE FLU: FIRST, SOW NO PANIC

NYT, May 3, 2009

By ELISABETH ROSENTHAL

Wash your hands.

I know this sounds silly, but it is far more effective at preventing flu than having a dose-pack of Tamiflu in the medicine chest. Take it from a doctor, mother and reporter who covered SARS as well as bird flu where they were most virulent.

In 2003, as SARS was spreading across Asia, I was posted in Beijing. Many families fled. My children’s school — the International School of Beijing — was one of the very few in the city to stay open, although my daughter’s class of 25 dwindled below 10. For the children who remained, the school instituted strict policies — the ones that schools promote all the time but never really enforce. For parents, the first was: Don’t send your child to school sick. For students, it was: Wash your hands frequently and thoroughly during the day — before meals, after recess. No one got SARS. But more than that, the stomach bugs and common colds that are the bane of elementary schools all over the world disappeared as well.

If hand-washing is the first lesson of the SARS epidemic to apply to today’s swine flu outbreak, the others are: Masks, the symbol of protection, are only rarely useful. And enjoy being outside; it’s not where you will get the flu.

I hate seeing pictures of people in Mexico riding bicycles and walking down the street in masks. Infectious diseases are not transmitted well outside and in sunlight. As a doctor and as a reporter, my cardinal rule is to interview sick people with infectious respiratory diseases — from garden-variety flu to tuberculosis to bird flu — in open spaces. That sometimes means an open-air hospital ward. So yes, avoid crowded, closed spaces in places where there may be danger.
Also, avoid touching things that lots of other people touch — door knobs and escalator handrails, for example — and then touching your nose or mouth. Having worked in an emergency room, I got into the habit.

Masks are for when you can’t avoid a closed space during a serious outbreak — when, say, you need to travel by a crowded bus or plane or subway. In 2003 I had a mask in my bag as I traveled to severely affected cities across Asia, but wore it only rarely. When transmitting an infectious disease through the air, a patient is generally sneezing or coughing. During the height of the SARS outbreak in China, if a nearby passenger exhibited symptoms, I moved to another part of the subway or plane.

I can tell you from my experience in Beijing that having an entire city of masked people is devastating to the social fabric. It is hard to have conversation through a mask — you can’t see smiles or frowns. Also, not all masks are equal. A good mask, well fitted and worn properly, is uncomfortable and hard to breathe through. And wearing a mask casually draped over your ears is more of a totem against disease than a scientifically valid form of protection.

In a normal season in the United States, tens of thousands of people die of complications of influenza. A baby’s death in Texas or the 200 people who have succumbed in Mexico are tragic cases, but not by themselves worrisome totals. They could even suggest that this strain of swine influenza is quite mild. We have no idea how many people came down with lesser infections — presumably a huge number — that went unrecorded by the public health system. More data is needed to sort this out.

Which is why public health officials are frantically performing contact tracing and surveillance to track where the outbreak is going. It is the best way to head off something worse and help society prepare. But watching them perform this important business should be reassuring, not a reason to panic.

Even with SARS, which had a high death rate (1,000 people died and about 8,000 fell ill), you could argue that the most profound consequences were economic. Panicked people canceled conferences and trips throughout the region for months afterward, devastating local economies.
Too little information as well as too much can be dangerous.

In 2003, China created panic by trying to cover up the SARS outbreak, denying at first that it had hit Beijing. The vacuum of good information led to wild rumors. The danger was everywhere and nowhere. People left Beijing and stayed away for months because they didn’t know if the risk was huge or small. I remember villages in the countryside setting up SARS screening programs. Villagers would stop cars and stick a thermometer in your mouth or behind your ear to gauge whether you were infected.

It was a great way to spread whatever was out there.

With swine flu, rightly and thankfully, we’re in full-disclosure mode. We get nearly minute-by-minute statistics. But people should understand exactly what information they are receiving. Potential pandemics make good headlines; hardworking scientists do not. People wearing masks make for great pictures; a school in Queens where children are returning to their classrooms does not.

As a physician, as a student of public health and even as a journalist, I cringe when I see the swine flu, or H1N1, called “the deadly virus.” Evidence to date does not suggest that it is any more deadly than the average flu. And there is this sentence that I have so often seen: The World Health Organization has not declared a pandemic yet. The sentence would be fine — and impart just as much known information without presuming what the future holds — if it dropped the final word, “yet.”