Teetering On The Edge Of A Flu Pandemic? As swine flu cases surface around the world, authorities say a pandemic may be imminent. Ira Flatow and experts discuss the current outbreak, lessons learned from the scare of 1976, and whether government restrictions could tread on individual liberties if a pandemic occurs.
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Teetering On The Edge Of A Flu Pandemic?

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Teetering On The Edge Of A Flu Pandemic?

Teetering On The Edge Of A Flu Pandemic?

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You're listening to SCIENCE FRIDAY from NPR News. I'm Ira Flatow. As of today, according to the Associated Press, 13 countries have reported about 500 confirmed cases of the swine flu epidemic. Mexico confirms 15 deaths, but only one death has been reported in all these other countries, and that's just one case. It's in the U.S., of a Mexican toddler in Texas.

That's the same number of U.S. deaths, just one, that sent politicians and public health officials into a frenzy in 1976, when a 19-year-old soldier died of a swine flu infection. The government rushed to stem what they thought was going to be a severe wave of deadly infections with a newly developed vaccine, producing public service announcements like this one.

(Soundbite of public service announcement)

Unidentified Woman: Joe brought it home from the office. He gave it to Betty, and one of his kids, and Betty's mother. But Betty's mother went back to California the next day. In California, she gave it to her best friend, Dottie, but Dottie had a heart condition, and she died. But before she died, she gave it to her friend, the paper boy, the mailman, and…

Unidentified Man: If the swine flu epidemic comes, this is how it could spread. Get a shot of protection, the swine flu shot. Recommended by U.S. Public Health Service.

FLATOW: And over 40 million Americans got the vaccine. President Ford even got vaccinated in public, but the virus never hit big, and it caused no more deaths. Instead, the vaccinations themselves were associated with hundreds of people developing a paralyzing nerve disease, and several dozen did die.

Now, would a similar scenario happen today? It's a difficult balancing act, protecting the nation yet not overreacting, and scientists and public health officials are still struggling to get the facts they need on the swine flu outbreaks, the flu now labeled H1N1, to make these decisions.

In this hour we're going to have a flu reality check. Just how much of what we know is fact? How much is fiction? How much of the advice we're getting to wash our hands, to stay away from crowds, is based on fact, and how much is based on fear?

For example, Mike Bloomberg, mayor of New York, which has had a significant amount of cases, 50, said it's beginning to look like this strain of flu is much milder than had been anticipated. But even if the mayor is right, can we get too complacent and not be ready for a possible second wave of the flu, much deadlier, as it has happened in previous years?

So this hour we're going to talk about what we know and what we don't know about H1N1 and how prepared we are for a pandemic should one occur, should it be upgraded to be calling it a pandemic, including plans for a vaccine.

And we'll be taking your calls and questions. Our number is 1-800-989-8255. That's 1-800-989-TALK, and if you're on Twitter, you can tweet us @scifri. That's the at sign followed by S-C-I-F-R-I. Also in Second Life, you can meet a bunch of avatars who are there, gathering to hear SCIENCE FRIDAY. 1-800-989-8255.

Let me introduce my first guest. Dr. Anthony Fauci is the director of the National Institute of Allergy and Infectious Diseases. That's part of NIH in Bethesda. He joins us by phone. Welcome back to SCIENCE FRIDAY, Dr. Fauci.

Dr. ANTHONY FAUCI (National Institutes of Health): Thank you, Ira. It's good to be here.

FLATOW: I guess the first question I'm asking is are we overreacting with so few cases of flu? Don't we normally expect tens of thousands of people to die of the flue worldwide, just the normal flu every year?

Dr. FAUCI: Yes, we do. So I don't think it's an overreaction. I think it's being cautious and implementing the preparations, the preparatory for the pan-flu possibility, the contingency that was discussed a few years ago.

You know, sure, it is true, and I think that needs to be a perspective that needs to be emphasized, that on a normal seasonal flu year there are 36,000 deaths, approximately, in this country, and about 200,000 excess hospitalizations.

That flu that we have seasonally, most of the time the vaccine we get it right; namely the vaccine's well-matched to the circulating flu, and there generally is varying degrees of background immunity in the population to the modifications, the small variations that we call drifts in the seasonal flu.

The reason that we're responding the way we are now, and why we're acting with caution, a considerable degree of caution, but I have to emphasize not alarm, is that we not have circulating a flu virus that we've not really been exposed to before, a flu virus that is really very unique and new to the human species.

So we have unpredictability in any kind of influenza. You compound that unpredictability when you have a virus that you've never had any experience before and no real substantial, underlying background immunity in the population to that.

So it could turn out that it isn't a really serious situation in the sense of how it evolves, but we are acting and preparing as if it could be a very serious situation.

FLATOW: You know, it's almost like déjà vu all over again, this conversation. We had sort of a conversation like this two years ago, where we thought a bird flu was going to come from Asia. We now have a swine flu coming from Mexico.

Dr. FAUCI: Well, there are some substantial differences in those two, and I think it's important to point these out, Ira. The bird flu, the H5N1 that has been smoldering for years in various regions, particularly in Southeast Asia, is an influenza that clearly comes from birds, mostly fowl, chicken. It infects them and kills them. We know that. But it jumps species in an inefficient way.

So there are hundreds of cases of infections. It happens to have a high morbidity and mortality among the people who are infected, but what that virus doesn't have, and hasn't adapted, to spread efficiently from human to human, not at all. Certainly that could happen sometime, but that is not where it has been, and it's been years that that has not happened.

The situation with the current virus, the H1N1 that we're dealing with now, in that as we're seeing now throughout the United States and in Mexico and now a number of other countries, that it can and does spread from human to human. The degree of seriousness of the disease is still something that is evolving.

It appears that in the United States, for the most part, it is not particularly more serious than a regular seasonal flu, but these things kind of evolve. They're really essentially unpredictable, and that's the reason why we're taking these precautions.

CONAN: Every year when we talk about the flu season, listeners always ask: What's the difference between how the flu is spread and how the common cold is spread? And we get an answer usually that is the common cold is spread by shaking hands, touching people with their hands, and the flu is spread by droplet infections in the air. Is that still true of the way this flu, this virus, would be spread around?

Dr. FAUCI: Yeah, most of the time it's by droplets, as you say, in the air when a person sneezes or coughs or what have you, but you've got to remember, Ira, that what people do when they sneeze and they cough, they put their hand over their face, and they have what is potentially and in reality often a virus in these droplets on their hand.

They may be not perceptible to them. They'll shake hands with someone, they'll embrace. They'll touch their mouth, touch their eyes, and that's how it can be spread. So when we say washing hands, that is a very low-tech way to prevent that kind of spread.

FLATOW: So then it is spread by not just droplets. It is spread by…

Dr. FAUCI: Well, yeah. The droplet gets on your hand, and then your hand goes on someone's nose or on your mouth or on them. I mean, that's the way it's spread. So I don't think we should get too over-technical about droplet versus not.

FLATOW: Okay, okay. Let's talk about face masks. Is there mythology about face masks protecting you?

Dr. FAUCI: Well, you know, it depends - really it depends, and let me explain what I mean by that. There are face masks that are used that if properly fitted will, in fact, protect from the kinds of exposures through respiratory secretions and droplets, as you mentioned.

There is certainly a place for face masks. I mean, a typical example that we're hearing about, if someone feel like they do have the flu, and they're on their way to going to a doctor to be seen where they'll be in contact with other people, that they should put a face mask on if they're coughing and sneezing in order to not infect other people.

FLATOW: If we had doses of that old swine flu left from the '70s, the '76 outbreak, would that still be usable and workable here?

Dr. FAUCI: Likely not. You know, what we're working on very, very vigorously right now is to determine what degree of cross-reactivity - some that is obvious through the typical test that we use, what's called neutralizing antibody test, or maybe even some subtle what we call cross-reactivity. And by cross-reactivity, Ira, we mean that if you're exposed to another virus, maybe years and years ago, that has some degree of similarity, you might have some residual, below-the-radar-type immunity that may not necessarily protect you against infection but could protect you against severity of disease.

These are the kind of things that are being very actively pursued now. The CDC has made available the complete sequence of these viruses and are making isolates available to researchers throughout the country who are going to be approaching these problems very aggressively, literally from now.

FLATOW: At what point do we start thinking about creating a swine flu vaccine?

Dr. FAUCI: Well, we're doing more than thinking about it. The process is already begun, and the process begins when the CDC, which has already done, gets the virus, isolates it, gets a reference strain and tries to grow it up as a seed virus, and a seed virus for the vaccine means you get it to the point where it can be grown and reproduced, usually in eggs, and then you give it over to various pharmaceutical companies to start making what we call pilot lots to be able to do the necessary testing and seeing is it safe, does it induce an immune response that you would predict would be protective, is it something that in fact needs to be boosted with an adjuvant or not? All of those kinds of things.

What is the proper dose is going to be very important because not infrequently, when you have a vaccine against a virus to which the human species has not been exposed to, if you want to get an optimal immune response, you may have to give more than one dose. We don't know that yet. Those are the things that are going to be examined during the clinical trial process. But the idea of growing up what we call seed viruses for vaccine development has already begun.

FLATOW: Before we go to the break, one more question, Dr. Fauci. Any idea why we've seen so many deaths in Mexico but hardly anywhere else?

Dr. FAUCI: You know, that's really unclear right now, Ira, and that's - the CDC and the Mexican health authorities and others are really trying to figure that out. Is there something special about how they're being treated, about other infections that they might have? It's still an open question about why there appears to be - one of the things that is of interest that it could be, and this is something that we're all focusing on, that what we're seeing are only the severe cases and a fraction of the deaths among those cases.

What we may not seeing, and we don't know this yet, is that there may be many, many, many more people who have been infected sub-clinically or do not have any major manifestations that would bring them to a hospital, and that's it's much, much more widespread. So the denominator, as we call it, of the number of people is so large that we're only seeing those who are very sick. That could be an explanation. We're not 100 percent sure.

FLATOW: All right. Stay with us, Dr. Fauci. Stay with us. We'll be right back after this short break, talking more about the flu. So stay with us. We'll be right back.

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FLATOW: You're listening to SCIENCE FRIDAY from NPR News. I'm Ira Flatow. We're talking this hour about the swine flu with my guest, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. That's part of NIH. Our number, 1-800-989-8255, if you'd like to call us. If you'd like to send us a tweet, you can send it @scifri, for Twittering us.

Let me ask you one more question before I bring on our next guest. We've heard comparisons, Dr. Fauci, to the 1918 flu. The AP is reporting today that U.S. health officials say the new swine flu virus lacks traits found in the deadly 1918 flu strain.

Dr. FAUCI: Right.

FLATOW: So that fear then - why is it that we see the flu coming back in a second wave much stronger in some of these cases?

Dr. FAUCI: Well, that historically, with the 1918 flu, is what we saw. It hit in the spring. It was a disease of, you know, not overwhelming significance. It kind of muted down over the summer and then came back with a vengeance in the fall. Whether something like this would happen here, it's completely unpredictable at all.

I think the point that you made is a good point vis-à-vis examining the sequence of this virus and looking for molecular signatures that would indicate similarity to viruses that had high virulence, namely could cause significant morbidity and mortality or that spread very rapidly. But you have to inject a word of caution there, Ira, because each virus, as it adapts to a new host, has a different complex interaction in - with regard to its ability to cause serious disease and to spread.

So although one could say there's some comfort in saying that it doesn't have various molecular signatures, I think that's, if anything, good news, but we've got to be careful because the virus, as it evolves and adapts some, can also pick up its own characteristics.

But right now, from what we're seeing, at least in this country, it does not look like it's acting any differently than a typical seasonal flu.

FLATOW: Let me bring on another guest. Dr. Michael Osterholm is director of the Center for Infectious Disease Research and Policy at University of Minnesota in Minneapolis. Welcome back to SCIENCE FRIDAY, Dr. Osterholm.

Dr. MICHAEL OSTERHOLM (University of Minnesota): Thank you, Ira. Good to talk to you.

Dr. OSTERHOLM: Thank you, Ira. Good to talk to you.

FLATOW: Thank you. In your opinion, are we going into a pandemic stage? We're at one level below that.

Dr. OSTERHOLM: Well, I think, as Dr. Fauci has already discussed, we really don't know where this is going to go. I mean, this could be a situation that could fizzle out in the next four to six weeks, and we don't see it again.

It could fizzle out in four to six weeks and come back, as Tony said, with a vengeance this summer, early fall, early winter, or we could be in the early stage of what could be a mild to moderate pandemic and one that surely the clinical illness could change over time if there are changes with the virus as it circulates through the world population.

So while the media and the public and all of our bosses want an answer as to what's going to happen, if you follow the science and stick with the facts, you're going to have to say we don't know what's going to happen.

FLATOW: People don't like to hear that.

Dr. OSTERHOLM: Well, you've got to tell the truth at this time because that's what's going to get us through these tough times, is when people can count on individuals like Dr. Fauci and Dr. Besser and those of us who are involved with this telling the truth, and that's what we're trying to do here.

FLATOW: Take us back. I remember 1976. I actually covered this story in Washington, and I remember President Ford publicly getting a swine flu shot to try to get everybody else to get it. What is different today compared to the '76 swine flu affair?

Dr. OSTERHOLM: Well, we've learned a great deal since then about both the science and the policy, dealing with influenza. First of all, there were decisions made in 1976 that several cases of influenza infection caused by a swine flu-like virus in these recruits, including one death, was basically a harbinger of things to come, that we in fact would have a pandemic wave of influenza coming either in the summer or that fall or winter.

So an initiative was brought forward in really what I'd call rapid order to not only decide to vaccinate the population or at least have the vaccine for it but to actually then carry out the vaccination, and from a policy standpoint and administrative structure today, we'd never do that.

I think as Dr. Fauci has laid out, there's intensive efforts being undertaken to procure a vaccine, but a decision to actually use that vaccine would actually be determined by what's happening with the virus at the time that we have it. So you know, we're a long ways from 1976, and I think that's good.

FLATOW: Dr. Fauci?

Dr. FAUCI: Yeah, I agree completely with what Dr. Osterholm said, and I think the public who's listening should appreciate the difference between ramping up and getting a vaccine that you might use versus pulling the trigger and using it, because a lot of things can happen between now and when one is ready to use it, if in fact it would be appropriate to use it.

One of the things that we keep our eye on is what happens, as Mike said, over the summer and what happens in the southern hemisphere during their flu season. Does this virus cause a great spread, a lot of morbidity and mortality? Those are the kind of things you keep your eye on when you make decisions about vaccination.

FLATOW: Well, have we kept our eye on this one? Why did we miss the signs coming from Mexico?

Dr. OSTERHOLM: You know, I've been asked that question a lot, Ira, over the last couple days. You know, as you well know, I've been doing field investigations on emerging infectious diseases for 30 years, and I have to tell you, I think this response has been nothing short of remarkable.

You know, the Mexicans have been completely transparent about a disease that began to emerge potentially in March, late March, early April, for which initially they did not have a cause, meaning that their lab tests were not showing this to be influenza, which they were correct in the sense that what they had for lab tests wouldn't.

You know, they reached out in complete transparency to the U.S. and Canada for help, and both countries responded quickly and completely. I think this has been a big success, but it points out that when you have these emerging infectious disease issues like this, where new diseases come forward, they do take time.

That's why some of us never did believe this concept of this Tamiflu blanket would in fact be usable to contain an emerging potential pandemic strain because this is just the reality of how you put it together.

So you know, you can look at the glass half-empty or half-full here. I think it's half-full, and I think that it's been a remarkable success in terms of actually early identifying the virus and the activity of getting a test out, and just look - think about a week ago today where we were.

I mean, we were just identifying for the first time these isolates coming out of Mexico in concurrence with the isolates here in the United States of this new virus, and look at what incredible activity has gone on. I mean, you heard Dr. Fauci talk about vaccine work already. This is remarkable in my mind.

FLATOW: I mean, with genetic sampling and genetic sequencing, you know, so much widespread today, could we not be routinely watching out for, you know, mutations occurring in viruses or flus that might suddenly show up in the population, be some sort of early warning system?

Dr. OSTERHOLM: You know, we do that right now. Our group here in Minnesota, which is actually actively involved in NIH work, where we are literally pulling out thousands of influenza isolates every year, out of wild birds, out of domestic birds, out of pigs, etcetera, and there would have been no way to pick this up and to say today this is a possibility, tomorrow it's going to cause a human disease problem.

So I mean, if you go look right now on the genetic tree of all the swine influenza isolates or isolates of virus from swine, many of those are from Minnesota in the work we've done here, and we've looked back ourselves and said there was no way that you could've said on, you know, this given month or this given season it's likely that this would emerge.

This is the mystery and the mystique of Mother Nature and infectious diseases and why we have to constantly be vigilant, because some of these you just can't anticipate.

CONAN: So you don't think - there have been accusations that your eye has been in the wrong spot. It's been focused on Asia looking for the avian flu, and you missed this one coming out of the South.

Dr. OSTERHOLM: Well, I can tell you right now we're doing extensive work in North America and Central America. You know, we're sampling birds, for example, and animals that are moving between the Americas all the time.

So - and this is federal supported work. This is work supported by Dr. Fauci's organization. So I don't think that really is a fair comment, and I think that part of that comes from people just don't know how much work has been ongoing. and you know, we really have kept our eye on the ball, and I think that in that sense I hope that there is a story told about how successful this was, not what a failure it was, because I think it's just the opposite.

FLATOW: You know, I've heard at least one story, I know firsthand from the person who told me this, that she called her doctor when she actually had been in Mexico and had come back from Mexico, and she called her doctor to get a checkup because - and when she told her doctor that she had been in Mexico and she wasn't feeling well, the doctor said, Don't you dare come into my office, go to some other place. And she called another doctor and he said the same thing. Finally had to shop around for a doctor that would allow her to come into the office. Isn't there something wrong with that?

Dr. FAUCI: Yeah, yeah, there is, Ira. There is, and that's the reason why we try so hard in public awareness about, as Mike said just a few minutes ago, what the facts are and what aren't facts.

I mean, for someone who has a reason to go to a doctor and does not have symptoms, just because they have been in Mexico is not a reason to essentially stigmatize them. I mean, that's just - that doesn't make any sense.

What you do want to do is if someone has been in the geographic location where there's a breakout of this particular disease in question that we're talking about now, and they have symptoms, then you have to take precautions to make sure that it isn't spread, and those are the kind of containments that you tend to block the broad, general spread. And the reason you do that is that when you're dealing with influenza, you want to try as best as possible not to give it the opportunity by going from person to person, which allows it to evolve in certain ways that you may not want to see.

FLATOW: Yeah. 1-800-989-8255. Chuck from San Francisco. Hi. Welcome to SCIENCE FRIDAY.

CHUCK (Caller): Hi. Thanks very much. A quick question that occurred to me while I was listening, not the question I call about - if it's maybe - we're only seeing the severe cases theory. Is there an unusually high number of deaths, given the total number of flu cases in Mexico, being that - I understand we can make estimates - Google makes estimates about the total number of flu cases, if there's not an unusually high number that would support the only-seeing-the-severe-cases theory.

But what I called about is if it's healthy people with robust immune systems that are the victims of this, for the most part, could - the theory I've heard is that this is because their immune systems mount an - kind of overreact to the infection.

Can these people be treated with immunosupression drugs? And I also understand that Mexico has - antibiotics are more easily available. Perhaps that could lead to a greater number of resistant strains of bacteria which could account for the higher number of fatalities because their - in cases of common infection with - a bacterial infection. So, that's a lot, but thanks for putting up with it.

Dr. FAUCI: That's a mouthful. But I'll jump in to answer one part of that, and then Mike Osterholm - who's had a particular interest in the issue of what the inflammatory response could mean. I'm not so sure that's really applicable at this point at all.

But whenever you see - and this is something that is not completely clear, but it's certainly a suggestion - whenever you see age discrepancies where you'll see younger people and not older people who are getting infected with a particular virus, you always have to keep heads up that what you're dealing with is some cross-reactivity to previous exposures to viruses that the older person may have had and has a degree of background immunity that might be protecting them, even though it's not measurable by the standard neutralizing antibody techniques.

And some of the younger people who may not have been around when there were viruses that have some antigenic cross-reactivity, which means that spurs an immune response that's not identical to what you would see with the actual infection, but it's something that might have caused reactivity. And that's something that is being very actively and vigorously pursued: Was there some exposure years and years ago to an influenza virus that, in fact, has lingering protection either against infection or against serious disease?

The possibility, we don't know for sure, but it's something we'll be exploring.

FLATOW: Talking about the flu virus this hour on SCIENCE FRIDAY from NPR News. Dr. Osterholm, do you want to follow up on that?

Dr. OSTERHOLM: Yeah. No, I think that Dr. Fauci, he was right on target. I would say one thing, that there's been a lot of speculation about just the seriousness or mildness of illness by country.

And I think, as Dr. Fauci has said, this is really premature to comment on that. The Mexican Department of Public Health and their laboratory testing group down there just announced today that as they're starting to do the backlog on the 2,900 samples they have, about 90 percent are turning up positive, so that, you know, the numbers in Mexico of milder and moderate illness is going to change quite a bit. When you look at even the reports in the United States of the cases that we've had here, as of Thursday - yesterday of this week, over 80 percent of those cases were in individuals 18 years of age or younger.

So if there is this age-specific related response in terms of either protection or some other factor. Just by adjusting our numbers and getting a more complete picture of the number of infections, you could turn out the infections right - exactly identical in the two countries.

So I think it's really too early. Speculation is just speculation. When we get more information, we'll be able to really make more statements about that.

FLATOW: Dr. Fauci, as we get close to running out of time, looking forward - so you're saying that we should expect to see a swine flu vaccine in the future. Will that - will we also expect to see ample doses of Tamiflu or any antivirals that we would need to in case we need them?

Dr. FAUCI: Well, let's take the vaccine situation first. What you certainly will see is the steps taken towards developing a pilot lot that could be used to scale up at - you know, manufacture scale up in the sense of commercially having, you know, millions and millions and millions…

FLATOW: Right.

Dr. FAUCI: …of doses. The decision of whether we're going to do that will really depend on how this evolves and whether the virus changes and what actually goes on in the summer. So the steps towards the vaccine have already been started. There are multiple decision points along the way about how much you'll make, how much you'll need, et cetera. So that's the answer to the first question.

The other question is, as you know, and as you probably heard, that this particular virus appears to be sensitive to the two drugs, of the major drugs in our stockpile: Tamiflu and Relenza. The manufacturers are geared up to make more.

You probably heard that a certain amount of money was designated by the Department of Health and Human Services to backfill or replenish the Strategic National Stockpile of the doses of the drugs that have been dispensed out to the states. So there is active moment to clearly try and have enough for our needs in the future.

FLATOW: Mm-hmm. And Dr. Osterholm, you're going to be watching and waiting also?

Dr. OSTERHOLM: I think that's all we can do right now. And I know that that's not very comforting to some of our policymakers, but that's how you're going to make the right decision because you'll have the right information at the right time. And that's what we need to do.

FLATOW: Mm-hmm. And I guess the whole world would be watching and waiting together.

Dr. OSTERHOLM: And I think at the same time, as much as we're waiting -I do want to emphasize one thing that Dr. Fauci said. There is a lot of work going on right now. If this thing never materializes as a pandemic, that work will not be wasted because one day we will have a pandemic. There have been 10 of them in the last 300 years.

Pandemics, like earthquakes, hurricanes and tsunamis occur. We're going to have one. And what I'm fearful of is that if this doesn't turn into the next pandemic, people will say - people like Dr. Fauci and myself have unnecessarily alarmed people.

And I think that this has been a very prudent effort to tell the truth, to get the facts out there, what'll happen will happen, and one day we're going to be dealing with a pandemic either sooner or later.

FLATOW: Well, you know, considering that we have avian flu and people were watching for that and it hadn't occurred, and I don't think people were turned off on it after that one. I think people are quite happy that we are being vigilant about this and getting the word out, rather 0 you know, being more safer than sorry.

I want to thank you, gentlemen, from both - for taking time to be with us today.

Dr. OSTERHOLM: Good to be here, Ira.

FLATOW: You're welcome.

Dr. FAUCI: Thanks.

FLATOW: Michael Osterholm is director of the Center for Infectious Disease Research and Policy, University of Minnesota in Minneapolis. Dr. Anthony Fauci is director of the National Institutes of Allergy and Infectious Diseases, and also winner of the Presidential Medal of Freedom.

We're going to take a short break. And when we come back, we're going to talk more about the flu and talk about the ethics of what happens and, you know, the politics of what happens if we do have to put people -tell them not to go places. What happens there? How will that be handled? We'll be right back after the short break.

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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY from NPR News.

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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow.

This weekend, Mexican soccer stars will be playing to empty seats, except for the ones people are sitting in in their living rooms, watching the match on TV.

The government's afraid that swine flu would spread too easily at large sports events. Schools and offices are closing, museums are empty, restaurants all over Mexico City, more than 30,000 won't be seating anyone for the next week or so. They're offering only take-out delivery. Well, it's not the first time a government has closed things down during an outbreak, but it's not an easy decision-making process for any government, finding a way to balance individual liberties with the greater good.

Can it be done during a pandemic? Here to talk about the ethical issues and responsibilities like these my guest, Dr. Howard Markel. He's a physician and professor of pediatrics and communicable disease at University of Michigan. Here's also a director of the Center for the History of Medicine there in Ann Arbor.

He joins us from the studios of WUOM. Welcome to SCIENCE FRIDAY.

Dr. HOWARD MARKEL (Professor, University of Michigan; Director, Center for the History of Medicine): Well, thank you for having me, Ira.

FLATOW: Dr. Markel, let me ask you this question. Are they watching -are you watching what they're doing in Mexico, the government mandating things, Dr. Markel? Is this something that they should be doing at this point?

Dr. MARKEL: Well, as someone who has studied quarantine for too many years, I'm watching very closely. And it is interesting to see how they are taking these age-old measures - public gathering bans, school closures and quarantine and isolation - and dusting them off and applying them.

It also allows a really wonderful opportunity in real time to study the efficacy of these measures.

FLATOW: Mm-hmm. And what can we learn from past events?

Dr. MARKEL: Well, our group at the University of Michigan, working with the CDC, has looked quite extensively at what are now called non-pharmaceutical interventions. But a historian like me would call them quarantine and isolation, school closure and gathering bans. And we look, particularly, at 1918 pandemic, because there, we had the largest database you could ever hope to imagine on such measures that were used in the modern era. And we collected materials from all over the United States, National Archives, Library of Congress, 50,000 pages of documents and looking at more than 50 cities now to see what they did, when they did it and how it worked out.

And what really happened is that those cities, you know, the popular history is that, you know, the flu came in 1918 and it just destroyed cities and destroyed lives wherever it went. But what we found with this fine-grained analysis is that different cities had different experiences.

Some cities did not have nearly as many deaths or cases as others. And we wanted to find out why that was. We did look at a whole host of factors - gender, age, distribution, population density. But the only thing that came up as a really highly statistically significant change was when these cities use these NPIs, as they're called - non-pharmaceutical interventions. And those cities that used them early -which makes a great deal of sense when you're talking about a rapidly spreading disease - layered, meaning they used more than one, and for a sustained period of time.

Because don't forget, these measures don't prevent the flu, nor do they always contain an epidemic, but they might mitigate the number of cases, might lower the peak burden so everyone is not going to the hospital at the same time, and might stretch out the length of the episode, which in the modern era, our 21st century, is really critical when we think about the lead time we need to make effective vaccine, which is probably the real magic bullet we're hoping for.

FLATOW: Mm-hmm. Do you see that we might be heading in such a direction if the flu outbreak gets worse?

Dr. MARKEL: Well, I think, you know, historians, by nature, are hesitant to predict the future, and nowhere is that fraught with more problems than predicting influenza epidemics because they're so predictably unpredictable. And yet, the CDC, working with NIH and other members of the federal government and scholars across the country, have been talking about these issues and trying to think about how they could be implemented if they should be implemented, their efficacy and so on ,for several years.

So these are on the drawing boards. But as your previous guest said very well is that we're trying to take a measured approach. We're trying to get the best information and scale up our aggression against this epidemic or pandemic, depending on what we see.

FLATOW: One interesting thing from the 1918 pandemic - and you could see these pictures from 1918 - was the mandatory face mask laws in San Francisco.

Dr. MARKEL: Ah, yes.

FLATOW: Now, tell us about that.

Dr. MARKEL: Well, that was fascinating. There was a health commissioner named William Hassler, who was the - running San Francisco. He had a lot of lead time because the pandemic, at least the American experience, started mostly in the East Coast and then worked its way West. So he had a six-week lead time.

And my own hypothesis about this is that he probably put his eggs in the wrong NPI basket. He decided to enact the first mandatory face mask law in the United States, which was, by the way, quickly picked up by several other cities.

Now, face masks back then - we have to talk about that - were really about four or six layers of surgical gauze. So they're very different than face masks today. But that mandatory part about it really rankled San Franciscans. There were anti-face masks leagues. There were women's groups that were protesting that they didn't like the way they looked. There were manufacturers making chiffon face masks because they were more presentable.

But what was most comical about that event occurred on Armistice Day when on the front page of The San Francisco Chronicle, you see a photograph of the mayor, a man named James Rolph, being hoisted above the shoulders of several ironworkers with his mask dangling around his neck. And then there's a news report right next to it about Dr. Hassler, who was fined the night before going to a boxing match. He was fined $100 for not wearing his face mask.


(Soundbite of laughter)

FLATOW: That's an interesting anecdote you bring up there. What about people willing to quarantine themselves? Can you ask people to do that? Would they do that?

Dr. MARKEL: Well, that's an interesting question. That's…

FLATOW: We've almost asked people to do that today, haven't we, sort of? Stay - you know, stay from crowds a little bit or, you know?

Dr. MARKEL: Yes. We have. And we have some experience with it. You know, years ago, a hundred years ago, when the quarantine officers came out, it wasn't a choice. They took you away. And there were islands and communities or places where they took you to. In our modern era, the post-civil rights era, we tend to hopefully value civil liberties and individual liberties. We want to maintain that fine tug of war between protecting the public and protecting the individual. But there have been a lot of voluntary quarantines. The most recent example was the Toronto Experience during SARS, where 10,000 or more people were voluntarily quarantined to their home.

Now, quarantine is very disruptive. It can be very lonely. There's psychological ramifications. There're stigmatization ramifications as well. So we've gotten better at working on issues of communicating with those people, at least during the SARS epidemic, making sure they don't feel so lonely and trying to tamp down those very negative, stigmatizing effects. But it's not a perfect tool.

FLATOW: But people would accept it if they really felt there was a threat, would they not? I'm trying to think back…

Dr. MARKEL: I think it would.

FLATOW: Yeah. You know, I'm thinking back to the white powder scare that we had in the Capitol. And then - and people were afraid to go out and they'd quarantined themselves, you know?

Dr. MARKEL: Sure. And, you know, one of the great things about, you know, we have so much more information today than we've had in years passed, is that there are a lot of people who are really up to date on what's going on. And, you know, there's this fine line between over-preparing and under-preparing, and what are you going to do? And I think people realize that.

A patient said to me the other day, you know, I was talking about this very issue and he said, you know what, doc? I'm not going to compliment you for under-preparing, so don't worry about it. And I think people realize that. And the bottom line is that that if you are sick, if you do have these symptoms that are similar to a flu or a cold, stay home.

FLATOW: Hmm. 1-800-989-8255 is our number. And, of course, all during these things - there's always an attempt. People are worried about scapegoating…

Dr. MARKEL: Yes. And…

FLATOW: …during possible pandemics.

Dr. MARKEL: Absolutely. And that's a topic that has fascinated me for some time. There's no shortage of those episodes in the broad history of medicine and epidemic disease.

For example, in 1892, when there was a worldwide cholera pandemic raging, there were cases of immigrants coming into New York Harbor, and Russian-Jewish immigrants were primarily blamed for that epidemic. Now only a few months earlier, by the way, literally, a boatload of Russian Jewish immigrants came into New York and imported a typhus fever epidemic into the Lower East Side. So there's that fine line between perception and reality. More recently, with the AIDS epidemic, we found scapegoating of gay men and intravenous drug users. And with SARS, we saw a quite a bit of scapegoating of Chinese people.

I do worry about scapegoating, and we're hearing reports in the news and on the Internet of very negative comments about Mexican people with this current crisis.

FLATOW: Mm-hmm. And yet…

Dr. MARKEL: But, you know, the real important thing is - it doesn't really help our public health efforts. Because when you scapegoat individuals or individual groups, they tend to go underground and stay away from public health authorities and doctors. And when you're talking about a contagious disease, that's precisely what you don't want to have happen.

FLATOW: And certainly, if you scapegoat a group and they certainly have nothing to do with the outbreak, you're not solving the issue, are you?

Dr. MARKEL: Absolutely. It's a relic, and we ought to put it in a medical museum.

FLATOW: 1-800-989-8255. Let's go to the phones. Meg in Cleveland. Hi, Meg.

MEG (Caller): Hi.

FLATOW: Hi, there.

MEG: I have a question for you.


MEG: I was in Mexico the very last week of March, and on my third day there, I woke up 1:30 in the morning with a fever of 102. I was in bed for a day and a half. I couldn't even get up to eat or anything. Like, they only had to bring me food to my room. I finally was able to get up and move around. But secondary to that influenza, I developed pneumonia. And I had the whole rigmarole: the swollen glands, the sore throat, coughing. And it turned into pneumonia, which I dealt with with antibiotics for quite a few weeks. And then I also got a raging sinus infection, which I am now being treated for. So I - you know, it's just a little too weird that I had all the exact symptoms, and this was in March, this was at the end of March.

FLATOW: Yeah. Go ahead.

MEG: So, I guess…

FLATOW: (unintelligible), yeah.

MEG: …my question is, how important is it for me at this point to even, you know, report it? I don't think they would be able to do a blood test to see if I had that string of virus. But they could run a tighter test, I know, to see if that particular strain of what I was infected with.

FLATOW: So you wonder about the ethics of reporting this or not?

MEG: Well, that's the thing. Is it ethical - is it unethical for me and not call it in? That's what I'm wondering, you know? It's, you know, the test itself is not going to be cheap. So, I guess my question is…

FLATOW: Good question.

Dr. MARKEL: Yeah.

MEG: …how important is it for me to call this in?

FLATOW: Dr. Markel?

Dr. MARKEL: Well, I think I would call my local public health department and they could help you on the expense of that test. I think they'd like to find out. There probably could be a tighter that was positive if it were indeed the H1N1 flu…

MEG: Right. Right.

Dr. MARKEL: …or if it was some other type of an issue. But it is an important piece of information. I also want to add that the good news is that you're not at all likely to be contagious to others at this point. So that's the real ethical issue, is that if you are really still sick and transmitting the disease. But out of pure surveillance issues, I think it's a very important one. And I would urge you to call your public officer in your town or your county.

MEG: Okay. Thank you. You know, my big question is, you know…

Dr. MARKEL: And I hope you feel better, too.

(Soundbite of laughter)

MEG: …I was out right about there with it for how long and I was probably infecting people, you know?

Dr. MARKEL: You may have, but you may not have had the flu, either. So this is a good way to find that out and I hope you recuperate soon.

FLATOW: Good luck, Meg.

MEG: Okay. Thank you very much.

FLATOW: 1-800-989-8255 is our number. We're talking about the flu this hour on SCIENCE FRIDAY from NPR News.

Any last thoughts, Dr. Markel, you'd like to leave us with?

Dr. MARKEL: Well, these are remarkable tools. These are - it's a remarkable era that we're in. As the guest said earlier, I mean, there's really - it's so remarkable what we've been able to do and what we have learned in terms of surveillance and communications and science and the tracking of these diseases, and the genetic structure of these diseases and so on, and we keep getting better at it.

Now, it's a human agency, so it'll never be perfect. And hitting the sweat spot of epidemic control is about as hard as hitting a fastball in the Major Leagues. And that's why there's not too many 300 hitters in either baseball or public health departments. But they - there's a remarkable effort going on. I've been so impressed by the CDC and other health officers around the country and around the world. And they're doing a wonderful job and they're protecting our public health. They've been training for a long time for this.

So we, as Americans, have to have a conversation of what we're willing to do and what we're willing to pay for because, you know, we pay for police every day. We pay for firemen every day. But we don't have fires every day. But this is really important. We live in a world of emerging infectious diseases. We have never conquered infectious diseases. At best, we have wrestled them to a draw.

FLATOW: All right.

Dr. MARKEL: But we have to be watching every day.

FLATOW: Thank you very much for taking the time to be with us today, Dr. Markel. Howard Markel is…

Dr. MARKEL: Thank you. It's a pleasure.

FLATOW: You're welcome - is a physician and professor of pediatrics and communicable diseases at the University of Michigan.

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