May 04 2009

Swine Flu – Science, Pseudoscience, And Panic

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Comments: 43

In 1918 the Spanish Flu (named after the country of origin of the first identified case) swept the globe, killing 20-40 million people – more than the First World War (which killed 15 million) which was just ending. When an epidemic spreads to multiple regions, especially multiple countries or continents, it becomes a pandemic. Flu pandemics happen every 40 years or so, and we are due for one now.

This is probably partly why there has been so much news attention, even some mild hysteria, surrounding recent outbreaks of swine flu, beginning in Mexico. It is hard to say how many cases and how many deaths there have been so far, because information from Mexico is spotty. Specifically it id difficult to say if people who have died with flu-like symptoms really had the swine flu or something else. Estimates are that about 150 people have died in Mexico with the swine flu. It is clear that we are dealing with a new strain.

Some Background on Influenza

But first, a little background. The influenza or flu virus is an RNA virus that comes in three genera – A, B, and C. Influenza A is the most common type. It can infect mammals and birds, with aquatic birds being its natural endemic host. Each year there is a seasonal epidemic of Influenza A, infecting millions of people and killing 100-200,000 – mostly the very old, the very young, and the sick.

Influenza B is less common than A and infects only humans, seals and ferrets. Influenza B mutates slower than A, and so has less genetic diversity and is less virulent as a result. Influenza C infects humans, dogs, and pigs and is the least common type, but can be virulent when outbreaks occur.

All off the pandemics over the last century have been of Influenza A. Its primary weapon is its ability to rapidly mutate, avoiding the immune systems of its hosts. This is why each year new strains of Influenza A are causing that season’s epidemic.

The flu starts out like a common cold, but lasts longer and becomes more severe. It is characerized by high fevers, muscle aches, fatigue, headache, and severe cough.

Influenza A strains are designated by the two main proteins that determine their infectivity and virulencs -haemaglutanin and neuraminidase, H and N. There are 16 Hs but only H 1-3 infect humans, and there are 9 Ns but only 1 and 2 infect humans. Haemaglutanin is a protein that allows the virus to latch onto and infect host cells, while neuraminidase allows expelled viruses to reinfect other cells.

The swine flu virus is Influenza A H1N1. This strain came about probably by four different strains of Influenza A infecting the same host (probably a pig, hence the name swine flu). Viruses can exchange genetic material, so one strain can combine bits from other strains, creating a new strain. The curren swine flu likely combined bits from a human virus, a bird virus, and two swine viruses, although this is still being confirmed.

The flu is potentially a fatal illness, killing about 1% of those infected. Death results from one of three types of causes – the flu infection itself can cause a serious pneumonia (lung infection) that can impair breathing to the point of death. A serious infection can also leave someone open to a superinfection (another organism causing a second infection while the host’s immune system is occupied with the flu). And those who have a chronic underlying illness may succumb from the added physiological stress added by the flu.

Should We Worry

This week on the SGU we interviewed Mark Crislip, and infectious disease doctor, host of Quackcast, and contributor to Science-Based Medicine. We discussed in detail the latest swine flu outbreak, and what level of concern is currently appropriate. The bottom line is this – this is a new strain of flu virus which appears to be spreading. It has the capability of producing a world-wide pandemic, and if it does it could theoretically rise to the level of the 1918 pandemic which killed millions. Some of the reported deaths from Mexico were young healthy adults (which was also common in the 1918 pandemic), which can mean that the strain is virulent.

But it is too early to tell. This epidemic may also fizzle out quickly, ultimately affecting very few. In 1976 there was a swine flu epidemic with concerns that it would be the next big pandemic, but it just fizzled and amounted to nothing.

What determines whether this latest strain with be a bang or a bust is how infectious it is (how many people with catch the virus) and how virulent it is (how may infected people will die from the infection). We do not yet know how this current swine flu will behave – we don’t have enough data points yet. Probably we will not know until the pandemic is underway, or until after it has burnt itself out.

At this point in time there is no reason to panic or make major changes in your lifestyle. The World Health Organization (WHO) and the Centers for Disease Control (CDC) are watching closely and will make recommendations. As of May 3rd the CDC reports 226 laboratory confirmed cases of H1N1 flu and 1 death. At present the CDC recommends the following:

People who are sick are urged to stay home from work or school and to avoid contact with others, except to seek medical care. This action can avoid spreading illness further.

That’s it – they are not recommending that we limit international travel or that we start shutting down schools. Essentially, if you have a cold or flu-like illness, don’t tough it out and go to work – stay home and seek medical care if necessary.

The WHO has similar recommendations. They are not recommending limiting travel at this time. While not explicity recommending the use of masks in public, they also provide guidance as to how to properly use a mask. The same document also details general recommendations to avoid spreading the infection – wash your hands, keep a meter away from symptomatic individuals, stay home if you are sick.

That is where we are today. If the infection continues to spread and show signs that it is developing into a pandemic, the WHO and CDC will update their recommendations.There are some possible signs already that this outbreak will not be the next major pandemic. Mexico just announced that new cases of swine flu are already past their peak. Also, early numbers indicate that this strain is no more infectious or virulent than the usuall seasonal flu strains.

There are treatments for the swine flu. This strain will respond to certain anti-viral drugs, which may decrease the severity of the illness and decrease the mortality. There is currently no vaccine for this strain, and it will take several months to mass produce one. Depending on the timing of the outbreak this may or may not be in time – but if it is a serious outbreak it will likely last several months, so the vaccine will come out toward the end. The role of the vaccine, therefore, may be to shorten the pandemic, but not to avoid it.

The Swine Flu Hubbub

Meanwhile the media has treated the swine flu with near panic. And not just the media – governments and health organizations like the WHO and CDC are stuck between a rock and a hard place. If they overreact to the potential threat then they are accuses of being hysterical. The US government and CDC were soundly criticized for sounding the alarm bells in 1976 when that swine flu amounted to nothing. Yet, if they under-react we could be left unprepared for the next major pandemic. Mark Crislip argued, and I agree, it is better to be a little over-prepared than a little under-prepared.

Already the WHO is being criticized for overreacting to this swine flu. In response WHO officials warn that there could be a second wave of swine flu outbreaks in a month or two – which is what happened in 1918.

It seems silly to play this game – reacting to reactions and then defending with more warnings. Rather, the WHO, CDC, and world governments should plan prudently for a pandemic, and then hope to be wrong.

Another aspect of the hysteria is countries fighting with each other. Mexico is getting a little defensive that travel and exports from Mexico may be restricted – so maybe they are downplaying the number and severity of cases to avoid this. Other countries, even old allies, are bickering over recommendations for travel restriction. Concerns have already been raised that the UK might horde their flu vaccines, leaving the US high and dry.

It seems to me that the purpose of an organization like the WHO is to coordinate international information and efforts to avoid this very type of national bickering in times of a world-wide health crisis. What may be the most worrisome aspect of this outbreak is not the outbreak itself but the response to it. It makes me wonder if we are as ready as I thought we were for such an outbreak. Still I am optimistic – if and when the next big pandemic hits I think the WHO, CDC and similar organizations will rise to the task and do what is necessary. Behind the headlines, their recommendations and actions are all reasonable and prudent.

And, of course, with swine flu grabbing headlines the quacks and cranks have come out of the woodwork to exploit the situation to push their woo and pseudoscience. Offers for snake oil for the swine flu infected spam last week, accounting for 2% of all spam.

The Huffington Post, rapidly becomming the leader of health pseudoscience on the web, has had several recent posts recommending every sort of dubious health treatments and preventions for the swine flu. Orac at Respectful Insolence does a nice takedown of the swine flu woo over at the HuffPo.

And of course the conspiracy theorists have to have their say as well. They can see the Truth behind the hype that the swine flu was manufactured as part of the latest government dark cabal conspiracy to control the world.


At present there is no cause to panic over the swine flu. Yes – this could be a serious outbreak, but we just have to wait and see. So far the early signs are already indicating this will not be a major pandemic, and may already be on the way out. But we still have to watch closely to see which way it will go. The CDC and WHO will be the best sources of information in the coming weeks, while news headlines are likely to be misleading and sensational.

The best recommendations are to take simple and rational steps to avoid getting infected, or if symptomatic to spreading the infection to others.

But even if the swine flu of 2009 proves to be like the 1976 fizzle, eventually we will be hit with another pandemic. For every pandemic there are likely to be a dozen false alarms. The public should not be dismayed by these false alarms nor should they lose faith in the CDC and WHO when early warnings do not pan out. Their job is to keep their eye on early outbreaks, knowing most will not amount to a pandemic, but waiting for the one that will. We need to avoid a “boy who cried wolf” syndrome the press seems intent on manufacturing.

When there is rustling in the bushes it is appropriate to cry wolf, knowing most of the time it will just be a deer or something else. But if we wait until the wolf is at our throats, it will be too late to react.

43 responses so far

43 thoughts on “Swine Flu – Science, Pseudoscience, And Panic”

  1. Ryan F says:

    Regarding the linked KXAN “conspiracy theory” article:

    This is the second time (there was also a Yahoo article) I’ve seen the role of industrial agriculture listed alongside “Obama did it!” or “surgical-mask inventories!” as a wacky conspiracy theory. While the link between Granjas Carroll and this current outbreak is far from proven, it seems quite a bit more plausible than anything else on this list that this disease came out of a factory farm environment. The factory farm link has led to some interesting discussion, and it’s somewhat dishonest for news organizations to list it as a “conspiracy theory” alongside the more bizarre stuff.

  2. nigelthomas says:

    Let’s also not under estimate what lies in store either. 898 confirmed infections worldwide resulting in 25 deaths is a 2.5% mortality rate. The worst outbreak in history, the 1918 Spanish Influenza, had a mortality rate of just under 3%. This represents one death in every 40 infections.

    So this new influenza pandemic is pretty high up there, and it’s just started. It still has time to mutate to a more dangerous strain. It is evidently infectious (human to human), and perhaps the only reason we haven’t seen many deaths outside of Mexico is because the statistics haven’t allowed for it yet. When infections in other countries reach 40 they should have already seen their first deaths.

    The public should not panic, this is true, but they will anyway, and the numbers will drive it upwards. Educating yourself and others is all we can do to try to keep panic in check.

    Many of those interviewed after recovery say it was the worst sickness they have ever experienced. They can’t eat, get up to go to the toilet or clean themselves. Yes most will survive but it is not something you want to go through. Nobody is immune and if it continues to go global is highly unlikely for anyone to escape exposure.

    Lets look at the numbers again though. Half the population will be the lucky ones and will not suffer any symptoms at all. The rest will suffer varying degrees of sickness from mild to severe (perhaps 15%?) , with roughly 2 in a hundred dying.

    Whilst 2.5% is horrible, society will recover quickly. Businesses which have survived through it will have lost 2% of their staff over an 18 month period, probably less than their normal turnover.

    What they will have to face though is 18 months of the high absenteeism rates people have talked about. Up to 50% for 18 months with people off work looking after children (schools will all close up quickly), caring for those who are sick and on home quarantine.

    Yes lets not panic, but there is no doubt now, the pandemic has just begun and managers haven’t got much time to get their businesses prepared.

    Nigel Thomas.
    Bird Flu Manual Online.
    2009 H1N1 Flu preparedness for businesses.

  3. Nigel – but there is doubt about whether or not this will be a pandemic. This outbreak may peter out quickly, like the 76 swine flu. It still cannot be predicted – we just have to wait and see what happens.

    We should prepare for it like you would prepare for a severe winter storm that may never come, while checking the weather reports.

  4. Mexican says:

    Dr. Novella, you can’t imagine the amount of email I have received with conspiracy theories, even my mom sent me one, damn it!. One friend’s mom told me that it was a strange coincidence that this happened right after president Obama visited us. He infected us!

    I am tired (but will still do it) of replying every single email to all people that misinformation is very infectious… just like viruses.

  5. Michael Hutzler says:

    A subtle note: the Spanish flu was not named for the country with the first outbreak, but the first published outbreak. It may well have appeared first in other European countries which concealed the outbreak, and its impact on fighting ability, because of World War I.

    More importantly, we may not be “due” for another pandemic. This is not a gambler’s fallacy since there is some biological basis to diseases in the same family emerging periodically. The loss of circulating antibodies in survivors making them subject to mild infections and two generations of people, naive to the disease, being added to the population reduce herd immunity. What is not so clear is the impact of flu shots. The annual influenza vaccine contains three strains including an H1N1 strain. Its impact on herd immunity may change the periodicity of pandemics. We may or may not be due.

    I’ll go with a different analogy than wolves. One that spreads: fire. When you see a fire start, you shouldn’t panic and it is not the time to cast wild accusations of who might have started it. You try to put it out and plan what to do if you are losing the battle. We have the resources to attempt to contain it while methodically looking for the source and planning for the possibility of it growing beyond our control.

  6. HHC says:

    I received the swine flu vaccine in 1976. Is this a sufficient immunization for the current variety? I even received a weekend adjustment from my chiropractor. He is advertising his expertise at “flu adjustments”. Is this useless to fend off flu?

  7. DrEvil says:

    The only ‘adjustment’ that’s going to keep you from getting the flu is one that snaps your neck and kills you.

  8. Khym Chanur says:

    What’s different about this variant of H1N1 that makes it a candidate for a pandemic, while the seasonal flus aren’t? Is it that it’s more deadly than ordinary flus? Is it more infectious?


    One friend’s mom told me that it was a strange coincidence that this happened right after president Obama visited us.

    I don’t know the contents of the email you got, so this might not apply, but maybe it’s phrased so that it could imply that God is punishing Mexico for welcoming Obama, rather than that Obama was practicing medical warfare on Mexico? I know that the American kooks who note on the “coincidence” of Obama and the swine flu are implying that the flu is God’s divine punishment for the electorate voting for Obama.

  9. HHC says:

    DrEvil, Its highly unlikely that I would die from a neck adjustment. Its not like the chiropractor is preparing chicken in his office.~:-)

  10. CKava says:

    I think it’s also worth factoring in that health services, medical research and general global communications have, by and large, significantly improved since 1918.

  11. superdave says:

    HHC, I suggest you look through some prior posts on chiropractic medicine right here n this blog..

  12. Mexican says:

    @Khym Chanur:

    It was no email, I heard it directly from my friend. I have received emails that this is a conspiracy from Mexican government, another one that is from multiple governments with a biological warfare, another one is that Big Pharma did it. Man, What an imagination these guys have!

    So far, I haven’t received one involving god. I’m sure there are a couple of those out there.

    I was reading the conspiracy theories posted by Dr. Novella:

    Surgical-mask producers needed to get rid of inventory…

    Haha, I will share this with some buddies since I work in a medical device company and we manufacture, among other stuff, respiratory products.

  13. DarwynJackson says:

    People die all the time from adjustments. The vertebral arteries tear under the shearing forces, predisposing you to plaques and subsequent stroke.

  14. HHC says:

    DarwynJackson, I am still interested in my original questions pertaining to swine flu. The side issue of chiropractic adjustments would be best handled by citing to me a few legal malpractice cases rather than hearsay or conjecture.

  15. taustin says:

    The media driven hysteria isn’t exactly deliberate, but it is inevitable when the news industry has adopted a business model based on advertising that says, basically, “Watch our program or you will die.” It’s a sad comment on our society that it works, and works well.

    HHC: Here’s a link for you, including discussion of the hazards of chiropracty, including cases in which the patient has died from the practice: is a discussion of malpractice claims against chripractors, and indicates that the most common reason for malpractice claims are (in no particular order, as the frequency of each seesm to vary by carrier): failure to diagnose properly, failure to refer to a medical doctor, and causing damage to the spine, such as ruptured or herniated discs.

  16. eiskrystal says:

    -The side issue of chiropractic adjustments would be best handled by citing to me a few legal malpractice cases rather than hearsay or conjecture.-

    or by pointing out that moving your vertebrae about is not going to have much of an effect on a virus.

    I wouldn’t run around imagining yourself completely immune with the vaccine, although it may help. That kind of question is unfortunately very difficult to answer at this time.

  17. Chunks Is My Dog says:

    “Each year there is a seasonal epidemic of Influenza A, infecting millions of people and killing 100-200,000 – mostly the very old, the very young, and the sick.”

    Holy crap – that’s a lot of people!

  18. Jason Apple says:

    “Let’s also not under estimate what lies in store either. 898 confirmed infections worldwide resulting in 25 deaths is a 2.5% mortality rate. The worst outbreak in history, the 1918 Spanish Influenza, had a mortality rate of just under 3%. This represents one death in every 40 infections”

    nigel –

    But to put it into perspective, ALL the 25 deaths (or whatever it currently is) were in Mexico (the 1 attributed to the United States was a Mexican boy brought across the border, so Im giving that point to the away team). So if its more than twice as deadly as the 1918 flu, it should be killing people elsewhere as well, indiscriminately. Obviously theres a lot of other variables, especially relating to how healthy the individual is and access to good medical care, but I think it is not only reasonable to assume that there is something specific going on with Mexico, but thats actually what the experts are starting to say as well.

    So while the absolute mortality rate may be up there right now (i haven’t checked the total numbers recently), certainly the ‘Mexico’ factor seems to be an important and potentially mitigating variable to consider.

  19. kvsherry says:

    Dr. Novella,

    I’m just wondering if you have any theories as to why the death rate has been higher in Mexico than other more developed countries.

    Could it be that people in other countries (USA, Canada, UK etc) are more prone to seek medical attention earlier? How does medical care measure up in Mexico? (BTW, I’m not implying anything, this is a real question)


  20. tmac57 says:

    Anecdotally, I heard a news report of a family in Mexico seeking to admit their relative into a hospital for treatment for the flu, and they were turned away from 3 different facilities. By the time that they found a hospital that would admit the woman, she was very ill with pneumonia. I don’t know if this is a typical scenario or not, but maybe access to medical help is easier in the U.S.

  21. TsuDhoNimh says:

    Mexico has only been counting deaths among people sick enough to be hospitalized. They have not been out tracking down milder cases like the rest of the world.

    If a group is sick enough to be hospitalized, that group will have a higher death rate than those who were not that sick.

    It’s an apples and oranges kind of count right now.

  22. Michael Hutzler says:

    I’ll offer a variety of reason that Mexico may be harder hit.
    1) The source has not been identified. It may be that those that get it directly from the source (assuming a non-human source) are more prone to get serious disease than those who catch it from humans.
    2) Sanitation and nutrition may make for better immune responses in the US and Canada.
    3) As TsuDhoNimh mentioned, the US and Canada may be detecting a greater percentage of mild cases with no difference in disease (sampling bias).
    4) One factor I’m sure the epidemiologists will look at, when evaluating who tended to get the more serious disease, is how many people were vaccinated for influenza virus or two potential organisms responsible for pneumonia afterwards: Hemophilus influenza and pneumococcus.

  23. HHC says:

    Ok, I read all the link material provided on this post by everyone concerned about caution and chiropractors. Its good to be cautious and use health providers you trust to treat your condition. But in the real world, authors such as MARK CRISLIP on SCIENCE BASED MEDICINE would be held accountable for libel and/or slander if he directed his remarks to a specific chiropractor in his medical neighborhood, to paraphrase CRISLIP, a chiropractic neck manipulation can provide 38% of the force of a bad hanging. Of course he estimated a good passive hanging was 686 Newtons of force and a chiropractic manual application is 264 Newtons(145 milliseconds). :-#

  24. HHC – SBM is in the real world, so I am not sure what your point is. Mark used some colorful illustration, but in order to prove libel a chiropractor would have to demonstrate that he knowingly lied. Are you saying Mark’s figures are wrong?

    The point is – chiropractic neck manipulation involves using significant force – forces which are sufficient to risk vertebral dissection. Since there is no proven benefit to chiropractic neck manipulation that is risk without benefit. If it were a drug it would be pulled from the market by the FDA.

  25. daedalus2u says:

    MH, typically diseases caught directly from animals are less virulent in humans. It is after diseases have adapted themselves to humans that they become more dangerous and virulent.

    In the bioweapons programs when someone became infected they always preserved the specimens they cultured from the infected person because they were more effective than the parent strain.

  26. Michael Hutzler says:

    In many cases, the infections caught from animals (zoonoses) are severe, but only weakly transmissible. Selecting the strain that has already made the jump to humans, out of all the wild type strains, is selection based on demonstrated virulence.

    The virus may not be able to form a particulary virulent strain in the new host, since its cellular structures are not the form to which the virus has adapted. In most cases, human to human transmission does not occur. SARS is the one recent notable exception, and one case of probable H5N1 avian flu human-to-human transmission was recorded.

    One of the dangers with influenza is that it has a variety of genes, each on different chromosomes. Where two strains of influenza virus meet, one new to the species and the other adapted to the host, a new strain can form. It has the new surface markers to which the novel host has yet to develop immunity, and the old intracellular proteins which make virus particles effectively.

  27. HHC says:

    Dr. Novella, In the U.S. there are twenty-five states with SLAP laws. This would allow today a chiropractic organization or college to sue Science Based Medicine and its affiliates on the basis of attempting to harm their reputation and business by equating neck manipulation with a bad hanging. The image is meant to scare the public and harm business economically. For example there is SLAP in Iowa, the original home of the Palmer School for Chiropractic medicine. They would have grounds to sue based on the remarks of Mark Crislip.

  28. daedalus2u says:

    HHC, you do not understand what SLAP laws are about.

    The more typical acronym is SLAPP, strategic lawsuit against public participation.

    If a chiropractic organization filed a suit against SBM objecting to their use of the metaphor “chiropractic manipulation is like a bad hanging”, that would be a SLAPP lawsuit, a lawsuit designed to intimidate SBM into not criticizing chiropractic treatments and chiropractors.

    It is SBM who could then file an anti-SLAPP action to block the lawsuit by the chiropractors.

    It is my opinion that SBM would prevail, and that all chiropractic organizations know that, and so they will never attempt to intimidate SBM by trying to sue them. They know that would invoke the Streisand effect, which occurred after she lost an anti-SLAPP action.

    I think that the authors of SBM would love to be sued by a chiropractic organization. It would be the best publicity they could get, and would amplify their message at least 11 times.

  29. tmac57 says:

    HHC-“He is advertising his expertise at “flu adjustments”. Is this useless to fend off flu?”
    I originally took this as a joke.Was I wrong?
    Are you really a chiropratic proponent or are you just being provocative?

  30. HHC says:

    Thank you for informing me that I misspelled the acronym. If a Chiropractic lawsuit were filed with respect to libel/slanderous statements, the admissions by Dr. Novella on his own blog would be used. He admits that the authors are not writing fiction,” SBM is in the real world.” Dr. Novella admits that ” Mark used some colorful illiustration.” Mark Crislip’s own words of the bad hanging would be presented in the complaint. A Chiropractic lawsuit would document harm from the statements made on the blog.

  31. weing says:

    Great harm would be done. That would be like bank robbers suing the security company for stopping the bank robbery.

  32. HHC says:

    tmac57, I asked two questions. The first question could be rephrased to this question, is there a beneficial residual effect of having received the original swine flu vaccine in past years, or is there no beneficial residual effect at all? The second question was answered by a poster stating the flu is a virus not subject to
    manual manipulation of the human body.

  33. HHC says:

    weing, your remarks are not clear with respect to great harm. Who are the bank robbers? Who is the security company?

  34. HHC says:

    From a legal standpoint, the consumer is robbed of their health and wealth by malpractice from a physician or a chiropractor.

  35. daedalus2u says:

    HHC, if a statement is true, it is a 100% protective defense against libel or slander. No matter how damaging, there is no legal bar to speaking or publishing the truth.

    Chiropractic manipulation is like a bad hanging. It exerts forces on the neck that are somewhat less than necessary to cause the acute damage characteristic of a well-done hanging, but not small enough that there is never any adverse effects.

    I see that as a completely true statement. There are even calculations to back it up. Where is the libel or slander?

  36. weing says:

    If chiropractic neck manipulation has no benefit and a risk of vertebral artery dissection then all such practice can be considered malpractice. That’s my view. I am not a liar, I mean, lawyer.

  37. Harry P. says:


    In the UK where Libel is easier to sue for, Simon Singh is being sued by the British Chiropractic Association. From his facebook support page:

    The BCA are promoting Chiropractic as treatment for children with (potentially serious) ailments such as asthma and frequent ear infections. Simon Singh criticised this in a Guardian “comment” piece. In particular, he criticised the BCA for doing this without appropriate clinical evidence. He is now being sued for libel. The BCA want damages and an injunction against him saying such things in future.

    FYI, I support Simon Singh’s Free Speech and look down upon Chiropractors and Osteopaths who promote manipulative treatments without sufficient evidence to show efficacy and safety.


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