A peak you reach

Friends visiting New York City this summer keep asking if it's safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.

I like to think my friends are pretty sharp, discerning folks (after all, they're choosing my company) so I have to attribute these inappropriate questions to a wider problem.

For reference, here's the latest though probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.

This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I'm guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.

So why were ED's swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:

...with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.

The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.

...The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.

All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process...

Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They've decided it's just not in their interest.

I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.

There are many factors driving the public appetite for health risk information -- and that's understandable. I think it's even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.

But what happened in NYC this spring was media malpractice -- night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasional, a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority -- by the next day the lead story was ED's are overcrowded and schools are closing.

EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.

But I'm more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.

It wasn't enough to help ED's this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It's really the first good viral news I've heard in a while.