FALSE ALARM: THE EPIDEMIC OF FEAR

Marc K. Siegel MD Associate Professor of Medicine NYU School of Medicine 1

THE SUPERBUG HAS NO SUPER POWERS

1 - The superbug, Methicillin Resistant Staph Aureus is nothing new. 2 - The Centers for Disease Control published a report documenting 94,000 cases of serious MRSA infection with 19,000 deaths in 2005, but this bacteria has been common in hospitals – where 85% of infections occur 3 – A colonizer not a killer. 2

BUG DU JOURS People are paying more attention to their bumps and boils than ever before. A neighbor was afraid to shake my hand because she knew I worked in a hospital, where the superbug was supposedly rampant. It sounds like Science Fiction. The media spins a story until it feels as if a biblicaltype scourge is rifling through every community.

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Media-fueled Overreaction Search for the superbug is underway from state to state. Fear-driven responses are never the best way to eradicate disease. The more obsessed with a potential threat a person becomes, the less likely he or she is to respond effectively.

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Fear is the Infection My patient with an infection around his eye was told by his opthamologist that it could be MRSA. He was so worried he couldn’t stop rubbing it, and spreading it on his hands. It turned out all he had was an allergy to the antibiotic eye drops that the eye doctor unnecessarily prescribed, because he too was consumed by the hype. 5

MRSA- What to Do? 1- Improve infectious disease precautions at hospitals. Hand washing, sterility of equipment, cleaner rooms and beds. 2 - Overcome the false notions that MRSA is community-based, new and mysterious. 3 - Need newer antibiotics (More profit and less blame for unexpected side effects) Overuse of current antibiotics helps breed resistant strains.

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SUPERBUG CURE

A bacteria like MRSA can be better contained by learning to keep its health risks in perspective rather than by reacting emotionally to overhyped news accounts.

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BUG DU JOUR TRAITS 1 – New and Mysterious 2 – Invisible to the Naked Eye 3 – Potential Tool of Terrorism 4 – Worst Case Scenario 5–A+B=D

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Catalysts of Bugs Du Jour 1 – Public Health Sound Bites 2 – Government Alerts 3 – News Media hype - obsession. 4 – Big Business - Fear Products

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21st Century Bugs Du Jour 1 – 2001- Anthrax – post- 9-11 vulnerability 2 – 2002- Smallpox – Russian rogue terrorists 3 – 2003 - SARS – CDC-WHO travel advisories 4 – 2004 - Flu – shortage of shots cured by Saddam capture 5 – 2005 - Mad Cow Disease – learning from British experience 6 – 2006 - Bird Flu – specter of 1918 – or1976? 7 – 2007 – Superbug sweeps the country 10

Climate for New Diseases FACTOR*ECOLOGICAL CHANGES (including those due to economic development and land use)

EXAMPLES OF SPECIFIC FACTORS: Agriculture; dams, changes in water ecosystems; deforestation/reforestation; flood/drought; famine; climate change

EXAMPLES: Rift Valley fever (dams, irrigation); Argentine hemorrhagic fever (agriculture); Hantaan (Korean hemorrhagic fever) (agriculture); Hantavirus pulmonary syndrome, southwestern US, 1993 (weather anomalies)

HUMAN DEMOGRAPHICS, BEHAVIOR

Societal events: Population migration (movement from rural areas to cities); war or civil conflict; economic impoverishment; urban decay; factors in human behavior such as commercial sex trade, intravenous drug use; outdoor recreation; use of child-care facilities and other high density settings

Spread of HIV and other sexually transmitted diseases; spread of dengue (urbanization)

INTERNATIONAL TRAVEL AND COMMERCE

Worldwide movement of goods and people; air travel

Dissemination of HIV; dissemination of mosquito vectors such as Aedes albopictus (Asian tiger mosquito); ratborne hantaviruses; introduction of cholera into South America, dissemination of O139 (non-O1) cholera bacteria (via ships)

TECHNOLOGY AND INDUSTRY

Food production and processing: Globalization of food supplies; changes in food processing and packaging. Health care: New medical devices; organ or tissue transplantation; drugs causing immunosuppression; widespread use of antibiotics

Food production processes: Hemolytic uremic syndrome (certain E. coli strains, from cattle, contaminating meat and other food products); Bovine spongiform encephalopathy; Nipah (pigs); avian influenza; SARS (probably)Health care and medical technology: Contaminated injection equipment (Ebola, HIV); opportunistic infections in immunosuppressed patients; Creutzfeldt-Jakob disease from contaminated batches of human growth hormone

MICROBIAL ADAPTATION AND CHANGE

Microbial evolution, response to selection in environment

"Antigenic drift" in influenza virus; possibly genetic changes in SARS coronavirus in humans; development of antimicrobial resistance (HIV, antibiotic resistance in numerous bacterial species, multi-drug resistant tuberculosis, chloroquine resistant malaria)

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WHAT WE FEAR AND WHAT WE DIE FROM Disease Smallpox Chemical Weapons SARS Mad Cow Disease Bird Flu Anthrax Terrorism West Nile Virus FLU Coronary Heart Disease Cancer Traffic Accidents Infant mortality

Deaths in the U.S. 0 0 0 0 0 5 in 2001 2,978 in 2001 200-300 yearly 36,000 yearly 700,000 yearly 500,000 yearly 100,000 yearly 25,000 yearly

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PUBLIC PERCEPTION- RISK Smallpox – December, 2002 – NEJM survey shows 65% of public choose immediate vaccination for all Avian Flu – April, 2006 – AP/IPSOS Public Affairs Survey – 35% believe they are family member will get H5N1. 53% believe it would be fatal.

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THE NEXT PANDEMIC? • DOOMSAYERS – Osterholm, Garrett, Webster • NAYSAYERS – Palese, Butcher, Orent/Ewald, Siegel • SCIENTISTS – Taubenberger, Fauci

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HHS: Map of H5N1 Cases

The Spread of H5N1 Influenza Virus and Time Line Showing Its Emergence

Webster R and Govorkova E. N Engl J Med 2006;355:2174-2177

A BIRD’S EYE VIEW • David Swayne – Director Southeast Poultry Research Lab – “New Strategies need to be developed…to protect birds from infection.” • Elizabeth Krushinskie – President, Society of Avian Pathologists – “There is no selective pressure to drive it (H5N1) towards humans. It could just as easily move away.”

What is a pandemic?

FLU Pandemics Vary • A major human influenza A pandemic—which could start as a mutated bird or pig virus— seems to occur, on average, three to four times each century. But no one can be certain when that pandemic will happen – or which virus will be involved. • Fortunately, the last three pandemics in the U.S. have been getting progressively milder. From over 500,000 dead in 1918 to 50100,000 in 1957 to 25-50,000 in 1968. Both these pandemics involved hybrid viruses.

CULTURAL DIFFERENCES Sabah Arar / AFP - Getty Images file You can't catch the bird flu by kissing someone. But you might from kissing an infected bird. Here, an Iraqi feeds his pigeon from his mouth in Baghdad, where birds have tested positive for the H5N1 strain.

Historical Differences • 1 – 1918 – no antibiotics or other lifesaving medications. No vaccines or ant-virals. Government suppressed information. • 2 – 1976 – prevailing pig “vessel mixing” theory. • 3 – 2006 – larger population, air travel, immunocompromised, public health, communications networks

How to Prepare? • Do I need stockpiles or emergency supplies? • Do I need a plan? • Is the government prepared?

SHORT TERM PREPAREDNESS • Stock a supply of water and nonperishable food, which can be useful in other types of emergencies.— Cover your mouth and nose with a tissue or upper sleeve when you cough or sneeze.— Stay at home if you are sick.— Plan home learning activities and exercises. Have materials such as books on hand.— Prepare backup plans for taking care of loved ones who are far away.— Consider working at home.— Ask your employer how business will continue during a pandemic.— Check with your employer or union about leave policies.— Create a family emergency health plan that includes information such as blood types of family members, past and current medical conditions, medications and important phone numbers.

LONG TERM PREPAREDNESS • 1 – Food, Energy, Medication independence. • 2 – Improve infrastructure – hospital surge capacity, emergency response system. • 3 – Anticipate and assimilate fear component. • 4 – Vaccine upgrades – reverse genetics, cell culture, adenovirus vector. • 5 – Computer models? Quarantine?

A New Language of Risk • Fear is a warning system. • Emotions increase perceived risk. • Fear of the unknown and new diseases. • Avoiding zero sum arguments. • Preparing for the worst case versus long term preparation.

SCARE TERMS

• Weapons of Mass Destruction • Global Pandemic • Superbug • Terrorism • Cancer 26

SCARE TACTICS • 1 – POLITICS OF FEAR - VOTE FOR YOUR PROTECTOR • 2 – PROFITS OF FEAR - PROPS • 3- IMPAIRED RISK ASSESSMENT = VOYEURS • 4 – DANGER EQUALS TV RATINGS

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FIGHT OR FLIGHT • 1 – What is Fear? • 2 – Fear of Death/ Fear of Loss of Control • 2 – The workings of the amygdala • 3 – Animal Fear & Human Risk Assessment • 4 – Stress Hormones • 5 – The Epidemic of Fear 28

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ELEPHANTS SMELL TO FEAR 29

NUTS AND BOLTS • JOE LEDOUX – NEUROSCIENTIST • ELIZABETH PHELPS – FEAR IN HUMANS • PAUL EKMAN PhD – How to Recognize Fear • Rebecca’s Bath • Joshua’s Dog

HUMAN RISK ASSESSMENT • Information bombardment – Info bytes, techno-bytes, sound bytes. • Misdirection • Misinformaton • No more Go-To People or Guides • Barry Glassner – Culture of Fear

DEBATE ON RISK • Consumer advocates versus experts • Cass Sunstein – fear intuition • Ropeik and Gray – fear meters • Gavin De Becker – personal safety • Bruce Schneier – security expert

PERSONAL TERRORISTS • CANCER • FEAR OF BEING HOSPITALIZED • FEAR OF MILESTONES • FEAR OF DYING • PATIENT NELLY • PATIENT TRIBUNE

CULTURE OF FEAR • Post 9-11 vulnerability • The Role of Government • The Role of Media • The Role of Private Interests • THE LANGUAGE OF FEAR

BREAKING THE CYCLE OF WORRY • TAKING CONTROL OF YOUR LIFE • DISCIPLINE AND ROUTINES • REGULAR SLEEP AND DIET • EXERCISE ROUTINE • GABA RECEPTORS AND BENZOS • SSRI MEDICATIONS • BETA BLOCKERS AND STRESS

FILTERS FOR FEAR • WHO TO TRUST? • WHO TO TURN TO? • CABLE NEWS AND THE INTERNET? • MY PATIENT’S FEAR BRED OF NEWSPAPER REPORTS • HURRICANES AND OTHER NATURAL DISASTERS –THE BOY WHO CRIED WOLF

Real Risks Versus Hyped Dangers • Automobiles • Obesity • AIDS • Malaria • Hepatitis • Infant mortality • DEPRESSION AND ANXIETY

THE MIND PLAYS TRICKS ON US • IS THE TERRORIST THREAT REAL? • IS IT PERVASIVE? • A SENSE OF PERSONAL RISK OUT OF PROPORTION TO THE REAL RISK • FALSE ALARM - AFTERWORD

BE AFRAID. BE VERY AFRAID

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MENTAL HEALTH • HOW TO TREAT FEAR AND BREAK THE CYCLE OF WORRY • WHAT IS THE DIFFERENCE BETWEEN FEAR AND ANXIETY? • HOW DO THEY INTERFERE WITH BUSINESS CONTINUITY? • HOW TO DEAL WITH FEAR AND THE STOCK MARKET?

WHAT TO TELL OUR CHILDREN? • FEAR IS CONTAGIOUS TO CHILDREN • IF WE ARE AFRAID OUR CHILDREN WILL BE AFRAID • THEY KNOW MORE ABOUT THE CURRENT NEWS SCARE THAN WE THINK THEY DO • WE ARE ROLE MODELS • TEACH PERSPECTIVE