Who's Afraid of the Flu?

Comment: I thought this was a good explanation of the range of reactions to the threat from pandemic flu. The flu is so unpredictable and how it impacts one location harder than another makes it even more difficult for us to process. Reading the article I realize that I keep trying to fit the flu into the "box" labeled weather. The way I've come to see the flu is that it's like we (people on dialysis) are at sea level (increased risk) and a hurricane (novel flu virus) is coming.

Weather is unpredictable - hurricanes can strengthen or weaken. Your town can make it through easily while the town right next door is devastated. The flu is unpredictable in the same way.

Find this article at: http://www.time.com/time/health/article/0,8599,1924228,00.html

Wednesday, Sep. 16, 2009
Who's Afraid of the Flu?
By Amanda Ripley

The brain loathes uncertainty. In laboratory experiments, humans actually fear uncertainty more than physical pain. We are simply wired this way. When we encounter uncertainty, the first thing we do is try to beat it back. The problem is, uncertainty may not be the biggest threat. It may be a distraction — the kind we have to cope with while we do the actual work of keeping ourselves alive.

Hayden Henshaw, 18, got sick on a Tuesday in late April. He was at his high school in Cibolo, Texas, just outside San Antonio, when he came down with a fever of 103°F (39°C) and felt nauseated. Three days later, his doctor confirmed he had a mysterious new strain of swine flu that had just hit the U.S. — a virus that would eventually be labeled H1N1 of 2009. (See pictures of thermal scanners hunting for swine flu.)

As word spread that three students at Hayden's school had the new flu, people in his town began trying to stamp out the uncertainty. It was an unsatisfying endeavor. Health officials came to Hayden's house and asked him dozens of questions. Had he been to Mexico lately? (No.) Had he had contact with any pigs? (No.) That weekend, Texas health officials closed all 14 schools in Hayden's district, sending 11,000 children home. Workers wiped down the school district's 100-plus buses. At Cibolo city hall, employees posted signs asking residents to pay their utility bills at a drop box instead of coming inside. Garbage collectors donned face masks. At the time, no one knew how deadly the virus was — or how many people had it.

Hayden and his family handled this storm of ambiguity with relative grace. Hayden complained only about being stuck inside. "After a while, TV got boring, and then games got boring, and then there was nothing to do," he says. His parents were worried but also grateful that health officials were taking the matter seriously. "Nobody knew how bad anything was going to get," his father Patrick remembers, "but at least we were together."

Other people, however, seemed to want more drama out of the story. Early on, the family agreed to do a local TV-news interview — to show that they were "just a normal family with a virus," as Patrick puts it. Then the national shows started calling. "What was it like when you found out you had swine flu?" a CNN anchor asked Hayden. He replied, in a teenager's deadpan, "I mean, it's just the flu. I just went through it normally." Producers asked the family to wear face masks on camera, even though health officials had told them that wasn't necessary. Meanwhile, regular people, some of them friends, started acting strangely toward the Henshaws. Their immediate neighbors and their friends from church were generous and helpful. But other neighbors crossed the street before walking in front of the Henshaw house. When Hayden's prom got postponed, disappointed classmates accused his family of exploiting the situation, making money off TV interviews. "Hayden was beaten up pretty bad on the Internet," his dad says. "He asked me, 'What did I do wrong?'" (See the top 5 swine flu don'ts.)

To make sense of the situation, some people needed a villain. Bloggers accused pharmaceutical companies of intentionally concocting the virus in order to sell vaccines. On one website, conspiracy theorists researched public records about the Henshaws and deduced that they were actually victims of radiation poisoning — possibly from a dirty bomb smuggled in through Mexico. As things turned out, Hayden's school reopened about a week later. To make up for the lost time, school officials canceled final exams. With that, Hayden's classmates found it in their hearts to forgive him. The summer brought a new consensus about H1N1 flu to Cibolo. "Now people say, 'Ah, it's no big deal. They blew everything out of proportion,'" says Patrick, who's still a bit mystified by the whiplash of reactions — from paranoia to complacency in a fortnight.

It would all be a surreal memory for Cibolo and the rest of America, if only it were over. Instead, Hayden's case is a flare in the darkness, a warning that as the nation begins its second big battle with a strange flu virus, we are up against a threat that we are not particularly skilled at overcoming, one that provokes an extreme range of emotions — from fear to indifference — none of which are all that helpful. The battle ahead is psychological as much as it is medical. And although we have heard a great deal about the importance of washing our hands, the real challenge may be in how to live with what we don't know.

Today, Americans are being told to brace themselves for explosions of flu, shuttered schools, mass vaccinations and tens of thousands of deaths — or perhaps not. Are the media to blame for the confusion? Absolutely. But no more than usual. What about the government? So far, officials have done a relatively decent job of explaining what they know and what they don't and planning for the worst. "It's going to be a unique flu season. The only thing certain is uncertainty," says Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC). "Even with the best efforts, influenza will cause severe illness and, tragically, some death."

Pandemic diseases have a way of revealing our vulnerabilities in quick order. Already we have been humbled by the virus's exploitation of our fragmented health-care system, as families without insurance overwhelm emergency rooms, schools flounder without nurses, and people without a sick-leave option choose between going to work with a raging fever or getting fired. At the University of Washington, some 2,000 students have reported having H1N1 symptoms. At Emory University in Atlanta, sick kids are relocated to a dorm dubbed Club Swine. But H1N1 has also homed in on the weaknesses in our heads — hovering in the blind spots where our risk analyses break down, just beyond the view of our mind's eye. What is the defense for the mind games of a virus?
See pictures of the swine flu outbreak in Mexico.

A Pre-Emptive Strike

Medically speaking, we are far better prepared than we used to be. In 1918, when many of our grandparents were children, another pandemic influenza killed more than 50 million people. Like the current one, the 1918 virus was a type of flu called H1N1. And like this one, it targeted the young: most of those who died were under age 40. Historical accounts suggest that it also began as a milder springtime flu before returning in the fall as a killing machine more efficient than World War I. In six months, that pandemic killed more people than AIDS has killed in 28 years. (See how the swine flu virus works.) This time around, we have superior armaments. We have global surveillance to track the evolution of the virus, antiviral drugs to help reduce the suffering, antibiotics to treat dangerous secondary infections like pneumonia, and real-time communications to spread the word. Soon we will almost certainly have a vaccine as well. We're living through an unprecedented opportunity for civilization — a chance to pre-empt a catastrophic pandemic influenza rather than just react to it.

But the technology brings a new conundrum: in order to exploit these tools, we have to act before someone we know goes to the hospital with H1N1. "Decisions have to be made in the absence of true, hard scientific information," says Dr. Paul Jarris, head of the Association of State and Territorial Health Officials. "We just have to be comfortable with that." (See how to track the swine flu outbreak on your iPhone.)>

Here's what we know: in the coming days, as the weather cools and children warehouse germs in school, many more Americans than normal may become sick with the flu. Everyone will probably know someone who is sick. (Most will never know for sure if they had H1N1, but if they had a fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue, that will be a safe assumption.) People under age 25 are more likely to get sick. Most who get it will be quite ill for about a week and then recover, assuming the virus doesn't mutate. Most cases will not require treatment.

Here comes the first asterisk: nearly half the country — pregnant women, children and everyone with asthma, diabetes, heart disease or kidney disease — will face a higher risk of getting seriously sick.

Second asterisk: the virus could become far more deadly at any time.

The asterisks help explain why, in October, the government will ask more of the public. The CDC, along with state and local health officials, will launch the most ambitious mass-vaccination campaign in U.S. history. This will be a new vaccine since the regular vaccine for seasonal flu will offer no protection against H1N1. But because it is being produced exactly like the seasonal-flu vaccine that manufacturers make every year, it is relatively predictable. It will have been studied in clinical trials, which are going on now, and so far, it appears that the risks of serious side effects are extremely low. That said, given rising skepticism about vaccines worldwide and a particularly dysfunctional health-care-distribution system in the U.S., the campaign will be hugely challenging. Whether it works will depend partly on science and partly on our ability to navigate the shadowy negotiations going on inside our heads.

How We Manage Risk

Over the past 50 years, researchers who study human judgment have realized that we rely on emotions to make decisions about risk. We can't possibly mull over every new piece of data our brains collect, so our emotions give us shortcuts, helping us make split-second judgments about that information. The more uncertainty, the more shortcuts we use. This is a good thing. People who have suffered brain damage that removes emotions from their calculations cannot function. They can't make decisions, even simple ones. So we need our emotions to make sense of the world. But our emotions also can lead us astray — particularly when we encounter an exception to a lifetime's worth of rules.

The brain's shortcuts come with certain predictable biases. In experiments, people reliably overestimate the chances of something happening if they can vividly imagine it. If we see something new, we try to fit it into a box that we understand — for example, a box labeled "Mild: The Same as Regular Influenza." Or maybe, more cinematically, "Plague Invading the Heartland," or perhaps another one called "Media Hype." All those boxes contain parts of the story. None is quite right. (See pictures of soccer in the time of swine flu.)

But how you sort and compartmentalize all the information about swine flu will probably determine whether you take it seriously, ignore it or begin freebasing hand sanitizer to get through the day. As with all viruses, influenza's only function is to replicate itself. It makes you sneeze so it can infect a new host and reproduce. When it encounters resistance, it changes. For the brain, this is maddening: How do we capture a threat that routinely escapes from one box and reappears in another?

To further confuse matters, influenza is inconsistent. It may lay siege to one town and leave the next untouched. That too perplexes the brain. We wonder why one school system shuts down and another stays open. We can't identify a pattern that makes sense.

So far, this strain of H1N1 has proved blessedly mild. So far, at least, many people get it; not many die. But mild is a tricky word. "Mild, when you're talking about flu, can still be dangerous," says Michael Shaw, a microbiologist at the CDC who has been working with influenza for 30 years. "It may be mild in the majority of cases, but the more cases you have, the more chances you have of infecting someone for whom it will not be mild. There are lots of kids with asthma."

The vaccine will pose a special dilemma for everyone measuring the risks this fall. We already know there will not be enough vaccine for everyone right away. So the priority will be to vaccinate high-risk people, such as those with chronic conditions like diabetes. But high-risk people tend not to think of themselves that way. "They feel fine. They go to work and take care of their kids. They don't define themselves day to day as someone with asthma," says Dr. Anne Schuchat, director of the CDC's National Center for Immunization and Respiratory Diseases. (Read how pork is getting a swine flu bailout.)/p>

Psychologists call this the Lake Wobegon effect — after the fictitious Minnesota town invented by Garrison Keillor, who described it as a place "where all the women are strong, all the men are good-looking and all the children are above average." We all tend to be overconfident about ourselves in surprising ways. About 90% of drivers think they are safer than the average driver. Most people also think they are less likely than others to get divorced, have heart disease or get fired. Likewise, according to a late-August poll by CNN/Opinion Research Corp., more than 60% of Americans surveyed said they were not worried about themselves or anyone else in their family getting swine flu.

In June the CDC organized 15 focus groups in three cities to discuss the public's impressions of the new flu so far. The participants had all heard of the virus, but they had a lot of questions. In an Atlanta group, the organizers had people read a news story about a real-life, healthy teenage girl from Milwaukee who had caught H1N1 in the spring and died. The group reacted with intense discomfort and then did what humans do: they looked for a way to fit it into one of the boxes in their mind. Some speculated that the girl's doctor must have made a mistake and that's why she died. Another woman wondered if perhaps the girl had been doing whippits — inhaling nitrous oxide — and that had contributed to her death. If we tell ourselves that we can prevent catastrophe by avoiding whippits, then we have reduced the uncertainty. But we haven't reduced the risk.

Read "The Swine Flu Wars: H1N1 Comes to Alabama" Will We Tune Out?

So what is the most sensible way for us to calibrate the risks posed by H1N1? This summer, public-health authorities have worried almost as much about people's risk-benefit equation as they have about the virus. Dr. Karen Remley, health commissioner for Virginia, has noticed that most people seem to fall into one of two categories when it comes to H1N1. "There's a group of people who think it's all gone and over," she says. "There's a group who say, 'Armageddon is going to happen!' The trick is getting people to the middle." Research into human decision-making has shown that if people feel as though they can influence their destiny, they tend to make smarter choices. But if authorities warn them not to panic (as President Obama has done), people may make worse decisions. They feel more frightened — not less — and wonder what they don't know that might make them panic. "Never tell people not to worry. That's really, really bad," Dr. Richard Besser, former acting director of the CDC, said at a recent government flu conference. "You can tell immediately in the body language, if you've ever said that to someone. When they do this" — he leaned back in his chair, crossing his arms over his chest — "then you lost 'em." (See five things you need to know about the outbreak.)

If the nation's most informed public-health experts do not share their best guesses, people will find worse information somewhere else. "People cannot make rational decisions without knowledge," says Dr. Sandro Galea, director of the Center for Global Health at the University of Michigan. "And knowledge has to flow centrally. Absent that, you will have a flow of mythologies."

Health agencies have bombarded the public with guidance on how to prepare for the virus. But people who study risk have advice of a different sort. They recommend seeking out information and not relying on emotion alone. Often, the best information can be found by checking with multiple sources — the kind that don't always agree. Come up with a plan for how you might stay home with your children for a week, if need be. Give your brain something to do. Be careful about relying too much on TV news, a highly emotional medium. The brain can stagnate if it marinates in fear for too long.

Should you get sick, consider the advice of those who have come before you. Hayden Henshaw and his family, who suffered through the early days of the flu in Texas, talk most about the challenges of staying at home — as a family — for days on end. "It sounds real easy, but that's not the way it works," says his father. "I hated it when I was doing it," says Hayden. "I was inside for like three weeks straight." Stock up on games, movies, books and extreme levels of tolerance. Sometimes the gravest threats are the ones we know all too well.

Ripley, a TIME contributor, is the author of The Unthinkable: Who Survives When Disaster Strikes — and Why
See more about swine flu.