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Swine Flu: Trying to Think Correctly

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Three years ago, at the height of the bird flu scare, I wrote an article for WebMD called "Bird Flu Over the Cuckoo's Nest." It began, "After several years of trying to educate myself in order to answer questions from my anxious patients about nerve gas, anthrax, swine flu, mad cow disease, West Nile virus, SARS, and now bird flu, I find myself thinking wistfully back to 1963 when, as a 10-year-old, all I had to worry about was total nuclear annihilation."

Swine flu is the latest in a series of problems that have kept us in a heightened state of alert for years now. This cannot be good for anybody's sanity. We are wired evolutionarily for brief surges of adrenaline, "fight or flight" responses that temporarily put us in overdrive. But what engine can remain in overdrive for years at a time without becoming seriously fried?

Nobody wants to overreact, but nobody wants to be caught unprepared. Responsible members of the media are faced with the difficult task of properly informing without needlessly alarming the public.

It's a constant challenge to try to serve the news not too hot and not too cold. "Just right" is easier said than done. Clearly the current outbreak of swine flu is of global concern. As chief medical correspondent for the CBS Evening News with Katie Couric, I have a responsibility to try to put it all in perspective -- not to hype the story but not to sugarcoat it either. On tonight's Evening News broadcast, we reported that nearly 2,000 cases of swine flu have occurred in Mexico and at least 149 deaths; today US health officials advised Americans not to travel there. Here in the United States, there have been at least 40 cases, and the number is growing. But for some reason, the cases in the US have been relatively mild; there have been no deaths. Today I interviewed Dr. Bruce Farber, Chief of Infectious Diseases at North Shore University Hospital, one of the physicians who has taken care of the students at St. Francis Preparatory School in Queens who have come down with swine flu. He told me he was surprised at how "unsick" the kids appeared compared to some of the very ill patients in Mexico. There are various theories but nobody is sure why this is the case.

The truth is that we are in a fluid situation and we don't know exactly what will happen. My goal as a doctor and as a journalist is to try to think correctly -- to do my homework, read as much as I can, listen carefully, ask lots of questions, and then try to translate it all for my patients and for our CBS audience. And not be afraid to admit uncertainty.

The past flu pandemics (e.g., 1918, 1957, 1968) may have little predictive value for a pandemic today. On the one hand, airplanes will help spread the virus more quickly than in the past. On the other hand, we have far more sophisticated tools for early detection and treatment than we've ever had. Meanwhile, what can you do for yourself and your family?

Skip stockpiling antivirals. We all love to have control, and if not actual control then at least the illusion of control. Enter Tamiflu and Relenza, the anti-viral drugs that can lessen the severity of flu if taken within 48 hours of the onset of symptoms. Why not hoard them now? Shouldn't you have some "just in case"? For most healthy people, the answer is an emphatic "no," something I confirmed today with both the CDC and the New York City Department of Health. Yet I called several New York City pharmacies this afternoon and was told there's been a run on Tamiflu. As a physician, I know how tough it can be to "just say no" to an insistent, worried patient. And I haven't totally gone over to the dark side of not remembering what it's like to be a patient; believe me, there's an insistent, worried patient hiding inside many physicians, myself included. But inappropriate use of Tamiflu and Relenza can lead to the swine flu becoming resistant to these medications -- the same thing that's happened with overuse of antibiotics. The virus is sensitive to these drugs now but that could change with overuse.

In addition, shortages created by hoarding would hamper our ability to treat patients with regular flu, which affects millions of people and kills about 36,000 annually in the U.S. And shortages during an outbreak of swine flu might contribute to a more rapid spread of the virus. So, ironically, the unused Tamiflu in your medicine cabinet could increase the likelihood of the disease infecting you and your loved ones.

Practice good hygiene. Because swine flu is likely spread in a similar way as regular flu, i.e. by respiratory droplets, you should follow the same advice you would for avoiding regular flu (hand washing, covering your mouth with a tissue when you sneeze and then throwing the tissue away, staying home when ill, avoiding touching your eyes, nose or mouth, and so on). Bottom line: When your cab driver licks his fingers to help him peel off a few singles from his wad of bills, tell him to keep the change. Information on the effectiveness of masks is limited but the latest CDC recommendations can be found here.

Stay informed. For specific advice on swine flu from the CDC, go to www.cdc.gov/swineflu. For general advice on how to stay prepared, check out the "Pandemic Flu" website at www.pandemicflu.gov (look under "Plan and Prepare").

Personally, I am amazed and heartened by how many competent and brilliant people all over the world are working on the problem. It does make me feel better to know, for example, that officials at the New York City Department of Health and Mental Hygiene, who were extremely valuable sources of information for me and many other New York City doctors during the 2001 anthrax crisis and 2006 bird flu scare, have been all over the current swine flu situation. Most of us have been thinking about swine flu for several days; they've been thinking about it -- and preparing for it -- for years.

How can we recalibrate our anxiety to an appropriate level? Communication. Whether the problem is swine flu or some other health threat, I have found that patients are comforted by an honest, clear explanation -- even if the answer is "I just don't know." And patients are relieved when I remind them that they don't have to solve the problem themselves because there are very smart, dedicated people whose job it is to come up with an answer.

Finally, doctors have a special responsibility to stay informed. Many of us are used to practicing on our own, following our own clinical judgment. But during a health crisis such as the current swine flu epidemic, we must also follow the advice of public health officials. The right thing to do is not always intuitively obvious. For example, yesterday the New York City Department of Health issued an email update that suggested that most patients with mild flu-like symptoms not come into the office for flu testing unless they have an underlying illness that puts them at increased risk. Had I not received the update, I might well have advised patients incorrectly. Doctors should contact their local department of health for instructions on how to get on their email list.

Since I'm preaching about communication, tonight I tried to practice it with something brand new. For the first time, the CBS Evening News with Katie Couric was followed by a live webcast about health. To discuss the current swine flu crisis and to answer questions emailed and tweeted by our audience, I was joined by Dr. Jennifer Ashton, the medical correspondent for The Early Show on CBS, and by Dr. Peter Gross, a Yale-trained expert in infectious diseases who is currently the Chief Medical Officer of Hackensack University Medical Center. I look forward to hearing your comments and to continuing the conversation online.

Around the Web

Swine influenza - Wikipedia, the free encyclopedia

CDC - Influenza (Flu) | Swine Influenza (Flu)

CDC: Swine flu viruses in U.S. and Mexico match - CNN.com

Swine Flu — Sciencebase Science Blog

BBC NEWS | Health | Swine flu: Your questions