Public health is the diverse, multidisciplinary field of study and action that considers human health from the point of view of populations, rather than individuals. The biomedical paradigm locates disease and death in the individual person, but the truth is that the most powerful determinants of our health and well being are our position in society. Rich people live longer than poor people, everywhere, and they are healthier while they are living. Other dimensions of social status -- education, race and ethnicity, occupational level -- also exert separate influences on our health. Access to medical care matters some, of course, but it's really a small part of the story. Health equity is a powerful frame for viewing issues of justice, democracy, and what makes for a good society. It profoundly engages the most basic ideological constructs -- liberty and equality, individualism and community, freedom and security.
It's what we need to be talking about here on Daily Kos, every day. But what are we talking about, obsessively, relentlessly, endlessly? Influenza.
The World Health Organization regularly assesses the global burden of disease. You can find all the statistics you could ever want here. They lag a few years behind, of course, but in 2004, 58,772,000 human beings died. That includes 527,000 women who died in childbirth; 3,180,000 children who died as neonates; and 487,000 children who starved to death.
It also includes 184,000 people who died in wars and civil conflicts that year; 844,000 people who took their own lives; and 600,000 people who were murdered.
Infectious diseases were a major cause of death worldwide, taking 9,519,000 lives. Among these, the leading causes were diarrhea (2,040,000) and common childhood diseases (2,163,000) which very rarely kill children in the United States: pertussis, measles, tetanus, etc. Malaria killed 889,000 people, many of them children. Other tropical diseases such as tryponaosomiasis and Chagas disease got 152,000. Tuberculosis took 1,464,000 lives, HIV 2,040,000. Influenza is not actually on the list -- when people have flu-like illnesses it isn't generally determined what specific infection they had. Lower respiratory infections were credited with 4,177,000 deaths, and some unknown percentage of these were linked to influenza. In the U.S. the standard estimate is about half but it is likely much lower than that in most of the world.
Worldwide, heart disease is the leading official cause of death -- 17,073,000 -- and cancer checks in at a middling 7,424,000.
Of course, we're all going to die, so the issue isn't so much, what kills us, as when, and how well we were living up until then. One way -- not perfect, but at least a common metric -- is so-called Disability Adjusted Life Years lost. I.e., assume we're going to buy the farm at age 70 (or whatever age you like) if nothing bad happens, add up years of life lost before that, plus a fraction per year of life for disability computed based on survey data about how people weigh disability vs. lifespan. In 2004, WHO estimates the DALYs lost were about 1.5 billion.
Among infectious diseases, diarrhea gets the biggest chunk because it kills little kid: 72.7 million. HIV kills young adults, and it causes disability along the way, so it gets 58.5 million. Malaria, 34 million. Maternal conditions, 39 million. Perinatal conditions, since they have huge bang for the buck, as it were, get credited with 126.4 million; malnutrition gets 38.7 million, the vast majority of them being the effect on little kids. You get the idea. Lower respiratory infections -- how much has to do with influenza I don't know, but it's less than half -- get credited with 94 million DALYs.
We're a rich country, so our profile looks very different. McKenna et al did some figuring for the U.S., which you can read about here (PDF). For both men and women in the U.S., the champ is heart disease, but for men traffic injuries come in second, while for women believe it or not it's depression -- remember we're counting disability, not just death. Lower respiratory infections are not on the list for men; for women they clock in at number 16. For men, 3 through 10 are lung cancer, HIV, the booze, stroke, COPD, violence, self-inflicted injury, and depression. For women, it's stroke, COPD, lung cancer, breast cancer, arthritis, dementia, diabetes, and car crashes.
What you see there is tobacco, obesity, and a lot of social conditions related to socioeconomic status and quality of life. Political and social issues. Tobacco is usually credited with about 450,000 of those deaths attributed to heart disease, cancer and COPD; obesity with 350,000 or so. I haven't seen a comparable calculation for the DALYs, sorry, but it's obviously a lot.
Now, emerging infectious diseases are a problem we certainly do need to be concerned about. It is conceivable that at some time in the next few years, a strain of influenza will emerge that will be more dangerous than usual. Right now, influenza gets credit for about 36,000 deaths in the U.S. every year, although the vast majority of those are people who are already sick or frail. Still, tragically, 150 or so children die from complications of influenza in the U.S. in a typical year. This is neither new nor strange -- it happens routinely.
We do not know when, if or how the next BIG KILLER FLU PANDEMIC will emerge. It is not, as it turns out, this H1N1 swine flu -- which was apparent to me more than 2 weeks ago, as I diaried here, although I was ignored. Yes, it could mutate and turn out to be worse -- as could any strain of influenza. There is no particular reason to believe it will, but I can't rule it out.
So let us suppose that the absolute worst case scenario happens, and next fall, the dread H1N1 swine flue comes "roaring back with a vengeance" -- it turns out to be more than normally transmissible, and it causes more than usually serious disease. No reason whatsoever to expect this, but let's just stipulate it. Will it be 1918 all over again? No, not even close. By then there will be hundreds of millions of doses of vaccine available -- not enough to immunize the world, but enough to deploy tactically to contain outbreaks. Antiviral drugs are widely available. Antibiotics, which did not exist in 1918, are also widely available to quash the secondary viral pneumonia which is actually responsible for most flu-related deaths. Systems are in place to track outbreaks and put in place isolation and quarantine measures to slow transmission. All of this already exists -- it is not a political problem, it's already there. Ill distributed, of course -- we in the U.S. will be much better off than people in poor countries.
So if this happens, it will be over in on year. Even in the worst possible case, it will kill fewer people, and cause far fewer lost DALYs (because you recover from it completely in a few days) than infectious diseases are already causing right now, every day. It will cause fewer deaths in the U.S., throughout it's entire course, than are caused by tobacco every single year; fewer than are caused by obesity every single year; and it will result in fewer lost DALYs than car crashes, HIV or alcohol abuse do in every single year, right now, already.
All of these indisputable facts have gone unnoticed, and unremarked here on Daily Kos for the past month, while we have talked about nothing else -- truly, just about nothing else -- but influenza. In that month, the swine flu has been credited with 3 deaths in the U.S., every one of which actually was caused by another condition but only precipitated by flu. That is far fewer than ordinary flu causes. While we have obsessed about influenza, day in and day out, one third of a million little children have died of diarrhea and common, preventable childhood diseases, completely ignored on Daily Kos.
Talking about a subject obsessively is not a sign of preparation, and deciding not to talk about it any more once what needs to be said has been said is not a sign of complacency. Once we have said what there is to be said, and done what there is to be done, we need to shut up. Especially if there are many, far more important things to talk about. What is happening here is misleading to our readership, harmful to the causes we care about, and completely irrelevant to the Daily Kos mission of progressive politics and electing democrats. It's off topic, off message, and beyond inappropriate.
It must stop.
And I'm not hiding behind Internet anonymity to say this. My name is Bart Laws, I'm a medical sociologist at Tufts Medical Center, and you can read what I have to say about swine flu on Alternet and listen to it on Counterspin. (Interview starts at about the middle of the program.)
Shut up about the goddamn flu.