The Known and the Unknown

Former Secretary of Defense Donald Rumsfeld once declared that everything in life can be broken down into three categories - the things that you know you know, the things that you know that you don’t know, and those that you don’t know that you don’t know. In other words - the known knowns, the known unknowns, and the unknown unknowns. Thus, in the case of the Swine Flu, we - as citizens - are left with facts that fall into all three boxes.

Here is what we know:

• We know that there is a new strain of Influenza that has emerged in the last few months.
• We know that the strain falls into the H1N1 sub-type, one that has been responsible for multiple pandemics in the past, including the Spanish Flu of 1918-19.
• We know that the epicenter of the outbreak is in Mexico, mostly in Mexico City.
• We know that the virus has now spread globally, with cases in about ten countries, most of them with a direct link to the Mexican outbreak.
• We know that there is no vaccine available.
• We know that some anti-viral drugs, such as Tamiflu, appear to be viable treatment options.

Here are some of the things that we know that we don’t know:

• We don’t know the degree to which the Mexican Government, hardly known for efficiency and incorruptibility in the best of times, is capable of coping with and making an honest accounting of the scale of the crisis. This is a serious factor, because we are going to have to rely upon them in ascertaining the magnitude of the problem that we face. If their numbers are correct and there have only been twenty additional deaths and a few hundred additional cases since the first reporting, then it’s possible that the problem may already be coming under control. If those numbers are, by deception or incompetence, inaccurate - then we may suffer an unpleasant surprise in the coming days.

• We don’t know the degree to which our leaders - at all levels - are acting upon information that has yet to be disclosed to the public. This is one element that bears close observation. I can’t recall of another example where I’ve seen such a flurry of governmental activity. Governments, by nature, are lethargic creatures - this has governments jumping into action globally. We’ve seen an awful lot of activity over this weekend. Are all of these Governors, Cabinet Secretaries, and so forth simply acting out of a post-Katrina CYA mode (“let’s make sure that we’re seen to do something in case this really gets bad!”) or do they have access to information that has frightened them enough to spur action.

• We don’t know how quickly it’s spreading. The first reports are of fairly isolated cases. However, if the sickness is easily passed on, those reports could quickly multiply. In particular, overcrowded hospitals with long waits could easily become a driver of infection. As could schools and the like.

• We don’t know what actual stockpiles of anti-viral drugs look like and who has control over them.

Finally, of course, there are the things that we don’t know that we don’t know. When you’re walking down the street you know that there’s a danger from the car speeding towards you. You know that you don’t know if there’s a car about to fly around the corner. You don’t know that you don’t know that there’s a decommissioned Soviet reconnaissance satellite about to fall on you.

“Less Dangerous” American Swine Flu?

Over at TPM Josh Marshall, who really should know better, makes a throwaway comment about the “mystery” of the American strain of the Swine Flu being, “much less virulent” than the one circulating in Mexico. This is something that, across multiple blogs, I’ve seen claimed over the last two days. It really needs to be addressed.

To do that, we need to discuss a basic question: why is this particular form of Influenza so threatening? Because it falls outside of predictable patterns for this disease. Where normally the flu needs to take out the very young, the very old, and the very sick, the strain that spread during this pandemic of 1918-19 killed by triggering a type of fatal immune reaction in otherwise healthy young and middle-aged people called a “Cytokine storm.” We seem to be seeing a similar pattern among the deaths in Mexico.

It’s really, therefore, far too soon to proclaim that the “American” version of the disease is somehow different or less fatal. Not only have there only been a handful of cases, but the demographic breakdown of those cases that we know some details of (IE - the Queens high school students) suggests that most of the known infected fall outside of the most vulnerable demographic subgroup.

The Mexican Flu: Time to Panic?

Should we panic about the new H1N1 virus that is ravaging Mexico City and seems, within the last few hours, to have quickly spread to New York City, Kansas, and possibly Montreal? Yes, probably, though I hasten to note that blind panic never does any good for anyone. So, in my very best official voice I will state that while we should not panic, we ought to view the developing situation with deep and growing concern.

I’ve heard some people, particularly commenters on various news sites, express thoughts like, “well, it’s just the flu - thousands of people die from the flu every time it breaks out.” That’s fair enough, but it misses several important points about this particular outbreak.

1. This is a new flu strain - it’s of the H1N1 type, but it’s a new mutation. There isn’t a vaccine for it. This is a Avian-Swine-Human hybrid virus.
2. Reports out of Mexico suggest that most of the dead are not in the classes typically vulnerable to the flu - the very young, the elderly, and the immuno-compromised. Instead, the reports have the contagion mostly claiming healthy young adults, much like the Spanish Flu of 1918-19.
3. Based on earlier reports, the case fatality ratio here seems to be very, very high - something like 6-7%. In comparison, the Spanish Flu had a CFR in the 2-3% range.

This is a problem we should take seriously. We don’t yet have enough information to answer the question of how seriously. The information that we have is sketchy at best but, overall, it paints a picture of a situation that is worse than the official statements have let on.

First of all, I think that it’s probably fair to say that the much-bandied numbers regarding the outbreak - about a thousand sick in Mexico and sixty-eight dead - are completely obsolete. The fact that we haven’t had any new numbers since yesterday is perhaps the most troubling fact before us at the moment. The Mexicans, the WHO, and the CDC all know that they’ve set off world-wide fears about a pandemic. If they had positive numbers to give us (“there have only been fifteen new cases reported in the last twenty-four hours and only two additional deaths”) I think that they would be pushing them out via every means of communication. By inference, that leads me to believe that the outbreak in Mexico City and its surrounding areas has not abated.

The actions of the Mexican Government, the CDC, and the WHO in the last twenty-four hours also suggest a deepening crisis. Remember - they have more information than we do. In the last few hours, we’ve gotten two bits of concerning news:

• The Mexican Government has empowered its health officials to begin conducting house-by-house inspections and to quarantine the infected. That suggests, to me at least, a deepening problem. The scale of the voluntary lockdown imposed on Mexico City also suggests something big.
• The WHO’s inconclusive meeting on whether to raise the pandemic alert level. Frankly, I can’t think of many things that make me more nervous than when Doctors can’t quite decide or agree on what to do.

What is the individual citizen to do about this? That’s a tougher decision. From where I’m standing, there isn’t much that the individual can do - other than perhaps to stock up on some supplies and to keep their head up. From there, we have some harder questions.

I can tell you one thing - I’d much rather be in the United States than anywhere else at the moment. For all of its flaws, the American health care system is the best-positioned to deal with this sort of pandemic. Most reports suggest that Tamiflu and other antiviral drugs are the best weapon against H1N1. Not only is the United States going to have the largest stockpiles of the stuff (and first dibs on additional production), but it also has a solid Doctor:patient ratio and an effective distribution of Doctors. Dispersion is going to be key in a crisis because major medical centers are likely to be overwhelmed and, more than that, are going to be as likely to spread as to combat the virus. As well, if things really get bad, the United States has a large enough military to render effective aid to the civil power - I don’t think that’s the case elsewhere. I know damned well that it isn’t the case in Canada.

I’m not sure how much use some of the other measures being discussed - travel bans and the like - will be of at this point. But, on the other hand, I can’t really see how they would hurt.