Public Health

New York's former Mayor John Lindsay once reportedly said he "didn't trust air he couldn't see." We're raised to be that way in that part of the world.  As a rule we don't spend much time fretting about the things we can't see unless we're seated with our back to the door in an Italian restaurant.

Washington on the other hand is, for the most part, in the business of intangibles: Empty words, empty promises, speeches in the place of action, "sense of the Senate" resolutions, reading a crowd rather than sticking to principles.

Today for instance, both pundits and real people are spending hours discussing whether Obama was sufficiently "presidential" last night, whether he had regained his campaign "magic" or whether he had changed the "national mood." Most of that stuff gives me a nosebleed.

Of course, in these parts politicians prefer discussing things that can't be measured because measurements tend to be so deflating, suggesting that their jobs are not about leadership or rhetoric but are rather about what and how much they get done. Also the real numbers don't lie (unlike their statistical cousins) and so, if you lie for a living you learn to avoid them early on.

This explains a lot, notably why our national accounts never add up, why budget forecasts are always wrong, why official economic projections are seen as being a substance-less as Georgetown cocktail party conversation. Old Washington hands expect roughly the same thing from "we expect a turnaround in the fourth quarter" as they do from "let's get together for lunch sometime." 

It's even why President Obama can get a lot of credit for a speech that was, to put it mildly, arithmetically challenged. To begin with "fraud, waste, and abuse" is neither a number nor even a measurable thing. It's just a mythical creature that wanders the halls of the Congress year in and year out, much discussed but in reality untouchable and constantly growing. It's certainly not a budget item you can line out to produce a measurable saving. Further, suddenly it was argued that we could provide coverage for the 45 million Americans without healthcare by providing it to only 30 million additional people. (When numbers suffer, so do absolute terms like "universal.") Finally, it's clear we ended up with a $900 billion proposal not because that was the sum total cost of all the reform we need but rather because it was not more than $1 trillion, which was considered a line that could not be crossed politically. It's a sad thing when we start pricing much-needed transformational reforms the same way we do ladies' shoes ($99.99 rather than $100. Which numbers bear as little relation to bills I have seen recently as do most Congressional budget projections to actual results.)

Having said that, I liked the President's speech last night and thought it was very effective. It may have been too vague. It may not have been what you'd call mathematically rigorous. It also was not, to my way of thinking, even sufficiently broad in its proposed reforms. However, it was a serious effort at addressing a critical national concern. It contained a few key principles (extending coverage, combating abuse by insurance companies, seeking savings) and it embraced ideas from both political parties. 

It was not the soaring but empty rhetoric of the campaign trail nor was it delivered by a magical president, the man who the media had made into Lincoln before he had spent a day in office. Rather, for me it was a much more real and appealing Obama, a smart, earnest political leader attempting to produce a meaningful piece of legislation. Oh I understand all about meta-messages and zeitgeists and stature and all that, but what struck me was that we were witnessing an important part of the business of democracy, of struggling over the details, of cajoling even an abusive opposition to come along.

In short, while we can save for elsewhere a debate over the specifics of the health care legislation, he made a solid stand for rationality in the face of irrational opposition, for progress in the face of intransigence. He was a man at work rather than a heroic figure and he made his case both well and far better than any of his opponents have made theirs.

In fact, President Obama was aided in all this by those Republican opponents -- as they have ceased to be the party of Lincoln and have become the party of Seinfeld, a party about nothing.

That may be consistent with the D.C. vacuousness I mentioned at the outset, but it looked callous and irresponsible to me last night. (I am not going to get into the issue of rudeness. It's small potatoes. A kerfuffle in a teacup. These people are grown-ups. Neither party has cornered the market on idiots.)

No to me, Obama last night showed that he is maturing into the kind of workaday president that we need. His rhetoric was not just strong, it was purposeful. He looked to me like a man committed to getting this thing done. One day at a time. I believe he will and I believe when he does it will make it easier to move ahead on other issues like climate and energy. 

That kind of approach counts for a lot where I come from. It's why I think while the Republicans are channeling Jerry and Elaine, Obama seems to be zeroing in on a better model (at least I hope he is) -- the dependable, steady, grace-under-pressure approach that has put another New Yorker, Derek Jeter, center stage this week.

To conclude with an unrelated anecdote that ties Jeter's Yankees to the Mayor Lindsay reference at the outset, and which seems to me to nicely contrast how Obama appeared last night versus how the Republicans did, there is always the famous story about Lindsay's wife. She once remarked to Yogi Berra that he (like Obama) looked cool despite the heat. He responded (as though speaking to the Republican leadership), "You don't look so hot yourself."

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And Dick Cheney thinks he knows something about terror. Republican terror threats are for sissies. Even Tom Ridge is willing to admit ... some of the time ... that they kinda-sorta-maybe were overblown. (Ridge's now-you-see-em-now-you-don't revelations have permanently damaged him. Either he screwed up back in the day by caving to pressure to elevate the threat level or he has screwed up by misrepresenting the situation in his memoirs or he screwed up most recently by caving to pressure to back off the "explosive" admissions that he thought would sell enough books to pay for his retirement.) 

But Democrats have all the luck. They didn't want a national terror threat. They don't even like talking about the "war on terror" (most of the time). But they've got a doozy brewing that makes the country's post-9/11 post traumatic stress disorder induced inclination to look for a terrorist behind every potted palm look mild by comparison.

Yesterday, I walked across the campus of Columbia University in New York and amid the light blue and white balloons and banners fluttering in welcome of new students, amid the registration tables and the orientation sign-up booths, every so often there were large Purell dispensers. No explanatory signs. No instructions, just big honking containers of disinfectant crying out to every passerby to stop and make that next handshake a safer one. The absence of signs made it all the more ominous. Signs weren't necessary as they once were along highways when people were asked to call in and report "suspicious activity."

While this threat was as hard to see as was the one that had the Bushies in a swivet, you didn't need Karl Rove's classified Ouija board to magnify this one, a microscope would do. 

The other day a dean at a major DC-area academic institution indicated that he and others on his team had spent much of the summer developing the distance learning protocols they would employ if H1N1 virus required them to shut down their campus and send everyone home. At around the same time, I received an email from the college one of my daughters attends explaining just how they would tackle swine flu. Today, the city of New York, a city now reporting that perhaps 800,000 of its citizens caught the disease in the first phase of its appearance, announced a new set of guidelines for how they would handle the disease as it appeared again this flu season.

Estimates suggest that perhaps as many as 90,000 Americans could die of the disease this next time around. That may be high. Estimates of the severity of this pandemic have been inconsistent and fortunately, thus far the illness has not taken an extreme toll. But the nervousness is palpable. For example, take this CBS story of a school district in Long Island that has banned touching for the foreseeable future (of course, just after my daughters leave high school is when they decide to ban touching!)

Chest bumps. High fives. Hugs and handshakes. Glen Cove Middle School students Ali Slaughter and Hannah Seltzer say that's what friends do on the first day of school. But when students in the Nassau community return to school next week, the superintendent will be urging abstinence. Everyone from the tiniest tots to the biggest high school football players will be asked to limit skin-on-skin contact in an attempt to prevent the spread of swine flu when it re-emerges this fall.

Thus far, it seems authorities worldwide have responded swiftly to the pandemic and, even if it seems like they are over-reacting, their caution is not misplaced. Flu annually kills 250,000-500,000 people worldwide each year, 36,000 in the United States. And that's not when a particularly virulent strain comes along, such as the 1918 pandemic that killed perhaps 50-100 million people and infected perhaps 500 million.

The 9/11 attacks claimed fewer people than would die worldwide of flu on the average weekend. So, it is quite clear that the current invisible threat is a lot worse than the old invisible threat. But there is another way to look at all this. First, it casts the current health care debate in a different light. Having 50 million people who don't have health insurance (thus more reluctant to see a doctor and more inclined to seek free emergency room treatment) puts everyone else at greater risk. Having hospitals teetering near insolvency and cutting back services does likewise. When you think about the real threats to our homeland security a broken health system (especially in the context of the threats of not just epidemics but biological or WMD attacks) may be at the top of the list.

Next, if this epidemic gets as severe as some people worry, it'll very quickly overshadow Afghanistan, Iraq, Iran, and the financial crisis. It'll become Obama's war and, absent a crisp, orderly, sustained response, his Katrina. There's no sign that's happening yet. It may not rise to that level. The response may be excellent and it could be one of the decisive factors in the 2010 elections in either case. But for the first time in years, a nation that has come to view threat level Orange as normal has started to get edgy over something bigger. Tell me Mr. Ridge, what color should we use to indicate to everyone that the threat could be real?

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Joe Biden wants to be alone. And after this morning's performance on the Today Show, it is quite likely that the Obama administration will be fulfilling that wish for him very soon. Where was that undisclosed location anyway?

Biden, when asked about how to mitigate the risks associated with the swine flu threat, said that people should avoid being in enclosed spaces with others. He specifically cited airplanes, subways, and classrooms. Which would mean, er, shutting down the entire economy. Actually, all social interaction. In fact, essentially what the Vice President was doing was sending all of us to our rooms.

Now admittedly, Mexico is shutting down much of its economy to contain the disease. But clearly, with the limited number of cases of the flu in the United States and its limited impact, he seemed to be over-reacting. Actually, he seemed to be exercising his unique gift for sticking his foot in his mouth. (Which is especially inadvisable in times like these. You just don't know where that foot has been.) But even for Biden, who truly has become the crazy old uncle in this administration, saying goofy things and considered to be having a good day when he doesn't actually set the White House on fire by leaving his oatmeal on the stove for too long, has really outdone himself today though directly pouring gasoline onto the flames of panic and over-reaction to the swine flu outbreak.

It is one thing for the WHO to ramp up warning levels to ensure the world can contain potential threats. It's another thing to suggest that people stay off airplanes (do it long enough and Steve Rattner will have another industry to rebuild), out of public transportation (guaranteed to produce more road-rage related traffic deaths in congested traffic than the swine flu will generate worldwide), and out of school (take that competitiveness). 

If the Vice President has become a Howard Hughes like germ-a-phobe, then perhaps he might want to consider going all the way and trying out reclusiveness for a while. We'll miss the light comedy but I'm not sure how many more gaffes of this nature an already weak economy can take.   Paging Dr. Gupta: If only Sanjay had been our surgeon general now, we would really be benefitting from his communications skills and the ability to have the administration turn to more qualified spokespeople than kooky old Uncle Joe.

Swine flu! World Health Organization at alert level 4! Markets rocked by sell-offs! Howie Mandel was right! Never shake hands! Bathe in Purell! See if you can borrow a face mask from Michael Jackson! Or hold your breath whenever you are near a ham sandwich! Armies of pigs in uniform marching on Washington! Orwell was right: the animals have turned on us, become more dangerous than us! Four legs bad, two legs good! Head for the hills!

Once again, the media is reacting to a potential threat with its usual calm, responsibly recognizing that sensational coverage of diseases can have far worse consequences than the diseases themselves. Or not.

Remember SARS? Fewer people died of SARS than choked to death in the United States on small objects that year. But estimates of global economic losses exceeded $40 billion. Back then, I wrote an article called "The Buzz Bites Back" for the Washington Post about this phenomenon dubbing it an "infodemic." And it was clear at the time that the progress of the information revolution was amplifying the impact of these information epidemics and accelerating their spread. Yet, still hysteria reigns again.

This is not to say that the WHO response has not been appropriate. It has. It is not to say that there isn't a vital public health role to be played by the media. It is critical that the media offer information about symptoms, precautions, and the spread of potential epidemics. But whereas health officials practice how to manage these crises, not only do the vast majority of media never think such matters through, newer "viral" media are all emotion all the time. 

One particularly fascinating element of the infodemic phenomenon is that the spread of rumors or news throughout society looks exactly like the spread of diseases; they are communicated in the same ways and patterns. (You'll note that in both the SARS case and the current instance, it was the infection of Americans that kicked mainstream media into gear and elevated the story into a code-one frenzy.)

The nature of the spread of such infodemics also, by the way, offers useful tools to epidemiologists trying to use modern media to identify potential medical risks and contain them. I know this was discussed in the Net Effects blog here at FP the other day and I would just like to offer one anecdotal insight that suggests to me that perhaps the skepticism about the value of using such tools expressed in the post has been overtaken by events. Back in the months before the SARS outbreak became public, I ran a company called Intellibridge which tracked "open source" intelligence for a variety of clients. In other words, we looked at what was available on the Net in many languages to see what it might offer government or business clients in the way of insights. 

One of our analysts spotted a small item in a newspaper in Guangdong province stating roughly that people should not panic due to rumors of an outbreak of a disease. When the Chinese government says do not panic, our analysts were trained to be skeptical and indeed, when we dug into the issue we found that word was spreading throughout southern China, largely by means of cell phone messaging, concerning this new outbreak of disease. In fact, we became so concerned that we called the Center for Disease Control...who proceeded to brush us off saying that they did not accept information of this source from the public. Ten weeks or so later the World Health Organization acknowledged the outbreak of the disease. 

The punch line: modern information technologies offer important tools for both containing and amplifying threats such as those posed by the global spread of epidemics. Considerable work remains to be done however, in understanding how to use these tools and to limit their abuse...and new media like Twitter and social networking sites do not make this task any easier. (Although figuring out how to manage this in the context of a free society is an especially important challenge for governments worldwide, arguably much more important than popular media-policy intersections like "public diplomacy.")      

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