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Pandemic Interventions Didn’t Help?

November 28, 2007

Spanish_flu_hospital You have to get up pretty early in the morning to beat Revere to a post, and I – don’t.  I see that as a benefit, thought, as my post is that much better spiced thanks to his commentary.  I did, however, get the CIDRAP Commentary on my page nearly twelve hours before he posted, so there.  Remember folks, it’s the small things.

But back to the important stuff.  Per Revere, there’s been some tension in the flu community regarding what are called non-pharmaceutical interventions (NPI).  These interventions were enshrined as part of our nation’s community response plan in CDC’s Community Mitigation Plan (pdf) published in February 2007.  An NPI is just like what it sounds like, an action to mitigate or respond to a stimuli (in this case pandemic influenza) that doesn’t use medication.  As you can imagine, that’s pretty broad – encompassing everything from hand washing to forced quarantine.

NPI has gotten a lot of play from the flu-heads as they, rightly, know that no vaccine will be available (for at least a long while) and anti-virals may or may not work in a pandemic situation.  NPI was furthered touted by author John Barry in his phenomenal book, The Great Influenza, as a major contributor to helping mitigate and end the 1918 Spanish flu.  Scientific evidence seemed to bear this out, as an August 2007 article in JAMA reviewed the actions of 43 cities and found that:

[A] strong association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States. In planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment.

Of course this article is behind a pay wall, and not available to us regular folk, so no link or cite.

John Barry responded to that article in stunning fashion.  I’ll give you what I could get access to below:

To the Editor: I believe that the study by Dr Markel and colleagues1 of the 1918-1919 influenza pandemic and the effectiveness of nonpharmaceutical interventions has a serious problem in its data that calls its conclusions into question. The authors assert that, of 43 cities in the study, New York City intervened the earliest, on September 18, 1918, at “–11” (11 days before excess deaths doubled the baseline), 6 days earlier than the second earliest city. Because New York City had a relatively benign experience, this assertion contributes to the conclusion that nonpharmaceutical interventions were effective.

However, I am aware of no evidence that New York City ever took any action that meets the authors’ definition of a nonpharmaceutical intervention: school closure, cancellation of public gatherings, and isolation and quarantine.1 The city never closed schools and never cancelled public gatherings.

Now, lest you think this is just a typical academic pissing match, Barry is refuting his own best-selling book by writing this letter.

Now onto today’s news.  Michael Osterholm, director of CIDRAP and all-around public health rockstar, invited Barry to expound on his letter and prefaced it with a commentary.  That was released yesterday, and I imagine is causing teeth-gnashing and garment-rending amongst the flu-heads.  Because it’s a pretty big deal, namely it calls into question our plans for responding to a pandemic, I thought we should dig into the commentary, especially Dr. Osterholm’s.

The thrust of Dr. Osterholm’s commentary is pretty withering.  See the following:

I believe Markel and colleagues did not address the important challenges that Barry presented. In my view, his information raises serious challenges to the scientific integrity of what Markel and colleagues have reported for two cites included in their study, which in turn raises important questions about the overall results of their study. This concern does not disprove that NPIs altered the course of the pandemic. But we in public health will face overwhelming challenges with risk communication and credibility during the next pandemic. While we will surely recommend the use of NPIs at that time, we have an obligation to society to tell exactly what we know and explain the science that supports our conclusions. How will we ever be able to dismiss and even condemn the crazy things that some will try to do during a pandemic if we don’t base recommendations on the strength of our science? We must hold ourselves to that standard now and in the future. I believe John Barry makes a clear and compelling case below that Markel has not met that standard. We must.

That, my friends, should be the essence of public health preparedness.  Based upon good science, plans should be made and communicated to the public.  In the absence of such good science, anything – anything – will be touted as a proper response to an emergency. 

That Dr. Osterholm’s commentary is so withering is telling, and frankly, what makes him such a rockstar in my eyes.  He understands that we’re dealing with is the real deal and the more perfect our planning is, the better prepared we will be.  Public health preparedness deserves – or should deserve – no less than exactitude.

John Barry’s commentary is a great example of just that kind of thorough examination of historical data (note that his review is ongoing; he published his book, and then continued to clarify those points that might not have been as clear upon his initial review) that informs and hones public policy.  I recommend everybody head over to CIDRAP’s site and read Dr. Barry’s commentary here.  I also encourage everybody to check Dr. Barry’s The Great Influenza out of the library.

Photo courtesy of the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C., United States.  Downloaded from

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