Posted: February 18, 2012
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Article SummaryWhen laboratory researchers succeeded in creating a potentially pandemic strain of bird flu, a U.S. government agency recommended editing out methodological details before the two papers were published. Others suggested the research should never have been done and should not be pursued. The result was a pitched battle over what limits, if any, should be put on research and publication. The World Health Organization responded in part with a two-day meeting of public health officials and flu experts. At the end of the meeting the group announced some recommendations of its own. Lisa Schnirring of CIDRAP News asked for my comments, so I sent her this email – parts of which she used in her story on the WHO meeting.

The H5N1 Debate Needs
Respectful Dialogue,
Not “Education” or One-Sided Advocacy

(a February 17, 2012 email to Lisa Schnirring of CIDRAP News )

Lisa Schnirring’s CIDRAP News article is also online.

This week’s WHO meeting to talk about the controversial Fouchier and Kawaoka H5N1 research was – as planned – a meeting mostly of public health experts and flu scientists, with only token representation at most of other relevant disciplines: bioweapons, bioethics, laboratory safety, public perception, etc.

There’s nothing wrong with that, as long as the meeting isn’t misperceived (or misrepresented) as an attempt to bring together all sides to negotiate a compromise.

There are issues on which WHO can function as a neutral facilitator or “umpire,” and issues on which it can’t. This is an issue on which it can’t, since it has its own strong interests to protect – especially its fragile virus-sharing agreement, which might be endangered if research conducted in western labs with Asian samples ends up unpublished or heavily redacted.

So when WHO calls together a group of scientists, most of whom are known or expected to oppose restrictions on publication or further research, the meeting should be seen as one side’s caucus.

Compromise and dialogue … maybe

That makes it encouraging that today’s news release and media briefing were not focused exclusively on the importance of continuing research and unfettered publication. The lede paragraph of the news release offers two exquisitely balanced recommendations: “extending the temporary moratorium on research with new laboratory-modified H5N1 viruses” and “recognition that research on naturally-occurring H5N1 influenza virus must continue.” [Emphasis added.]

With regard to publication, too, the group offered a compromise of sorts. It recommended against publishing redacted versions of the two studies soon, noting that there is “significant public concern surrounding this research that should first be addressed” – apparently in the hope that complete publication might be feasible after the public’s concerns are addressed.

The question is how the group intends to “address” the public’s concerns. If it intends a respectful dialogue, that should help – though I am far from confident that any process, even a respectful dialogue, will yield a consensus in favor of unredacted publication and unfettered research regarding a virus that might launch an unprecedentedly catastrophic pandemic. Still, it could lead at to a compromise, and to a shared understanding of what’s at stake.

My fear is that the group, and the World Health Organization itself, may intend to “educate” the public out of its concerns. That will never fly. It never does. In the risk communication literature and the planning literature, this strategy goes under the label “decide – announce – defend.” It is thoroughly discredited, because it doesn’t work. It certainly doesn’t work when serious risks are involved. “How safe is safe enough” is a values question for society, not a science question for experts who have a horse in the race.

WHO and the scientific community are essentially supplicants, asking everyone else for permission to carry out work with huge (but unquantifiable) potential risks and huge (but unquantifiable) potential benefits. I’m skeptical that that’s how they intend to “address” the public’s concerns … as a supplicant.

One-sided advocacy from both sides

In the battle that arose out of the NSABB recommendation, both sides have been frequently one-sided and even dishonest as they made their case for or against publication of the two papers and for or against continuation of the papers’ research focus. Both sides have often sounded more like advocates than scientists.

Without taking the time to parse individual statements that exemplify this point, let me note the strange correlation of opinions on the core debate with opinions on such scientifically disparate questions as whether ferrets are a good animal model for human influenza response (which would suggest that Dr. Fouchier probably created a pandemic virus) and whether there are likely to have been large numbers of asymptomatic or mild cases of human H5N1 that were missed (which would suggest that natural H5N1 isn’t as deadly to humans as we think).

The majority of scientists who support constraints on research and publication seem to believe that ferrets are a good model and there were few undiagnosed cases; the majority of scientists who oppose such constraints seem to believe that ferrets are an unreliable model and there were lots of undiagnosed cases. I can’t find anyone on either side saying, “Well, you’re right about the ferrets but…” or “Well, you’re right about the undiagnosed cases, but….”

This can’t be a coincidence. Rather, it suggests that both sides are too often marshalling ammunition rather than assessing evidence. Both sides have too often failed to acknowledge the other side’s solid arguments and their own side’s uncertainties. In other words, both sides have done substandard risk communication.

But I think the side that opposes constraints on research and publication has generally done worse risk communication than the other side. In particular, in advocating unfettered science that side has too often shown contempt for the public’s concerns, typically representing those concerns as “perceptions” or “fears.” As used by these scientists, “perceptions” are misperceptions, and “fears” are unjustified fears.

Paradoxically, this contempt for public concerns might actually provoke stricter regulation of science. If scientists are nasty enough and myopic enough in their insistence that nobody but other scientists has a right to an opinion about the risks of what they do and what they publish, it is conceivable that the society might rebel against unbridled scientific autonomy. Even that is a long shot. Most people have a very strong conviction that governments don’t know how to regulate scientists and we’re better off leaving them alone. That autonomy has nurtured a lot of scientific arrogance, but the arrogance hasn’t yet undermined the autonomy, and odds are it won’t this time either. But if there’s a threat here to scientific autonomy, it’s not coming from the NSABB recommendations. It is coming from the arrogant, scientifically dishonest, risk-insensitive way some scientists are responding to the NSABB recommendations.

Perhaps this week’s WHO meeting will yield a more collaborative, respectful tone as scientists try to address public concerns.

Getting distracted from the big question

But there is more at stake here than whether the two papers are published without redaction, or whether research resumes on ferret-to-ferret transmission of the new H5N1 strains created in laboratories in Rotterdam and Madison, or even whether this controversy leads to broader constraints on scientific research and scientific publication. Important as these questions are, they are not the most important question raised by the two papers.

The most important question is what we should do to address the risk of an H5N1 pandemic.

Now we know it is possible for H5N1 to mutate into a strain that is both deadly and efficiently transmissible among ferrets, and probably therefore among humans. So the risk of a catastrophic natural H5N1 pandemic is higher than we thought it was a few months ago. Now a variety of bioweapons researchers (in terrorist cells, state-run laboratories, and biohackers’ garages) know such a strain can be bioengineered; with or without additional clues from published papers, figuring out how to get it done is a lot easier once you know it can be done. So the risk of a catastrophic intentional H5N1 pandemic is higher than it actually was a few months ago. And now such a strain exists in at least one lab (Fouchier’s), and may soon exist in many more labs. So the risk of a catastrophic accidental H5N1 pandemic is also higher than it was a few months ago.

I’m not qualified to have an opinion on which sort of H5N1 pandemic is likelier: natural, intentional, or accidental. But all three risks are objectively higher than we thought they were a few months ago, and the latter two are objectively higher than they actually were a few months ago.

What would be an appropriate agenda for addressing this pandemic risk – or, rather, these three pandemic risks? Speed up the effort to develop and mass-produce a universal flu vaccine? Put H5 antigen into the seasonal vaccine in hopes of priming vaccinees against the pandemic virus? Try to prime as much as possible of the world population? Develop a human vaccine specifically against Fouchier’s strain? Invest more western money in Asian efforts to cull birds with HPAI H5N1 – enabling governments to pay farmers enough for sick birds that they actually turn them in?

I’m just a risk communication expert. I haven’t a clue how best to address the risk of an H5N1 pandemic.

What’s stunning to me is how little this question has been discussed. I understand that some experts think restricting H5N1 research and publication can help reduce the pandemic risk, while others think unfettered H5N1 research and publication is likelier to help reduce the pandemic risk. But that argument seems to have preempted the broader discussion that should be taking place over what else we should be doing to reduce the pandemic risk.

I don’t see much evidence that this week’s WHO meeting spent significant time talking about that.

A hijacked teachable moment

Nor is the public talking about it. Public and media interest in bird flu peaked in 2007. Expert warnings between 2004 and 2007 hadn’t overstated the possible severity of an H5N1 pandemic. In fact they understated it; WHO referred incessantly to “2 to 7 million deaths,” not the several billion that we could infer from bird flu’s 59% case fatality rate so far and the typical 30–40% attack rate of a new flu strain. But they overstated the probability of such a pandemic. And they overstated its imminence, sometimes giving the impression that they expected it momentarily. (It’s hard to remember now that George W. Bush’s Secretary of Health and Human Services did a road show to urge people to stockpile food, medicine, and other supplies against a possible pandemic.) When the bird flu pandemic didn’t materialize, commentators and comedians scoffed and people (and journalists) lost interest.

The swine flu pandemic worsened the situation. We finally got a pandemic, and it turned out mild, killing fewer (though younger) people than an average flu season. Once again, the experts’ pandemic warnings seemed overblown.

Maybe, just maybe, the Fouchier and Kawaoka papers offered a teachable moment, a chance to overcome accumulated skepticism and alert people – or re-alert people – to the risk of an H5N1 pandemic. But that teachable moment got hijacked in large measure by a sideshow discussion of the pros and cons of unfettered research and publication. And the WHO meeting continued to keep the focus where it shouldn’t be: on the sideshow.

At least ordinary people (and journalists) are talking about bird flu again. But they’re talking about it in terms of censorship versus scientific arrogance. The focus is on whether scientists should be left alone to create monster viruses in their labs. It isn’t on what they should do – and what we should do – to address the risk of an H5N1 pandemic.

Note: This email drew many ideas and some words from the thinking of my wife and colleague Jody Lanard.

Copyright © 2012 by Peter M. Sandman

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