Joe Collier on swine flu and ministries of fear

Professor Joe Collier One thing about the current swine flu pandemic is that it has brought with it a universal sense of fear. As with all fears, individuals respond differently, but we know what they are feeling because the sensation of fear, which varies from a mild anxiety to incapacitating panic, is so much part of our constitution that some see it as a normal component of the human condition. The odd thing is that the fear, as an emotion, seems to offer no survival advantage, rather it just causes trouble. That being so, such a response must be seen as irrational and unhelpful.

Where, for example is the advantage of fear to those with new (and worrying) symptoms, who, for fear of being diagnosed with a serious condition are struck by inertia and don’t dare consult their doctor? Or the advantage to those in whom the fear of a ‘positive’ test result, causes endless sleepless nights and anxious days? Or the advantage to those who are prevented from going out at night for fear of being attacked by a stranger? Or the advantage to those in whom the fear of having the wrong body shape causes them to embark on perverse dietary and lifestyle manoeuvres that can end in premature death (cf anorexia nervosa)? Finally, and to some extent extreme, the advantage to those with agoraphobia or claustrophobia whose all-consuming panic attacks make life unbearable?

Back to swine flu – we need to ask why there is a sense of fear (albeit unhelpful) and whether it is justified. The position amongst the population at large is far from straightforward but last weekend Libération, a serious daily in France (England and France are affected by flu similarly) made a strong case that the current flu fear factor is actually the product of French government manipulation.

Traditionally fear is used as a control mechanism by dictatorships. But now, democratic governments are also turning to fear (for example see the use of threats of terrorist strikes, bird flu, missiles from Iraq, computer millennium meltdown etc), as a tool to control populations. Moreover, they have a ready ally in the media who love a bit of drama. In general one might expect governments to calm their populations, but now it seems that calming is not the priority.

Interestingly, Libération also says that the people are wising up to this strategy and that some are rebelling so that in France, as in the UK, there are countless doctors and patients rejecting the offers of vaccination (is it safe? is it effective? are we being used by industry?).

But something else might also be going on. Could it be that health departments themselves are the victims of fear? Recognising that panic and irrational behaviour are key features of fear, could these explain the almost manic activities at the centre as letters and recommendations aplenty are sent out (6 letters in 5 weeks telling managers of the importance of vaccination)? Or the bizarre decision in the UK to make the antiviral oseltamivir (Tamiflu) essentially available over- the-counter despite its unproven value when used in this way, despite the risk of unwanted effects, despite the inevitable risk of inducing virus resistance, and with apparent disregard of the expense to the NHS.

The current flu pandemic is clearly of great relevance with regards to health, but in passing it might also reveal something about our current relationship with governments, and the latter is not a trivial issue.

Joe Collier is emeritus professor of medicines policy at St George’s, University of London



  • I disagree with your assertion that there is a sense of fear about swine flu. There was some worry and concern about it earlier in the year, but the view among my friends and work colleagues is that the initial fears were unfounded and that the risk of catching flu is small, and the consequences of catching it are no more than normal seasonal flu. The viewpoint of my friends and colleagues may be incorrect, but I don’t think it is atypical.

    What evidence do you have that there is a “universal sense of fear”?

  • Mark Struthers

    I think Liz Miller really understands the fears, if not the terrors, of many GPs today. Hers was a recent comment published in Pulse magazine,

    “Dr Liz Miller, a locum GP in London, said she would not recommend the vaccine to her patients because of safety concerns: ‘I do not intend to be vaccinated, nor will I recommend it to patients. It is untested and unnecessary. It’s time doctors started thinking forthemselves instead of mindlessly obeying the Department of Health because they are terrified of missing out on free money.”

  • Jen Trask

    Depends on where you are. Here in the Midwest US the last two weeks have been disrupted by school closures for absences. It is all put down to swine flu, even though none of the children are tested for it. Of course if I were still in high school I could easily put on some symptoms and would for a few free days!

    Now schools are sending home forms for in-class vaccination and students are told that if forms are not returned they will be expelled. Totally non-evidence based and completely illegal, but here there are many fear-mongers and plenty of people to believe them. So in a week when the local health department rolls into the school to vaccinate and my son does not have a signed form things could get interesting.

    Jen Trask

  • Peter Flegg

    It is the unwarranted scaremongering by those who are against vaccination and the totally unfounded fears surrounding the vaccine’s efficacy and safety profile that we should be concerned about.

    I’d like to remind Mark Struthers (and Liz Miller, if she gets around to reading this blog) that it is one of the duties of a doctor and an integral part of good medical practice (as defined by the GMC) to protect your patients, yourself, and your colleagues by getting immunised against infections. I think the GMC would take a very dim view of suggestions that actively discourage this.

    Dr Miller indicates she will not be recommending vaccination to her patients. I pity them, for among their ranks will be many who are are great risk of the complications of swine flu. God forbid one of them becomes seriously ill; I think Dr Miller’s medical defence organisation will also view her actions with some dismay once the medical negligence claims start to roll in.

    Some doctors seem to think that they can randomly pick and choose what they do and what they advise their patients to do, basing their decisions purely on uninformed opinion. This is not acceptable medical practice and is quite unethical. Imagine if I arbitrarily decided to announce I would not be recommending that my myocardial infarction patients take antiplatelet drugs, or my leukaemia patients get chemotherapy….. You get the picture.

    Over 140 people have died from swine flu thus far in the UK, and the death toll will undoubtedly reach four figures. There is a specific and effective vaccine which could prevent many, if not most of these deaths, and it is negligent not to offer vulnerable patients its protection.

  • Damian Williams

    Joe Collier is right that the media ‘love a bit of drama’ but they also ‘love a bit of dissent’. Dissent against any form of authority. And the public seem to love this too. Why was there so much fuss about the MMR vaccine? Was it because there was any truth in it or because the DoH so boldly proclaimed it was safe?

    Dr Miller is correct in pointing out that there is a danger in mindlessly obeying the DoH but she misses the danger of rebelling against the DoH because it is a position of authority. It may be popular to do so but it is no better a position to take.

    Another thing we have missed is the importance of public health. And I mean public as a whole, not just individuals. As doctors we do not just have a responsibility for the patient in front of us but for all our patients. Maybe the patient in front of us wouldn’t benefit from vaccination (and may even get some side effects) but the population as a whole will benefit.

    Much of it comes down to statistics. More specifically, NNT – Number Needed to Treat. I think for swine flu we are going to have to treat (with tamiflu or vaccine) a lot of people to save a relative few but is that not worth it? The answer to that may be NNH – Number Needed to Harm. I haven’t seen the numbers but when we are talking about people dying I doubt the potential harm really outways the benefits.

    Individual patients are free to choose whether they take tamiflu or have the vaccine. Doctors need to be very careful what they advise as their opinions have the power to do good, or harm, to many.

    For the record I will be having the Swine Flu vaccine and I will be helping my patients to make an informed decision about whether they should have it.

  • Karen Brubaker RN

    I agree and feel that the fear factor is being used to sell vaccines. At some point the public will become suspicious and then the people may see healthcare in a more realistic light. It takes time for the public to decipher propaganda and high pressure sales from what is the truth. It will make it especially hard for those of us who truely want to provide the best care possible to our patients. My feeling is that the swine flu vaccine is not a harmful vaccine but I have serious doubts about it’s effectivness, therefore might as well give it a shot. I do believe it is a long shot as to whether it will truely protect you from the flu. With so much money and profit to be made in the healthcare industry I question what is truth and what is aspired truth driven by the almighty dollar.

  • Mark Struthers (Dr)

    Over in the land of the free, free swine-flu vaccine is not tempting folk and their kids according to the New York Times.

    Seven clinics across NYC supplying free shots were apparently either “puzzingly underused” or “puzzlingly overprepared”. Puzzlingly, American folk may be wising up to the downside of socialized medicine.

  • Mark Struthers

    Here’s an interesting report on H1N1 from the Los Angeles Times in the land of free …,0,1594862.story

    “As concern spreads about H1N1, a new survey of California voters found that while most consider the vaccine safe, a majority had no plans to get vaccinated.”

    I don’t get it? Wasn’t it just a short while ago that the POTUS (President of the United States) declared a ‘national emergency’ over the swine-flu pandemic? In the circumstances, I feel sure the Commander-in-Chief will crack down hard on the perversity of such vaccine dissent.