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Terry Maguire is vice-chairman of PharmacyHealthLink,
the UK charity
that promotes public health through pharmacy
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Avian influenza resources
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Recently, one of my more erudite patients said to me: “This
avian influenza sounds like a lot of nonsense.” I thought he might
have a point, yet when it comes to risk people can be very silly indeed.
Risk
is an objectively neutral concept and simply means the probability of
an event — good or bad — happening. But since most people
do not understand risk in numerical terms, we opt for emotion, and this
can result in some bizarre behaviour.
You do not agree? Then why do 30 million, seemingly sensible, apparently
rational human beings play the EuroMillions Lotto? They all must think
they have a risk of winning, which numerically they do. What they do
not appreciate — and this is the problem when trying to describe
risk — is that the risk of winning is small. Indeed it is so small
that each player is at greater risk of being struck by lightning, dying
from a heart attack on the day of the draw or contracting tuberculosis
within 12 months. They would certainly be more prudent keeping the ticket
fee and investing it in a Nigerian mining venture. This hopeless enterprise
would be at greater risk of making them rich. Funny how risk is always
associated with the negative whereas we use “chance” or “luck” to
convey the more positive aspects of risk. But that is just being emotional.
Edwina Curry, many years ago when she was a health minister, nearly put
an end to the egg industry when she commented that the UK flock was rife
with Salmonella typhi. Technically she was right but the risk to public
health was something close to nil. Yet for years, before Mrs Curry’s
comments, health promotion boffins had tried to reduce egg consumption
since the heart attack risk to someone who eats more than two a week
is real. Despite that, the health promoters failed to get their message
across.
What we emotionally perceive as risky we respond to by changing our behaviour.
In the case of eggs we stopped eating them when we risked a bout of copious
diarrhoea, yet we failed to understand the longer-term risk of heart
attack. Risk, it seems, needs to be acute and in the present to affect
behaviour. Many people refuse to step onto an aeroplane, yet the risk
of death or serious injury associated with air travel is small and certainly
a risk many times less than other forms of transport, including the bicycle.
With emotion replacing a true appreciation of risk, it is not surprising
that politicians, pressure groups and the media can easily manipulate
us. They spin and we believe, and we do what is risky or, conversely,
they spin and we believe and we do not do what is not risky — if
you see what I mean. This is beginning to sound like a Donald Rumsfeld
speech so let me give an example.
A pressure group successfully demonised the measles mumps and rubella
vaccine and, with the support of one dubious piece of research, they
noisily claimed an increased risk of autism in children immunised with
it. Yet there is no risk. Over 50 good pieces of research support this
but this mischief has created a major public health crisis. In parts
of London, immunisation rates are lower than that required for herd immunity
and, as a consequence, many cases of measles have developed. Simply explaining
health risk is not enough to affect behaviour and, ironically, as the
MMR case shows, with spin, behaviour can be changed in a way that increases
the risk to health.
Take also the scares associated with the contraceptive pill in the 1980s.
Newspapers reported a major health risk for women using oral contraceptives.
The risk of stroke was doubled, the newspapers said. Women took this
statistic at face value, got scared, stopped taking the pill and became
pregnant. The result was that adverse health events, mainly associated
with unwanted and complicated pregnancies, increased nine-fold.
What researchers had found was that the number of thromboembolitic events
affecting women not taking the contraceptive pill was, let us say, one
in 100,000; for women who used oral contraceptives this went up to two
in 100,000. Yes, it is a doubling of the effect but this is a very small
effect; the unintended and resultant health problems associated with
pregnancy, however, were greater at something like nine in 100,000.
Scientists do sometimes get the calculation of risk and prediction of
events wrong. It is scientists’ job to estimate risk and they often
do this using mathematical models. Where their model turns out to be
incomplete because some factor in the complex processes of nature is
left out, risk predictions may prove to be wrong. Reassuringly, scientists
are more often correct and government is always obliged to take scientists
seriously and take necessary steps to reduce risk: to warn us, legislate
or at least print a leaflet. But when risk is identified and things do
not happen government begins to sound like the evangelical A-board men: “The
end of the world is nigh.”
Then there was the SARs virus. We were warned of a plague coming out
of the East, we took heed, looked West and switched our holidays to America
and, in the process, caused more than a few airlines to go bust. In the
end it just did not happen and we only had 60 deaths. Creutzfeldt-Jakob
Disease, also known as “mad cow disease”, was thought to
be a major health risk. We were in for it and, moreover, we had already
eaten the damned hamburgers. In the end there were 100 deaths — and
T-bone steaks are now back on the menu.
And let us not forget the Millennium Bug. We were told this was the biggest
risk ever to our information infrastructure. Millions of pounds were
set aside to ensure Year 2000 Compliance. Nothing happened. It was our
Y2K risk planning, said the smug, very rich, computer programmers and
we all thought a disaster had been averted. But nothing happened in Italy,
either, where the people, in their usual Latin way, swaggered, did nothing
and said to the bug: “Bring it on!”
So where does this leave us with bird flu? With a big problem, I suspect.
With 5 per cent mortality from an outbreak we need to be very scared
indeed. But the public simply do not understand this risk and they think,
well, scientists have been wrong before. This is a risky place to be.
A comprehensive national risk management strategy is essential. To ignore
this risk would be irrational, foolish and arrogant so I am relieved
that such a plan exists. But where, can anyone tell me, is pharmacy in
this risk management plan?
Let us not be silly; we need this plan even if bird flu turns out to
be only as serious as the common cold. |
The
Pharmaceutical Journal