Risks Compared, 2001/08/23:09:29
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Biology
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West Nile virus has been confirmed to be present in a bird in Southwestern Ontario. Health authorities are apparently warning people to stay indoors, wear long sleeves, slather themselves with insect repelant containing DEET, and run for the hills. The death rate from West Nile virus in the U.S. last year was 0.01 per hundred thousand people. The death rate due to mistakes by doctors was, being conservative, between 1 and 10 per hundred thousand people (estimates of iatrogenic mortality range as high as 100 per hundred thousand, but let's be generous.) The death rate from anti-biotic resistant bacteria was 5 per hundred thousand people. The overall death rate was 500 per hundred thousand people. All of these things are health risks. None of them except possibly anti-biotic resistant bacteria are public health risks. What's a public health risk? It's a risk to the average person that is largely independent of that person's actions: it is something that's difficult for an individual, acting alone, to control or limit. Clean water and effective sewage treatment are public health issues, because they can't be dealt with by individuals alone when the population density is reasonably high. Going to the doctor is not a public health risk because it's largely in the control of the individual patient--you should not blindly trust your doctor to do the right thing, and should look at your doctor as one aspect of the health-care delivery process. West Nile virus is not a public health risk (or, by ordinary standards, a health risk at all) because the only people at risk from it are the very elderly, and the best approach is for the small number of individuals at risk to take appropriate precautions. We might want to say that care of the elderly is a public issue, but it isn't a public health issue. Anti-biotic resistant bacteria are a public health risk, albeit a relatively small one that I think, given the millions of years of anti-biotic usage already behind us, is likely to remain small. While looking up the data on death rates I was surprised to find that the death rate from anti-biotic resistant bacteria is relatively flat across age groups, which suggests fairly uniform vulnerability across the population. In contrast, the death rate from all causes roughly doubles each decade from 15-25 onward as the aging progress goes on. Furthermore, there is some evidence that prescription patterns to have an effect on the prevalence of these bacteria, which is hardly something under an individual's control. When discussing public health risks, one is always discussing allocation of public resources because the only way we know how to deal with these things involves actions by governments. There is not now nor has their ever been a free market in sewage, and problems like effective sewage treatment have always required action by governments, with all the private and public corruption and peculation that entails. So while the popular press (including a front-page article in the Globe & Mail yesterday) seems intent on making out West Nile virus to be the next Black Death, it doesn't seem to serve much purpose to focus a lot of attention on miniscule threats whose only notable feature is that they're new, especially given the state of Canada's public infrastructure for water and sewage treatment. It will be a long, long time before the death rate due to West Nile virus comes anywhere close to the death rate due to improperly treated water. |
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Reading
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I've been reading George MacDonald Fraser's Flashman books lately. They're an interesting worm's-eye-view of Victorian history, where "worm" can be taken in many ways. The framing device for the stories is that they're the memoirs of Harry Flashman, the bully from Thomas Hugh's classic Tom Brown's School Days, who is a viscious coward blessed with fine looks and a convivial aspect to his character that gives him a superficial appearance of likability. Written when Flashman is an old man, they are his opportunity to tell the truth about his life, which has seen him rise to the highest ranks of Victorian society based on his ability to lie and bluster. Flashman is a despicable character, and yet he proves to be an effective reporting device for a fairly despicable age. Indeed, far from being outstandingly vile he comes across as a natural product of his times, a fairly rational if not particularly intelligent person responding to irrational circumstances. He clearly understands that the reigning morality is inhuman, but doesn't have anything much to replace it with beyond "to thine own appetites be true". There's always a tendency in historical novels for authors to project modern values on their protagonists. By setting out with the premise that Flashman is an immoral character, MacDonald Fraser has effectively short-circuited this tendency. Flashman can be portrayed honestly, echoing verbatim the attitudes of men of his class and time about women, non-whites and the lower classes without any outrage on the part of the reader precisely because we know he's a cad. I've read enough Victorian history to realize that the attitudes he's portraying were fairly common, but no one writing a book today would think of depicting them in a character we're supposed to see as heroic or good. Flashman's view of the world can be summed up as: "Everyone weaker than you is to be exploited at your convenience. By default, assume that anyone other than an Englishman of your own class is weaker than you, although there will be a few exceptions here and there who have to be treated with respect. Toady up to anyone stronger than you. Remember that appearance is more important than reality. When in doubt, run away." There were certainly heros in the Victorian age--Flashman meets Raja Brooke on his travels, for example. But there was also a huge amount of incompetence and outright maddness, which was particularly obvious in the military. Yet the myth of England required that the heros be brought to the fore and the failures glossed over, no matter how egregious they were. After all, the cost was usually only a few thousand more dead young men, mostly of the lower classes, and there were always more where they came from. The person who comes most to mind when reading the Flashman books is Bill Clinton--a compulsive womanizer (the number of ways a Victorian gentleman could say "had sex with" is astonishlingly large) with a superficially winning character and no concept of truth. Flashman's great redeeming feature is that his cowardice and dishonesty inevitably land him in terrible circumstances (the retreat from Kabul, the India Mutiny, the charge of the Light Brigade...) and he sometimes even has to stoop to honesty and courage to get himself out again. |