If more proof were required to establish that swine flu has caught the imagination of the media and the public across the world, here it is: a video game called “The Great Flu,” created by Dutch scientists in what they say is an effort to raise public awareness. The game, which is free and can be played only online, apparently challenges players to control a new pandemic. It begins with images of bedridden patients and graveyards from the 1918 Spanish flu. As head of the fictitious ‘World Pandemic Control,’ each player picks a flu strain and monitors its spread around the world.

According to Albert Osterhaus, head of virology at the Erasmus Medical Centre in Rotterdam, who designed “The Great Flu” along with colleagues, the video game’s approximation of the process of combating a pandemic, requiring players to choose between various interventions while keeping a watch on the spread and impact of the outbreak as well as the budget, may help people understand how difficult it is to make decisions regarding public health.

If everyone in the government and the media dealing with swine flu in India had had earlier access to the game maybe some of the errors and excesses of the past few weeks could have been avoided.

Much has already been said and written on the media’s role in generating panic over the present pandemic and much of it has already, predictably, been denied. In response to a recent “non-advisory” issued by the Ministry of Information and Broadcasting to TV news channels on the subject, “cautioning” against or “conveying concern” about “creating panic,” the (unnamed) editor of a leading news network is reported to have said, “News coverage is always a subjective thing. Some may feel that we are exaggerating matters, and we respect all viewpoints… There’s panic among people. Schools, malls and cinemas are being shut. We are not spreading any panic.”

The ongoing debate over who ignited and who fuelled the panic is reminiscent of the squabble over who was more responsible for the problematic media coverage of the terrorist attacks in Mumbai in November 2008: the media (specifically news television), which was guilty not only of hyperventilation but some fairly serious mistakes, or the government, which did not respond to the crisis in a coordinated manner with designated spokespersons authorised to provide clear information to the public through the media. It appears that neither party is able or willing to learn from the past.

In this case, the government clearly failed to plan strategy in a timely, sensible, systematic and scientific manner despite the substantial time-lag between the first global alerts about the swine flu pandemic and the arrival of the A(H1N1) virus in India.

According to Dr T Jacob John, who formerly headed the Department of Clinical Virology at the Christian Medical College, Vellore, “Had the government not responded in panic and plunged into kneejerk responses, instead of taking proactive and deliberate steps, soothing the fears of the public and appointing specific, informed spokespersons to present the official view, the anarchy witnessed in the first couple of weeks of August could have been avoided… This time we may have got away with our less-than-professional approach because the disease is a mild one; the next time around we may not.”

He believes the media, too, played its part in magnifying the fear psychosis: “They pictured a disastrous epidemic when there were only a few cases, and carried on with the self-fulfilling prophecy of projecting the growth of the epidemic, with more expert opinions than facts…” To make matters worse, he points out, while seeking opinions, the media failed to distinguish between medical experts and public health experts, whose areas of expertise are different.

Which came first?

It is difficult to pinpoint which was the chicken and which the egg, who said what first, what was misquoted or presented out of context when, but it is clear that the resulting confusion and conflicting news and views in the media caused fear and uncertainty among the public which, in turn, led to considerable overreaction and irrational behaviour.

As Joshua Holland noted on Alternet, an award-winning online news magazine, way back in April, when the US was going through a similar situation, “With the media stirring up a frenzy of panic over the flu, hospital emergency rooms are going to be jam-packed with people suffering from head-colds, some providers may be overwhelmed and shut down if the number of cases increases significantly, and it’s entirely possible that someone will die as a result of the crunch. If that should happen, it’ll be murder by media hype, although nobody will be held culpable for approaching The Big Story with anything less than complete and utter hysteria.”

He could just as well have been writing about the situation in India, especially in the first half of August. Apart from overcrowded hospitals and overwhelmed health services in places where the presence of this particular form of influenza had been established, the impact of the hysteria was felt further afield.

For example, according to a recent report in The Times of India, attempts to identify a hitherto unknown virus that has already caused the deaths of at least 166 children suffering from Acute Encephalitis Syndrome in Uttar Pradesh this year have been stymied by the preoccupation with swine flu. The National Institute of Virology in Pune has reportedly been too inundated with samples to be tested for the A(H1N1) virus, which had caused an estimated 93 deaths across the country (as of 30 August), to be able to devote due attention to AES.

And, of course, the scare-mongering created favourable conditions for the exploitation of gullible and vulnerable people. Some healthcare entrepreneurs were quick to offer magic remedies to prevent or cure swine flu. Others obviously decided to take advantage of the panic to make a quick buck. The Bangalore edition of The Hindu recently reported that some private hospitals in the city had begun charging between Rs. 1500 and Rs. 2500 for a nasal/throat swab. Shashidhar Buggi, Director of the Rajiv Gandhi Institute of Chest Diseases, pointed out in the report that this is more than five times the actual cost of this elementary procedure. Masks – many of them spurious – were sold at a premium in many places.

According to Holland, in instances of what are known in public health circles as “catastrophic infectious disease outbreaks” (CIDO) the disease itself is only a small part of the bigger picture: “It’s the ancillary effects a CIDO can have on an entire society — especially the healthcare delivery system and other vital services — which have historically caused as much death and suffering as the underlying infectious disease organism that caused the outbreak.”

At present it is not even clear how many of the deaths attributed to A(H1N1) were actually caused by swine flu. Although the media continue to highlight deaths ostensibly due to swine flu, even featuring human interest stories about the victims and their families and friends, there is little evidence of parallel efforts to uncover medical details about the deaths which could help determine whether the fatalities were caused by true viral pneumonia or secondary bacterial pneumonia (which is eminently treatable with antibiotics) or indeed other ailments, pre-existing or otherwise.

Glamorous virus?

Why is it that swine flu makes major national headlines while encephalitis, which has claimed many more lives this year (not to mention malaria, tuberculosis, gastro-enteritis, etc.), does not? Even dengue and chikungunya, which regularly afflict many people across the country, do not merit the kind of media attention swine flu has received despite the fact that some deaths from dengue are being reported even now, even in cities captivated by the present pandemic.

Could it be that the A(H1N1) virus is more glamorous – imported from abroad, declared a pandemic and monitored by the World Health Organisation, etc.? Could the fact that it made its debut in India as an urban phenomenon, initially thought to affect mainly globe-trotting, high-flying middle and upper class people, have played a role in catching the attention of the national news media, which cater primarily to that particular section of the country’s population? As American medical sociologist Bart Laws observes, “News stories about something that could affect any one of us are particularly saleable.”

However, he also identifies “the social amplification of risk” as one of the most important factors involved and points out that this is primarily done by the mass media. Well-known American public health blogger, Cervantes, explains the concept thus: “Worries can be contagious, and rapidly infect people within a social group. In modern society, the mass media are by far the most powerful carriers of contagion… ‘Pandemic’ influenza has come along to create another misleading, damaging media feeding frenzy.”

According to him, “What nobody bothered to do was to put these events in any sort of perspective. In fact, the incidence of influenza and the rate of serious complications was entirely normal. If we did not have the recently acquired ability to rapidly and cheaply sequence viral genomes, nobody ever would have known that anything identifiable was happening whatsoever. The ‘news’ was generated entirely by the act of labeling ordinary events as significant based on laboratory findings that reified the invisible.”

Passing the buck via SMS

There are a couple of other sidelights to the current “flu-steria” that raise interesting questions about the interface of media, communication and public opinion. Take, for example, the decision of the Municipal Commissioner of Mumbai to conduct an sms poll to determine whether or not schools should be closed to contain the swine flu outbreak. Is it possible that Commissioner Jairaj Phatak could have been influenced by the daily diet of sms polls on all manner of subjects served up by multiple news channels?

By saying, “If majority of people feel that there should not be anything and schools should be closed, we will do that,” he conveniently sidestepped mounting political pressure, passing the buck to parents and the general public. Could this be the beginning of a new trend in governance? Will others in official or political decision-making positions follow suit?

For instance, will the question of which districts will be declared drought-hit now be settled via sms polls? Will the Finance Minister conduct an sms poll before drafting the next union budget – or, indeed, finalising the new tax code? Will environmental clearance be granted on the basis of sms polls in order to avoid corruption? Will governments send sms messages to those likely to be displaced by projects such as dams, power plants, mining, SEZs, etc., to solicit their opinion on whether or not they are willing to hand over their land for the supposed greater good of the nation?

By the way, no prizes for guessing the likely results of an sms poll seeking the public’s opinion on Sonia Gandhi’s reported recent directive to Congress Party MPs, MLAs and MLCs to accept a 20 per cent pay cut for a year as an austerity measure in view of the drought ravaging large parts of the country and causing extreme distress among large numbers of people.

In a country where political leaders and governments at all levels constantly and consistently cock a snook at public opinion on many important issues of public interest, what do we make of the Mumbai Municipal Commissioner’s sudden willingness to abide by people’s feelings about the closing of schools in the time of flu?

Who over-reacted first?

A recent episode of “We the People” on NDTV (16 August) focused on swine flu, asking the question: is India over-reacting? It was the usual kind of discussion on this weekly talk show, with too many panelists getting too little time to say anything remotely substantial and meaningful, and too few “people” getting even less time to raise legitimate questions and express their opinions. Even though the show’s anchor Barkha Dutt herself posed the question, “Is it media that drove the panic?” every time someone suggested that it was, she responded with a broad, indulgent smile indicating that she was going to take the predictable media-bashing in good humour but not too seriously.

Yet there were several references to the media in the course of the discussion. The principal of a well-known school in the capital, trying to justify the school’s decision to close the junior section because of the anxiety over swine flu, said, “If even one child was lost, the media wouldn’t have spared us.” Clearly the media frenzy over the death of schoolgirl Akriti Bhatia in April was still fresh in her mind. A member of the audience suggested that instead of looking for novelty to excite people the media need to focus on educating people.

It was a non-Indian in the audience who brought up the issue of India’s abysmally low expenditure on health, suggesting that the present focus on the swine flu pandemic could be used to address this important issue. But, of course, in the reams of newsprint and hours of air-time expended on the issue, hardly any attention has been drawn to such larger concerns – honourable exceptions aside.

Nor has there been much meaningful inquiry into the continuing high prevalence of many preventable diseases and the unacceptable levels of death and disability caused by what are basically treatable ailments, both of which raise fundamental questions about our environmental and healthcare priorities.

A well-known public health activist on the show highlighted the need for more education on health and hygiene at both personal and societal levels. But few in the media have paid much attention to the appalling lack of public hygiene in the country, which contributes to the spread of communicable diseases. One of the handful of exceptions was a recent article on the op-ed page of The Hindu (19 August) which asked the question: Are Mumbaikars wearing masks for all the wrong reasons?

One of the most interesting aspects of the show was the spirited defense of public hospitals by people who had been successfully treated for swine flu – despite leading questions reflecting familiar middle-class skepticism about the country’s public health system. A young girl from Pune who had recovered from swine flu said the attending doctors had not only provided information at every stage but, together with “the nurses, ward-boys and everybody, comforted and consoled us so much.” Her father added, “We would see the same doctor at seven o’clock and then at 9.30 with the same smiling face – through all the five days. Hats off to those doctors – they were excellent.”

An obviously affluent couple from Delhi, who were among the first to be diagnosed as H1N1 positive on their return from a holiday in the US, also highlighted their positive experience at the public hospital to which they and one of their daughters were admitted. Arun Gupta went so far as to say that that the next time they are in need of medical care they will definitely go to a government hospital. Interestingly, this statement was greeted with applause from the audience.

This particular couple, Arun and Anju Gupta, had been earlier interviewed on Times Now, introduced as “survivors” of swine flu. The editor-in-chief of the channel, Arnab Goswami, who anchored the discussion, began with an obvious reference to criticisms about the media’s handling of the pandemic: “The focus has been on information, not hype. We have tried to break misconceptions but the fact is, the reality is, that H1N1 has spread, it has spread across many metros. So there is no point downplaying the information that we have…”

The first question put to Anju Gupta exposed what he wanted to hear: “How bad was it? How bad was the experience? … Because for a lot of viewers who are hearing the fact that it is like any other influenza, it is not so bad, it is not fatal, it doesn’t always aggravate…, what can you tell us as someone who has been through it?”

Although most of the interviewees, including doctors and a state health minister, responded to such loaded questions with sober answers that suggested that it really was “not so bad,” the information scrolling at the bottom of the screen of the screen conveyed another message: Chennai’s first death, 4-year-old dies of H1N1, boy put on ventilator, school closed for a week, cases on the rise in Bangalore, Karnataka records over 85 cases… To be sure such information was interspersed with practical, useful advice against self-medication, for covering the face while coughing or sneezing, etc. However, the overall tone and tenor of the programme (“How does the country handle this?”) created the impression of a deadly, out-of-control crisis.

The most perceptive response to the “We are not spreading any panic” defensive declaration mentioned earlier was provided by Arun Gupta on the NDTV show. According to him, the panic was created by the media. There are two ways of reporting something, he pointed out: one is to have breaking news that 10 people died because of swine flu; the other is to report that 50 doctors all over India saved 10,000 lives.

Belated course correction

Happily, the message appears to be getting across to the media, albeit belatedly – witness the front page headline in The Times of India on 25 August: “350 cured patients prove swine flu’s no big killer” and an NDTV news anchor’s remarks the same night highlighting the fact that not only have countless people have been successfully treated for swine flu but many others have recovered from it without any special treatment.