Epidemic? Says WHO?

By Rebecca Oas, Ph.D.   | April 20, 2017

Earlier this week, the World Health Organization (WHO) hosted a webinar to discuss its updated guidance on Depo Provera, issued in response to reports suggesting its users may be at increased risk for acquiring HIV.  As we reported in the Friday Fax, WHO called for women to be given counselling, but continued to encourage the use of Depo among women at high risk of HIV on the grounds that the downsides were outweighed by the benefits.  These benefits are presumably limited to the avoidance of pregnancy.

In a FAQ about the new guidance, WHO states:

“The recommendations were prepared according to the standards and requirements specified in the WHO handbook for guideline development with due attention to human rights standards and principles, as well as consideration for the balance of benefits and harms of contraceptive use and values and preferences of end-users.”

It would be interesting to know how those values and preferences were weighted in creating the guidance.  The typical measurements of desire to avoid pregnancy frequently ignore high levels of ambivalence among women forced to express their feelings in a yes-or-no question.  Meanwhile, it is probable that the same women would be far less ambivalent about their desire to avoid HIV.  Women’s attitudes about becoming pregnant, as well as about contraceptive use, involve complexities that are often obscured by boilerplate family planning talking points that equate non-use with lack of access, and thus, a human rights violation.

One of the more interesting parts of the webinar came at the end of the official WHO segment explaining the guidance, before turning the discussion over to other members of the related study group.

The WHO representative affirmed the organization’s commitment to addressing the “twin epidemics of HIV and unintended pregnancy.”

In advocacy literature that prioritizes alarm-raising over technical accuracy, it is not unusual to see the word “epidemic” deployed to signify scale in the absence of infectiousness.  However, the use of epidemic terminology in the metaphorical rather than literal sense invites scrutiny when it creeps into more elite settings.  For example, WHO characterized obesity as an epidemic in a 1988 report, as did the U.S. Surgeon General in a 2001 “call to action.”  In their article “The US Obesity ‘Epidemic’: Metaphor, Method, or Madness?” Gordon Mitchell and Kathleen McTigue credit the Surgeon General’s “rhetorical effectiveness” in part to the use of epidemic terminology, but acknowledge:

“…several features of the Call to Action leave it vulnerable to criticism that the report’s utilization of the epidemic metaphor constitutes evidence of institutional “madness.” Rhetorical theory shows how the resulting controversy plays out as a frame conflict, the outcome of which has the potential to shape both patterns of public deliberation and policy-making agendas. This line of analysis helps clarify a source of confusion in debates about whether there is in fact an “obesity epidemic.” In many cases, different answers to this question flow from different assumptions regarding the literal or metaphorical status of the term epidemic.”

The authors suggest that the U.S. might adopt a literal response to the metaphorical obesity “epidemic” and deploy the Epidemic Investigation protocol to attempt to address it.  In closing, they write:

“…it is apparent that new forms of intellectual collaboration that bridge standard categories of knowledge production will be helpful in meeting the challenge posed by the advent of complex chronic disease patterns.”

To a cynical mind, that might sound less like a call for advances in medical science than an invitation to those seeking to spin the straw of hyperbole into (literal and metaphorical) policy gold.

The question of whether it makes sense to address the metaphorical “epidemic” of obesity with interventions more typically used in literal epidemics is an interesting one, but its answer cannot be resolved by semantic sleight of hand.  Doctors frequently prescribe medicines for “off-label” uses without intentionally misdiagnosing their patients with “on-label” conditions to justify the prescription.

Similarly, the U.S. could choose to adopt an “epidemic-like” response to obesity without provoking think pieces about whether its chief surgeon used the word “epidemic” in a literal or figurative sense.  It just might not be as “rhetorically effective” in stirring up concern.

Finally, returning to WHO’s “epidemic” of unintended pregnancies: if the notion of an obesity “epidemic” could be characterized as “madness,” this surely qualifies as full-on barking-at-the-moon psychosis.  At least obesity has been classified as a disease by WHO as well as the American Medical Association, whereas pregnancy, intended or otherwise, has not.  Like obesity, pregnancy is not infectious, which further rules out the use of the literal form of “epidemic.”  But to use it in a metaphorical sense is incredibly irresponsible given the context in which it appeared in the webinar.  The reference to HIV and pregnancy together as “twin epidemics” implies that either both are literal or both are metaphorical.  Yet no one denies that the HIV epidemic is very literal indeed.

The characterization of unintended pregnancies as an epidemic raises further potential questions. For example, given that regions with high desired fertility tend to have lower levels of unintended pregnancy, why does WHO seek to send them Depo instead of holding them up as exemplary leaders in tackling the “epidemic?”

In conclusion, it is notable that WHO’s motivation to preventing unintended pregnancies seems to exceed that of the women it seeks to serve.  Moreover, its eagerness to characterize human fertility as a disease state is a very “rhetorically effective” way to justify the promotion of drugs and devices with dangerous side effects and health risks.  Promoting the protection of women from a metaphorical “epidemic” by increasing their risk from a literal one is a much bigger problem than linguistic imprecision alone.