With Every Epidemic, Tough Choices

[Guest guest]

The Doctor's World

With Every Epidemic, Tough Choices

By LAWRENCE K. ALTMAN, M.D.

Published: March 28, 2006

To warn. Or not to warn.

That classic dilemma in public health has been brought into sharp

focus by the A(H5N1) avian influenza virus that is spreading around

the world and has led to the death of tens of millions of birds in

Asia and Europe.

For health officials, few decisions can be as crucial as deciding if

and when to sound early warnings when they believe that an epidemic

is possible but do not know whether it will become a real catastrophe.

The dilemma often concerns the influenza virus because it continually

mutates, leading to human pandemics that predictably occur

unpredictably. Although scientists lack the knowledge to predict when

and what strain will cause the next influenza pandemic, they say they

are convinced that another one is inevitable and so preparation must

start as soon as a threat is detected.

That kind of immediate action occurred in 1976 after four cases of

swine influenza were detected at Fort Dix, a military base in New

Jersey. Fearing that the cases represented an early warning of an

impending pandemic of influenza, Public Health Service officials

rushed President Gerald R. Ford, who was running for re-election,

into recommending a swine influenza shot for every American.

Mr. Ford proposed a $135 million program to make enough vaccine to

immunize 200 million people, about 95 percent of the United States

population at the time. It was the government's first effort to

immunize all Americans against one disease in one program, and

Congress authorized it.

But the effort was suspended shortly after it began because a

paralyzing ailment, Guillain-Barré syndrome, occurred among a small

number of the 42 million vaccine recipients.

A few cases of the syndrome had been linked to influenza vaccine, but

government officials failed to mention the risk in the consent form

or to discuss it publicly.

The feared killer disease never came. But by the time the effort

ended, 535 cases of Guillain-Barré had been diagnosed, including 23

deaths, outnumbering the mostly mild 230 cases of swine flu at Fort

Dix. The virus did not spread. The immunization plan was a fiasco.

Health officials were dismissed, some say unfairly.

The episode has become a textbook case in training a new generation

of health officials about the dangers of sounding warnings too early

without having a well-thought-out plan.

The opposite problem — failing to warn about preparations for an

outbreak — occurred in 2001.

Shortly after Sept. 11, Tommy G. , then the secretary of

health and human services, went on national television to assure

Americans that the government was fully prepared to respond to any

bioterrorism attack.

Within days, the deliberate release of anthrax spores through the

postal system proved him wrong. The outbreak was small — 22 cases,

including 5 deaths. But it showed how poorly the government

communicated in a timely way to doctors and the public. It left many

government officials wanting never to be perceived as underreacting

to a health threat.

The two episodes led many people to lose trust in government health

warnings, or in the lack of them.

Warnings about A(H5N1) avian influenza began in 1997, when scientists

in Hong Kong discovered that that strain of virus had jumped directly

to cause disease in humans without first mixing in pigs, which had

been the pattern until then. With the spread of the virus among

birds, officials have warned that it could mutate, combine with a

human influenza virus and create a new one to cause a human pandemic.

That has not happened, although 105 of the 186 people in the world

who have developed A(H5N1) avian influenza have died.

Should health officials risk issuing stern warnings that may frighten

people? Or should officials play it safe, going about their business

and informing the public only when a pandemic becomes real?

If officials do issue early warnings, and nothing happens, they stand

to lose credibility among people who say that scientists promoted the

worst possibilities to grab more grants and waste taxpayer dollars.

If officials do not issue early or timely warnings, and a pandemic

occurs, critics will say the public was not informed and protected in

time.

The situation also leaves health officials vulnerable to charges

of " I told you so, " even though there is often no way to prove that

the Monday morning quarterbacks actually made their criticisms known

at the time key decisions had to be made.

Two types of dilemmas are often involved in deciding when and what

warning to give, said Dr. Harvey V. Fineberg, who wrote a book with

E. Neustadt in 1978 analyzing the government's and industry's

responses to the swine flu immunization program.

One is like a Category 5 hurricane with long odds on its occurring,

but with devastating consequences if it does.

" In such cases, the naysayer is most often going to be right, " said

Dr. Fineberg, president of the Institute of Medicine of the National

Academy of Sciences, said in an interview, referring to those who

contend preparation is unnecessary.

The second dilemma involves a tension that can arise when scientists

believe that political leaders and the public do not understand risk

as well as scientists do. Problems can arise if an expert believes

action is needed because the risk of an outbreak is, say, 10 percent,

but perceives that government officials will consider 10 percent to

be too low for action to be taken.

So the scientist may choose a way to present the facts and estimates

to persuade government officials to do what the scientist believes is

correct.

In deciding whether to warn and act, the tendency is

often " reluctance to do something that may cause harm as opposed to

allowing nature to create its own harm, " Dr. Fineberg said.

Last year, the Bush administration released a comprehensive plan to

counter an influenza pandemic. Even with it, the dilemma of when to

warn will remain.

http://www.nytimes.com/2006/03/28/health/28docs.html