On “Crying Wolf”

Imagine that you are president of the United States and have just learned that your top health official wrote a warning memo to your budget director stating, “The indication is that we will see a return of the 1918 flu virus.” The director of the Centers for Disease Control and the director of the National Institutes of Health agree: It is the Ides of March, 1976, an election year.

The reason for all this concern is that a month ago, four U. S. Army recruits stationed at Fort Dix came down with influenza, one of whom died. Analyses of virus samples showed an H1N1 virus strain different from the H1N1 seasonal strains and most likely closer to the virus that had caused the catastrophic 1918 pandemic.[1] These results suggest that most Americans are not immune to this virus. As president, you might be advised to implement a nationwide vaccination campaign.

Your decision, Mr. President?

You have almost no time. Delay will make it difficult or impossible to procure the vast number of fertilized poultry eggs needed for the lengthy process of producing several hundred million vaccine doses for “every man, woman, and child in the United States.” by the beginning of the coming flu season.

If you decide to prepare, you risk a huge amount of money that is necessary to goad a dysfunctional private-sector vaccine and insurance industry into action. And of course you’ll need funding for vaccine production and vaccination campaigns. You also risk losing political capital and, perhaps, an election.

1976 (H1N1)		Prepare for Pandemic?
		Yes	No
Experience Pandemic?	Yes	You are celebrated as a hero	You will be responsible for the deaths of hundreds of thousands
	No	You may be voted out of office and ridiculed	(Almost) nobody will notice

If you decide not to prepare, you risk the lives of hundreds of thousands of people.

The President’s Decision

In March 1976, President Ford decides to prepare. Since then, there have been no further cases caused by the dreaded H1N1 strain.[2] All the money, vaccine production, and vaccination campaign efforts are wasted. Litigation about deaths -- that might or might not have been due to the swine flu vaccination -- has depleted U.S. government funds.

It is a debacle that becomes known as the “Swine Flu Affair.”[3] It contributes to further weakening of the U.S. public health infrastructure, as you would expect, after the public health establishment “cried wolf.”

What about now?

The uncertainties now are at least as great as they were then. Then and now there is evidence of human-to-human transmission, but it is not sustained. As with the 1976 Fort Dix swine flu strain, H5N1 may disappear, never to be seen again, but that does not look likely right now.

Instead of one H1N1 death, we have over 130 confirmed H5N1 deaths. H5N1 strains are mutating rapidly, spreading to new geographic regions, and to new species. The sustained case-fatality rate of H5N1 infections is far greater than of the 1918 H1N1 virus. Population density now is higher, more persons travel, and they do so at higher speed. Oh, and we are less able to produce influenza vaccines than we were in 1976.

Can we learn anything from 1976?

What can we learn from President Ford’s decision? In hindsight, there are many reasons to take issue with poor risk communication and perhaps overinterpretation of evidence.[4] But my sense is that President Ford made a courageous, highly ethical decision for the nation. He refused to risk lives and instead risked money, prestige, and an election.

You and I don’t have to make a big decision. I don’t know about you, but I’d rather be prepared without a pandemic, than be in a pandemic unprepared.

Your decision, Sir or Madam?

2006 (H5N1)		Prepare for Pandemic?
		Yes	No
Experience Pandemic?	Yes	You and yours may owe their lives to your foresight	What’s going through your mind?
	No	You have wasted money and may have made a fool of yourself	You knew it all along -- right?

---

[1] A bit of a stretch, since at the time the 1918 strain was not available for analysis. However, the clinical picture, especially the apparent preferential attack of young, healthy persons supported this hypothesis.

[2] Retrospective analyses of soldiers who had reported sick in January revealed an additional nine cases of “swine flu.”

[3] Neustadt RE, Fineberg HV.

The swine flu affair: Decision making on a slippery disease.

Washington, DC: U.S.DHEW, 1978.

[4] E.g., Stoto MA.

The precautionary principle and emerging biological risks: lessons from swine flu and HIV in blood products.

Public Health Rep. 2002 Nov-Dec;117(6):546-52.