The fast-spreading outbreak of a new coronavirus in Wuhan, China, has spurred a cascade of public health responses, which some critics have faulted for sluggishness, others for overreach. Millions of Chinese have been quarantined, foreigners (including more than 200 Americans) have been evacuated from the region and flights to the country have been curtailed.
There is real cause for concern. As I write, at least 170 people have died among nearly 8,000 known to be infected, virtually all in China. In the U.S. as of midweek, five people returning from the region were found to be positive among the first few hundred tested.
But some perspective, in relation to similar threats, is also in order. The Centers for Disease Control and Prevention estimates that, so far this winter, at least 140,000 in the U.S. have been hospitalized with seasonal influenza, with at least 8,200 fatalities. And this has been a fairly mild flu season.
Easily obscured in the coronavirus story are the difficult decisions that public health officials face as they struggle to avert or subdue a crisis—decisions that often must be made quickly based on scant information. Should borders be closed? Should vaccine production be increased? Should local schools shut their doors?
As a former emergency room physician now engaged in emergency health research, I’ve seen how these calls are made at various levels of government, which must figure out when and how to act—and whether to act at all. A look at three episodes from the annals of epidemics in the U.S. reveals some lessons worth heeding as the news unfolds.
Overreaction can be just as damaging as under-reaction. In February 1976, a soldier at Fort Dix in New Jersey died from a mysterious but fast-acting virus identified as a strain of pig influenza—a member of the H1N1 family of pathogens responsible for the 1918 influenza outbreak that killed as many as 100 million people world-wide. Amid fears of another deadly world-wide influenza pandemic—but after only one death—officials ramped up production of flu vaccine and aimed to inoculate every person in the country by autumn.
The project posed risks for the hard-won public acceptance of vaccination programs. Such a large number of flu shots could be inaccurately blamed for deaths that would statistically be expected in the population and thus spur a backlash. Dr. Hans Newman, a public health official from New Haven, Conn., warned, “Can one expect a person who received a flu shot at noon and who that same night had a stroke not to associate somehow the two in his mind?”
The concern led some public health officials to advise that the vaccine should be merely stockpiled, but President
decided to proceed with the vaccination campaign. “No one knows exactly how serious this threat could be,” he said at a White House briefing. “Nevertheless, we cannot afford to take a chance with the health of our nation.”
Inaction is the bane of all politicians, but a wait-and-see approach is often the most prudent medical course to take. Sure enough, when three elderly people died after receiving flu vaccinations at one clinic, the backlash was so severe that
tried to reassure the public about vaccinations on his evening news show. In the end, not one person died from swine flu, but thousands claimed ill effects from the vaccine, a number of judgments were won in lawsuits against the government and the director of the Centers for Disease Control (as it was then called) was forced to resign.
Choose official words carefully. In 2009, swine flu again threatened, but this time it was accompanied by a different sort of viral outbreak:
For the first time, a disease had its own hashtag, #swineflu. After 30,000 cases had been diagnosed across 74 countries, the World Health Organization declared a pandemic. Following the example of President Ford, who had been vaccinated on national television in 1976, President
rolled up his sleeve and sought to turn his own vaccination into a teachable moment.
Inaction is the bane of all politicians, but a wait-and-see approach is often the most prudent medical course to take.
But the official messaging changed during the year, leading to public confusion. In April, President Obama said that there was no cause for alarm, but in October, based on new data, he declared the H1N1 outbreak a national emergency. In the end, the 2009 influenza season turned out to have been much less deadly than usual.
An investigation led by the British Medical Journal later reported that some of the experts who had been advising the WHO had not revealed their financial ties to the pharmaceutical industry. And the WHO later conceded that it had been sloppy in using the word “pandemic,” which it had meant to convey only that swine flu was widely dispersed. Its own website referred to “enormous numbers of deaths and illness,” which a WHO spokesperson called a mistake that painted “a rather bleak picture and could be very scary.”
Victory is often temporary. In December 2014, a nurse named Nina Pham contracted Ebola from a patient in Dallas. She was transferred to the National Institutes of Health in Bethesda, Md. and treated by a team led by
director of the National Institute of Allergy and Infectious Diseases.
When Ms. Pham was discharged, the cameras captured an indelible moment: Together with NIH Director
Dr. Fauci, dressed in a crisp white lab coat, walked her out with his arm draped over her shoulder. This conveyed a critical message at a time when public fear about the disease was widespread. “We would not be releasing Ms. Pham if we were not completely confident in the knowledge that she has fully recovered, is virus free and poses no public health threat,” an NIH statement read.
But scientific certainty often carries an asterisk. Six months later, doctors in Atlanta discovered that in some patients who survive, the Ebola virus could still be found hidden away in parts of the body. This did not indicate that they could transmit the disease, but it meant that they could no longer be declared “virus-free” with certainty. This episode demonstrated how quickly our knowledge about public health threats can alter. What we once thought was true for the Ebola virus had changed, and no doubt will continue to evolve.
We must not play down the threat from the new coronavirus. But placing it in historic context can allow us to catch our collective breath. The lessons of these previous public health crises are familiar to those tasked now with our health and safety. How we respond to the current outbreak in Wuhan may one day be taught in public health classes to a cadre of eager students. Such instruction must also include one enduring precept: Modern medicine, especially in such unprecedented situations, is still full of uncertainty.
—Dr. Brown, writing in a private capacity, is Director of the Office of Emergency Care Research at the National Institutes of Health. He is the author, most recently, of “Influenza: The Hundred-Year Hunt to Cure the Deadliest Disease in History.”
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