The Epidemic That Never Was

President Trump is not the first president to find himself embroiled in controversy regarding the threat of a global pandemic.  In 1976, Gerald Ford found himself struggling with some of the same issues confronting Trump.  Fortunately,  Richard Neustadt and Harvey Fineberg were tasked with analyzing Ford’s response to the threat. Their report, which was submitted to Joe Califano, Secretary of Health, Education and Welfare (HEW – the precursor to HHS) in 1978, has subsequently been published in full. Neustadt and Fineberg also wrote about the affair in a separate book – the title of which I’ve used for this post – covering the same material.

 

The swine flu story is fascinating by itself, but it also offers some useful insights into the struggles that Trump has confronted in fashioning an effective response to the coronavirus pandemic.  As we shall see, some of Trump’s difficulties could have been anticipated by a careful study of the Ford swine flu case.  In the rest of this post, I lay out the facts of the case.  In a follow-up post, I’ll discuss the recommendations Neustadt and Fineberg derived from their swine flu study and try to apply those to better illuminate Trump’s predicament.  Let’s begin with an overview of the story.  

In January 1976, several recruits lodged in Army barracks at Fort Dix in New Jersey began complaining of a respiratory illness. A few were hospitalized, and one – who refused hospitalization – died after an overnight hike.  Cultures taken from the hospitalized men turned up evidence of a virus that local doctors couldn’t immediately identify. But when the sample was analyzed at the Center for Disease Control (CDC), alarm bells sounded among the epidemiologists there.  In four cases, including the dead soldier’s, the respiratory illness was caused by the swine flu.  Subsequent testing of soldiers’ antibodies revealed that some 500 had been infected by this illness. In response to the preliminary lab results, the CDC director David Sencer convened a meeting of experts from HEW, the Public Health Service, the Food and Drug Administration, and the National Institute of Health, among others – all agencies familiar to those following the coronavirus pandemic.

The health specialists were not surprised by evidence that the swine flu had resurfaced, but they were concerned – a concern predicated on four factors. First, they feared the four recruits had been infected via person-to-person transmission – something not seen with swine flu for several decades.  Second, they believed swine flu had been the primary source of the flu during the decade after World War I but as far as anyone could tell it had since confined itself to pigs.  This meant anyone under the age of 50 would have had no exposure, and no immunity, to the disease.  Moreover, since the surface proteins of this virus differed from the dominant strain of flu then circulating, it was unlikely (they thought) that exposure to other strains of flu would mitigate the impact of contracting the swine flu.  Finally, and perhaps most crucially, a version of swine flu had produced the 1918 global pandemic that caused 20 million deaths worldwide.  Although many of those had succumbed to bacterial pneumonia, which was now treatable with antibiotics, a significant portion had been killed by the flu itself.  The prospect that the Ft. Dix cases signaled the onset of another global flu pandemic was unsettling, to say the least.

The first order of business was to determine whether and how far the disease had spread. During the next several weeks, testing and inquiries of other health organizations, including the World Health Organization, found no evidence, beyond those soldiers infected at Fort Dix, of swine flu infection anywhere else. Reconvening in early March, Sencer and his colleagues now faced a difficult decision, driven by a deadline.  If they were to proceed to develop a vaccine for the swine flu, that process had to be set in motion now, in time for a possible pandemic in the next flu season because of the lengthy lead time needed to produce the vaccine.  But no one knew whether there would be a pandemic; among the experts, guesses – and they were essentially guesses – varied widely.

Guided by Sencer, the health specialists decided to err on the side of caution, reflecting in part their dominant professional ethic: to prevent harm. The logic behind their decision was deceptively simple: how could they fail to act when they had the chance to prevent a potential pandemic, however remote? Accordingly, they moved ahead with a proposal to vaccinate the majority of the population against swine flu in time for the fall flu season. It was Sencer who wrote the 9-page action memorandum that recommended that the Ford administration ask Congress for $134 million to fund the development and distribution of the vaccine nationwide.  Under the plan, the federal government would buy the vaccine from private manufacturers, test its effectiveness and set dosage levels, the states would distribute it, and public health agencies and private physicians would administer it.  Significantly, it does not appear that the health professionals gave much thought to manufacturing the vaccine but then stockpiling it pending further evidence regarding how widespread the swine flu might be. This may again reflect their innate caution – if they waited for confirmation through testing, the disease might have spread too far for the vaccine to be as effective. Better to be proactive and produce the vaccine with the goal of immunizing everyone.

By most accounts, Sencer’s memo, which was transmitted to his superiors at HEW, the Office of Management and Budget (OMB) and eventually to President Ford at the White House, drove subsequent decisionmaking.  This was, in part, because it dovetailed with the health specialists’ professional interest in publicizing the merit of disease prevention to the broader public. What better way to demonstrate the efficacy of preventive medicine!  Ford’s political advisers, however, including officials in HEW, the OMB and members of Ford’s White House domestic council, approached the issue from another perspective.  They immediately realized that the political system would demand that the administration do something; inaction, in their view, was not an option.    

The situation was further complicated because it was a presidential election year. Ford, who had assumed the presidency upon Nixon’s resignation in 1974, was in the middle of a tough nomination challenge from Ronald Reagan when the memorandum hit his desk in late March.  On March 23, the day after Ford met with health officials to discuss Sencer’s memo, Reagan won a surprise victory in the North Carolina primary. As it turned out, the election would color the media’s narrative regarding Ford’s motives in responding to Sencer’s memo.

In a meeting with the health specialists, Ford was warned about the dangers of inaction, but also the repercussions if they went ahead with full-scale vaccination only to see no pandemic occur.  He would be accused of being an alarmist and a spendthrift and would surely face consequences in November’s election if it appeared he had overreacted. Even if the vaccination program was put in place, however, it would likely not prevent widespread deaths from a swine flu pandemic.  As one adviser put it – using words that Trump would surely appreciate – Ford was in a “no win” position.

Perhaps of greater significance, however, is what Ford was *not* told.  To begin, he was not warned about potential side effects from the vaccines and the liability issues that might raise.  Moreover, no one fully conveyed the impact on his political credibility if he decided to go ahead with mass vaccination during an election year.  Already, reporters at major news outlets who got wind of the story were quoting unnamed sources in the CDC saying the vaccines were unnecessary.  To some journalists, the entire effort seemed a political ploy by Ford to boost his reelection chances. In a subsequent interview with Neustadt and Fineberg, Ford made no mention of political calculations, saying instead that he felt he had to err on the side of caution for health reasons.  As he recalled, “If you want to get 216 million immunized this requires the imprimatur of the White House.”  But certainly some of his advisers felt that Ford would get a political boost by acting decisively to protect the public’s health.  That sentiment may have blinded them to the political cost of doing so.  

On March 24, Ford met at the White House with a blue-ribbon panel of health experts – many of whom mistakenly thought Ford had already decided to pursue widespread vaccination, and that the meeting was just for show. Ford, however, wanted to be sure he heard from health specialists who might oppose Sencer’s recommendation.  None did, at least not at the meeting, despite Ford’s offer to meet separately with individuals who wished to voice dissent.  Shortly after the meeting, Ford stepped outside and flanked by Jonas Salk and Albert Sabin – national heroes for their work developing the polio vaccine – announced his request to Congress for appropriations to fund a mass vaccination program to prevent a recurrence of the 1918 flu pandemic.  The press, however, cast a jaundiced eye on Ford’s announcement; on the nightly news covering Ford’s decision to request the money, all three major broadcasts quoted open sources saying the mass vaccination program was not justified.  

Within a month, Congress voted overwhelmingly in bipartisan fashion to appropriate the requested money, and the program to develop the vaccine was underway.  What ensued next was a series of unanticipated problems that plagued and eventually, in the eyes of many, discredited the entire effort to vaccinate the nation against the swine flu.  I take those up in the second part of this story, as well as the lessons Neustadt and Fineberg draw, before applying those to the current effort by the Trump administration to combat the coronavirus.  What, if anything, can the swine flu case teach us regarding Trump’s response to the coronavirus?