In my previous post, I revisited the effort by another president – Gerald Ford – to address a different potential pandemic. This was the 1976 swine flu case, documented so ably by Richard Neustadt and Harvey Fineberg. I ended the narrative at the point when Ford decided to follow the recommendations of his health experts by adopting a strategy first laid out by CDC (Center [now Centers] for Disease Control) head David Sencer. That strategy is summarized below, in an excerpt from the memo Sencer drafted that was signed and forwarded by Assistant Secretary of Health Theodore Cooper to Ford.
As noted in the previous post, Ford largely adopted Sencer’s recommendation. Congress, acting quickly, and in bipartisan fashion, overwhelmingly voted to appropriate the requested money, and the vaccination program was underway. What followed, in Neustadt’s words, “was a long series of unanticipated or underestimated troubles.” To begin, it was not always clear who led the immunization program; although Sencer oversaw actual coordination, both he and Cooper were name co-directors, which somewhat blurred public perception regarding responsibility. Second, in testimony before Congress, Cooper stated that immunization would be offered to 95% of Americans, echoing Ford’s promise to inoculate practically every man, woman and child. However, although the CDC asked manufacturers to produce 200 million doses (the U.S. population was then about 215 million), manufacturers warned that they would not be able to meet that goal in the required time frame. By late fall, they had produced about 165 million doses, which meant had the epidemic hit during the next flu season, a substantial portion of the population would still be unprotected, despite assurances to the contrary. In a related issue, early tests on children showed that one dose was not enough to confer immunization, and so they were left out of the initial immunization effort.
In June, Albert Sabin, who had stood next to Ford when the President announced his backing for mass immunization, now recommended stockpiling the doses, rather than moving immediately to implementation of the vaccine, fueling skepticism among some doctors regarding the wisdom of the program. Sencer and Jonas Salk, however, argued for immediate implementation, fearing that to wait might risk losing valuable time to combat an actual outbreak of swine flu.
Meanwhile, manufacturers were balking at producing the vaccine because their insurers would not protect them against lawsuits. Ford was forced to ask Congress to step in and provide guarantees, which it did, albeit reluctantly, and not until August. At this point vaccine production began, but it meant widespread vaccinations were not started until October 1, almost three months after the target date laid out that spring. And when immunization did begin, it was almost immediately halted to investigate the deaths of three adults immediately after they have received the vaccination. It turned out they had died from unrelated causes, but the incidents made some citizens reluctant to get immunized.
Nonetheless, through October and November, some 45 million Americans were vaccinated – an unprecedented number historically. However, in December, vaccinations were halted again as doctors began receiving reports of a severe side effect in some individuals: paralysis or even death, termed Guillain-Barre syndrome. Scientists poured over the data, and by January concluded the probability of death from the vaccine was about one in two million, and of paralysis about one in one hundred thousand. By this time, however, not a single case of swine flu had appeared and, with public confidence in the program shaken, further immunizations were not undertaken and the program, at least publicly, seemed largely discredited.
Ford, of course, was defeated by Jimmy Carter in the 1976 election. Although some in the press had insinuated that the vaccination program was politically motivated, designed to cast Ford as a decisive leader, it is not clear that how it unfolded played a significant role in Ford’s defeat. In any event, both Cooper and Sencer were replaced by the incoming administration.
What are the lessons? It is important to note that Neustadt does not argue that Ford’s decision to follow his experts’ advice and pursue mass immunization to prevent a swine flu pandemic was wrong. But he does suggest that Ford was not well served by his advisers, and that the President did not probe deeply enough into the assumptions underlying his health experts’ advice. In their post-mortems, both in the report to Califano and the public version of that report, Neustadt and Fineberg raise the following questions – all relevant to any inquiry into President Trump’s response to the coronavirus. (In addition to the books I cited in my previous post, you might also enjoy Neustadt’s discussion of this case in his Thinking in Time, coauthored with Ernie May.)
1. Did Ford fully understand the motivations underlying the push by health professionals for mass immunization? While their paramount concern was to prevent a swine flu epidemic, Sencer and others also saw an opportunity to bolster public perceptions regarding the efficacy of preventive medicine. How much that played into their willingness to push for widespread immunization is unclear, but certainly it was something for which Ford should have been aware.
2. There were several unexamined assumptions built into the CDC’s decision to push for mass immunization. Those included the prevailing belief that major shifts in flu viruses tended to occur at relatively fixed cycles, and that a swine flu outbreak in 1976 was not inconsistent with that pattern. Moreover, those shifts were invariably followed by pandemics. These assumptions turned out to be incorrect.
3. As noted in the previous post, it was presumed that producing – but stockpiling – the vaccines was too risky, since delay might allow the virus to spread too far before effective action could occur. Among the health specialists, the idea of stockpiling seems not have been fully considered, but Ford might not have realized that stockpiling was not given serious thought.
4. Finally, there were several assumptions that went unexamined and proved to be wrong. This included the belief that the vaccine would produce no serious side effects and that there would be no liability issues; that children would be immunized with one dose; that the media would largely follow the experts’ lead and assume that mass immunization was a public health necessity; and that physicians would fall in line without questioning the recommendations of federal health officials. Although all of these were incorrect, none were questioned, it appears, by Ford or his advisers.
Underlying all of this was an evident lack of understanding regarding just how much the health specialists did not know about the swine flu. With memories of the 1918-19 “Spanish” flu hovering in the background, it was easy to accept the experts’ assurances that a swine flu outbreak was “probable” without pushing to clarify just what probable meant. In fact, as noted in the previous post, estimates varied widely among even the most well-versed epidemiologists, ranging from one in five to one in fifty. Simply put, no one could be sure, and so the default position became to anticipate the worst. But that left the Ford administration, to say nothing of his health experts, unprepared to address the possibility that nothing would happen. As an historical analogy, the 1918 pandemic served better, in Neustadt’s words, as a “warning light” rather than as the most likely outcome in 1976. It also helped support the case made by advocates of mass immunization than it did the politicians who had to deal with the political repercussions of getting it wrong.
Having warned of the misuse of historical analogies, it would be a mistake to say that the corona virus is, in broad outlines, a reprise of the swine flu case. It clearly is not. For starters, health officials, and politicians too, are dealing with a pandemic now – not the threat of one. But at one point Trump and his advisers were in a similar position as Ford: relying on medical experts to provide recommendations for addressing a potential pandemic. And it seems clear, based on the comments of Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases (NIAID) and Deborah Birx, the Corona Response Coordinator, that there is a lot that experts do not understand about the corona virus. Did Trump and his advisers probe that uncertainty? Are they doing so now? More generally, are they pushing their health experts to make implicit assumptions explicit, and to make clear what is presumed, as opposed to clearly known? Looking forward, Trump faces critical decisions, beginning whether, and when, to reduce strict social distancing as a step toward restarting economic activity. He, or his successor, will also likely face questions pertaining to undertaking a nationwide vaccination program of magnitude as great as the undertaken by Ford. Understanding what questions to ask experts is crucial for presidents to fully understand the ramifications of the different options they are given. Without that probing, it becomes far too easy to simply adopt what experts say is the preferred course of action.
The media, understandably, acting with the benefit of hindsight, has already zeroed in what they judge to be missteps in Trump’s response, attributing those mistakes to administrative incompetence, or worse. That is the media’s role, of course, but this Monday-morning quarterbacking is often too simplistic to aid in understanding why Trump made those decisions. Nor does it help Trump and advisers make better ones moving forward. For that, we need the type of analysis produced by Neustadt and Fineberg in the swine flu case – one that gets underneath the instant analysis produced by op ed writers and cable news pundits designed to elicit page views and social media clicks, and instead critically analyzes the alternatives presented by advisers to Trump dating back to the start of the pandemic, the assumptions built into those alternatives, and the degree to which Trump and his immediate aides probed the advice and information they were getting. It’s not too late to learn from the current crisis in order to make effective policy choices moving ahead. But it requires those in power to ask the right questions.
“But it requires those in power to ask the right questions”
Given this end line, are we to be optimistic that the present administration will be up to the task or are there to many ‘acting’ advisers unwilling or incapable of providing Trump with alternate opinions based on a careful analysis?
Fred – That is the question, isn’t it? My sense is that the health care experts, including Fauci, the head of the National Institute of Allergy and Infectious Diseases, and Deborah Birx, the White House Coronavirus Coordinator, are generally providing the best medical advice in what is probably an evolving set of guidelines as new data comes in. The difficulty for a layperson like Trump, or his senior advisers, is understanding the degree of uncertainty and the assumptions built into the advice Fauci and Birx are giving. If you don’t know what questions to ask, you pretty much have to rely on the medical experts to make the right decisions.
Matt, as you know, I used to work in the intelligence community. A basic set of questions, recently attributed to Gen Colin Powell when he was Chairman of the Joint Chiefs, but the formula goes back much further, went like this:
– Tell me what you know (meaning, only the facts and direct evidence, not any assumptions or conclusions)
– Tell me what you don’t know (known unknowns, as well as probing for blind spots, or unknown-unknowns)
-Tell me what you think and why (explain the logic from evidence to conclusions or opinions).
As a template for questions, that series still seems to me as good as any starting point. But I emphasize it is a starting point, because the questions that the decision maker then develops and asks of his/her advisors based on these must explore the various paths, implications, and branches that these initiate.
I used to think that most of the question development would proceed from Q#3, but I’ve seen really important lines of questioning arise from Q#1, because often the advisors or experts don’t really know what they think they know, or didn’t question their assumptions; and similarly for Q#2.
“But it requires those in power to ask the right questions”
I am very interested in this concept, as it is often the ability to formulate meaningful questions that makes for good science (and good decision making). It requires a person to be naturally curious, interested in finding answers, but also have the ability to respond to uncertainty in the answers with additional questions. Does Trump actually have these attributes?
Many US citizens, and my guess is others around the world, have many relevant questions (as of October 11, 2020). Are there signs that Trump is even asking questions?
Speaking of the law of unintended consequences, as you and Neustadt do, Michael Lewis makes a related point about how Califano’s firing of Sencer and the reports characterization of Sencer as a wily schemer, had long-term negative implications for the CDC by undermining its integrity and independence. In short Ford and his folks made a decision that turned out to be unwarranted, but Sencer was the one who was blamed. You don’t have to be an Ibsen fan to understand chronic tensions between public health people and politicians. But the CDC might have been more effective in the Trump years had it retained its onetime independence.