by Richard Tofel, ProPublica
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In January 1976, flu broke out among Army recruits training at Fort Dix, New Jersey. Most of the flu, tests revealed, was of a common strain, A-Victoria, but four cases (one of them fatal) proved to be swine flu, similar to the strain that caused the 1918 pandemic that killed half a million people in this country and 50 million worldwide. Swine flu had, in 1976, not been seen in humans for more than a half century, so immunity was almost nonexistent. Further testing at Fort Dix turned up some alarming results — an additional nine cases with as many as 500 recruits who had been exposed to the virus but were asymptomatic. While a vaccine had been developed for A-Victoria and many other flu strains, none existed for swine flu. Public health authorities, led by the Centers for Disease Control, quickly became alarmed.
The CDC recommended in March that a swine flu vaccine be developed on a crash basis and that every American be vaccinated by fall. President Gerald Ford concurred, and implementation of the plan moved into high gear, with Congress appropriating money for the vaccine and later effectively indemnifying vaccine manufacturers.
The swine flu epidemic never materialized, which was fortunate because the vaccination rollout was slower than planned and riddled with problems. About one quarter of all adults were vaccinated before the program ended in December 1976. Compounding the rollout problems, about 450 people developed Guillain-Barre syndrome, a serious muscle disorder, as a side effect of the vaccine. The federal involvement in the entire episode was widely labeled a fiasco.
In 1977, Joseph Califano, the new secretary of health, education and welfare in President Jimmy Carter’s administration, commissioned Harvard professor Richard Neustadt, author of the classic “Presidential Power,” to write an after-action report on the swine flu affair, looking for lessons learned. Califano was inspired by a report Neustadt had written for President John Kennedy after the abrupt 1962 cancellation of a missile program had opened a rift between the U.S. and the United Kingdom. To help with the assignment, Neustadt recruited a 31-year-old doctor and professor named Harvey Fineberg who had studied under Neustadt when receiving a masters in public policy along with his MD and was then teaching with him. The Neustadt-Fineberg report was delivered in 1978 and later published.
Fineberg went on to a distinguished career, including stints as dean of Harvard’s School of Public Health, provost of Harvard and president of the Institute of Medicine (now the National Academy of Medicine). He is currently president of the Gordon and Betty Moore Foundation. (Gordon Moore was a co-founder of Intel.) ProPublica President Richard Tofel, who also studied under Neustadt, spoke with Fineberg this week about lessons from swine flu for the current crisis. The transcript of their conversation has been edited for length and clarity.
You probably thought this might happen one day, but I confess I did not.
I won’t say it was inevitable in any given decade or lifetime, but emerging infection is not a new phenomenon. We had HIV, which was a zoonotic transition from primates to humans. We had SARS in 2002 that killed hundreds of people and had focal outbreaks that were very difficult to contain, but were contained. We had MERS, which emerged a decade after and still is causing illness; it’s not completely out of the picture. We had Ebola. So emergent infection is not itself a novel thing. What isn’t known is what organism will be next to emerge and exactly what properties will that have that matter to us as humans, namely, how infectious, how lethal, how readily transmitted.
One of the similar aspects of both 1976 and today is the interaction between scientists and politicians, which necessarily takes place in a public health situation like this. When you’ve thought back about this, which I assume you have in recent weeks, what stands out for you?
You know, Dick Neustadt also taught a wonderful course with his colleague Ernest May about the uses of history in policymaking. Dick and Ernie made it clear that the first question one needs to ask in thinking about historic metaphors is how exactly is the current situation like, and how exactly is the current situation unlike, the past. So in thinking about lessons from swine flu days to the coronavirus crisis, the most obvious difference is that in 1976, no epidemic from swine flu occurred. In 2020, a major global pandemic from coronavirus is underway.
When you look at the process of decision making, there is a similarity in the interdependence of policymakers and scientific health advisers and experts. Very interestingly, the politicians all felt they were being compelled to go forward because the experts were telling them it had to be done. A number of the experts within the Centers for Disease Control and elsewhere understood the uncertainties about whether there would be an epidemic, and they concluded the politicians must be doing this for reasons other than pure science. As the decision went forward, one could say it did not take full advantage of all the relevant expertise on the one hand, and it was not really implemented and decided in a politically sophisticated way on the other.
Is that a similarity to what’s happening now?
In my opinion, at this moment, the answer is yes. And here’s why. The president is being forced today into a false choice between saving the economy or saving lives. That is not the actual choice.
We are in a desperate situation where the economy has tanked and hundreds to hundreds of thousands or more Americans’ lives are in jeopardy. The choice is not one or the other. The choice is what is the mix of policy and strategy and execution that optimizes the best outcome, given where we start today with both a serious pandemic and a fractured economy. From an economic point of view, ironically, there is an optimal choice. There is a dominant choice, and that choice is based on experience in other countries that we can adapt — and based on the as-yet incomplete commitment to solve this problem.
Our goal should not be to flatten the curve. Our goal should be to crush the curve. We should be mobilizing under the leadership of a supreme commander who has the full confidence of the president and can act with the full power and authority of the presidency, to mobilize every resource of the federal government, civilian and military, to win this war against the coronavirus. We should set a goal of achieving victory in 10 weeks. We should make this year’s D-Day victory over coronavirus day.
First, we need to have adequate numbers of tests available and distributed for diagnosis. We do not have that in place, and it must be within two weeks. Second, we need to provide protective personal equipment to every health professional who is going to be caring for patients. We would not send soldiers into war without body armor. We should not ask our health professionals and attendants to serve without adequate protection. Third, every citizen in the United States has a part to play. We should all be mobilized. Everyone should be maintaining physical distance. In public, everyone should now be wearing a surgical mask. Surgical masks should be delivered to every American household by the U.S. Postal Service, perhaps also mobilizing and utilizing the Amazons, Walmarts, Costcos, CVS, Walgreens and other major distributors. All should be mobilized to get those surgical masks and hand cleaner in the hands of every American household. The surgical masks do not prevent you from receiving the virus. But if everyone wears them, they will diminish the spread from those who are unknowingly infected to others.
Next, we need to test enough to be able to classify every American as documented infected, suspected infected, exposed or not yet known to be either exposed or infected. Each of those classes of Americans needs to be treated appropriately.
Everyone who is infected or presumed infected — because the test, by the way, is not perfect — should be separated into dedicated clinical facilities. Serious cases and those at highest risk should be hospitalized. Every convention center in every major American city should be converted into an infirmary where presumptive cases and documented cases with mild illness can be cared for and segregated, both from the general community and from other patients with emergent and urgent needs that are not infected.
Everyone who has been exposed to an infected person should be placed in quarantine. All the hotels that are now empty in our cities could be mobilized with the staff retrained on appropriate sanitation procedures to be able to house, in comfort, dignity and appropriate care, those who need to remain in quarantine for a two week period of time, which would allow 99% of those who are going to develop symptoms to already have expressed symptoms.
If we take these steps and we simultaneously work on new treatments, a vaccine — which, by the way, will not come online in 10 weeks but will be available as a further deterrent after the acute victory — we can turn the tide and defeat coronavirus. This is totally different from the response to the 1976 swine flu when no epidemic appeared. But this is the kind of radical approach that actually would bring together intelligent political decision making with expertise that can solve the problem from a scientific and public health point of view.
And by the way, if we do this, it is the best way to get the economy moving again. Because if we eliminate the threat of coronavirus in the space of 10 weeks, the economy can be sparked into action. If we proceed in ways that are half-measures, incomplete approaches, gradual and not effective, we will persist with people falling ill, with people fearful, with workplaces disrupted, with an inability to get the economy humming again.
That’s a very bold program and, let’s be frank, no one in political life seems to be proposing it. I just want to propose some possibilities, and ask you if you think they are part of why we are so far from what you’ve outlined. First, in your report, you say that there was a failure in 1976 to reconsider what had been known risks all along, once a strategy was set. Is that happening again?
There were two aspects that bear on your question. First, there was the original decision that rolled into one, which was making and administering the vaccine. It was true that one needed to begin immediately to manufacture a vaccine. It was not true that one needed at that moment to commit to administer the vaccine to every American. And secondly, as months rolled by and no new cases of swine flu were appearing anywhere in the world, the likelihood that the detection at Fort Dix was a one-off zoonotic event, meaning that it was a transmission from animal to human with very limited human spread, grew increasingly likely. At that point, a reconsideration of strategy would have been in order. Public health leaders believed that the best way to store vaccine was within the arms of recipients. But they did not take adequate account of the possibility that there could be a rare but severe side effect such as actually materialized with the Guillain-Barre syndrome. If there had been an epidemic that was threatening thousands of lives, the added risks to 10 or 20 per million people from an effective vaccine would have actually been part of the background, the woodwork. It would not have deterred the deployment of a vaccine that on balance was saving millions and hurting tens.
If you jump forward to today, we can learn the lessons from the Singapore, South Korea and China experiences of what can work in containing this epidemic. We can learn what it takes if we’re willing to keep our eyes open, and our minds open, to adopting strategies that others have tried. We also will need to be adaptive, because in America, as complex and diverse as our nation is, we need to be flexible about the application of policies in different parts of the country. It’s not the same in major cities as it is in rural America in terms of access, separation and challenges of logistics. So in a general way, those lessons do apply to make timely decisions and to reconsider decisions in a way that is based on evidence.
You just mentioned the very different local experiences around the country, and that was also something that you said in your report that the federal government failed to take adequate account of. Is this a weakness at the intersection of pandemic epidemiology and our federal system, that this is a big country run in diverse ways, and yet you have a central federal government that is inclined to make one-size-fits-all decisions?
American federalism can be both an asset and a handicap. It means that we do have jurisdictional variation, and therefore decisions that may be taken and correct, need still to go through the layers of decision making from the federal, state and local levels. So that’s a weakness.
The strength is because of the diversity. It is, in fact, the case that the same strategy does not necessarily apply at that moment everywhere. For example, I mentioned before that we need to establish infirmaries in new facilities to isolate cases. That would be done very differently, and with very different pacing, depending on where the epidemic stands in your part of the country, in your community. That we can only determine with adequate testing, which is another reason why testing stands at the heart of all of these strategies.
We do want to allow for appropriate variation to meet the real needs in each community and in different states. At the same time, a war footing would mean that the president’s supreme commander would need to have counterpart statewide authority lodged in one person in each state with whom to work, to both implement and to refine for local application the strategies and approaches that would be carried out. So we have an added challenge in our American system, but it’s a challenge that is consistent with the diversity and spectrum of need and circumstance in our country.
You also talk in your report about operational limitations of the CDC, that the CDC ended up getting tasked with things that might not have been appropriate for them. Is there an analogous problem today?
The CDC is a very different organization than it was in the 1970s in terms of scale and scope of expertise and capacity for mobilization and management. At the same time, the CDC is only one part of a U.S. public health system response.
CDC relative to the need has been underfunded. CDC is not fully equipped to manage in an operational way the implementation of policy and programs through every state, though it has good ongoing relations and a very willing set of state health directors. The time of a pandemic makes it very challenging to start anew to set up the necessary relations and chains of authority and responsible actors. But we have to manage it the best we can. The CDC is still a backbone of U.S. capacity to respond to a pandemic. Its guidance, its recommendations on everything from protective equipment to public health measures still matter.
What is important now is to be sure that the CDC, and the process of taking advantage of the expertise of the public health community, is not subverted to serve an otherwise incompletely informed policy agenda. In particular, the risk now is an agenda that is designed to save the economy — which, as I’ve explained, is a false choice. If that becomes more prominent, it threatens to modulate public health recommendations and judgment about the ways that the epidemic can most successfully be contained.
Is there a federal agency that has been insufficiently brought into the mix here?
I don’t know. Everyone wants to be involved. If you asked me from the very beginning, I would say this was a time when the Department of Defense and the assets of the U.S. military, which appear now to be coming online and available, needed to be rapidly assessed and mobilized in this civilian war effort. So that may be an example.
Interestingly, in the 1970s, Nelson Rockefeller, as vice president, suggested calling on the Department of Defense for assistance. As we wrote in in our report, his suggestion was ignored, as indeed were many of the vice president’s ideas at the time.
In your report you stress the need for political decision-makers to understand that experts talk in terms of probabilities, not certainties. Do you see a problem in that respect today?
Yes, this is still a serious challenge for communication and clarity between policymakers and advisers of various stripes, the informed experts. And it’s a problem on both sides. It’s not that one is deficient and the other is perfect. The expert may be unprepared and unable to communicate in ways that would be accurate and meaningful to the policymaker. On the other side, the policymaker is unable to ask the question in a form that will bring out the relevant judgment from the expert. In the 1970s, for example, as the summer wore on and no swine flu appeared anywhere, when the policymakers asked the CDC whether the epidemic was still possible, they said yes. But the likelihood of an epidemic had radically diminished. So in that case, a simple “yes” was not a very informative answer for policymakers. If you don’t know how to probe that answer and understand the scientific basis beneath it, you will miss out on critical information to inform a thoughtful decision. That problem persists. [Neustadt and Fineberg interviewed the government’s experts and found that in March most believed a swine flu epidemic was relatively unlikely, estimating the possibilities at between 2% and 20%. Senior officials never probed for those assessments. The CDC director, in a memo that reached the president, called a widespread epidemic a “strong possibility.” By late summer, before the inoculations began, experts agreed that the probability of an epidemic was significantly less than had been initially thought.]
How is that problem manifesting itself today as you see it?
Well, a small illustration: There’s some speculation about what will this epidemic do, what is the likely sequence over time. And some of those who are coming at this, mostly with an economic view, are speculating, and maybe even assuming, that over time a virus will become less severe in the human population because of some general notion that it must adapt and evolve, because if it kills off all of its victims, it’s not going to be as evolutionarily successful. Well, that maybe has some validity over millennia. But HIV was not changed from a killer to a chronic disease because the virus changed. It changed because of effective treatment. Smallpox, over millennia, did not become milder in humans. It was defeated by a global immunization campaign. So here’s an example of an ungrounded assumption that then becomes a source of comfort about longer term prospects, that simply has no good basis in scientific experience.
I’ve got one last question, before I offer you the chance to add whatever you’d like. What did happen in 1976 was an attempt to vaccinate the entire country, at least for a time. When we do have a vaccine for this virus, what do you think we need to bear in mind from the 1970s in approaching that?
The vaccine will not come in time to solve the current threat.
In the 1970s, had the swine flu actually spread across the country in the fall, the book that would have been written would have been about the failure to immunize adequately the American people who were smitten with the swine flu virus. A very different report.
So the first point about vaccine is it is not going to save us from the immediate problem. The second reality is that the public acceptance of the vaccine will depend in some good measure on the then current degree of threat from coronavirus. Very likely, this is going to be an ongoing risk, because of global travel and the fact that this virus is likely to persist in some populations in some parts of the world, and be a continuing threat to countries even where it has been eradicated.
Vaccination will still be an important part of a long-term victory over this virus. We can expect that different parts of the country and different settings will have varying degrees of success in immunization. Many people, having had personal experience with the disease among a loved one, or having lost a loved one, will be more than ready to accept the vaccine. Even if not everyone accepts it, there may be sufficient immunity generated in the public to forestall any major new outbreaks.
All of this is premised on a critical assumption, and that is long-term immunity is possible against a coronavirus. That’s not fully established. That premise will need to be amply tested, and of course it can be. The vaccine will need to be vetted in the usual way of testing for safety and appropriate dosage and then efficacy.
Apart from the technical challenge of identifying the target for the vaccine, developing the actual molecule of the vaccine, the carrier, the way in which it will be administered, there are many other questions that will need to be resolved before it will make sense to administer a new coronavirus vaccine.
Is there anything else you’d like to add?
One thing, in a way ironically, we haven’t expressly discussed is the importance of the public media in communication, and in setting public understanding, and serving as a vehicle for experts and policymakers to reach both one another and the public.
The world today is, of course, very different in its media mix as compared to the three major networks of the 1970s. And yet the same principles of working effectively with the media remains as important today, if not more so, than it was in the 1970s.
Is there any particular bit or type of misinformation flying around at the moment that concerns you especially?
I can’t tell you the number of internet-based solutions to this problem that friends or family or acquaintances have sent to me, and asked, can you comment on this or that — it would be an endless task. There’s any number of flawed ideas, ranging from deep breathing, to it doesn’t really matter if you’re close to people. Virtually all of those are unfounded.
What about the drug combination that the president seems to be promoting?
Well, you know, it’s easy to get out ahead of yourself on drugs. Pharmaceutical development efforts show clearly how many promising agents fail, even though they were theoretically effective against this or that target, or this or that type of patient, but when applied in practice did not measure up to the hope. So that speaks toward a degree of accurate caution in describing the state of knowledge about different agents, none of which is to deflect us from aggressively testing a whole range of potential antiviral agents that could play a part in saving lives.