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Foreword The swine flu program of the Federal government was launched in March 1976 with a White House announcement by President Gerald R. Ford. The program was finally set aside in March 1977, when HEW Secretary Joseph A. Califano, Jr. stated influenza prospects for the coming year. These did not include swine flu. The program thus out- lasted, although not for long, the Ford Administration. The National Influenza Immunization Program, the official title for this venture, was unprecedented in intended timing and in scope among American immunization ef- forts. It aimed at inoculating everyone before December 1976 against a new flu strain that might conceivably become as big a killer as the flu of 1918, the worst ever. The program was funded by Congress through a $135 million appropriation, and it was later buttressed by special legislation in the field of liability. It was conducted through state health de- partments, with technical assistance from health agencies in HEW. Inoculations started late, October 1, 1976. They had been slowed somewhat by difficulties in deciding chil- dren’s dosages and seriously stalled by liability issues. On December 16, the program was suspended to assess statistical evidence of a serious side-effect. Mass immunization never started up again. As a full-scale operation, the program’s life was thus not twelve months but two and a half. The killer never came. The fact that it was feared is one of many things to show how little experts understand the flu, and thus how shaky are the health initiatives launched in its name. What influenza needs, above all, is research. Decision-making for the swine flu program had seven leading features. To sim- plify somewhat, they are: • Overconfidence by specialists in theories spun from meagre evidence. • Conviction fueled by a conjunction of some preexisting personal agendas. • Zeal by health professionals to make their lay superiors do right. • Premature commitment to deciding more than had to be decided. • Failure to address uncertainties in such a way as to prepare for reconsid- eration. • Insufficient questioning of scientific logic and of implementation pros- pects. • Insensitivity to media relations and the long-term credibility of institu- tions. These and other features are discussed and qualified below. One thing we are convinced the program was not. Whatever the contemporary no- tions from outside, it wasn’t party politics; President Ford wanted to protect the public 1
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health. In the year of its formal existence from March to March, the swine flu program chalked up numbers of accomplishments which give it weight historically. In these terms it may go down as a qualified success. More than 40 million civilians were inoculated, twice the number ever reached before in one flu season. A notable surveillance system was developed, better than anything before. A serious side-effect of influenza vaccina- tion, Guillain-Barré syndrome, occasionally fatal, was tracked by that system and remains under investigation. A critical policy problem for all public health interventions and re- search, the problem of liability, was brought into sharp focus for the first time; it is now being addressed at policy levels both in HEW and in Congress. The flu as a disease and shots as a preventive were dramatized sufficiently so that a permanent program aimed at high risk groups is now in view. With that comes what the influenza specialists in public health have long desired, recognition for the flu alongside polio or measles among Feder- ally-supported immunization initiatives. While media attention focused on the troubles of the swine flu program—which were many—net effects on general public consciousness seem small. Possibly, indeed, they will turn out on balance to have been more positive than negative for public health. Swine flu may have a bad ring in public ears, but millions may have heard of flu shots for the first time. On this nobody has good information. Yet to attentive publics in and near the Washington community, to doctors in the country’s schools of medicine and public health, to professionals in print and electronic journalism, to members of Congress and the Carter Administration, also to most members of the Ford Administration, the swine flu program was once widely seen and now is overwhelmingly recalled as a "fiasco," a "disaster," or a "tragedy." More interesting still, it was and is a trauma to the government officials most in- volved and to their scientific advisers. A year and more later, cheeks flush, brows furrow, voices crack. In February 1977, as the program waned, Secretary Califano asked us to review and reconstruct it in detail for his own education. His purpose was managerial. He sought lessons for the future useful to a man in his position. He had just authorized a limited re- sumption of the program through the rest of the flu season for the sake of high-risk groups. His position and its problems were vivid in his mind. Lessons were what he wanted, not a history; finger-pointing did not interest him in terms of last time; his con- cern was with next time. Yet as he was aware, having read a comparable report by one of us done years ago for President Kennedy, we know no better way to draw most lessons than to tell the applicable portions of the story. We began with that bias. It was only reinforced when we discovered the persistence and pervasiveness of trauma. The lessons of this program, we believe, will be obscured for relative outsiders unless they understand why it had such profound effects, not on the country but rather on its own participants. That understand- ing is imparted best by a selective narrative. 2
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This calls for a reconstruction of events, which we have undertaken by combining press accounts, hearings, official files, and interviews with participants, as many as we could reach during the time we had available. Our efforts still leave some participants unreached, some happenings unrepresented. We are sorry for that but time pressed. In establishing "what happened" we have sought not less than three and preferably five opi- nions when there were as many or more persons present. In the case of actions taken by one person we have sought both his account and the impressions of contemporary by- standers, along with written records if available. Throughout we have sought views from informed observers. This remains a reconstruction. It cannot be "the" truth as actually experienced, for there were many truths then, all imperfectly recalled; we now select among them with the benefit of hindsight. We are surely not infallible; we seek to be responsible; the judgment is our own. Many of our informants spoke for background only. All were offered confidenti- ality if they so chose. Therefore, attributed quotations from our interviews have all been checked with sources for accuracy and propriety. As cannot help but happen, checks pro- duced some changes of memory, or concerns about good taste, or insistence on non- attribution. For quotation purposes we honor the source’s preference. Readers need not fear. This does not change the substance of the story; it just makes for a little less enjoy- ment in the reading. What follows is our response to the Secretary’s request, written for him and for whomever else he chooses. There are ten chapters of narrative ending in March 1977. We do not deal with everything. We deal with those things we believe can best help Califano think ahead. Chapter 11 sketches open issues in the swine flu program’s wake: a national commission, liability legislation, and a new immunization initiative. These we watched while researching the earlier story. We are current through March 1978. We then stopped watching; for the last three months we have been editing. Those issues remain open but our text closed as of March, a year after the program’s termination. We conclude these chapters with our own reflections, placed in Chapter 12. They bring us to administrative issues and to realms of current policy for Russian flu and after. They bring us also to the underlying issues posed by current knowledge about influenza, and by ignorance as well. We deal here with a slippery disease. What makes it so we ad- dress in a technical afterword. There follow five appendices. "A" is a "cast of characters" named in our narrative, and a chart of certain agency relationships. "B" is a glossary of abbreviations and "C" is a detailed chronology from January 1976 to mid-March 1977. "D" contains certain docu- ments described in narrative chapters, and "E" offers questions useful for the next pan- demic threat. With preliminaries over we can now begin. 3