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The Swine Flu Affair: Decision-Making on a Slippery Disease 3 Cooper Endorses Sencer’s paper was completed March 13 and he took it to Washington. On Monday morning, March 15, he met Secretary Mathews in an emergency session. This had been arranged by Cooper’s deputy, Dr. James Dickson, who attended and brought Meyer. Cooper was in Cairo, keeping a long-planned engagement, but Dickson had his proxy; Cooper and Sencer had talked on the phone the week before (and Cooper had arranged to be reached, if wanted, through White House facilities). Mathews had been in office only since the previous August. A gracious man and graceful, he had left the Presidency of the University of Alabama where he had deep roots (and to which he would return) for a Department where he was almost unknown. Seven months had scarcely changed that; he remained but a name to most of Cooper's people. Moreover they were unaware that by his own account to us he had brought with him a deep feeling for preventive medicine. He thinks that he and they were philosophically in tune. From what they tell us most of them would find the thought surprising. Before seeing Sencer, the Secretary held his daily staff meeting. Dickson filled in for Cooper. Mathews' custom was to go around the circle of his operating chiefs and principal staff officers. When Dickson's turn came he described the swine flu problem much as Sencer’s paper had done: “strong possibility.” The meeting dissolved then and there in stories of 1918. As one participant explained to us, “We understood it might not happen … but lots of us had tales to tell about what it might be like if it did ….” The meeting with Sencer followed. Sencer pushed Mathews hard. He did not rely on his paper (who does?), he enlarged upon it. He had been bracing for this meeting and apparently worried about it. In PHS, Mathews was often called "the phantom," all too readily dismissed as uninformed, uninterested, and worse, uninfluential at such crucial places as the 0MB. Sencer was in budgetary trouble and he had been for some years. President Nixon's New Federalists—still more James Lynn, Ford's Budget Director—liked discretionary funds for states and maximum reliance upon private medicine. CDC believed in limiting discretion to assure results. Also it drew sustenance from categorical grants and wanted more of them. Under the Republicans both OMB and planning staffs at PHS had sought to hold back new departures and to trim the old. Revenue-sharing with the states plus Medicare and Medicaid, not project grants through CDC, had seemed to them the way to go. Sencer’s memorandum is expressive of his worries: Given this situation can we afford the administrative and programmatic inflexibility that would result from normal considerations about duplicative costs, third party reimbursements and Federal-State or public-private relationships and responsibilities? The magnitude of the challenge suggests that the Department must either be willing to take extraordinary steps or be willing to accept an approach to the problem that cannot
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The Swine Flu Affair: Decision-Making on a Slippery Disease succeed. From what others tell us, Sencer pressed Mathews harder than he need have done. He evidently underestimated either the sheer force of his own message unadorned, or Mathews, or perhaps both. Dickson remembers: I presented the issue to Mathews…. He said to me, “What's the probability?” I said, “Unknown.” From the look on Mathews’ face when I said that, you could take it for granted that this decision was going to be made. Mathews bears him out, commenting to us: The moment I heard Sencer and Dickson, I knew the "political system" would have to offer some response. No way out, unless they were far out from the center of scientific consensus (a small band of people in influenza). They weren't—although some if those people waffled later. So it was inevitable…. As for the possibility of another 1918 … one had to assume the probability greater than zero. If they say "unknown" that's the least they can mean. Well, that's enough for action if you know in time. You can't face the electorate later, if it eventuates, and say well, the probability was so low we decided not to try, just two or five percent, you know, so why spend the money. The "political system" should, perhaps, but won't react that way…. So again, it's inevitable. Moreover, Mathews recalls favoring the substance, risk aside. Sencer, in his view, would have been wrong had he conceived Administration preferences for state and private medicine as tantamount to lack of faith in immunization programs. These Mathews remembers liking. He recalls thinking the addition of a flu program desirable even had the risk seemed far away. Dickson recalls something more in Mathews' reaction: … politically impossible to say no, but more, it’s what “unknown” conveyed to [Mathews] about the risk in human terms … lives…. It didn’t seem to him remote at all. Meyer, listening, watching, took relatively little part until late. This was not shyness, just prudence. He recalls some discomfort at Sencer’s “hard sell” but never having met Mathews before, he was unsure of the ground-rules. As he put it to us: I felt uncomfortable about the firmness, absoluteness with which Sencer put the issue and the decision to the Secretary. Yet being a stranger to the Secretary I was hesitant about having rows with Sencer over tone. Meyer remembers making two main points: The first was that with the uncertainty of a pandemic and likely reactions if none appeared, “everybody should be brought into the act ….” The second, in response to Mathews' inquiry, concerned safe manufacture of enough vaccine up to the proper standard: "a hell of a job" but it could be done. The meeting ended on that note.
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The Swine Flu Affair: Decision-Making on a Slippery Disease Then, or sometime after, Mathews heard of a new book just out coincidentally, Epidemic and Peace, 1918 by Alfred Crosby. Mathews promptly ordered copies and sent them to associates in HEW, the Budget and the White House. He also gave one to Ford. Late in the morning of March 15, Mathews wrote a note to Lynn, the Director of the Budget: There is evidence there will be a major flu epidemic this coming fall. The indication is that we will see a return of the 1918 flu virus that is the most virulent form of flu. In 1918 a half million people died. The projections are that this virus will kill one million Americans in 1976. To have adequate protection, industry would have to be advised now in order to have time to prepare the some 200 million doses of vaccine required for mass inoculation. The decision will have to be made in the next week or so. We will have a recommendation on this matter since a supplemental appropriation will be required. Note the escalation since the ACIP meeting five days earlier. There, except for the expectant Kilbourne, members tell us they had in their heads such likelihoods of epidemic spread as two or 20 percent, which translate into odds of 49:1 or 4:1 against. Nobody there explicitly equated spread with the severity of 1918. Kilbourne expected something relatively mild. Others may have thought the single figure in their mind applied quite separately to spread and to severity. A two percent chance of a two percent chance is exceedingly long odds. Sencer’s memorandum then converts these (mostly unacknowledged) odds into "strong possibility" of a pandemic “antigenically related” to 1918: writing about spread he hints at severity, but never anywhere commits himself. Now Mathews, after their Monday meeting, equates spread with severity, converts the possible into the certain, “will,” and with a doubled population he projects twice the casualties of fifty years ago. Had Sencer's case so moved him? Had he simply not thought it through? Or was he impressing his addressee, the Budget Director? Perhaps some of each. Lynn already had heard something of this. So had his deputy, Paul O'Neill, the bright young man of OMB in Lyndon Johnson's time (beginning as a health programs examiner) who since had had a meteoric rise. O'Neill consulted with his colleague in the White House “deputies club,” James Cavanaugh, soon to become deputy to Richard Cheney, the chief of staff. Cavanaugh was then still Deputy Director of the Domestic Council, handling “operations” (which meant processing the day-to-day particulars). He formerly had been the health man on the Council's staff and liked to keep his hand in. His successor, Spencer Johnson, was brand new. A notable survivor, Cavanaugh had come to HEW in John Gardner's time, continued as a staffer under Robert Finch, been briefly Acting Assistant Secretary for Health and then had been “loaned” by Elliot Richardson to John Ehrlichman when the Domestic Council was first formed. There, remarkably, Cavanaugh remained and even flourished under Ford, while the Council’s Director, James Cannon, Vice President Rockefeller’s choice, dealt with policy issues in the longer run. Cavanaugh already had the ball, more or less, Cooper having warned him before leaving town. Dickson sent the Sencer memorandum over and Cavanaugh checked it out.
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The Swine Flu Affair: Decision-Making on a Slippery Disease The man with whom he chose to check was an old boss, Dr. Charles Edwards, Cooper's predecessor, now out of government. Edwards, hearing Cavanaugh's account, said, as the latter tells us, that from what he'd heard he'd go with Sencer, “the only possible course.” Cooper, returning March 21, emphatically agreed. For Cavanaugh this sufficed. Johnson had inherited a duty to spy out the second and third echelons in HEW, although his acquaintance barely extended to Rockville, much less Atlanta. Cavanaugh saw no need to use him. O'Neill, meanwhile, who had the final action since new money was involved, heard grumbling from his health examiners. Victor Zafra, the division chief, had read the New York Times of February 20 and had been waiting since for CDC to come in crying doom. He and his assistants deeply suspected a cooked-up job. Their relations with technicians inside PHS, however, were too strained or distant to give them a grip on anything like Alexander's worry (not at least in the short time available). So they wrapped their suspicions, instead, in classic budgetary guise, questioning the estimates. To quote from their internal memorandum: PHS did not consider the possibility of reprogramming funds … we are not convinced that the $134 million estimate is a hard figure…. We think the figure could be trimmed down considerably using alternative assumptions and divisions of responsibility among the Federal and State governments and the private sector. Tactically this could not help but fail by light of Sencer’s urgency. O’Neill and Lynn saw that at once and although they too were suspicious—having Sencer in their sights—forbore to press the point. They did ask whether a new authorization was required to support appropriations; the examiners, along with Cooper's aides, said no (perhaps too flat an answer but accepted). Objections become harder still if nothing is needed but money. Cavanaugh recalls pursuing other subjects, among them the idea of going for vaccine production right away while holding off a bit on choosing among options for its distribution. He spoke with “somebody at HEW” and was told no: “jet spread.” He did not argue. The thought occurred to others besides him. At some point in the week before decision, as he told us: There was a discussion between the President and the Vice President, after some meeting or other, in which Rockefeller said maybe one should go over to the Pentagon and get hold of a logistics officer and figure out how to do inoculations [throughout the country] in two to four weeks, thus beating "jet spread." Those were the time limits we'd been given and we also had been told they were too tight for manageable mass-immunization. Rockefeller’s attitude was “HEW just doesn't know how, but I'll bet the military do.” The thought wasn't followed up. In Ford’s Administration, few of Rockefeller’s were. If Cavanaugh was serious about distinguishing immunization from production he did not press the point. The others around Ford whom we have seen heard nothing of it, did not think of it themselves, and doubt they would have liked it had they thought about it. O’Neill remarked to us:
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The Swine Flu Affair: Decision-Making on a Slippery Disease As HEW presented the issue the time factor was key, not only to production—egg supplies—but to protection of the population before winter. Everybody by November. That’s what Sencer was saying. So why decide twice? Commit now and be done with it. There isn't time at the White House to create extra decisions for the man to make. He’s got plenty as it is. Besides, Sencer was ready to press his case. If we held off on part of it how would the President look: Pennypincher? Trading lives for bucks? Indecisive? Can’t make up his mind? Besides the case was not now simply Sencer’s. Cooper, returning, had made it his own. And Cooper was trusted in quarters where Sencer was suspect (“manipulative”), not least in the Domestic Council and the White House. Cooper very often, as his aides report, mistrusted Sencer too. Sencer was 800 miles away and played his own game and had wherewithal to do it. This is a formula to drive a strong Assistant Secretary to distraction. Cooper certainly had strength and we gather was often distracted. A mercurial man, he was sometimes very angry. Yet here he showed himself an instant convert to Sencer’s cause. How did it come about that those two were together on this matter at this moment? The question is intriguing and important; the answer is elusive; we may not have fathomed its depths. But what we find is clear. First, Cooper respected Sencer’s professional judgment, the more so on an issue outside his own specialty (he was trained as a cardiac surgeon). Second, Cooper had a personal agenda into which Sencer’s proposals fit. As leader and trustee of Federal services for health (which is, we think, how Cooper saw himself) he had been seeking ways to raise the consciousness of private citizens—of voluntary agencies, of parents, of physicians—to prevention of diseases through immunization and other means. Now there were vaccines for many infectious diseases; later, perhaps, for neurological disorders, conceivably even cancers. An associate commented to us: Cooper had a strong sense of the importance of volunteer organizations and our dependence on them and the need to change and perfect them for the tasks ahead…. He wanted to move immediately onto a new footing, steadily supported by the voluntary groups and by parents all across the country—not subject to unpredictable shifts of government priorities. He was keen to increase comprehension of preventive medicine and support for it out there in the private sector where it could be shielded from those governmental ups and downs … those Nixon economy drives…. Third, Cooper’s father, a physician, had told him ghastly tales about 1918. He and Dickson, who also had a father with grim stories on the subject, traded recollections back and forth. The “worst case” possibility was vivid in the mind of the Assistant Secretary for Health. Dickson mentioned to us: Cooper really feared 1918. Something happened in Hershey, Pennsylvania, that stuck in Cooper's mind. They'd had to call out the troops to bury people en masse—they died so fast.
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The Swine Flu Affair: Decision-Making on a Slippery Disease So Cooper, from the time Sencer first talked to him in February, was prepared to take an activist approach, provided it had backing from the “scientific community,” that is to say from the relevant experts. He wanted to be sure that anything from CDC was first reviewed by the ACIP, and had support from NIAID, BoB and their advisers. Not leaving everything to others, Cooper himself talked to Dr. Albert Sabin. The latter’s live vaccine for polio (superseding in this country Dr. Jonas Salk’s killed-virus vaccine) had been used in the last nationwide mass immunization, 100 million in two seasons, “half the number in twice the time” that Sencer was now seeking. Sabin was encouraging, as Cooper knew when Sencer phoned him to report affirmatively on the ACIP meeting. So Cooper left for Cairo confident he could support what Sencer came up with. When he returned he did. Meanwhile, his colleagues had gone to the President.