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The Swine Flu Affair: Decision-Making on a Slippery Disease 4 Ford Announces President Ford first heard of HEW’s request for supplemental funds and all these entailed the afternoon of Monday, March 15, when Lynn, O'Neill and Cavanaugh met with him on another project. Three days later Ford heard somewhat more from Mathews and agreed to have a full review the following week. It was a busy time for all concerned, not least for Ford. Swine flu was by no means the biggest item on his agenda. Among other things, presidential primaries were underway. Ford narrowly defeated Ronald Reagan in New Hampshire and had picked up strength in the next four primaries, especially the March 9 battle in Florida, where Reagan had hoped for an upset. On the same day, Ford had improved his position by telling Cheney to get rid of their lackluster campaign manager, Bo Callaway. But Ford’s confidence was to be shaken by Reagan’s surprise victory in North Carolina on Tuesday, March 23. The day before the North Carolina primary, Lynn and O'Neill with Mathews, Cooper, Cheney, Cannon, Cavanaugh and Johnson met the President to review HEW’s recommendation. From Lynn he got a packet in advance, including as was customary a summary paper with “talking points,” questions for Mathews and Cooper. This was backed by Sencer's action-memorandum. In between was an OMB attachment labeled “Uncertainties Surrounding a Federal Mass Swine Influenza Immunization Program.” Into this Lynn’s aides had poured the hardest questions they could think of (or extract from other sources) on short notice. It was not a very arresting list. For what it’s worth we include it in Appendix D. Cooper made short work of it. Someone on Mathews’ staff or Cooper’s had prepared a swine flu flip chart. Ford made short work of that. As one of his auditors says he “blew up … waved it away,” sensibly preferring discussion. By all accounts the discussion ranged widely, covering at once the arguments for action, and a long list of drawbacks: The pandemic might not come and then the President would seem a spendthrift and alarmist, or a bumbler. If it came, the states and private sector might be overwhelmed, or seem so—"however well they did, it wouldn't be enough"—and he'd be blamed, again a bumbler. Or vaccine might not be ready soon enough. Uncertainty about the egg supply meant, ultimately, roosters. The Secretary of Agriculture had been reassuring: “The roosters of America are ready to do their duty… .” Still, yield per egg of vaccine might be less than was wanted. And so forth. As one participant recalls: I told the President that this was a no-win position politically. There was no good to come of it as far as the election was concerned … if there were no pandemic a lot of people would have sore arms in October. If there were a pandemic, no matter how much we'd done it wouldn't be enough and he'd be roundly criticized.
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The Swine Flu Affair: Decision-Making on a Slippery Disease Others tell us they said much the same, but one of them remembers thinking (and, he hopes, saying): There is no way to go back on Sencer’s memo. If we tried to do that, it would leak. That memo's a gun to our head. Among the things Ford was not warned about were six: trouble with serious side effects, with children's dosages, with liability insurance, with expert opinion, with PHS public relations, and with his own credibility. On the contrary, the vaccine was presumed both safe and efficacious; insurance was not known to be a problem; experts were pronounced on board; Cooper and Sencer could cope with the press. And while the venture’s cost to Ford in public terms was aired nobody raised the opposite, the burden to the program of his sponsorship amidst a problematic fight for the Republican nomination. These six are the drawbacks that in fact would give the effort the bad name it has today among attentive publics. Some of them may not have been foreseeable, as most of Ford’s aides tell us now. For what it may be worth, we tend to disagree. At least it can be said that signs of each were somewhere to be seen had staffers penetrated far enough. But with agendas of their own, or sitting on the sidelines, or beset by other work, they didn’t. Hearing what he heard, Ford saw the issue simply. Politics had no part in it. As he recalled when we saw him: I think you ought to gamble on the side of caution. I would always rather be ahead of the curve than behind it. I had a lot of confidence in Ted Cooper and Dave Mathews. They had kept me informed from the time this was discovered. Now Ted Cooper was advocating an early start on immunization, as fast as we could go, especially in children and old people. So that was what we ought to do, unless there were some major technical objection. This agrees with what others remember. Some may have been pleased that what was right to do was also politic, one-upping Reagan: Here would be the President, decisive for the public good. Others though were worried by the public risks Ford ran in longer terms. Mathews recalled for us: I told him that I knew it was a no-win situation for him, and that it wasn’t necessary for him to make the announcement—I said I would do it if he wished me to. Two of Ford’s aides had talked of this, but Mathews was a weak reed in their eyes and anyway, “we thought he'd punted.” Besides the President seemed quite content, some even thought him eager, to announce a swine flu program as his own and urge public support of it. He evidently thought then, and still does, that this was his plain duty: “If you want to get 216 million people immunized this requires the imprimatur of the White House.” Like Mathews, Cooper, Sencer, Ford may also have had a refreshing sense of doing a direct, uncomplicated, decently heroic deed. So Mathews’ offer was not pursued. Cooper tells us that he would have been glad, even then, to make the announcement himself. The same can be said of Sencer, who
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The Swine Flu Affair: Decision-Making on a Slippery Disease wishes they had simply let him walk the supplemental up to the House Appropriations Committee and announce it there. Nothing like that was suggested to Ford by Cooper or anyone else. The meeting of March 22 did not end with a final decision. Instead the President decided to postpone decision until he had heard the views of experts in the field outside the government, the scientific community personified. O’Neill, who pressed the point, remembered in our interview: I really felt strongly that the President should meet a representative group of “scientists” in advance. In private conversations we had found no discernible dissent…. The President, of necessity, had to rely very heavily on their scientific judgment…. I thought they ought to be willing to commit themselves publicly. Ford himself seems to have seen still more in this, not only shoring up his credibility but genuinely reaching for advice. Like Mathews before him he had been told that a swine flu pandemic, shades of 1918, was “possible,” but that the probability remained “unknown.” (Cooper refused to put any numbers on it, although once he offered “one to 99.”) If those words meant what Ford took them to mean, justifying an unprecedented Federal action, he wanted to be sure the experts felt the same, or know if some did not, and why, and wanted to hear it from them at first hand. Lacking a science adviser (the post was in abeyance then), he asked, as he recalls, that the “best” scientists (along with experts on such things as manufacturing) be brought together with him two days hence. Others recall his asking for “a full spectrum” of scientific views. Either way, he ended this first meeting on that note. Cavanaugh undertook to assemble the required experts in consultation with Cooper, who consulted in turn with Sencer and Meyer, among others. The list of expert invitees as they contrived it included Kilbourne, Stallones, Dr. Frederick Davenport (a noted virologist), Maurice Hilleman (the respected head of Merck virology labs), and as a crowning touch both Salk and Sabin. These two were outside the ACIP circle—which to Cavanaugh assured a spectrum—and were inveterate opponents, personally and professionally. To Cavanaugh this meant that if there were clay feet on Sencer’s program, Salk would be the man to find them (Sabin having indicated his support). If they agreed, despite their enmity, this should assure the President the “best support available.” They, at any rate, were by far the best known to press and public. Alexander was not on the list. Cavanaugh did not know him. The others, juggling numbers, did not propose him. No members of Congress were on the list either. Several were due to be informed by phone, but no one proposed to have them in the meeting. The Senate sub-committee chairman most interested, Edward Kennedy, had been lambasting Ford for a retreat on health insurance. No one proposed Kennedy; if not him, nobody. Besides, in retrospect at least, the aides with whom we've spoken are convinced it would have seemed either “political” or “weak” for Ford to have brought in the opposition to share his decision. On March 24, at 3:30 p.m., Ford met his scientists and some others from the
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The Swine Flu Affair: Decision-Making on a Slippery Disease states, the AMA and so forth, in the Cabinet Room. He was accompanied by a full complement of aides and HEW officials. Sencer opened with a briefing. The President then turned to Salk who strongly urged mass immunization. In back rows aides sighed with relief. Salk recalled for us: When the President asked for comment I made the points that influenza was indeed an important disease, and that the program was an opportunity to educate the public and to justify further research…. I don’t think I then said but I certainly thought of it as a great opportunity to fill part of the “immunity gap” [between antigens in our environment and populations without antibodies]. We should close the gap whenever we can. Here was a chance…. That’s what I saw in the program, so of course I supported it. Sabin followed Salk, then Hilleman, and then the President asked others to chime in. He went around the table seeking views as if he really wanted them, which indeed he did. His respondents saw that and it gratified them but it also puzzled them. Summoned to the White House on short notice, many for the first time, ushered into a large, formal meeting, watching Ford call first on one and then another, most of those we’ve interviewed took it to be “programmed,” a “stage set” and they “players” … “the decision taken” … “we were used.” Indeed it had been programmed, oddly enough twice. Stallones recalled for us a call from Sencer, the night before, to tell him when to speak and what the President would ask. The “talking points” Ford got from Johnson were, however, different in detail. Sencer evidently had to vie for programming with the Domestic Council. At some point in the meeting, Ford asked for a show of hands on whether to proceed. All hands went up. He then asked whether there were any dissents or objections on the other side. A long silence ensued. One of the experts present tells us now: Later, I regretted not having spoken up and said, “Mr. President, this may not be proper for me to say, but I believe we should not go ahead with immunization until we are sure this is a real threat.” However that may be, it wasn't said. Earnestly in his mind, though pro forma to his listeners, the President then observed that he would be glad to talk to anyone who had doubts for his ear alone. He would suspend the meeting and would wait a few moments in the Oval Office. So he did. While waiting, Ford reviewed with Cavanaugh and others the announcement he would make and when to make it. If done at once, it could but strengthen the impression of a “programmed” meeting (so, in fact, it did). But if delayed, the television news that night and then the morning papers might be filled with separate interviews from leaky scientists. One of Ford's advisers said to us in retrospect: … the net result might be a speculative spate of new stories and editorials which either scared people or presented them with the impression of an imminent national emergency or made it look as though the President couldn’t make up his mind.
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The Swine Flu Affair: Decision-Making on a Slippery Disease Or the press might charge him with deliberate stalling to create a media event. And Ford himself, remembering the moment, added in his talk with us: “If you've got unanimity, you’d better go with it….” So he went. He stopped by the Cabinet Room, collared both Sabin and Salk, waved good-bye to the others, and continued to the Press Room, over the old swimming pool, with its facilities for instant briefing. Then and there with Salk and Sabin flanking him, he announced his decision: I have been advised that there is a very real possibility that unless we take effective counteractions, there could be an epidemic of this dangerous disease next fall and winter here in the United States. Let me state clearly at this time: no one knows exactly how serious this threat could be. Nevertheless, we cannot afford to take a chance with the health of our nation. Accordingly, I am today announcing the following actions. … I am asking the Congress to appropriate $135 million, prior to their April recess, for the production of sufficient vaccine to inoculate every man, woman, and child in the United States. Sabin spoke up also. Mathews and Cooper then took questions. The reporters were relatively well-prepared. To Cavanaugh’s chagrin a “Fact Sheet” for the briefing had arrived while Ford was still consulting in the Cabinet Room. Simultaneously, a group of White House aides had called the subcommittee chairmen and some others on the Hill to give them advance warning. Word of this began to trickle back. And two days earlier, John Cochran of NBC News had scooped his confreres with a story on the Monday meeting. They had been boning up on swine flu since. Cochran, who had Alabama ties, got wind on Sunday night that Mathews had a White House meeting the next day, and pulled its purpose out of sources in the Secretary’s Office. He then got it confirmed, still more reluctantly, from White House aides who feared it would be played “sensationally” in a way to preempt Ford or scare the public. When NBC ran a straightforward, circumspect account instead, they were relieved. Cochran and Robert Pierpoint of CBS, among others, thereupon proceeded to the question they, as White House correspondents, had to ask: was this political? Those two went about seeking answers differently. In reportorial terms, one way seems as good as the other. Cochran ranged across the list of Ford's political advisers, covering them thoroughly, we believe, from top to bottom without finding an enthusiast among them. This made a lasting impression. He was ready, thereafter, to assume the politicians felt compelled to do the bidding of the experts. Pierpoint, hearing that his bureau in Atlanta had some input, called and got an earful. A local CBS man had been following the story. With his interest heightened by the coverage on NBC he had called sources inside CDC, professional sources, experts, and been told on deep background that, given present evidence, nationwide immunization was unjustified, “a crazy program,” or words to that effect. Sencer's advocacy they attributed to obscure pressure on him from above, to some “political” motive he, for reasons unknown, could not resist. Doctors often use the term “political” for anything that isn't “scientific.” To the CBS reporters, and especially to
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The Swine Flu Affair: Decision-Making on a Slippery Disease Pierpoint, it could have only one meaning in this case. He was so exercised that he persuaded his superiors to put his findings in the same story as Ford's announcement of March 24. The Cronkite show that night had Pierpoint saying: Some experts seriously question whether it is logistically possible to inoculate two hundred million Americans by next fall. But beyond that, some doctors and public health officials have told CBS News that they believe that such a massive program is premature and unwise, that there is not enough proof of the need for it, and it won’t prevent more common types of flu. But because President Ford and others are endorsing the program, those who oppose it privately are afraid to say so in public. A day later all three networks aired dissent from open sources, mainly Dr. Sidney Wolfe, a frequent critic of the public health establishment. But the critics Pierpoint mentioned were the ones who left a mark at CBS. For him, for his bureau chief in Washington and for at least some of the Cronkite show’s producers, Ford’s program was forever suspect: dubious in expert eyes, hence probably political. As one of them put it to us: It was a rotten program, rotten to the core. We thought it was politically inspired … it certainly was awful in technical terms… unwarranted… unnecessary. That impression came straight from CDC. We didn't get onto Wolfe until later. It might be that the President himself had been imposed upon. Pierpoint liked Cavanaugh and thought him a good citizen. As both remember, Pierpoint called to tell him (without revealing sources) that there was dissenting medical opinion in the government. Cavanaugh was startled, having heard none, nor had Cooper, nor had Mathews. Sencer had reported unanimity from the ACIP, polled on the phone, and so had Meyer from polling a panel of his own. Sencer’s polling may have been a bit contrived; one member told us he remembers hearing that an all-out program was required for congressional approval, another that the White House was insisting on immunization. Cavanaugh knew nothing of such details. Besides there was no going back; the thing was done.