The Swine Flu Affair: Decision-Making on a Slippery Disease (1978)

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5 Organizing Congress responded promptly to the President’s call for funds. An appropriation in precisely the amount requested was tacked onto a pending supplemental bill by an ac- commodating Senate Appropriations Committee. It was voted by the Senate April 9, by the House April 12, and signed into law April 15. The substantive health subcommittees, especially in the House, wanted and saw need for authorizing legislation, which the House indeed passed, but the Senate acted on the appropriation only. Chairman Paul G. Rogers of the House Health Subcommittee and Chairman Edward M. Kennedy, his Sen- ate counterpart, both held hearings on the substance of the swine flu threat. So did the chairmen of the relevant House and Senate subcommittees on appropriations. Sencer tes- tified at all hearings, but Cooper, who also testified on each occasion, was the star wit- ness, particularly with the substantive committees. He had credibility at both ends of the Avenue, no mean feat in 1976. He was taken quite as seriously by Kennedy and Rogers as by Cavanaugh and Ford. And what he told them was what Ford had told the country: By reviewing the epidemiology and natural history of this process, we do feel that a strong possibility exists that in the next flu season. . . there is a good likelihood that there will be influenza caused by this particular agent. . . . The strain is related to the swine influenza virus which has been implicated as the cause of the 1918-19 pandemic. This pandemic caused approximately one-half million deaths in the United States alone. I would not be happy with a 70-80 percent response. . . . I would like to make sure that we reach 95 percent . . . but our target population is a large one. My aspiration is for no less than 95 percent. In retrospect Cooper told us wryly: “One lesson is ‘watch your mouth’.” His over- statement of achievable objectives ran with Ford’s: 95 percent amounted to about 200 million people. This pained some of the specialists at CDC who looked at the acceptance rates on past immunizations, together with exemptions for allergic persons, infants, and the very ill, and never dreamed of trying to inoculate more than 150 million.5 They said to themselves “politics” and shrugged it off. The legislators, on the other hand, took Coo- per's word as “science” and they gave him what he asked. He himself thinks now that he should have stopped first to figure out precisely what result would satisfy him, then dis- tinguished that from any wider aims. He takes this as a lesson for next time. In anticipation of the money, there was a short struggle over its administration. As early as March 13, Sencer at CDC had called on the director of his Bureau of State Ser- vices, Dr. Donald Millar, to head a planning task force. On April 2, at a meeting with state health officials, Sencer introduced Millar as “manager” of the prospective “National Influenza Immunization Program.” Yet a week later in Washington, with funds at hand, Cooper by press release conferred the same title on Dr. Delano Meriwether of the PHS staff. 27 

The coincidence of titles infuriated Sencer, but he seems not to have been the tar- get of the tactic. This, rather, was the Secretary, who as Cooper’s aides recall showed an uncharacteristic (and to them a quite unrealistic) interest in the running of the swine flu program. Mathews had been energized by Ford, who looked to him for action. Besides, the swine flu program seemed to him a proper task, unlike so much of what his department did. Much of HEW left him cold. He was a believer in the states and a university admin- istrator. Also, he considered it the Secretary's role to be a gap-filler, a “defensive secon- dary,” becoming active only when the roles of none of his subordinates were wide enough. Sencer covered only CDC while Cooper added NIAID and BoB, but not the General Counsel (OGC) or others. As we piece it together from associates (Mathews himself has less precise recol- lections), in the first days after March 15, he encouraged Jack Young, HEW’s comptrol- ler, to help Dickson design a swine flu organization. This would function under a depart- mentwide committee meeting daily. Young was a NASA alumnus from the moon-shot days. He and Dickson may have suspected what was coming at them operationally. Young’s organization chart had certain interesting features, among them a place for pro- gram review, another for media relations. But Cooper would have none of it. No new or- ganization could be built in time, “Flu season would have come and gone.” In this he had concurrence from a crucial ally, with whom on other subjects he had often tangled horns, the Assistant Secretary for Planning and Evaluation, William Morrill, known in PHS as the Department's "other strong man." Cooper also thought—and Morrill seems to have agreed—that a committee under Mathews’ wing would be a hopeless case and a commit- tee meeting daily an abomination. Feeling responsible, welcoming the challenge, Cooper saw himself in charge, at least as much attracted to the task as Mathews and better equipped to do it. Cooper’s problem then was to keep Mathews at bay. Dickson was loyal and shut up. Young had no personal stake. Morrill was accommodating. The departmental com- mittee, which soon started to meet weekly, then less frequently, never worked as Ma- thews wanted. And Meriwether was announced as Program Manager. A program with a manager is, ipso facto, organized. Mathews went along, never having thought to run the thing alone, or without Cooper, and in no shape to hold out against him. As one of Mathews' aides told us: Coming in only a year before the Republican Convention, that late in the Admini- stration, we had no troops with which to challenge the “health division.” To have had any chance of doing that, we’d have had to strip the University of Alabama clean of all Mathews’ cadre of experienced assistants. We couldn't do that! For his part, Sencer had been quite prepared to do it all through CDC, with NIA- ID and BoB and anybody else coordinated by Millar or by himself for working purposes. He would gladly have left it as Cooper’s task—and Mathews’ for that matter—to back them up. “The trouble was,” Sencer commented to us, “that Cooper was looking for work; he had nothing much else to do . . . . That Administration had stifled all initiatives. 28 

The place was at a dead stop.” In Cooper’s perspective the trouble of course, was differ- ent. It lay in Sencer’s limited authority, distance from Washington, and personal style. How could he coordinate two other, equal agencies? How keep the White House happy, or the Washington press corps? And how carefully would he attend to the concerns of the Assistant Secretary—Sencer was not noted for that. So Cooper sought to limit CDC to tasks he recognized it could do better than oth- er existing agencies: encourage planning by the states, set standards and allot administra- tive funds to them, purchase the vaccine for them, and conduct surveillance. He was ea- ger to include private physicians, also voluntary agencies—this indeed was one of his main interests in the program—but he had to hope state health departments would make these arrangements with encouragement enough from CDC. Perhaps this was expecting water to run uphill; time-pressures, in his view, left him no choice. As for liaison with the vaccine manufacturers, field trials and testing, or related research, NIAID would do its job, so would BoB, coordinated as need be with CDC and states in usual informal ways or on appeal to Cooper. Meriwether would be his staff man for that; also for congressional, White House and press relations. Meriwether was a dedi- cated public health professional, loyal to his boss, an upright, high-achieving black with the stamina of an Olympic track star. What got beyond him Cooper would take on him- self. This arrangement cut out hordes of planners in the PHS but Cooper liked to travel light. Besides in his opinion, as he told us, “nobody there knew anything about it.” The arrangement also kept at arm's length PHS’s Public Information staff, known then as one of the Department's best. No one recalls why they were so little used, except that Meri- wether was a one-man band, and was meant to be. Cooper, in the words of a collaborator, “trusted his capacity to doctor his way through.” He sought to duck committees, stay lean, work fast and keep control. The scheme had two major flaws. The Department’s General Counsel worked for Mathews, not for Cooper, a matter of small moment in April. (July would be another story when legal issues moved center stage.) And the media worked for themselves, on ground rules no M.D. in PHS seems to have fully understood. There was, besides, Sencer’s irritation with the Meriwether title which he never ceased to think a clumsy and intrusive complication of Millar’s essential role. But since the states looked to Millar in any case, while Washington press mostly went to Meri- wether, and nobody there mistook him long for boss instead of staffer, it is hard to see what harm was caused except to Sencer’s feelings. He, indeed, sanctioned the loan of a key man in Millar’s bureau to be Meriwether’s general-purpose aide. From July this kept lines open through the whole of the hard times ahead. Inside CDC there was no jockeying at all, or rather what there was Sencer sup- pressed. Millar and his associates were soon working on three main lines: First, they put together a PERT system, a way of charting all relationships among 29 

things to be done in order to identify and treat impending bottlenecks. Although prepared by amateurs it was pursued with gusto and may actually have helped. It also offered vis- ual demonstration that the CDC could do a piece of project management as stylishly as NASA or the Navy. (Millar's master chart was on display for visitors—and still is.) Second, they expanded and computerized the CDC’s surveillance system. Dr. Mi- chael Hattwick, who had urged this course for years, was put in charge with funds for staff and the computer of his dreams. He recruited a young statistician right out of gradu- ate school and enticed young epidemiologists from other duties. Together they developed disease indicators matched imaginatively with reporting sources. The upshot was a cen- ter, manned around the clock, with all the verve and the devotion of a war room on alert. The public health community had never had anything like it, and the men who manned it trained hard for the task of tracking (beating) swine flu if (when) it should come. They wanted to be first to spot new outbreaks and they wanted to be sure about the timing, scale and consequences of mass immunization. Hattwick himself was eager to track neurological complications. He recalls that he expected side effects upon the nervous system of some vaccinees—Guillain-Barré syn- drome was one of three likely prospects—but he had no notion on what scale. As he put it to us: “We knew there would be some neurological complications. What we didn't know was just how frequently they would occur.” No one then expected a high frequency and no one then explored the policy implications of low frequency, although each case could matter in the absence of pandemic. Policy was not Hattwick’s concern. He was a techni- cian’s technician—knowledge for its own sake—and his success, in his eyes, was inde- pendent of the program’s. Quoting our interview again: “What mattered to us was know- ing exactly what was going on. That’s how we measured success.” Third, state plans were solicited and reviewed in quick time. CDC wanted above all to get the states started on recruiting staff, procuring guns for fast injection, and iron- ing out details rapidly enough so that the immunization could at least begin during July. In CDC itself much work was done on educational materials for local use, a form of technical assistance. But CDC could not lay down the infrastructure for immunization. Local conditions had to be allowed to govern how the vaccinations would actually be conducted. CDC could only defray extra costs and offer free advice; it did not try to im- pose tight standards on state plans. While this was happening in CDC, Cavanaugh, from the White House, reflecting Ford’s commitment and his own involvement, watched the evolution of the whole pro- gram. His recollection, as he told us, is that: Mathews felt responsible for the program, Cooper wanted to run it and Sencer was determined to do so out of CDC. Their jockeying delayed getting the thing off the ground and especially delayed coming to grips with liability. . . . The basic elements of the program that were operating out of CDC got off to a swift start, notably state plans and other aspects of Millar’s operation. Up above, where CDC met the Assistant Secretary and the Assistant Secretary met the Secretary, it looked more confused than perhaps it really was . . . . 30 

The Domestic Council sought and got first weekly, then bi-weekly status reports from Meriwether. These were supplemented by occasional calls to Cavanaugh or John- son, as matters arose requiring their intervention with other departments. As the spring wore on, the biggest of these became liability. With the Secretary on the sidelines, Cooper at the top, White House liaison ar- ranged, and CDC or BoB doing the work, internal organization from mid-April on was relatively clear, even coherent, as perceived inside the program, and apparently as seen from the state capitols. It was less so as seen from Capitol Hill; indeed Chairman Rogers, aware of early jockeying and soon to be beset by liability, recalls “disorganization” as the most disturbing feature of the whole affair. “There were too many cooks, no clear line of command, no single 'head' to hold responsible or ask for information.” In this he sees the lesson for next time. Rogers almost certainly reads summer troubles back into the spring. He said to us: Ted Cooper is a very able person. It struck me that he knew what he was doing and trying hard. But every so often Mathews got into the situation. Sometimes I couldn't tell who was in charge—Cooper, Mathews or Taft [William Howard Taft IV, the new HEW General Counsel, who became involved during the summer]. Cooper often didn’t have as much authority as he should have. On the Senate side, Chairman Kennedy has comparable recollections. These strike us as a tribute to Cooper’s congressional relations: Inside he appeared a strong man, “Big Doctor,” “Substitute Secretary,” in the words of two associates, while on the Hill he seemed a good man beset by Mathews. Actually, whatever else he may have been, Cooper was a man dependent upon three subordinates whose long service had adjusted their relations with one another, Sencer, Meyer and Seal. Adjustments had been careful: accommodations among equals, gentlemen’s agreements. Cooper might be the boss, but they ran their own agencies and their agreements more than his intentions set the swine flu program’s course. 31