to have spread to other groups, the disease would spread faster than any ability to mobilize preventive vaccination efforts. Three cases of swine influenza had recently occurred in persons who had contact with pigs. In 1918, after the initial outbreak of influenza at Fort Riley in April, widespread outbreaks of influenza did not occur until late summer (Schoenbaum et al., 1976).
The Delphi exercise of Schoenbaum in early fall of 1976 (Schoenbaum et al., 1976) was the most serious scientific undertaking to poll scientists to decide whether or not to continue the program. Its main finding was that the cost benefit would be best if immunization were limited to those >25 years of age (and now young children are believed to be a potent source of spread of influenza virus!). Unfortunately, no biblical Joseph was there to rise from prison and interpret the future.
As Dowdle further states (2006), risk assessment and risk management are separate functions. But they must come together with policymakers, who must understand both. These discussions should not take place in large groups in the president’s cabinet room but in an environment that can establish an educated understanding of the situation. Once the policy decisions are made, implementation should be left to a single designated agency. Advisory groups should be small but representative. CDC had the lead responsibility for operation of the program. Implementation by committee does not work. Within CDC, a unit was established for program execution, including surveillance, outbreak investigation, vaccine procurement and distribution, assignment of personnel to states, and awarding and monitoring grants to the states. Communications up the chain of command to the policymakers and laterally to other directly involved federal agencies were the responsibility of the CDC director, not the director of NIIP, who was responsible for communications to the states and local health departments, those ultimately implementing operations of the program. This organizational mode functioned well, a tribute to the lack of interagency jealousies.
When lives are at stake, it is better to err on the side of overreaction than underreaction. Because of the unpredictability of influenza, responsible public health leaders must be willing to take risks on behalf of the public. This requires personal courage and a reasonable level of understanding by the politicians to whom these public health leaders are accountable. All policy decisions entail risks and benefits: risks or benefits to the decision maker; risks or benefits to those affected by the decision. In 1976, the federal government wisely opted to put protection of the public first.
Dr Sencer was director of CDC from 1966 to 1977.
Dr Millar was director of NIIP in 1976.