Thursday, October 27, 2005

The specter 1976

The specter of 1918 is a pervasive and explicit influence on the professional and the public attitude to the current threat of a pandemic from H5N1. That much is clear to everyone. What is less recognized, however, is that for the professional influenza community in the US there is another specter, the Swine Flu episode of 1976. There have been a number of good accounts, so we will only sketch it here, but it is worth acknowledging there are important reasons for ambivalence among experienced public health professionals who went through that traumatic episode.

In highly abbreviated form, this is the gist. During an otherwise routine influenza outbreak at Fort Dix, New Jersey in January of 1976, several new recruits were discovered to have become ill with an influenza virus whose origin was apparently pigs, i.e., instead of the then (and now) circulating A/Victoria/H3N2 a few of the many ill soldiers were infected with H1N1 whose origin was pigs. This raised alarm bells at CDC because it was widely believed that the 1918 virus might have retreated into pigs after the mid 1920s and there was a possibility it was now re-emerging into a world where the only effective the immunity was in those over fifty (those born before the 1920s). Some notable flu experts also believed pandemics were on a regular and predictable cycle and we were "overdue for one." Adding to the alarm was a follow-up seroprevalence survey at Fort Dix which suggested as many as 500 soldiers might have become infected, that is, swine flu had gone "human to human." Outside Fort Dix there was no apparent infection. Not yet. If there were to be a pandemic the following flu season, a decision about making a vaccine had to be made immediately. Moreover, because of the gravity of a repeat of a 1918 pandemic, if a vaccine were to be made, it was thought a full-scale vaccine program should be cranked up to vaccinate the entire population (at that time a little over 200 million people).

You can read accounts of the messy decision making process in a reconstruction of events (with oral histories) done for Department of Health, Education and Welfare Secretary Joseph Califano by Richard Neustadt and Harvey Fineberg. A book by Silverstein came out in the 1980s and shorter accounts can be found in the popular books on influenza by Alfred Crosby and Gina Kolata. Within a short period of time, the highest levels of the nation's health establishment had decided universal vaccination with a yet to be produced swine flu vaccine was needed, President Gerald Ford agreed almost immediately, and he personally announced it on television rather than leaving it to the Director of CDC or Secretary of DHEW. His view was that if everyone were to be asked to take the vaccine, the request should come from the President. It was in fact an act of courage on his part, as it was understood it was a no win situation politically and Ford was locked in a bitter primary campaign against Reagan (it is not easy to imagine the current incumbent taking this route). Ford asked for and received congressional approval for $135 million for the vaccine and associated programs. Four vaccine manufacturers immediately switched their production from A/Victoria to the new swine flu virus. When they balked at the last minute to bottle the preparation because of liability concerns, congress further insured vaccine-associated risks.

I have skipped many details, but the most important facts for our purposes are these. Just as the full scale effort was underway, news media began to publicize hitherto unvoiced strong disagreements with the universal vaccination policy by a few scientists, some within the government, At the same time, epidemiologists pointed out the likelilhood that a wide variety of adverse events would occur in close temporal relationship to vaccinations just because tens of millions of people were involved. Sudden deaths occur with regularity, with or without vaccines, but any that would occur shortly after vaccination would inevitably be associated with it. Indeed that is what happened. Within three weeks, 41 vaccination-associated deaths were counted. The CDC's response that this was within the number "expected" was not persuasive to most people. Even more troublesome was an apparent association with a rare but potentially serious neurological condition, ascending transverse myelitis or Guillain-Barré Syndrome (GBS). To this day there is no agreement as to whether GBS was truly related to the swine flu vaccine or not. There are persuasive arguments on both sides. In any event, there was a definite public and professional perception that GBS was a side-effect of swine flu. As a result, the entire swine flu program was abruptly halted in December 1976 after three months. By then 45 million people had been vaccinated and there was long list of claims of vaccine-associated maladies, including GBS. There were 52 deaths, more than 500 hospitalizations and compensation claims of over $1.7 billion in a wave of litigation.

But not a single case of swine flu. The feared pandemic never happened. An extraordinary national commitment to stave off a disastrous epidemic, for the first time in history, was overshadowed by doubts, recriminations and second guessing. While the public has largely forgotten the episode, the American public health establishment has not. It is still remembered as a monumental fiasco that those involved would not like to repeat. Many of those professionals--people who genuinely were trying to do the right thing, who acted on that impulse boldly, and perhaps did do the right thing--are still around in senior policy making positions.

One can hear the echoes of 1976 in the hesitancy and ambivalence over the correct response to H5N1 today. Because there are many parallels: the specter of 1918; the uncertainty as to whether there will be a pandemic or not, when it will be, how bad it will be; the downside of doing nothing; the risks and costs of doing other things. Nobody wants to guess wrong.

And like 1976 there are numerous other agendas: desire not to distract from other priorities; desire to use the real threat of a pandemic to rebuild public health; numerous politically partisan motives; ideological currents. One of the lessons some have taken from 1976 was that a more prudent course would have been to stockpile the vaccine and only deploy it if a pandemic was getting underway. We see the stockpile theme prominent today, and probably it isn't a bad lesson to learn.

What we don't see, however, is a public commitment to rebuild the kind of social solidarity that will be an essential element in managing the consequences if a pandemic were to materialize. You can say that's my agenda. To promote the power of neighbor helping neighbor. I'm not hiding it.