The 1976 Swine Flu Program versus the 2005 Avian Flu Program

I have been reading Neustadt and Fineberg’s great book, The Epidemic that Never Was; Policy-Making & the Swine Flu Affair. It is interesting, and would be great for a course on decision making.

In 1976 the federal government of the United States initiated a massive program against a pandemic of swine flu which some experts believed might be imminent. Much money was spent and much effort was exerted, but the epidemic never arrived. The authors of the book stress that some of the pain could have been averted had mid-course corrections been made when cases of the swine flu did not show up in the United States or abroad. I too feel that planning for a possible pandemic should start early, but should allow mid-course corrections.

I also came away from the book convinced that had there been a pandemic, the United States would have fared badly. The program immunized many fewer people than had been planned, and did so later than had been planned. If there had been a pandemic, the U.S. population would have been less protected than would have been appropriate. In part this was due to the failure of leaders, in part to the delays introduced by the checks and balances in the U.S. political system, and in part to the lack of general underlying preparedness for pandemics.

I like the way the book shows the multiple objectives of different players. My favorites players were the public health officials who wanted to protect the public’s health, to live up to their own professional expectations, and to do their jobs. No one wanted a pandemic, but no one seemed especially concerned with guarding against a pandemic’s effects on other countries. The press wanted to inform the public, and to cover a hot story. Senior government officials were seeking not only to protect the public, but to enhance the bureaucratic position of their agencies. Pharmaceutical and insurance company executives wanted to lead their firms in performing useful services, but also wanted to preserve profits and avoid excess business risks. Politicians wanted to protect the public, but also to select a course of action that enhanced their political positions. A lot got lost in the interaction among these differing objectives.

President Ford had assumed office after the resignation of Nixon, and was running for reelection; he was facing difficulties in the primaries early in 1976 and, of course, eventually lost the election to President Carter. CBS and others seemed to suggest that Ford initially approved the swine flu immunization program largely to advance his candidacy in the primary elections. Others suggested he chose what was believed to be the least politically damaging course of action in difficult circumstances.

It is interesting to note that Vice President Cheney was Ford’s Chief of Staff, and must have played a role in the decisions. Donald Rumsfeld was Secretary of Defense then as he is now. (Between the two stints as Secretary of Defense, his jobs included president of a pharmaceutical company and Chairman of the Board of Gilead Sciences, Inc., a pharmaceutical company that holds patent rights to Tamiflu.) Since the initial outbreak of swine flu occurred in an army base, he too must have been involved.

President Bush announced his avian flu pandemic initiative at a time when his popularity was suffering from a series of major setbacks. It may well be late. The flu preparedness plan might well have been promulgated earlier. Other countries have much more adequate stocks of Tamiflu, because they took vigorous action to procure the drug earlier. U.S. leadership to strengthen the global disease surveillance system might have been exercised earlier, and might have been more effective if the administration's international health programs had been more widely respected.

Still, from my amateur’s perspective, a lot of the current proposal seems well conceived and probably useful. The global public health community is taking the avian flu threat much more seriously than it did the swine flu. Stimulating improvement of vaccine manufacturing processes seems likely to be useful in the long run, as well as against a putative avian flu pandemic. So too, there has been a movement to improve surveillance systems against viral diseases for a long time, and such systems seem extremely valuable. Stockpiles of anti-flu drugs seem useful, since seasonal flu is so serious a disease, and we can hope that the drugs retain their utility.