Flu’s Fine Line

What does it take to protect the American public?

The swine flu that swept the world this spring posed challenges to the public sector that find remarkable precedent in a similar outbreak of the disease 33 years ago.

Then, as now, the president and his advisers were treading a fine line between shirking their public health duties and administering an unneeded and potentially harmful regimen to the American public. The U.S. government's reaction to the outbreak of swine flu among Army trainees at Fort Dix, N.J., was far from perfect. We will see whether mistakes made then are repeated this year.

A detailed review of government's overwrought reaction to the January 1976 outbreak was commissioned by Secretary of Health, Education and Welfare Joseph A. Califano Jr. Two Harvard professors, historian Richard E. Neustadt and public health specialist Harvey V. Fineberg, interviewed all the key players and wrote a 189-page report titled "The Swine Flu Affair: Decision-Making on a Slippery Slope." This classic case study was published in 1978.

Swine flu had not been seen in humans since the 1920s. In 1976, as now, fears arose of a pandemic that might rival the worldwide killer of 1918. Prodded by ambitious science bureaucrats wanting to set new preventive medicine precedents, President Gerald Ford got behind a program to inoculate every American with a quickly produced swine flu vaccine. Forty million people were given shots between Oct. 1 and Dec. 16, 1976-twice the number ever before reached by flu vaccination programs. Then it appeared that the shots might have caused a small number of people to contract debilitating Guillain-Barré syndrome. Ford, who had led the way by bringing in television cameras to witness his own inoculation, abruptly canceled the program. Swine flu had not, in fact, spread as had been feared.

A key episode in the affair came when Center for Disease Control Director David J. Sencer drafted an action memorandum saying a pandemic was a "strong possibility, probability unknown." This memo, which was leakable at will, forced the hand of his superiors. Decisions thereafter came too quickly, without pause for adequate reflection, write the study's authors. For public health, a terrible consequence was CDC's loss of credibility, for as the authors say, this important agency could "be surely tagged as crying 'wolf' " the next time it attempted another massive exercise in preventive medicine. Sencer lost his job over the episode. And the government eventually paid more than $90 million to people who said the vaccine caused neurological problems.

Government officials of the day displayed little understanding of the power of television journalism. Of course, media hype has multiplied tenfold since 1976, when cable gabbers and the Internet were not even on the scene. For weeks this spring, it was swine flu 24 hours a day on cable; and the prospect of a sweeping pandemic has captured the rest of the media as well.

The Obama administration has benefited from the interagency effort that produced the National Strategy for Pandemic Influenza Implementation Plan, published in 2005. If officials haven't always put out a consistent message this spring, missteps have been corrected quickly. And use of new media has been impressive: a downloadable widget at HHS.gov provides links to CDC, pandemicFlu.gov, and the World Health Organization and the White House in early May rushed to launch pages on Facebook and MySpace and a Twitter feed to help meet the demand for information.

But the story is not over. Today, health experts, worried that swine flu will make an aggressive comeback this fall, are urging President Obama's incoming public health team to learn the lessons of the 1970s episode. For Obama may yet be confronted more gravely with what Califano called "the enormous difficulty that a lay official has in fulfilling his responsibility to make sound, balanced judgments about scientifically based public health issues."

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