AMERICAN JOURNAL or EPIDIMIOLOOT
Copyright © 1979 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved
Vol. 110, No. 4 Printed in UJ3A.
Letters to the Editor RE: "THE SWINE FLU AFFAIR: DECISION-MAKING ON A SLIPPERY DISEASE" It is now over two years since the nationwide program to vaccinate the USA against "swine flu" was suspended, and about a year since publication of the critique (1) commissioned by the then Secretary of the Department of Health, Education, and Welfare. There is a very real danger that this critique—written in order to review and criticize the handling of the "swine flu" episode in depth, and to offer present and future government officials some guidance on similar problems—may become, by default, the definitive report on this problem. To be sure, Wade (2) has done a commendable job in his comments, and has had the imagination to find out that the principals involved would do it again under similar circumstances. This in itself greatly dilutes the impact of the report, since the advisors to the President—as well as the government administrators involved— were and are men of a caliber that could scarcely be exceeded if a similar question should arise in the future. I am impelled to get on the record at least some of the major flaws that lower the usefulness of the book, either to the Secretary or to his successors. In the first place, such a book simply cannot be written by anyone not steeped in the knowledge essential to making a judgment on the control of influenza. This is illustrated as early as page 6, in the authors' understatement of the significance of the 1918 influenza pandemic. The fact is that this was the worst outbreak of human disease since the Black Death in the 14th century, and possibly the second worst pandemic in human history. Anyone who lived through the 1918 episode
could tell "ghastly tales" about it. In my own case, the graveyard was just beyond the house in the village where we were living, and—as a 10-year-old boy—my most ineradicable recollection of the period came from watching the unending sequence of funeral processions that went by our house. No responsible person in public health nowadays, who knew the nature of that epidemic, could have failed to regard the death of a soldier from "swine flu" in early 1976 as a possible harbinger of disaster. The statement on page 6 that "no one at CDC knew any reason to suppose that the Fort Dix swine flu was a comparable killer" further reflects the bias of the book; a more reasonable statement would-have been, "Given the massive evidence that the 1918 episode was caused by swine flu or a virus barely distinguishable from it, no one could possibly say with confidence that we were not faced with another 1918 disaster." Further down the page the calculations and prognostications of Dr. Edwin Kilbourne are presented without the necessary qualifications. In the first place, he has omitted the 1947 epidemic (which would have strengthened his theory) and which was, incidentally, the first time that an effort was made to produce vaccine in large enough quantity to stem the expected onslaught. The time proved too short, as Dr. Herald Cox pointed out at the American Public Health Association meeting that Fall, noting that up to six months "lead time" was essential for large-scale production of vaccine. This long interval plagued each subsequent effort to make a new, adapted influenza vaccine in time for its large-scale use. in
522
LETTERS TO THE EDITOR
April 1957, Dr. Maurice Hilleman spotted the tiny news item in the New York Times that signaled "Asian flu" in that year. We cabled the US Army lab in Japan to get the virus fast, yet it was late May before we were able to distribute it to manufacturers and to the Division of Biologic Products (now the Bureau of Biologies). In other words, the urgency—which is repeatedly questioned inferentially by Neustadt and Fineberg—was very real, and will be again the next time a new strain with pandemic characteristics appears. Finally, the evidence that major new strains appear about once a decade is certainly not "scanty": 1947, 1957, 1968—doesn't this suggest something? The next major error in the book is to characterize Dr. Sencer as "an able, wily autocrat." This might also—as far as it goes—describe Roosevelt, Churchill, or innumerable other lesser figures who have contributed to government by their foresight, imagination, and ability to make decisions. But it is ludicrously inadequate. Sencer turned the CDC into a dynamic, flexible, broad, responsive and competent agency which has been regarded around the world as a model to emulate. He transformed the quarantine service, etc., etc. It is interesting to note that in a recent review of the book (3), Dr. Edward Kass pointed out the imperative need for a scapegoat, which is so well stated that it deserves repetition: "In the absence of an epidemic, blame had to befixed.The muffled drumbeat of society, of some elements of government and of the media, all calling for a culprit, should give us deep concern." One brief note regarding page 14: the CDC's first task was not to "ponder manufacture"—it was to decide (if anything) what should be done. When the decision to go ahead with a vaccination program was ready to take to the President, I had a personal chance to evaluate it, since I happened to be at the Bureau of
523
Biologies at the same time the national panel of experts were gathering there to make sure that they agreed on what to say, before the trip downtown to the White House. When one of them told me they would recommend a national vaccination program, I questioned this on the basis of the slim evidence at hand. He replied, "Look, I know that the chance of a pandemic may be as little as 1 to 50 or even less; but if you were the President of the United States and were told that the country faced a 1 to 50, or maybe even a 1 to 100 chance of a national disaster— which on the basis of all available evidence could be largely averted by a vaccine program—what would you say?" I got the point. This takes me up only to page 15, and there is much more to say—including the rather strange omission of any adequate discussion of the compensation problem, which Dr. H. B. Dull of CDC had already studied extensively and which was already a matter of established government policy in Denmark, Germany and other countries. But I cannot refrain from one final comment: if there was a major oversight in the American procedure, it was not the failure to warn the profession and the recipients of the vaccine that something untoward and unforeseeable might possibly happen; it was the failure to test out the candidate virus for virulence. The British did this, found that the virus caused practically no disease in human volunteers—and decided to sit back and simply watch developments, meanwhile making a small batch of vaccine in case of emergency. This took courage, not just to hold back, but to test the potential "pandemic" virus on humans. It is noteworthy that the British have for years had a unit which did this sort of thing regularly, caused no alarm, and yielded reams of useful information. None of this is meant to imply that there is nothing good to be found in the Neustadt-Fineberg book. But, as the
524
LETTERS TO THE EDITOR
above comments suggest, I and many others consider it essential to make it clear on the record that Prof. Neustadt and Dr. Fineberg have written not a definitive but in many ways a highly misleading account of "The Swine Flu Affair." REFERENCES
1. Neuatadt RE, Fineberg HV: The Swine Flu Af-
fair: Decision-Making on a Slippery Disease. Washington DC, US Department of Health, Education, and Welfare, 1978 2. Wade N: Swine flu campaign faulted yet principals would do it again. Science 202: 849-852, 1978 3. Kass EH: Book review. N Engl J Med 300:740-741, 1979
Geoffrey Edsall 6017 Tulane St. University Hills, CA 92122
RE: "TEMPORAL VARIATION IN SUICIDE AND HOMICIDE" The recent report by Lester in the The earlier paper dealt with the period American Journal of Epidemiology 1962-1966, and included deaths from ac(109:517-520, 1979) on the temporal cidents, suicide, and homicide. variation in deaths due to suicide and homicide for 1972-1973 inadvertently omitted mention of an earlier report in David Lester the Journal by Rogot, Fabsitz and FeinPsychology Program leib entitled "Daily Variation in USA Stockton State College Mortality" (103:198-211, 1976). Pomona, NJ 08240
Copyright © 1979 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved
Vol. 110, No. 4 Printed in UJ3A.
Letters to the Editor RE: "THE SWINE FLU AFFAIR: DECISION-MAKING ON A SLIPPERY DISEASE" It is now over two years since the nationwide program to vaccinate the USA against "swine flu" was suspended, and about a year since publication of the critique (1) commissioned by the then Secretary of the Department of Health, Education, and Welfare. There is a very real danger that this critique—written in order to review and criticize the handling of the "swine flu" episode in depth, and to offer present and future government officials some guidance on similar problems—may become, by default, the definitive report on this problem. To be sure, Wade (2) has done a commendable job in his comments, and has had the imagination to find out that the principals involved would do it again under similar circumstances. This in itself greatly dilutes the impact of the report, since the advisors to the President—as well as the government administrators involved— were and are men of a caliber that could scarcely be exceeded if a similar question should arise in the future. I am impelled to get on the record at least some of the major flaws that lower the usefulness of the book, either to the Secretary or to his successors. In the first place, such a book simply cannot be written by anyone not steeped in the knowledge essential to making a judgment on the control of influenza. This is illustrated as early as page 6, in the authors' understatement of the significance of the 1918 influenza pandemic. The fact is that this was the worst outbreak of human disease since the Black Death in the 14th century, and possibly the second worst pandemic in human history. Anyone who lived through the 1918 episode
could tell "ghastly tales" about it. In my own case, the graveyard was just beyond the house in the village where we were living, and—as a 10-year-old boy—my most ineradicable recollection of the period came from watching the unending sequence of funeral processions that went by our house. No responsible person in public health nowadays, who knew the nature of that epidemic, could have failed to regard the death of a soldier from "swine flu" in early 1976 as a possible harbinger of disaster. The statement on page 6 that "no one at CDC knew any reason to suppose that the Fort Dix swine flu was a comparable killer" further reflects the bias of the book; a more reasonable statement would-have been, "Given the massive evidence that the 1918 episode was caused by swine flu or a virus barely distinguishable from it, no one could possibly say with confidence that we were not faced with another 1918 disaster." Further down the page the calculations and prognostications of Dr. Edwin Kilbourne are presented without the necessary qualifications. In the first place, he has omitted the 1947 epidemic (which would have strengthened his theory) and which was, incidentally, the first time that an effort was made to produce vaccine in large enough quantity to stem the expected onslaught. The time proved too short, as Dr. Herald Cox pointed out at the American Public Health Association meeting that Fall, noting that up to six months "lead time" was essential for large-scale production of vaccine. This long interval plagued each subsequent effort to make a new, adapted influenza vaccine in time for its large-scale use. in
522
LETTERS TO THE EDITOR
April 1957, Dr. Maurice Hilleman spotted the tiny news item in the New York Times that signaled "Asian flu" in that year. We cabled the US Army lab in Japan to get the virus fast, yet it was late May before we were able to distribute it to manufacturers and to the Division of Biologic Products (now the Bureau of Biologies). In other words, the urgency—which is repeatedly questioned inferentially by Neustadt and Fineberg—was very real, and will be again the next time a new strain with pandemic characteristics appears. Finally, the evidence that major new strains appear about once a decade is certainly not "scanty": 1947, 1957, 1968—doesn't this suggest something? The next major error in the book is to characterize Dr. Sencer as "an able, wily autocrat." This might also—as far as it goes—describe Roosevelt, Churchill, or innumerable other lesser figures who have contributed to government by their foresight, imagination, and ability to make decisions. But it is ludicrously inadequate. Sencer turned the CDC into a dynamic, flexible, broad, responsive and competent agency which has been regarded around the world as a model to emulate. He transformed the quarantine service, etc., etc. It is interesting to note that in a recent review of the book (3), Dr. Edward Kass pointed out the imperative need for a scapegoat, which is so well stated that it deserves repetition: "In the absence of an epidemic, blame had to befixed.The muffled drumbeat of society, of some elements of government and of the media, all calling for a culprit, should give us deep concern." One brief note regarding page 14: the CDC's first task was not to "ponder manufacture"—it was to decide (if anything) what should be done. When the decision to go ahead with a vaccination program was ready to take to the President, I had a personal chance to evaluate it, since I happened to be at the Bureau of
523
Biologies at the same time the national panel of experts were gathering there to make sure that they agreed on what to say, before the trip downtown to the White House. When one of them told me they would recommend a national vaccination program, I questioned this on the basis of the slim evidence at hand. He replied, "Look, I know that the chance of a pandemic may be as little as 1 to 50 or even less; but if you were the President of the United States and were told that the country faced a 1 to 50, or maybe even a 1 to 100 chance of a national disaster— which on the basis of all available evidence could be largely averted by a vaccine program—what would you say?" I got the point. This takes me up only to page 15, and there is much more to say—including the rather strange omission of any adequate discussion of the compensation problem, which Dr. H. B. Dull of CDC had already studied extensively and which was already a matter of established government policy in Denmark, Germany and other countries. But I cannot refrain from one final comment: if there was a major oversight in the American procedure, it was not the failure to warn the profession and the recipients of the vaccine that something untoward and unforeseeable might possibly happen; it was the failure to test out the candidate virus for virulence. The British did this, found that the virus caused practically no disease in human volunteers—and decided to sit back and simply watch developments, meanwhile making a small batch of vaccine in case of emergency. This took courage, not just to hold back, but to test the potential "pandemic" virus on humans. It is noteworthy that the British have for years had a unit which did this sort of thing regularly, caused no alarm, and yielded reams of useful information. None of this is meant to imply that there is nothing good to be found in the Neustadt-Fineberg book. But, as the
524
LETTERS TO THE EDITOR
above comments suggest, I and many others consider it essential to make it clear on the record that Prof. Neustadt and Dr. Fineberg have written not a definitive but in many ways a highly misleading account of "The Swine Flu Affair." REFERENCES
1. Neuatadt RE, Fineberg HV: The Swine Flu Af-
fair: Decision-Making on a Slippery Disease. Washington DC, US Department of Health, Education, and Welfare, 1978 2. Wade N: Swine flu campaign faulted yet principals would do it again. Science 202: 849-852, 1978 3. Kass EH: Book review. N Engl J Med 300:740-741, 1979
Geoffrey Edsall 6017 Tulane St. University Hills, CA 92122
RE: "TEMPORAL VARIATION IN SUICIDE AND HOMICIDE" The recent report by Lester in the The earlier paper dealt with the period American Journal of Epidemiology 1962-1966, and included deaths from ac(109:517-520, 1979) on the temporal cidents, suicide, and homicide. variation in deaths due to suicide and homicide for 1972-1973 inadvertently omitted mention of an earlier report in David Lester the Journal by Rogot, Fabsitz and FeinPsychology Program leib entitled "Daily Variation in USA Stockton State College Mortality" (103:198-211, 1976). Pomona, NJ 08240
