Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It

by Gina Kolata

Then take the other side of the argument, supposing there was no pandemic. Then, the staff member said, the Centers for Disease Control could be accused of wasting money, of “crying wolf,” he said. Everyone, from the people who got the shots to those who administered them, would criticize the agency. “It was a no-win situation,” the participant concluded.

“Better a vaccine without an epidemic than an epidemic without a vaccine,” Kilbourne said.

Neustadt and Ernest R. May, a historian at Harvard University, later analyzed what they saw as crucial moments in the swine flu vaccine decision. It shared features, they said, with several other crucial moments in history, the Bay of Pigs and the Vietnam War. In each instance, they say, “the individuals who made the key decisions, or at least some of them, looked back and asked, ‘How in God’s name did we come to do that?’”

In fact, Neustadt and May realized, “What ‘Alexander’s question’ forces into the light are causal associations thought to be validated by past experience.” It would have showed the power of the analogy of the 1918 flu and exposed the paucity of scientific data behind the swine flu decision.

When Neustadt and Fineberg interviewed Alexander in preparation for their report on the swine flu affair, he told them, “My view is that you should be conservative about putting foreign material into the human body. That’s always true … especially when you are talking about 200 million bodies. The need should be estimated conservatively. If you don’t need to give it, don’t.”

Seal later recalled that one staff executive from the Centers for Disease Control privately told Sencer, “Suppose there is a pandemic accompanied by deaths. Then it comes out: ‘they had an opportunity to save life; they made the vaccine, they put it in the refrigerator …’ That translates to ‘they did nothing.’ And worse, ‘they didn’t even recommend an immunization campaign to the Secretary.’”

Several of the scientists were careful to express reservations, however, noting that it was entirely possible that there would be no swine flu epidemic the next winter, making a vaccine campaign unnecessary. Nonetheless, Kilbourne said, “our reservations, though voiced, were subservient to our mutual wish that the program proceed.”

By early afternoon of March 10, the group had reached an agreement—to go ahead with a national campaign to immunize all Americans against swine flu.

“Stallones summed it up best,” noted Sencer. “First there was evidence of a new strain with man-to-man transmission. Second, always before when a new strain was found there was a subsequent pandemic. And third, for the first time, there was both knowledge and the time to provide for mass immunization.” So, he said, “if we believe in preventive medicine we have no choice.”

“We have not undertaken a health program of this scope and intensity before in our history,” he explained. “There are no precedents, nor mechanisms in place that are suited to an endeavor of this magnitude.”

Earl Butz, the Secretary of Agriculture, was also present, telling Ford that although an unprecedented number of eggs would be needed to grow the flu virus in order to make the vaccine, “the roosters of America are ready to do their duty.”

Some of the specialists in influenza saw the new flu strain and its ties to the 1918 flu as an excuse to try an immunization campaign that might vastly improve upon what happened in the last flu pandemic, the Hong Kong flu of 1968. That time, too few were immunized, and too late, to staunch the virus’s spread. But most others had a different response to the 1918 metaphor. It “came as a bolt from the blue,” to many who had to make a decision, Neustadt and May wrote, “capturing imaginations and dominating impressions. Though the 1918 influenza holds but a small place in most histories, biographies, and memoirs, it seems that almost everyone at higher levels in the federal government in 1976 had a parent, uncle, aunt, cousin, or at least a family friend who had told lurid tales of personal experience with the 1918 flu. The killer had been known then as ‘Spanish flu’: the term ‘swine flu’ meant nothing much to laymen off the farm. But the year 1918—more precisely 1918–1919—cited in conjunction with the flu called up vivid images in Washington almost sixty years later. Those images were rooted in folk history and were more powerful because of it.”

Sencer opened the meeting by reviewing the facts of the potential swine flu epidemic, as he saw them. Ford then asked Salk and Sabin for their opinion. Both were enthusiastically in favor of a swine flu campaign. Finally, Ford asked those who wanted the nation to proceed with a swine flu immunization effort to raise their hands. All did.

Ford felt confident that the medical community was behind the decision to start a swine flu campaign. But, Neustadt and May argue, that consensus was less than firm. Look at the medical experts who were invited to the meeting. Salk and Sabin agreed with each other for once and supported Sencer and Cooper, who were sponsoring the program. Sencer himself had suggested the others at the meeting, and most of them had already made up their minds to support the program. Alexander was there but, Neustadt and May observed, he “rarely spoke up anyway.” The others “were already committed to Sencer’s plan.” As a result, the group’s “unanimity meant less than Ford assumed. It neither kept Sabin and Salk together (Sabin turned against the program three months later) nor reflected firm views in the medical community where opposition (and indifference) mounted as months passed without swine flu,” they write.

Ford was unaware of these complications. When no one crept into his office to express reservations about the program, he concluded that there were no doubters. So he decided to go ahead, reasoning, as he said, that “if you’ve got unanimity, you’d better go with it.”

Flanked by Sabin and Salk, Ford began: “I have been advised that there is a very real possibility that unless we take effective counteractions, there could be an epidemic of this disastrous disease next fall and winter here in the United States.” Ford said: “Let me state clearly at this time: no one knows exactly how serious this threat could be. Nevertheless, we cannot afford to take a chance with the health of our nation.”

It should have been a scene of triumph when President Gerald Ford appeared before the nation to announce his swine flu vaccine. All the elements were there: Advances in science and medicine were going to allow humans to take arms against the virus. The most revered doctors in America, Dr. Jonas Salk and Dr. Albert Sabin, were giving the battle their blessing, flanking President Ford in solidarity.

But the trouble began almost immediately.

Maybe it was the sheer hubris of President Ford and the two doctor-gods of vaccines, thinking that they could pull this off, assuming that the press would remain credulous and simply report the news. Maybe it was that just beneath the surface of the seemingly unified federal bureaucracies lay dissenters, political advisors, and scientists who told themselves that even if the decision makers did not want to hear them, the public would. Or maybe it was just that there was a critical mass of people who were convinced this swine flu immunization campaign was a cockeyed idea.

Reporters found these skeptics, of course. It is part of a reporter’s job to ask who, if anyone, disagrees with a pronouncement, especially one as dramatic as Ford’s decision to start the swine flu immunization campaign.

The advisors said that they themselves were skeptical of the campaign; as a group they conveyed a distinct lack of enthusiasm.

Cochran and Pierpoint were not just selectively hearing the grumblers either. In a detailed official investigation of the swine flu affair a year later, Richard E. Neustadt and Harvey Fineberg interviewed all the participants and verified for themselves the same surprising lack of support for the program. They report that they “ranged across the list of Ford’s political advisors, covering them thoroughly, we believe, from top to bottom, without finding an enthusiast among them.”

Cochran and Pierpoint also learned that scientists within the Centers for Disease Control were saying privately that the national immunization ...

And here were the true experts, those silent minions who gave political and scientific advice, saying that the whole idea was loony, misguided, a political ploy, scientific idiocy.

“Some experts seriously question whether it is logistically possible to inoculate two hundred million Americans by next fall. But beyond that, some doctors and public health officials have told CBS News that they believe that such a massive program is premature and unwise, that there is not enough proof of the need for it, and it won’t prevent more common types of flu. But because President Ford and others are endorsing the program, those who oppose it privately are afraid to say so in public.”

But, for the moment, Ford’s program went forward. After all, even though a substantial number of prominent critics had qualms, it was, in the end, hard to argue that it was better to do nothing, or to stockpile a vaccine, with the shadow of another 1918 flu epidemic looming.

“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,” Edsall said. “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 largely be averted by a vaccine program—what would you say?’ I got the point.”

So did Congress, which immediately approved the full $135 million that Ford requested to immunize virtually the entire nation. Although the Senate and the House of Representatives held hearings in which they questioned the gravity of the swine flu threat, the hearings turned out to be pro forma.

In addition, vaccine makers were told to stop making a vaccine to protect against what everyone had thought would be the predominant flu strain in the fall, A/Victoria, and shift over to making only swine flu vaccine.

The vaccine makers had already produced about 30 to 40 million doses of A/Victoria vaccine, but that would not go to waste, it was decided. It would be mixed with swine flu vaccine and given to people at high risk of becoming seriously ill or dying from the flu—mainly the elderly.

Pig farmers complained to the Centers for Disease Control that the name “swine flu” might frighten people away from eating pork. They asked, to no avail, that the flu’s name be changed to “New Jersey flu.”

“There are as many dangers to going ahead with immunizing the population as there are with withholding. We can soberly estimate that approximately fifteen percent of the entire population will suffer disability reaction.”

Even Dr. Albert Sabin of polio fame, who was last seen standing at President Ford’s side as he announced the swine flu campaign, began questioning it now that it was underway. He spoke at the University of Toledo on May 17, recommending that the vaccine be made but held in storehouses unless and until it was clear that a deadly swine flu epidemic was in progress.

With the steady drip of criticism, the tide started to turn, as reflected by the views of newspapers that had initially been supportive of the immunization program. When the Department of Health, Education, and Welfare surveyed the nation’s newspapers in May, it found that only 66 percent were still promoting the swine flu program, a big drop from the 88 percent that supported it a month earlier.

Outside the United States, other nations looked on with detachment. Some could not afford a campaign like the one underway in America; others were wary and decided to simply stockpile the vaccine and possibly provide it to people at high risk of serious illness if they were infected with the flu. There were a few countries, like the Netherlands, that decided to follow the U.S. lead and immunize, but they were the exceptions.

Dr. Nancy Cox, who is current chief of the influenza branch at the Centers for Disease Control and Prevention, as the agency is now called, says that it is not surprising that the United States was virtually alone in the world in reacting so strongly to the threat of a deadly influenza epidemic.

Moreover, Cox added, even though many countries had an air of detachment, that does not mean they were not concerned.

results of the field tests of the swine flu vaccine—the attempts to see if volunteers who were given the vaccine developed antibodies that would protect them against the swine flu. The vaccine worked well in people over age twenty-four—those who received it developed abundant antibodies against the swine flu. But children were not well protected, which meant that much more vaccine would have to be produced and that children would have to be induced to return for a second vaccine shot, complicating efforts to immunize the population.

In a season of bad surprises, none surpassed the next to beset the swine flu program. The vaccine makers announced that they could not get liability insurance for the vaccine. And until they could, they said, they would not bottle it.

those concerns were more or less swept aside by federal officials concentrating on the logistics of getting a vaccine program of unprecedented scope underway in record time.

The American Insurance Association and individual insurance companies had argued that the federal government should indemnify the vaccine makers, but few in the government took them seriously. The thought was that they were bluffing. Federal officials were convinced that all that would be necessary to satisfy the insurance industry would be for the government to assure them that it would be responsible for warning against possible side effects and for making sure that those vaccinated gave their informed consent.

If the public really was endangered, the government should take the risk; it certainly could, we wouldn’t.”

It simply was not worth taking a chance, the companies reasoned. No matter if they warned of any and all known dangers of the vaccine. No matter if they could easily explain to the scientific community the illnesses and deaths that were bound to occur by coincidence when more than 100 million people were vaccinated. The fact remained that the companies could be sued, and they could lose big. Even if they won, they could be saddled with immense costs of defending themselves against a barrage of lawsuits.

He wrote that if Americans have flu shots in the numbers predicted, as many as 2,300 will have strokes and 7,000 will have heart attacks within two days of being immunized. “Why? Because that is the number statistically expected, flu shots or no flu shots,” he wrote. “Yet can one expect a person who received a flu shot at noon and who that same night had a stroke not to associate somehow the two in his mind? Post hoc, ergo propter hoc,” he added.

within a week after receiving flu shots, 45 people will develop encephalitis and more than 9,000 will get pneumonia. Nine hundred will die of pneumonia. “Sequential to the immunizations? Yes, but not a consequence of them,” he said. “These are only a few examples of what is bound to happen the day and the week after immunizations.”

Neumann cautioned: “It is one thing to see matters objectively in light of statistical expectations. It is quite another when it affects one personally. Who can blame someone for assuming the events are linked? Hence, the pre...

Even in the Department of Health, Education, and Welfare, which wanted to indemnify the companies, ther...

Inevitably, vaccine production was delayed.

On May 21, a leading vaccine maker, Merrell National, told the chief lawyer for the Department of Health, Education, and Welfare that the company would not provide the swine flu vaccine unless the federal government provided indemnification. On June 10, the insurers for Parke-Davis and for Merrell National told the companies that their liability coverage for the swine flu vaccine would expire on July 1.

The only solution would be for Congress to pass a law requiring the federal government to...