The Coming Plague

The Coming Plague Page 26

by Laurie Garrett

  In its first official pronouncement the CDC’s words were crafted with careful attention to the ambiguities and tentativeness inherent in interpretation of the Fort Dix cases. After hours of meetings with top CDC and Washington Public Health Service officials, the agency published its first Swine Flu notice on February 14, in its regular weekly publication.23 It explained that a small influenza outbreak had occurred at Fort Dix during the previous month, involving one death. Eleven blood samples had been tested, seven proving to be the relatively harmless A/Victoria strain; four resulted from an A/H1N1 strain “similar to swine influenza.”

  The report also noted, “There is some evidence from antibody prevalence studies that occasional infections with swine influenza virus might have occurred in more recent [since 1970] years among persons in frequent contact with swine.”

  In 1974, a sixteen-year-old Minnesota boy suffering from Hodgkin’s disease (a type of blood cancer that produces severe immunodeficiency) died of what appeared to be Swine Flu. A year later, an otherwise healthy eight-year-old Wisconsin boy contracted the disease, surviving thanks to his body’s production of antibodies that cross-reacted with Shope’s 1930s Swine Flu virus. Both boys lived on farms and handled pigs. More important, in both cases the infection never spread to other schoolmates, and though most of the Wisconsin boy’s immediate family tested antibody-positive for exposure, none had developed the flu.

  In February, then, the agency readily acknowledged that there might be some low-level background rate of Swine Flu infections among people who lived around domestic pigs, and the presence of antibodies to swine antigens did not, in and of itself, indicate that a particularly lethal or highly transmissible form of influenza was afoot in America.

  Many years later CDC influenza expert Nancy Cox, who was not directly involved in the events of 1976, would summarize a large body of evidence indicating that people who lived and worked around domestic livestock were routinely exposed to the viruses those animals harbor, including swine strains of influenza. The great 1889 pandemic, for example, began as an epidemic of “the cough” among European horses (probably Russian) sometime in the early 1880s. Nearly ninety years later the 1968 Hong Kong flu also proved capable experimentally of producing “the cough” in horses.

  Swine influenzas, Cox would later explain, were particularly worrisome because pigs were highly permissive hosts, capable of harboring influenzas from a wide range of animals, birds, and humans. Inside the swine, various influenza strains shared genes, and recombined, resulting in major antigen shifts.

  “We do see in hindsight that the farm Swine Flu cases in 1976 were separate and isolated events from what occurred at Fort Dix,” Cox explained.

  A week after the CDC’s first 1976 publication, the agency noted discovery of six more Fort Dix soldiers with Swine Flu, bringing the total to ten (including the deceased Lewis). The remainder of the base’s epidemic appeared to result from A/Victoria flu. An additional agricultural Swine Flu case was reported, involving a young man from Mississippi, who also suffered from Hodgkin’s disease and worked in a pig slaughterhouse.24

  Large-scale blood testing at Fort Dix soon revealed a total of 273 individuals who may have had swine antibodies, thirteen of whom had actually contracted influenza. Unclear, and never clarified in any subsequent CDC publications, was how many of the influenza-ailing soldiers were co-infected with A/New Jersey/76 and A/Victoria/75. Even thirty years later no technology could tell which strain was responsible for disease in an individual who was co-infected, although it is generally assumed that whichever strain is present in largest numbers is the pathogenic culprit.

  The CDC interviewed the Fort Dix recruits to see which might have had direct contact with swine, and found twenty-two men who had been around pigs and had antibodies to the Shope swine influenza. Investigators then tested the families of those twenty-two soldiers: one family tested antibody-positive. Four out of eleven members of that family tested positive; none were sick. They were not farmers, and the flu-exposed members were all under twenty-five years old. When 200 classmates of the children were tested, no further spread of the apparent infection could be found.

  Policy decisions and actions moved forward rapidly, though investigations at Fort Dix were far from complete. Army and CDC investigators would spend several more weeks combing the base for clues to the origin and spread of the apparent Swine Flu, eventually concluding that no more than 155 recruits were definitely infected with the virus. Another 300 Fort Dix soldiers were infected with the A/Victoria/75 strain.

  More important, the investigators concluded that the only time or place shared by all soldiers infected with Swine Flu prior to their illnesses was the Fort Dix reception area. The mini-epidemic began, they concluded, sometime in the first or second week of January, when hundreds of fresh recruits were processed onto the base following the Christmas holidays, and assigned to basic training. In the reception center the new recruits were given physical examinations, vaccinations, and basic military instructions.

  The first of the new recruits subsequently shown to have Swine Flu arrived at the reception center on January 5. Designated only as V4, he complained of illness on January 28.

  Private Lewis came through the reception center the following day. All Fort Dix Swine Flu illnesses occurred between January 12 and February 8, the time span of high reception center activity. The infections probably incubated between the initial transmissions in the reception center in early January, and the flu illnesses appeared two to three weeks later.

  The only other possible shared source of infection for the thirteen soldiers struck with Swine Flu was the base medical system. All the men made visits to the base dispensary for a variety of health problems prior to developing the flu. Under General Russell’s personal command, Army investigators searched for a source of viral contamination at both the reception area and the dispensary: none was found. It is not likely, however, that weeks after the events any evidence of viral contamination of equipment or medical instruments would persist, available for discovery. Thus, the possibility remained that America’s Swine Flu outbreak of 1976 was iatrogenic.

  By mid-March influenza of all types was on a sharp decline worldwide, even at Fort Dix, and the agency’s virus branch director, Dr. Walter Dowdle, said, “Influenza in the United States has decreased markedly, and there is no longer evidence of nationwide epidemic activity.”25

  “By the beginning of March,” Dowdle would write six years later, “the only signs of the Swine Flu epidemic in the world [his emphasis] were at Fort Dix. But the possibility of a Swine Flu outbreak in the future could not be disproved. What could not be disproved must be allowed for. Most of the scientists were well aware of the professional risks they incurred if they mounted a national immunization program and the virus did not appear. Most were equally aware of their responsibility for the public’s safety in the event of an epidemic. Something had to be done.”26

  On March 13, the CDC director, David Sencer, completed a special memorandum for his superiors in Washington, detailing the evidence for a Swine Flu outbreak and requesting a $134 million congressional allocation for development and distribution of vaccines. Within less than a week, word of Swine Flu was all over Capitol Hill. By March 18, Sencer’s memo had been signed by Assistant Secretary for Health Dr. Theodore Cooper, and lay upon the desk of HEW Secretary F. David Mathews awaiting his urgent attention.

  Stated as certainties, rather than hypothetical conjectures, were the following points listed under the memo’s heading “Facts”: The virus found at Fort Dix is “antigenically related to the influenza virus which has been implicated as the cause of the 1918–19 pandemic which killed 450,000 [American] people; every American under the age of fifty”is probably susceptible to this new strain”; severe flu epidemics”occur at approximately ten-year intervals.â€


  After laying out four different plans of suggested action, the Sencer memo suggested mass vaccination, sponsored by the federal government, conducted by local authorities and supported publicly at the highest possible level.

  Within two weeks the snowball was roaring down an Alpine slope, gathering size as most sectors of the federal government, from congressional aides to the White House Office of Management and Budget, signed on.

  March 24 found an extraordinary group of scientists gathered in the White House at President Ford’s request. Edwin Kilbourne, polio vaccine inventors Jonas Salk and Albert Sabin, and a host of CDC and other federal researchers were asked point-blank by Ford, “Do you agree that the nation is facing a Swine Flu epidemic, and mass vaccination is necessary?”

  There were no voices of dissent in that room.

  That night, President Ford went on national television in a press conference that found him flanked by the icons of immunization, Sabin and Salk.

  “I have just concluded a meeting on a subject of vast importance to all Americans,” the President said. “I have been advised that there is a very real possibility that unless we take counteractions, there could be an epidemic of this dangerous disease next fall and winter here in the United States … . Accordingly, I am asking the Congress to appropriate $135 million, prior to the April recess, for the production of sufficient vaccine to inoculate every man, woman, and child in the United States.”

  Congress had no choice but to support the President. The politicians were nearly unanimous in their shared apprehension about being responsible for massive numbers of influenza deaths should they balk. Former Senator Edward Kennedy staffer Arthur Silverstein said there “was an almost unseemly race” on Capitol Hill to approve the President’s $135 million vaccination appropriations request. Senator Kennedy said, “There is nothing more frightening to a society than an epidemic,” throwing his liberal weight behind the Republican President’s request.

  Only two members of Congress were sharply vocal in their criticism of the program. California Democrat Representative Henry Waxman and his New Jersey colleague Andrew Maguire denounced the program as a “rip-off” that was guaranteed to generate profits for vaccine manufacturers. Consumer advocate Ralph Nader accused the government’s health establishment of crying wolf, wasting taxpayer dollars.

  Recognizing Ford’s position, some members of Congress decided to exploit the President’s absolute support of the flu campaign by attaching a long list of liberal riders to the immunization bill, adding $1.8 billion worth of social service spending and environmental protection funds to a bill they knew Ford could not possibly veto.

  Meanwhile, when Osborn saw President Ford’s press conference on television, she was outraged. Forced to work by telephone from Madison, Wisconsin, rather than in direct conference in Washington because her twin daughters were just seven years old, Osborn couldn’t believe that the sober, cautious approach that all her colleagues had tried to follow was suddenly shoved aside.

  “Everybody knows Salk and Sabin detest one another, and that they’re the two most famous vaccinologists in the world,” Osborn told fellow FDA advisers she reached that night by phone. “Neither of them has been involved in this in any way. Putting them together with the President like that spells disaster.”

  Years later, Osborn and Sencer would both argue that Ford’s March 24 press conference marked the turning point, bringing healthy skepticism to an end and putting politicians in the Swine Flu driver’s seat.

  As support built in Washington, the pharmaceutical manufacturers played their trump card, telling Ford directly that their insurance carriers would not indemnify such hastily produced vaccines. Unless the government absorbed liability for all possible ill effects from the vaccines, drug companies could not possibly cooperate in the $135 million effort. Well before Congress approved, and the President signed Public Law 94–266 allocating funds for the flu campaign, word was out that the real price tag might exceed by millions of dollars the requested sum. Some liberal members of the House of Representatives accused the pharmaceutical industry of trying to pull off a major scam, milking taxpayers for hundreds of millions of dollars and refusing to accept any responsibility for vaccine product quality.

  But on April 15, 1976, PL 94–266 was signed by President Ford in a televised ceremony. As he placed his signature on the bill, Ford dropped all pretense of doubt or conjecture, saying the Fort Dix virus “was the cause of a pandemic in 1918 and 1919 that resulted in over half a million deaths in the United States.”

  Though dissent and controversy would increase in political and scientific circles over subsequent months, a seemingly intransigent White House and public health establishment would speak with ever-greater certainty about the likelihood of a catastrophe, and all semblance of theorizing and guesswork would disappear from official pronouncements. Anger built during the late spring in response to pharmaceutical manufacturers’ insistence that no vaccine could or would be produced before the federal government agreed to absorb full liability. Some politicians accused the industry of casting off all vestiges of public responsibility, while corporate representatives reminded members of Congress that they were working in a tough, highly competitive free market in which profit making (or, at the very least, breaking even) was essential to survival.

  With a good deal more dissent than was engendered by the PL 94–266 enactment, Congress would eventually pass a law that officially waived corporate liability for Swine Flu vaccines, placing all legal culpability squarely on the shoulders of the U.S. taxpayers. It would be signed on August 12 and designated the National Swine Flu Immunization Program of 1976 (Public Law 94–380), scheduled to go into effect October 1, the same day the CDC planned to kick off the national flu vaccination program.

  The nation would then be irrevocably committed.

  It might not have made that leap from April’s bill to the August open-ended liability price tag had it not been for a unique and entirely unexpected set of events in July. Throughout the spring and early summer of 1976, opposition to the very concept of a mass epidemic was building in both scientific and political circles.

  Several leading physicians, notably consumer advocate Sidney Wolfe, vocally protested the government’s dire forecasts of a million dead Americans, noting that the CDC had projected those numbers from a base of 500,000 dead in 1918–19, multiplied by the increase in the U.S. population size since that time, and factoring for other changes, such as air travel and urbanization, which were thought to speed the spread of airborne microbes. The dissident doctors attacked the projection, noting that medical science had advanced considerably in its ability to diagnose and treat influenza, and it was highly unlikely that even a super-virulent strain could kill 21 million people worldwide in 1976. After all, they said, most influenza deaths were usually produced not by the virus but secondarily by bacterial infections that took advantage of the weakened immune defenses of influenza-infected lungs. Bacterial pneumonia was easily treated in 1976 with a number of readily available antibiotics. Though the CDC insisted (and still would nearly twenty years later) that the 1918–19 virus killed massive numbers of people directly, without secondary bacterial infections, many vocal physicians maintained that some, perhaps most, of the lung hemorrhages and fatal heart attacks reported in 1918 might be treatable in intensive-care units in 1976.

  There was also increasing skepticism about the basic assumption that the Fort Dix strain was equivalent to the deadly 1918–19 Swine Flu. There was no evidence of mass spread, and Fort Dix medical officer Bartley told Science magazine’s Philip Boffey that Private Lewis might well have lived if he hadn’t gone on the long winter march. Some Army physicians quietly told their civilian colleagues that it was possible even the dreaded virulence of the 1918–19 strain was more an enviro
nmental than genetic issue. Rather than ascribing the rampant spread and quick die-offs to some unique characteristics of the virus, these researchers discreetly insisted it was World War I trench warfare conditions, horrendous overcrowding in military encampments, and the movement of hundreds of thousands of troops in jam-packed ships, submarines, and train cars all over the world that spread the disease.

  Dr. E. Russell Alexander, chair of the University of Washington’s School of Public Health, was a dissident member of the CDC’s flu advisory committee. From the beginning he had advised that the government hold off on a mass immunization campaign and instead stockpile vaccines for possible use should an epidemic appear. As months rolled by without additional cases, Alexander’s position drew support from many circles.

  If the CDC was facing obstacles due to controversies in the United States, its ability to win over public health counterparts in other countries was firmly blocked by strong scientific skepticism. Though the World Health Organization lent official support to a global Swine Flu campaign in a special meeting convened in Geneva April 7–8, the backing was lukewarm, and fell short of recommending widespread vaccination. Instead, WHO suggested that national health ministries worldwide be on the alert for unusual flu outbreaks, consider adding Swine Flu vaccines to the list of immunizations offered to elderly citizens of richer nations, and stockpile supplies of vaccine once it was available. It seemed Russell Alexander’s position was garnering support outside the United States, with the exception of Canada, where the CDC’s arguments held sway.

  On July 3 the prestigious British medical journal The Lancet published three articles critical of the American campaign. In the first, physicians from England’s Harvard Hospital in Salisbury compared the A/New Jersey flu strain with two other varieties found in American pigs and a strain then common in England. Six human volunteers were injected with viral samples. The researchers concluded that the Fort Dix virus was “evidently intermediate in its virulence for man between a human virus and a swine virus … . The conclusion, therefore, was that in its present form, A/NJ/8/76 was less virulent in man than an established human influenza-A virus, but a good deal more infectious and virulent than two swine pathogens … tested previously.”27

 

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