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The fiasco of the 1976 ‘swine flu affair’
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The political handling of the swine flu fiasco had elements of farce (Credit: Getty Images)
With a pandemic looming, the US president announced a warp-speed effort to vaccinate every man, woman and child in the country. As Richard Fisher discovers, the mistakes that followed hold lessons for today.

Pascal Imperato was waiting in line for his vaccine shot. So were the cameras.

It was around 10:30 in the morning on 12 October 1976, and Imperato was at the Chelsea Health Clinic, an Art Deco building in the lower west side of Manhattan. The clinic was one of around 60 locations dotted around New York, preparing to vaccinate almost everyone in the city.

That year, fears of a swine flu pandemic had loomed large, so President Gerald Ford had ordered an unprecedented mass vaccination of everyone in the United States. As Imperato rolled up his sleeve, it was the first day of the effort in New York.

Imperato was deputy health commissioner and the chair of the task force charged with rolling out the programme in the city, so had volunteered to be photographed for the newspapers as he got his shot. The mayor of New York City, when asked, had refused, so Imperato had stepped up. Turnout was strong across the city that morning.

But what was meant to be a ceremonial opening and positive public relations effort would turn sour. That week, the papers had begun reporting troubling news from vaccine clinics in Pittsburgh: three apparently unexplained deaths due to heart attacks.

“I remember that day. I remember it vividly,” recalls Imperato. “I saw those headlines on the subway. And I said, ‘Good God. All hell is breaking loose here.’”

Pascal Imperato in the 1970s, who led New York City's swine flu vaccination drive (Credit: Pascal Imperato)

Pascal Imperato in the 1970s, who led New York City's swine flu vaccination drive (Credit: Pascal Imperato)

The headlines would get worse. Two days later, the New York Post tabloid wrote of “The Scene at the Pennsylvania Death Clinic”, featuring emotional but almost certainly embellished tales: “One of the old people, 75-year old Julia Bucci, had winced at the hypodermic needle in her arm, had taken a few feeble steps, then dropped dead on the floor of the health station. Right in front of their eyes.”

The stories, it would turn out, were false and misleading. But it was just one of many problems that plagued the “swine flu affair of 1976”, when a US president decided to rush a vaccine to the entire American population based on ill-founded science and political imprudence. Lawsuits, side-effects and negative media coverage followed, and the events dented confidence in public health for years to come. What happened might even have laid the foundations for the mistaken anti-vax views and distrust in public health that would spread decades later.

As the world rushes to roll out a vaccine to billions of people today, what might we learn from the ill-fated events of 1976? 

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It began at a US Army training base in New Jersey. In February 1976, several soldiers at Fort Dix fell ill with a previously unrecognised swine flu. None had been in contact with pigs, so human transmission was assumed. Testing revealed that the virus had spread to more than 200 recruits.

The pandemics of 1957 and 1968 were still fresh in the memory, and fears soon escalated of another 1918-like influenza pandemic, which had killed tens of millions. Further investigation found that people under 50 years old had no antibodies to this new strain.

Urgent decisions were needed. Public health officials realised it might be possible to get a vaccine to the public by the end of the year if they acted fast. The pharmaceutical industry had just finished manufacturing vaccines for the normal flu seasons. They also had an animal advantage: roosters. Back then, influenza vaccine was produced in fertilised hen’s eggs. That season’s roosters were due for slaughter, so a slow decision would add a delay of several months to vaccine manufacture.

In March, President Ford announced a $137m (£67.5m in 1976) effort to produce a vaccine by the autumn. “Its goal was to immunise every man, woman and child in the US, and thus was the largest and most ambitious immunisation program ever undertaken in the United States,” wrote Imperato in a 2015 paper reflecting on the events.

With hindsight, it’s easy to see that the fears of the time were unfounded. The swine flu strain spotted at Fort Dix was not dangerous, and there would be no pandemic. Later, researchers discovered that benign swine flu strains had been circulating in the US population long before this one was identified at the military base. And scientists who feared another Spanish flu did not know that the 1918 influenza was avian, not swine. Researchers at the time also suffered from a form of recency bias: based on experience from the 1950s and 60s, they assumed major influenza pandemics happened on an 11-year cycle, when they are actually more irregular.

Outbreak fears began at Fort Dix army base. A soldier there is given a standard vaccination a few years later (Credit: Getty Images)

Outbreak fears began at Fort Dix army base. A soldier there is given a standard vaccination a few years later (Credit: Getty Images)

So, as has happened throughout the Covid-19 pandemic of 2020, the scientists could only give the best advice they could based on incomplete knowledge. Many public health officials were sceptical and uncertain too, including Imperato in New York. “I think all of us were in agreement that yes, it's probably unlikely but we can't be absolutely sure,” he recalls.

Ford did convene a high-profile meeting of scientists to decide if there should be a vaccination programme, but “this was interpreted to be a political event rather than a scientific process”, according to David Sencer, the then-director of the CDC (the Center for Disease Control, as it was known before a renaming in the 1990s).

Still, that’s not to say that scientists were neutral in their uncertainties. As former president of the Institute of Medicine Harvey Fineberg concluded in a lacerating review of the events in 2008, plenty of senior scientists supported the vaccine with pre-existing agendas. Some researchers saw the chance to improve the credentials of their institution or field on the national stage, he wrote, while others held a “conviction that prevention of disease by vaccination was an achievable perfection of the human condition”. 

As the US summer arrived, no outbreak had emerged nationally or internationally, but efforts continued nonetheless. Four pharmaceutical companies had begun production, and testing was underway in clinical trials. But in June, there was a problem that would have far-reaching effects for years afterwards.

It began when the industry manufacturers announced that they had been refused liability insurance, effectively downing tools. They asked Congress to indemnify them, but were turned down.

The swine flu virus under the microscope (Credit: Getty Images)

The swine flu virus under the microscope (Credit: Getty Images)

For weeks, this hampered the plans of local public health officials like Imperato, but crucially, also dented public confidence. “While the manufacturers' ultimatum reflected the trend of increased litigiousness in American society, its unintended, unmistakable subliminal message blared ‘There's something wrong with this vaccine,’” writes Sencer. “This public misperception, warranted or not, ensured that every coincidental health event that occurred in the wake of the swine flu shot would be scrutinised and attributed to the vaccine.”

In July, the Ford administration agreed to bear the cost of defending lawsuits and asked Congress to pass legislation. The programme was back on track, but it was too late to reverse the damage to public perception.

The October crisis

By mid-October, as Imperato was queuing with the photographers for his shot in New York City, the whole enterprise was already well on the way to another crisis, even if leaders did not acknowledge it.

“The president himself was vaccinated on television on 14 October, further heightening perceptions that this was a politicised event,” writes Sencer.

President Gerald Ford invited the cameras for his own swine flu vaccination (Credit: Getty Images)

President Gerald Ford invited the cameras for his own swine flu vaccination (Credit: Getty Images)

The deaths in Pittsburgh would be the start. While there was no causal evidence linking these deaths to the vaccine, they triggered many people to come forward claiming evidence of ill health, falsely blaming the inoculation. Nine states shut down their programmes.

With such a high-profile roll-out, closely attached to the White House, many journalists unused to covering science reported only what they saw and heard from the public, without interrogating whether it was linked. Tabloid journalists gave few column inches to epidemiological nuance. What they should have looked for was “excess mortality” – deaths that would not have happened otherwise – but the daily emerging tales of unexplained heart attacks, distraught nurses, and political failure won more attention.

The events became known in Imperato’s team as “the October crisis”. Take-up of the vaccine in the following days plummeted as public confidence waned. “Some of those headlines were really terrible. I remember, one of them was ‘death toll mounting’,” he recalls. “What they were really doing was monitoring the normal pattern of deaths in a population of older people that would have occurred anyway.” Blaming the vaccine, he says, was akin to concluding that a man killed by a falling tree limb died because of his red socks.

Vaccination drives began all over the country, but fears were soon raised in the media (Credit: Getty Images)

Vaccination drives began all over the country, but fears were soon raised in the media (Credit: Getty Images)

Imperato grew frustrated with the CDC during this period, who he believes should have stepped in faster to reassure people and present the evidence. “The CDC remained silent. We were not happy about that,” he recalls. “We were very angry with them.” Echoing the speculation around the CDC today, he wonders whether they were muted for political reasons, but does not know. (Sencer, the CDC chief at the time, could probably say, but he died in 2011. In 2006, he did write, however, that the CDC believed that local and state public health departments were best placed to communicate with the media and public.)

A problem of nerves

As the months continued – still with no outbreak – new problems arose. And this time, they were real side-effects. Millions of vaccinations meant dozens of cases of Guillain-Barre syndrome, a rare problem where the body’s immune system attacks the nerves. It leads to weakness and tingling in the extremities, and in some cases can be severe, leading to other complications and paralysis. The syndrome was less understood in the 1970s. Research has since found that the chances of developing the condition after vaccination are extremely small, but the scale of the 1976 roll-out meant that a handful of people were bound to be affected.

As Sencer once pointed out in an interview with the World Health Organization, if a pandemic had happened in 1976, then these rare cases would have been “a blip on the screen” amid a much deeper, wider problem. It’s no secret that vaccines can have side-effects, but their protective effects against deadly diseases significantly outweigh these risks for the vast majority of people. As Helen Branswell of Stat News pointed out recently, mild side-effects should be anticipated as new vaccines emerge for Covid-19 and it’s no cause for alarm. Also, you are more likely to get Guillain-Barre syndrome from an infection such as the flu than the flu vaccine. The rate of extra cases associated with the 2009 swine flu vaccine was two in a million.

Still, the Guillain-Barre problem in 1976 did, sadly, cause illness and suffering among an unlucky group of people – perhaps as many as hundreds – who we can now conclude did not need to go through what they did.

The swine flu affair, the New York Times concluded, had been a “sorry debacle” and “fiasco” marked by political expediency and unwarranted confidence

After months of negative media coverage, the Guillain-Barre reports brought an overdue end to the swine flu affair. Ford’s programme was suspended in December 1976 with only some 20% of the US population vaccinated. And since the US government had offered liability coverage to the pharmaceutical manufacturers that summer, hundreds of compensation claims from Guillain-Barre claimants followed for years afterward.

The swine flu affair, the New York Times concluded after the programme was suspended, had been a “sorry debacle” and “fiasco” marked by political expediency and unwarranted confidence. “The danger now is that the whole idea of preventive medicine may be discredited,” the editorial warned.

While it would be a stretch to suggest that it led directly to the anti-vax movement decades later, the botched decisions of 1976 would remain in the American memory, and would have done little to boost confidence in vaccines and public health advice for years afterwards.

The media played a huge role in public perceptions of vaccines in 1976, and history is repeating itself (Credit: Getty Images)

The media played a huge role in public perceptions of vaccines in 1976, and history is repeating itself (Credit: Getty Images)

So, as our politicians stand at their podiums making claims and promises about vaccines during the Covid-19 pandemic, what else might be learnt from the swine flu affair of 1976?

For Fineberg, “the fundamental strategic blunder” was announcing a mass vaccination programme so early. It was premature, and locked politicians into a very visible commitment. So, when presidents and prime ministers make bold promises to the public – like Operation Warp Speed, the current US effort to roll out 300 million doses to the US public by January 2021 – it makes a scientific process into a political pledge.

As 1976 showed, such a commitment can make leaders less willing to adapt to new evidence – or changes in risk. Sencer writes that Ford and other leaders were continually briefed that a pandemic remained “possible”, but not how “probable”, even as the likelihood declined with time. There was also arguably a language gap: to a scientist, possible can mean a one in a million chance; to a politician, it necessitates action.

In the post-mortems of 1976, it is also striking to read of the pitfalls of politicians presenting scientific information to the public. When Ford was the face for the vaccine initiative, Sencer writes, it did not foster trust. “Scientific information coming from a non-scientific political figure is likely to encourage scepticism, not enthusiasm,” he writes. How quickly these errors of judgment have been forgotten during the Covid-19 pandemic, as politicians shoulder out experts when the cameras point their way. 

When politicians talk of “the science” as a complete body of knowledge, a manual for what to do, it neglects the uncertainty of evidence and ignores that science is a human endeavour.

Scientists, however, are human too. Today, it’s easy to see gaps in the scientific evidence of 1976, such as the belief that the virus mirrored the 1918 outbreak or that a pandemic was due. But the scientists of the time could not, so faced with uncertainty, they made conclusions influenced by belief, instinct or fear. The same must almost certainly be true today. The science of viruses in 2020 may be far more sophisticated, but the science of Sars-Cov-2, the virus that causes the disease Covid-19, remains incomplete. According to Fineberg, the swine flu affair was characterised by “overconfidence in theory spun from meagre evidence”. There was also a kind of “hero” effect at play, says Fineberg, where the fear of disaster led to an immovable zeal. 

So, when politicians in the present day talk of “the science” as if it is a complete body of knowledge, a manual for what to do, it neglects the uncertainty of evidence and ignores that science is a human endeavour.

As for Imperato, remembering the day he was vaccinated for the cameras and the surrounding chaos gives him some concerns about what’s ahead in 2020. “I really see the beginnings of the same patterns of commentary about the Covid-19 vaccines and the trials,” he says. There’s no reason, he believes, why a mass vaccination effort could not be rolled out quickly, but he worries about the media context it will happen within. “There are so many talking heads, on television and on social media, commenting on every aspect of this pandemic,” he says. “Their credentials are not matched to what they're commenting on. I refer to them as trespassers.”

The swine flu affair of 1976 holds many lessons for today, says Imperato, and there’s wisdom in the aphorism that those who ignore the lessons of history are doomed to repeat it. Still, throughout his career he has remained a strong advocate for the life-saving properties of vaccines. “You know, all that happened while I was getting my shot, it didn't dissuade me. I still went ahead with it.”

*Richard Fisher is a senior journalist for BBC Future, and tweets @rifish

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