Learning from Pandemics

Featured

Aug 1

The recent COVID-19 pandemic has not generated the kind of self-critical examination that we need to undertake if we are to avoid repeating mistakes in the future. Unfortunately, this is far from the first time that that we have failed to learn from such experiences. One such failure, the so-called swine flu of 1976, occurred during the presidential administration of Gerald Ford. Had politicians and public health officials learned its lessons, the nation might have mounted a more measured and effective response to COVID, but such lessons are still not receiving the attention they deserve.

The first cases of the swine flu, caused by an H1N1 subtype of influenza type A, were reported at Fort Dix in New Jersey, where they resulted in 13 hospitalizations and one death. A month later, the director of the Centers for Disease Control called for a mass immunization program against it. President Ford convened a blue-ribbon panel that included Jonas Salk and Albert Sabin, developers of the polio vaccine, after which Ford announced his support for mass immunization. At the time, he said, “No one knows how serious this could be, but we cannot afford to take a chance with the health of our nation.”

The first doses of the vaccine were administered in October, and more than 40 million people received it within just three months. To boost public confidence, the president and his family were photographed receiving their injections. Within six weeks of immunization, several hundred people developed Guillain-Barre syndrome, a neurologic condition associated with muscle weakness and paralysis. In December, the immunization program was suspended, and in February of the next year, after the Carter administration assumed office, the program was terminated.

Harvey Fineberg, a former president of the National Academy of Medicine, has highlighted several lessons from the government response to the swine flu. First, there was a tendency to place excessive confidence in biomedical science. For example, experts at the time had concluded that flu epidemics occur about every 11 years, so they were primed to identify an outbreak in the late 1970s. In fact, however, it turns out that the idea of an 11-year cycle has no predictive value. Experts saw what they expected to see, rather than what was really occurring.

There was widespread fear that the swine flu might turn into another global scourge like the 1918 influenza pandemic, which may have killed as many as 500 million people worldwide. Fanning these flames was the fact that people under 50 seemed to have no antibodies to it. Yet a pandemic never materialized. It is widely thought that the virus circulated for a period of months and then disappeared, resulting in very few deaths. The hospitalizations and deaths at Fort Dix may have stemmed from crowded conditions in the base’s military barracks during winter months.

A second lesson relates to a mixture of motives among politicians and public health experts. Politicians such as Ford lacked medical and scientific expertise but wanted to take no chances, while public health officials, uncertain as to the risk, wanted to ensure that political inertia would not prevail. It was widely assumed that every possible outcome needed to be guarded against, even though, as Fineberg indicates, an event with a 1-in-10 probability is still possible when its probability drops to 1-in-a-million. Moreover, experts failed to clearly revise their estimates as more information became available.

A third lesson relates to the final common pathway of decision-making, which could be characterized as a simple yes-or-no decision. Multiple decision points were involved – whether to develop a vaccine, whether to produce it, and whether to administer it to every American – but all of these decisions were essentially collapsed into a single choice that took place early in 1976. The key lesson, Fineberg suggests, is to “separate what needs to be done to prepare for future decisions from reaching conclusions and announcing them before relevant information is at hand.”

The swine flu immunization program undermined the credibility of both the Ford administration and the Centers for Disease Control (CDC). In the latter camp, some felt that scientific evidence was being trumped by a political agenda, while in the former, politicians felt they had no choice, given the magnitude of the potential public health crisis, but to authorize the mass immunization program. There was no process in place to review new evidence on an ongoing basis, or to reexamine and perhaps revise prior decisions. Some felt that questioning the March decisions would smack of disloyalty.

The failure to learn such lessons took a heavy toll on the US during COVID. For example, federal and state authorities mandated lockdowns of various types, including restricted movement and the closings of businesses and schools. Subsequent analysis has shown that such policies resulted in massive economic costs, severe social and psychological distress, and permanent educational losses, yet, in the best-case scenario, they reduced deaths by a small fraction of one percent. Moreover, the lockdowns disproportionately harmed the poor, who could not stay home and work or learn from laptops.

Such misguided policies sprang in part from a substantially mistaken estimate of the lethality of the disease. Initial mortality rate estimates from the World Health Organization were around 3%, but it turned out that the number of people who had been infected at the time was much higher, lowering the mortality rate to less than 1/10th that level. It was still far lower in healthy children and young adults. Yet as this much-reduced rate of mortality became apparent, many politicians and public health officials were reluctant to reexamine their initial strategies.

Subsequent reviews of different government approaches produced striking results. In the early days of the pandemic, California instituted very stringent lockdowns, while Florida quickly backed off its initial lockdown policy and never reinstituted it. Yet after adjusting for differences in age and disease rates between the two states, there is essentially no difference in health outcomes, although Florida fared far better economically and educationally. Similarly, Sweden did not lock down, while other European nations such as France and Germany did, yet mortality rates in Sweden were actually lower.

The overarching lesson is one Ford himself would appreciate. We need to regularly reexamine our decisions, admit mistakes, and attempt to learn from them to avoid future repetition. As Ford himself said early in his presidency, “I believe that truth is the glue that holds civilization together. In all my public and private acts as your president, I expect to follow my instincts of openness and candor, with full confidence that honesty is always the best policy in the end.” To avoid needlessly repeating serious pandemic mistakes, we need to take Ford’s call to rigorous self-scrutiny to heart.