Tuesday, January 31, 2012

A Gun To Our Head: The 1976 Swine Flu “Debacle”

For a nationwide effort deemed--in the perfect vision of historical hindsight--a “debacle,” the coordinated efforts of multiple federal agencies, state health departments, and local volunteer organizations and individuals to prevent a “strongly possible” (Neustadt, et al., 1978) swine influenza epidemic in the winter of 1976-77 were uniquely successful from several perspectives. Prior to 1976, there existed no organized, efficient way to rapidly manufacture and deploy hundreds of millions of doses of vaccine, no way to perform nationwide disease and adverse-effect surveillance in real time, and no appreciation for the legal and logistical challenges that would result from such an effort. The lessons our public health infrastructure learned from the 1976 “debacle” are important tools we still use today.

The story starts with the sudden appearance of a respiratory disease outbreak among Army recruits returning from Christmas break to Fort Dix, New Jersey, in January 1976 (Gaydos, 2006). Martin Goldfield, a civilian epidemiologist (who would later strongly and publicly criticize the vaccination campaign), sent samples from the Fort Dix patients to the Centers for Disease Control (CDC), where on February 12th, lab director Walter Dowdle reported that a previously unidentified viral vector was swine influenza antigenically similar to the virus responsible for the 1918 pandemic. On Feburary 14th, CDC director David Sencer met with representatives from the Food and Drug Administration’s Bureau of Biologics (BoB) and National Institute for Allergy and Infectious Disease (NIAID) (both of which were responsible for licensing and testing vaccines), the Army and Dr. Goldfield to discuss the potential early outbreak.

By March, all reported cases (500 total, all in young, previously healthy recruits) were still confined to Fort Dix, but Sencer and his colleagues knew three worrisome facts so far: (1) human-to-human transmission was occurring, (2) no “herd immunity” existed in patients younger than 62 years old, and (3) traditional “high risk” groups did not apply--this virus was attacking the young and healthy, just as in 1918. On March 13th, Sencer sent an “action-memorandum” to the Secretary of Health, Education and Welfare (HEW) that became the motivating declaration for the nascent national immunization campaign. In the memorandum, Sencer wrote of a “strong possibility” that a swine influenza epidemic would occur during the 1976-77 season, and that the government must act swiftly and decisively to prepare. Although the memorandum was moderate in its tone, it argued that “less than 100% coverage” by vaccination would be “socially and politically unacceptable.” In subsequent meetings with Secretary Mathews (HEW), Sencer boldly argued with even more certainty that an epidemic would occur. Mathews took Sencer’s memo to the White House, where it was felt to be “a gun to our head” -- the social and political fallout of failing to prepare would indeed be a nightmare. President Ford chose to act and announced his decision to the public, flanked by vaccination luminaries Salk and Sabin, on March 24th.

The CDC, with limited time and resources, focused on encouraging planning by state health authorities, setting standards, allotting administrative funds to the states, purchasing vaccine on their behalf, conducting surveillance of disease and adverse effect activity, and encouraging involvement of private physicians and volunteer organizations. In comparison, the state and local public health organizations were responsible for planning the logistics of vaccine distribution and administration, injection gun acquisition and other details, using CDC-written educational materials to prepare the public. The CDC was simply unequipped to work on a state or local level, except to help in defraying costs and advising.

On the vaccine side of the effort, the NIAID and BoB acted as liaisons between the federal government and private vaccine manufacturers. These organizations conducted field trials and testing, and were instrumental in the decision to stop manufacture of the Victoria flu strain vaccine (which had been responsible for the 1975-76 flu season, including the majority of Fort Dix cases). Instead, it was decided to use all available resources to manufacture swine flu vaccine and combine it with the existing 30 million doses of Victoria vaccine to create bivalent vaccine doses for those at highest risk.

The coordination of these organizations across the federal, state and local levels was unprecedented and, in many ways, worked well. The first doses of swine flu vaccine were given in October 1976 and before the campaign was stopped, 40 million doses were given (over twice as many as had ever been given in any previous flu season) (Zimmer, 2009). However, the epidemic never materialized. Furthermore, 532 cases of Guillain-Barre syndrome occurred (and were reported “upstream” from local to federal authorities, in almost real-time, to the CDC’s first-ever computerized epidemiologic surveillance system), prompting cessation of the campaign in December (Turnock, 2009). In a sense, the rapid cessation of the program was as much a success of multi-level public health coordination as was the initiation of the 1976 swine flu immunization campaign. There is reason for optimism that the skills the public health system learned from 1976 will be useful the next time a metaphorical gun is held to its head.


Gaydos J.C., Top F.H., Hodder R.A., Russell P.K. (2006). Swine influenza A outbreak, Fort Dix, New Jersey, 1976. Emerging Infectious Diseases. Atlanta, GA: Centers for Disease Control.

Neustadt RE, Fineberg HV. (1978). The swine flu affair: Decision-making on a slippery disease. Washington, D.C.: Government Printing Office.

Turnock B.J. (2009). Public health: What it is and how it works (4th ed). Sudbury, MA: Jones and Bartlett Publishers.

Zimmer S.M., Burke D.S. (2009). Historical perspective--emergence of influenza A (H1N1) viruses. New England Journal of Medicine. Boston, MA: Massachusetts Medical Society.

Monday, January 30, 2012

What’s So Bad About Socialized Medicine?: The British National Health Service

The health care reform debate in America seems to reliably raise the specter of “socialized medicine,” complete with fears of long lines, “cookbook medicine,” rationing and--a more recent canard--the Death Panel. However, the United Kingdom has been somehow surviving under a system of universal, publicly-funded health care since 1948. Riding the post-World War II election of the Labour Party, social reformer Lord William Beveridge’s plan for a National Health Service (NHS) was passed in 1946. A son of generations of poor coal miners, parliamentarian Aneurin “Nye” Bevan then implemented the plan with his unique mix of political strong-arm tactics and artful compromise, achieving the cooperation of insurance companies, hospitals, general practitioners (GPs) and other stakeholders.

Now entering it’s seventh decade, the NHS is still widely popular with the British public. Its organization and governance has changed, but the experience for the patient has not - almost all medical care, from a common cold to a coronary bypass graft, is free. As originally designed, the NHS was divided into three main branches: (1) government-owned hospitals with salaried specialists; (2) GPs and dentists practicing in independent offices, but paid by the NHS; and (3) the public health authority. Reforms in the 1970s and 1980s under Thatcher’s Conservative government simplified layers of administration and improved integration and coordination of services. Further reforms in the 1990s created Regional Health Authorities (RHAs) which received disbursement of tax funding from the Department of Health. The RHAs then distributed funding to smaller District Health Authorities (DHAs), which contracted with hospitals and specialists, and Primary Care Trusts (PCTs), which contracted with GPs for services. More recent reforms have increased competition between hospitals for GP referrals, decreased waiting times, and resulted in improved physician and patient satisfaction.

The philosophy behind the NHS seems to be that, in a system into which everyone pays (with 15-17.5% sales taxes, and higher income and social security taxes than in the US) and by which all are served, it benefits everyone to stay healthy. The NHS incentivizes primary and secondary prevention. Primary prevention is encouraged by a system that pays GPs for implementing proven preventative strategies (e.g., “flu jabs [shots]”). Secondary prevention is promoted by a system that ensures universal access, very low cost (e.g., although a $10 fee is “required” for prescription drugs, this fee is waived for children, pregnant women, anyone over 60, and the chronically ill--that is, 85% of those who take prescription drugs), and evidence-based screening strategies vetted by the National Institute for Clinical Excellence (NICE).

In contrast to the US system, which spends one-sixth of its GDP (the greatest proportion of any industrialized nation) on care heavily weighted toward tertiary and hospital-based care, the NHS salaries specialists--the average specialist in the UK makes less than the average GP! Furthermore, 60% of physicians in the UK are GPs, whereas only 35% of physicians in the US are generalists. The NHS’s distribution of resources and specialties removes the incentives for high-cost tertiary care and shifts the emphasis toward cost-saving (and life-saving) preventive, public and primary health care.

But does it work? The NHS is certainly popular with the British public. As journalist T.R. Reid writes in The Healing of America, “There are private health insurance plans in the United Kingdom, but few people bother with them. Nine of out ten Britons get all their health care from the NHS.” The culture of “no medical bills” is also a point of national pride, as evidenced by the resounding defeat of a 1990s suggestion by the British Medical Association to institute a low copay for all patients. Not only is it popular, the NHS is also cost effective: it provides care for a population one-fifth the size of the United States, for one-fifteenth of the cost. Yet the UK has lower child mortality rates, longer healthy life spans and better recovery rates for most major illnesses.

Not that the UK or NHS are perfect, by any means. Before the reforms made by the Blair administration, a common complaint about the NHS were long waits to see consultants (i.e., specialists). There were several British popular press reports of patients dying while they waited for speciality treatment. However, this problem has been largely ameliorated by Blair’s infusion of funds into the NHS and the implementation of payment-for-results to hospitals and competition among hospitals for GP referrals. The UK, like the US, also continues to suffer healthcare disparities between its social classes--and also as in the US, these health disparities are greater than would be predicted simply from health factors alone. The NHS has not yet closed these gaps.

Despite these shortcomings, the NHS experience would seem to belie the notion that “socialized medicine” is an evil to be avoided. And how un-American can it be? The Veterans Administration system and the Indian Health Service in our own country are quite similar to the NHS: government-paid physicians working in government-owned hospitals for patients who pay little to nothing for the care they receive. It works there, it works here, it lowers costs, it improves outcomes, and it shifts the focus from tertiary to primary prevention.


Turnock BJ. Public Health: What It Is and How It Works. 4th ed. Sudbury, MA: Jones and Bartlett, 2009. [Chapter 3: Public Health and the Health System.]

Safra JE, et al. Encyclopaedia Britannica. 15th ed. “National Health Service,” vol 8, p 534. Encyclopedia Britannica Publishing, 2003.

Tulchinsky TH, Varavikova EA. The New Public Health. 2nd ed. Elsevier, 2009. [“Chapter 13: National Health Systems,” pp. 482-486.]

Reid TR. The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Press, 2009. [“Chapter 7: The UK: Universal Coverage, No Bills,” pp. 103-124.]