The progress of medical science in the last hundred years has been stupendous. The ultimate goal of medicine, the eradication of disease...is no longer Utopian.—Henry E. Sigerist, MD
The right to a long life, which is theoretically averaged at 100 years, is a basic right of every individual.—Hiroshi Nakajima, Director, WHO
Everyone knows that HIV causes AIDS, but until about a decade ago no one knew that. We believe that HIV causes AIDS because the doctors tell us it does. It's gospel. They might amputate the wrong limb, or misdiagnose cervical cancer, or cause 25% of pensioners to be hospitalised through misprescription of drugs, but they couldn't blunder about a thing like AIDS. Could they? Well, yes they could. The phantom swine flu epidemic of 1976 proves that it is possible. The very same people who gave America the swine flu scare gave the world the AIDS epidemic just five years later. By learning how one epidemic was concocted, we learn how a few people in positions of power can set a whole nation on a wild goose chase.
Our heroes are a medical elite whose institution is the Centres for Disease Control (CDC), a branch of the US Public Health Service. They are a special breed whose tasks mingle medical forensics with diplomacy, intelligence gathering, and rapid response capabilities. The intelligence gathering is meant to be so sensitive that no case of infectious disease diagnosed in a nation of 250 million escapes its notice. The organisation is wired up for around-the-clock surveillance when need requires, and for rapid response to any threat to health from biological agents suspected to be infectious. The CDC expresses the public will to prevent and conquer infectious disease.
In February 1976 an army recruit at Fort Dix, New Jersey, died in what the CDC called a "respiratory epidemic" on the army post. Examination revealed that the lad carried an influenza virus similar to influenza A virus causing illness in swine. A search of the army post discovered five other confirmed cases, and eight probable, among the 500 troops who went on sick call with respiratory complaints.
The CDC's vigilance systems were triggered. The new virus was thought to represent a major mutational shift in human influenza viruses. There was no immunity to it in the general population. Could it cause a national pandemic? If so, would it be as virulent as the 1918 virus? It seemed that the very scourge that had caused nations to establish infectious disease control agencies had now returned to put modern infectious disease control systems to the test. The 1918-19 world pandemic had taken 20 million lives, 600, 000 in the US. The spectre of that calamity is the reason why, on the basis of one death and 13 cases, all at the same site, the CDC called a national epidemic.
The Centres created two panels of experts charged with providing statistically valid advice. The two panels did not agree on the probability that a pandemic would occur. One panel rated the probability at 10-25%, the other at 40%. The panels did agree that if the pandemic occurred, and no protective measures were taken, there would be 56 million cases of swine flu. The attack rates would be highest among the young and would decrease with increasing age. They predicted the death rate to be 23.4 per 100,000; in raw numbers, about 55,000 deaths.
This is scary stuff, but Washington is bloated with bogus advice from glossy experts. Skilful lobbyists representing interests of all descriptions peddle panaceas. To the medically untrained mind that deals constantly with deceptive persuasion, the CDC's forecasts seemed far-fetched. How then did it mobilise the political establishment? It was easy.
The CDC was then one of the few remaining credible government agencies. It enjoyed an untarnished reputation as a responsible, dedicated, internally harmonious, well-informed agency untouched by scandal. This reputation gave its Director, Dr David Sencer, the clout he required. Less than six weeks after the first case diagnosis, he had rallied America's senior health officers behind his proposal for a $135 million crash program to inoculate 210 million Americans. On 24 March, President Ford told a press conference that "every man, woman and child" should be vaccinated, and that the government would see that the necessary supplies were available. 1976 was an election year. Congress quickly agreed to the President's package. The media fell in by giving currency to the CDC's tag line, "killer flu stalks the nation."
When the vaccine was delivered in late September, not one new case of swine flu had been reported in the US since the Fort Dix "epidemic". Indeed there was none in the Western Hemisphere. Volunteers who submitted to experimental infection with the new virus suffered only a mild illness. Public support for inoculation had faded. Opinion polls revealed indifference, and comedians cracked election season jokes about President Ford's "Flugate". Editorials in the media and in the medical press were calling the epidemic a false alarm.
The CDC remained steadfast. Where others saw in the Fort Dix statistics 13 mild flu cases, the CDC saw one death and extrapolated to 55,000 deaths. It countered public indifference by a renewed education campaign. As June Osborn, a CDC scientific advisor, explained: "The successful practice of public health requires salesmanship of a high order". The CDC is skilled in marketing anxiety.
The inoculation of what would eventually be 45 million persons commenced on 1 October. Trouble quickly developed. Three weeks on, 41 deaths were associated with vaccination, but the CDC's investigations showed that this was a statistically normal rate of mortality. By mid-November, 11 cases of neurological damage from the vaccine were reported; a month later, this number had increased to 54, with 10 fatalities. There was still not one new case of flu, but prevention was creating a medically induced epidemic. On 16 December Dr Sencer announced suspension of inoculation until adverse side-effects could be investigated. His attempts to restart the program two months later failed and the vast project was shelved.
In all, 52 persons died of side-effects, 500-600 were impaired or hospitalised, compensation claims reached $1.7 billion, and not one case of human-to-human swine flu infection was reported outside Fort Dix.
The swine flu mirage triggered evaluations of epidemic management. In their study of decision making in this case, policy experts Richard Neustadt and Harvey Fineberg found fault with developing a vaccine of unknown risks when there was no evidence of an epidemic. They wrote:
"The threat was never established . . . in the absence of manifest danger, [inoculation] was a mistake . . . since research has not yet found a good predictor of virulence, one may have no means to establish in advance the severity of a presumed pandemic".
This is a soft landing for the CDC. Neustadt and Fineberg do not report central facts relevant to the CDC's epidemic mismanagement.
When the first consignment of vaccine was delivered from manufacturers in March, it was found to produce no antibodies. So it was useless as a preventative. On investigation it transpired that the virus given to manufacturers by the CDC was not swine flu. Two million doses of the incorrect vaccine were discarded.
Difficulties were experienced in establishing the proper dosage of the vaccine. Dosages that produced ethical/legal minimum side-effects evoked insufficient antibodies, while dosages that were efficacious produced side-effects. In test cohorts, 2% suffered severe reactions, 5% developed fever, and 20% experienced headache and malaise. These data persuaded insurers that writing liability insurance for the program was not tenable. The vaccine clearly met the "unreasonably dangerous" test established in US law for liability in administering medical drugs. Insurers guessed that the liability pay-outs might be as high as $5 billion, for which the premiums would be $342 million. But insurers would have no part of it because the data provided by the CDC were too indeterminate for actuarial computation.
The CDC's alarm that the Fort Dix virus represented a dangerous antigenic shift was not well founded. Research conducted in 1931 by Richard Shope indicated that the 1918 virus by itself produced only a mild illness. It became lethal only when combined with the bacillus Haemophilus influenzae suis, which had been isolated from 1918 influenza patients. Shope showed that humans alive in 1918 had high levels of immunity to the swine virus recovered from living swine. He also concluded that the swine virus and the 1918 influenza virus were the same. Experiments conducted in March and April 1976 showed that persons alive during 1919-29, a decade of many flu epidemics, produced antibodies to the Fort Dix virus. All these facts taken together were strong evidence that the Fort Dix virus was harmless. This conclusion was further reinforced by tests made by the UK Common Cold Research Unit. Doctors there injected the Fort Dix virus into six volunteers. The result was that four developed mild flu symptoms, while two were unaffected.
The evidence indicated that the contagion level of the virus was very low. None of those who were in contact with the Fort Dix virus fell ill, including the sergeant who gave the deceased recruit mouth-to-mouth resuscitation.
The CDC's smoking gun, the deceased recruit, collapsed and died while on a strenuous training exercise. Such deaths are a familiar aspect of military training. He insisted on participating in the exercise contrary to medical direction of light duties only.
An alternative to a vaccine was available in the therapeutic drug, Amantadine, which had been extensively tested for 10 years prior to 1976. It is not specific to any strain of flu virus and it had been found to reduce symptoms within 48 hours. Given the other data about the Fort Dix virus, Amantadine would have been a reasonable response.
Under US law, informed consent had to be given by each of the proposed 210 million inoculates. The informing process had to include the administering physician's plain language statement of the hazards of the vaccination. In addition, under the indemnification conditions established in a special Congressional law, physicians were indemnified only if they charged no fee for giving the injections. Thus, the epidemic management burdened physicians with the prospect of spending many hours in counselling for no charge. Most of them opted out, and advised patients against inoculation. A survey of inoculates after the event showed that 13% were given no information about side-effects.
The CDC's expert panels' estimates of the probability of a national pandemic, and its morbidity/mortality consequences, were made in the absence of information that the swine flu virus is harmless in the absence of the bacillus. In his study of the epidemic's management, Cyril H. Wecht, MD, cited numerous incidents of relevant facts hidden or ignored, and disinformation disseminated by the CDC and other agencies. He felt justified in saying that the facts of the case show "just how unprincipled the agency's actions apparently were. Half-truths and omissions seemed to come in a steady stream throughout the immunisation program." The full significance of the swine flu mirage is not appreciated unless it is realised that it was not due to an unfortunate lapse in one agency. The entire spectrum of relevant US Public Health Service agencies formed a combined front of official prestige and unimpeachable scientific authority to sanction belief in the urgency of the vaccine method of epidemic management.
A proper review of the swine flu episode, and corrections made accordingly, might well have spared us the AIDS epidemic. Let's look at what such a review might have indicated.
Public health services operate in an environment of high public expectations. June Osborn described it well:
"Ironically the very success of medical science [has] distorted the image of its practitioners . . . the discovery of antibiotics and vaccines at first awed the public but later made them as demanding as spoiled children".
The child was spoiled because Mother Medicine had accustomed the public to demand feeding. Or to change the metaphor, doctors and patients had come to regard medical service as a smash repair shop. When something is broken, you take it in for a fix, the quicker the better. Health is not thought of as an ongoing condition to be lived and striven for. Instead it is an endowment that from time to time is compromised by injury or sickness.
Doctors and government promote this mechanical notion of health. Its trinity is Diagnostics, Pharmaceuticals, and Surgery. Omitted from the conception is prevention, and its associated conception of health as natural therapy actively lived. Prevention is not funded by medical insurance. Doctors have no time to instruct patients on how to live healthily. They write a contract with patients that reads: "You smash, we repair". No thought is given by doctors, patients, or governments to the cumulative effects of injecting millions with medical drugs.
The decision to proceed with the inoculation is understandable in this context. Had the vaccine not been administered, but an epidemic did materialise, there would have been a great outcry. Besides, public health agencies are committed to smash repair medicine of the utopian kind—conquering disease. This goal activates a cluster of powerful private and public motives. One is zeal in "saving lives". Doctors need only to inflect an anxious voice, shed some tears, and wave the "saving lives" flag to win the applause of millions of "spoiled children" (as June Osborn called them) for projects that are manifest nonsense, for example, "conquering disease" (equivalent to a promise of immortality). The nonsense is kept in countenance by exaggerating the effects of temporary local victories. Just before the onset of the AIDS epidemic, the CDC had celebrated two triumphs: it had developed a vaccine for hepatitis B and it had "eradicated" smallpox in Africa. In this vision, infectious microbes are not a natural, ineluctable part of the earth's biota, harming some organisms and helping others. They are alien invaders to be exterminated with the ingenious weapons of science.
This attitude is so integral to contemporary medico-social thought that no alternative to it is ethically acceptable, at least not in our culture. But as a conception it is new. We need only step back a century to find in the West the same stoic attitude toward sickness that prevails in Asia and the Third World today. Among ourselves, diagnosis of an untreatable disease is a terrible experience, registered in the saying: "If you get AIDS, you die". But in Japan, the Zen master says: "Also if you don't get AIDS, you die". The transition from the older to the contemporary attitude toward sickness and death is expressed in Charles Darwin's reflection on the value of epidemic control. He wrote:
There is reason to believe that vaccination has preserved thousands, who from a weak constitution, would formerly have succumbed to smallpox . . . the weak members of society [thus] propagate their kind. No one who has attended to the breeding of domestic animals will doubt that this must be highly injurious to the race of man . . . [but] the aid which we feel impelled to give to the helpless is mainly an incidental result of the instinct of sympathy, which was originally acquired as part of the social instincts, but subsequently . . . rendered more tender and more widely diffused. Nor could we check our sympathy, even at the urging of hard reason, without deterioration in the noblest part of our nature . . . if we were intentionally to neglect the weak and helpless, it could only be for a contingent benefit, with an overwhelming present evil. We must therefore bear the undoubtedly bad effects of the weak surviving and propagating their kind.
Darwin was far enough into the transition to progressive values to forget his own insight that one season's survivors are the next season's mortality. The Zen master, if he were a biologist, might point out that the human species is host to many thousands of inactive microbial passengers, any of which can mutate into a harmful pathogen. Pathogenic bacteria, for their part, mutate into antibiotic-resistant strains under the pressure of medically induced selection. The "conquest of disease" will be a while coming. But Darwin was right about the "instinct of sympathy". The modern therapeutic state is geared to extend the appearance of compassion and assistance to all the suffering. I say the "appearance" because outcomes depend on adequate funding and much else.
An advantage of the mechanical conception of health in democracies is that the patient is not required to be an agent in the healing process. Healing is conceived as technical skill in manipulating subtle and refractory organic processes. The patient is a bystander who, from time to time, may be conscripted to dietary or exercise chores. But for the most part doctors do not try to change lifestyles.
This view of medicine's social role dominated the CDC's response to another epidemic that received scant public attention until after the damage was done. During the 1960s and 1970s, US doctors reported sexually transmitted diseases at the rate of 5-7 million cases per year. Thus the CDC knew the dramatic increase of chlamydia and the high rates of infertility that it causes. It knew of the increase of syphilis and of STDs that previously were rare. It was especially concerned about the spread of hepatitis B, which clustered in gay populations. It enrolled a cohort of 7000 gay men to study their lifestyle and viral load in connection with the search for a vaccine. From this study it knew that syphilis, gonorrhoea, and hepatitis B were endemic in the gay populations of the cities. Parasitic infections of the colon, known as "gay bowel", were also endemic. It was found that the annual hepatitis infection rate among gays was an astonishing 12%, as against a 1% lifetime rate for the general population. The stage was set for rapid transmission of unusual pathogens.
Thus on the eve of AIDS, the CDC was fully aware of the increase of sexually transmitted disease and the possible bacterial and viral "bomb" that the sexual revolution had planted. It was of course concerned: it promoted improved clinical descriptions of STDs, particularly the interactions of simultaneous infections; and it promoted more effective therapies. However, it did not mount a vigorous safe sex campaign to reduce the incidence of STDs and to warn young women and men of the grave consequences of some infections. It did not because it was confident that antibiotics in the cabinet of every GP could restore health to those affected by STDs, no matter how many of them there were.
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