The Swine Flu Affair Decision-Making on a Slippery Disease (1978) / Chapter Skim
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12 Reflections
12 Reflections
Pages 72-86
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From page 72... ...
But we are moved to offer further comment now on certain critical phenomena: program reviews, implementation analyses, media reactions, agency reputations, and slippery diseases. Mindful of our charge, these five bear on decision-making at the level of the HEW Secretary.
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From page 73... ...
Deciding on a swine flu program is like placing a bet without knowing the odds. A serious stake in the outcome ought to concentrate the mind on breaking down the issue and scrounging for anything that might inform judgment.
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From page 74... ...
A program curbing a pandemic equals public health, ditto a program without a pandemic, ditto neither; only in the fourth cell, a pandemic without a program, does the public health suffer avoidable harm. And health was an absolute value.
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From page 75... ...
It does not exist to serve him. Thus far, advisory panels in the public health field, even including Califano's ad hoc groups, have not proceeded in a fashion to assure explicit statements of underlying assumptions, nor has the Secretary yet systematized the science advisory function.
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From page 76... ...
Even Sencer, urgent as he was once he decided, might have shaped both his decision and his conduct rather differently had he paused to consider dosage problems, ghetto problems, skeptical physicians, media reactions, and the fruits of the most serious surveillance ever tried if there were not a visible pandemic. The probability of no pandemic was always higher than the chance there would be one, as Sencer heard from almost everybody except Kilbourne.
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From page 77... ...
In retrospect, here's where he should have probed details but evidently didn't. In immediate terms, Sencer gained a tactical advantage by attaching to the manufacturing decision, with its short deadline, the less tightly constrained decision to inoculate.
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From page 78... ...
Yet being an M.D., being indeed the only medical practitioner among Assistant Secretaries, he was almost bound to heed the same call Sencer heard: "If we believe in preventive medicine, we have no choice." Why then think farther ahead than Sencer about implementation issues in advance of choice? Mathews, not a doctor, responded to the same imperative.
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From page 79... ...
There was a glaring lack of institutional connections between medical professionals of every stripe and anybody knowing much of anything about the news profession, above all television news, the primary news source for most Americans. What was at stake amounted less to influencing coverage -- in any event hard to do except for fleeting moments -- than to anticipating it, preparing for it, weighing in the balance of decision both prospective benefits and costs.
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From page 80... ...
On that standard we find relatively little to complain of and some things to admire in our sampling of the swine flu TV coverage.37 As the Secretary deals with public health officials, he has either to make doctors appreciate electronic journalism, a hard job, or to help the Assistant Secretary and his agency chiefs instill some good sense about television into their advisory system. Daily news reporters and producers cannot serve.
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From page 81... ...
The President could offer visibility, but in his circumstances as a primary campaigner he had no credibility to spare; indeed his needs ran the other way, he had to borrow. Those he borrowed from were on the one hand individuals established in their own careers, like Salk or for that matter Cooper, and on the other hand the agencies established in the field of public health, like CDC.
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From page 82... ...
Both pile up doubts about the role that Sencer chose, the super-salesman's role. Had Sencer posed the issues candidly, with the uncertainties spelled out, the likelihoods compared, deadlines unscrambled and production his immediate concern, the credibility of CDC would now be better than it is.
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From page 83... ...
Five features combine to make it so. First is the changing character of the influenza virus, with spread and timing mortgaged to the processes of antigenic change about which there are painfully few documented observations.
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From page 84... ...
Its members shared an inferential base of medical knowledge, public understanding, and support, far beyond that now accorded influenza. On the evidence of swine flu, it is tempting to propose a restoration of the former line, and consciously bar slippery diseases, flu included, from Federal immunization initiatives.
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From page 85... ...
But if and when a comprehensive liability solution comes to pass, then all too easily the definitions of "high-risk" could be progressively relaxed, and we would lose our tight tie between preventive and risk of death. Judging from the swine flu story this is precisely what one should expect to follow upon liability legislation.
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From page 86... ...
To do so is to court medical dissent, to spread public confusion, and to provoke suspicion in the Washington community. 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.
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