As the United States struggles to distribute and administer COVID-19 vaccines, we’re looking back at the history of vaccine rollouts in our country, including the logistical roadblocks to shots and communicating with a fearful public. The COVID vaccines have been widely shown to be safe and effective, unlike some historical examples that had significant associated risks. But what can stories of failures from the past teach us about how to fairly administer them?
On Tuesday, Feb. 16, at 1 p.m. Eastern, join Future Tense for a conversation with Atul Gawande and Helene Gayle, co-chair of the National Academies framework for vaccine distribution, about the COVID-19 vaccine rollout.
In January 1976, an Army recruit at Fort Dix in New Jersey died of a respiratory illness. After a lab at the Center for Disease Control reported that the cause was an influenza of a strain related to swine flu, the federal government spent most of 1976 developing, and partially executing, a large-scale immunization program. The plan was to dose 213 million Americans with a vaccine aimed at protecting them from a pandemic that some officials feared might become a “second 1918.” The whole thing collapsed in late 1976: The swine flu failed to show up, and only 40 million Americans were inoculated.
Although I wasn’t able to find systematic research on the degree to which the swine flu episode has contributed to anti-vaccination sentiment in the United States, anecdotally speaking, it certainly seems possible. One California man interviewed by the Los Angeles Times in 2009, when the H1N1 flu strain pandemic threat loomed, said, recalling 1976: “I’m not getting [a vaccine]. I felt back then like it was a bunch of baloney.”
Harvey Fineberg was one of two experts commissioned by President Jimmy Carter’s secretary of health, education, and welfare to write a postmortem of this failed immunization program in 1977. At the time, Fineberg was on the faculty at the Harvard School of Public Health. His resulting report—which has been published a few times over the years, most recently under the title The Swine Flu Affair: Decision-Making on a Slippery Disease—is a highly readable account of the whole regrettable episode.
I spoke over the phone with Fineberg, now president of the Gordon and Betty Moore Foundation, about the logistical issues this rollout faced, the role of media coverage, and the aftereffects of its failure. Our conversation has been edited and condensed for clarity.
Rebecca Onion: What did officials think the biggest problems were going to be with vaccinating so many Americans so quickly?
Harvey Fineberg: This was an unprecedented effort to immunize every adult and child. There was at that time not the same level of vaccine hesitancy that we see today—that really wasn’t a major movement back in the 1970s. But what we did see, and frankly what we’re still seeing today, was wide variation in the local degree of success at immunizing the population. It starts with our federal system of national state and local authority. Our country just varies tremendously in the approaches and degrees of organization and degrees of success in carrying out a campaign like this. That was true in the ’70s and it’s still true today.
What were the places that were better at this in 1976, and what were they doing that that made them more successful?
One interesting example is Pittsburgh vs. Philadelphia. Pittsburgh actually had the experience of coincident deaths—which, by the way, is a phenomenon that you can anticipate and expect if we really [are] to immunize millions of people a day. We would see people who drop dead within a day of getting the vaccine, and that’s because somebody drops dead every day anyway. Pittsburgh was still much more successful than Philadelphia in organizing and carrying out the campaign, because Allegheny County [where Pittsburgh is located] was organized to do it. Even within the one state you saw these wide variations.
When you say “organized to do it,” what do you mean specifically?
They had established vaccination stations. They had a public announcement urging immunization—a communications campaign. They had people trained and at the station to carry out the work. So they just organized in the same way today, you know: We’re seeing certain localities already using stadiums and open parking areas [for COVID immunization], and others are still talking about which ones they might want to use. That’s a difference of planning and readiness to implement.
The planning was done in the beginning of ’76, in anticipation of the campaign—[state and local governments] had months to figure it out because, don’t forget, in the case of influenza, even in the 1970s, they knew there was a vaccine. It wasn’t the question, as we had in 2020, of “When are we going to get a vaccine?” Even though there were some production glitches and complications in the evaluation, especially in children, there wasn’t the same uncertainty we had this past year about whether a vaccine would exist.
But [scientists] were never able to see if the vaccine was effective—because don’t forget, in ’76 the pandemic never happened.
You mentioned some production hiccups. What were the biggest logistical problems in producing all that vaccine back in 1976?
All the vaccine then was grown as viral cultures in fertilized eggs. The yield per egg was uncertain—how many viral particles you would actually get—and it was a little less than they had expected. So that was a bit of a setback. And then they did measure what was required to get you an immune response, and that’s when they found it took more than they expected for children. So that, again, hurt productivity—the number of vaccines you could produce from a given batch.
But mostly, they encountered delays not around manufacturing per se, but whether the manufacturers would be indemnified by Congress against lawsuits. The manufacturers weren’t even really worried about genuine side effects; they were worried about a plethora of lawsuits based on coincident issues that might tie them up in court and cost a fortune. So they held up production and packaging until that indemnification came through.
Which, incidentally, finally came through when there was an utterly coincidental Legionnaires’ disease outbreak in Philadelphia. When that first occurred, nobody knew exactly what it was, but some said, “Well, this could be that flu, the first outbreak.” And that frightened Congress into saying, Well, gosh, it COULD have been the flu! How’s it going to look if this whole thing is held up because we didn’t indemnify the manufacturers? So with that, the insurers came back on board, the manufacturers proceeded.
So, yes, a series of hiccups, but by the fall, October, they were finally ready to get going.
How much did the coincidental deaths that you mentioned affect public perception of the immunization campaign and uptake of the vaccine?
Well, really what affected it more was the absence of disease! Nobody was getting the swine flu, so what, people felt, was the point?
Why was the program discontinued?
People were getting a little antsy—should we really be doing this? And then there was the identification of the rare side effect, Guillain-Barré Syndrome [in some vaccine recipients]—this is an ascending paralysis that occasionally occurs after viral infection and has not been associated with any other influenza vaccine [nor has it been found to be associated with the COVID-19 vaccines]. But it does appear, from the best assessments, that this was a rare side effect, maybe one in a million. And that occurrence was enough. That, along with the fact that there was no disease, led to the formal abandonment of the program. That was in December.
Then, what happened, as you know, there was a change in presidency—Jimmy Carter was inaugurated in 1977. There was an outbreak of influenza in a nursing home in Florida, not the swine flu, but A/Victoria influenza, the other flu that had been circulating. And the question came up: Should we start using this vaccine we have, to protect against A/Victoria? Because all the vaccines that had been produced that year were combination vaccines, meant to protect against both swine type and A/Victoria.
Did they end up using those doses for the other flu?
Yes, they did. [Editor’s note: And for A/Victoria influenza, at least, the combined vaccine seems to have worked.]
[President Gerald] Ford was running for another term when this was happening. How did the decision to do this big immunization campaign affect him politically? Was he considering that in making the decision?
You know, it’s a very interesting historical question. When we investigated [in writing our study] and talked to pretty much every actor of consequence, including President Ford, we came away quite convinced that politics per se did not affect his decision and that he was genuinely trying to follow the best advice of the scientists.
What was the political fallout when it came to attempts to immunize for various other diseases later? And was there anything positive that public health took away from the experience, any knowledge gained?
This was a severe setback to the CDC at the time, and it did take time to recover. One of the biggest lessons they took away was the importance of communicating clearly to the public. I think it’s been very striking to contrast this with the kind of coverage you heard from the CDC with the 2009 H1N1 or the 2014 Ebola outbreaks. They took away, among other things, a very important lesson about the importance of clear and consistent communication with the public. But it did take time to restore the brand, if you will.
And of course, now we’re in another moment of setback, aren’t we? Almost like a throwback to the 1970s.