Last month federal health doctors shut down their long troubled swine flu vaccine program - a program Dr. David Sencer here likened to "the Perils of Pauline" - because the vaccine seemed to be causing paralytic disease.
This month the same doctors nonetheless recommended restarting the program, mostly for older persons and the chronically ill, but also for everyone if any local health officers so rule.
Few are likely to do so, unless swine flu flares up. For a debate has already started on whether this whole vaccine program was needed and, if not, who, if anyone, was to blame.
All the facts now known lead to these conclusions:
The suspected vaccine-paralysis link will almost certainly stand up as a true cause and effect when all the statistics are in.
Months of bad publicity about this vaccine could easily slow down all kinds of vaccination programs and increase disease.
While most other vaccines are virtually always safe, the swine flu-investigation may well show that many other shots, and not just swine flu shots or other shots, cause more illnes than almost anyone has suspected.
Nobody has yet come up with any facts showing that the flu program's origin was "politiccal" rather than medical, or that it was dictated by the White House.
Many Americans, conditioned by Watergate and other scandals, are likely to remain convinced the program was political, and even engineered by the White House.
But nobody has yet produced a smoking gun - any solid evidence that the doctors who recommended the program acted in response to any political pressure. Even the program's severest medical critics do not charge this.
One of them is Dr. Martin Goldfield, New Jersey's assistant health commissioner and the doctor who first thought there was some kind of unusual flu at Ft. Dix. N.J. last January. He calls the attempt to vaccinate the whole nation against Ft. Dix Swine flu "a ghastly mistake."
He says it was caused "by steamrollering and orchestrating" doctors and scientists, and "avoiding any real dissent" to give what falsely seemed to be a unanimous recommendation to President Ford.
Sencer, director of the federal Center for Disease Control in Atlanta, is the man who did the steamrollering if anyone did. He made the key decision to recommend mass vaccination.
He calls the decision "unavoidable . . . one I would make again in the same circumstances . . . a unique opportunity to save lives" with "a virtually unanimous agreement" of his staff and flu experts.
"Praise it or damn it, but it was a bottom up decision made here in Atlanta before the White House knew anything about it," says a CDC associate of Sencer who asked not to be identified.
"Last January, February and March we really feared a new kind of flu," he said.
As of a year ago, there had been little flu during the winter. Then in late January there suddenly began a ferocious "A-Victoria" flu epidemic that caused 20,000 deaths from flu and pneumonia.
At the same time soldiers at Ft. Dix began getting sick. Goldfield asked the Army for some throat washings.
Tests showed that most contained A/Victoria virus. But three, to everyone's surprise, proved to resemble the virus of swine flu.
Today's swine flu virus, most scientists believe, is not identical to but is a descendant of the human virus that swept the world in 1918-1919, causing 20 million deaths. The virus, somewhat changed in nature, as all flu viruses tend to change, had evidently moved into pigs around 1930. Ft. Dix's were the first known human-to-human transmissions.
On Feb. 4 a sick recruit ignored medical orders and went on a forced march. He collapsed and died within a few hours. He, too, had swine flu.
It was soon found that 13 soldiers had been sickened by this virus, and an estimate 500, according to blood tests, had been infected.
"I sent some samples to Ed Kilbourne and asked him to gamble and try to grow the virus in case we needed a vaccine," Goldfield says. Dr. Edwin D. Kilbourne is head of microbiology at Mount Sinai Medical School and a world authority on influenza.
Human flu viruses, often grow poorly in the laboratory. It was Kilbourne who first learned to wed them to better-growing strains to make a vaccine still close enough to the original virus to promise protection.
What Kilbourne ended up with was not strictly swine flu virus but one with two surface antigens - like swine flu's. One, though the least important, was somehow lost later in manufacturing.
These points are important because some vritics charge that the Ft. Dix flu was not the 1918 virus and that the vaccine did not contain Ft. Dix virus. Neither fact was ever a secret, but both were often glossed over in brief official statements and the news.
Federal health officials and advisers met repeatedly in February and March. They had two concerns.One was the appearance of any even thinly 1918-like virus.The other, and main, concern was that, historically, a new flu strain usually causes an epidemic.
The Ft. Dix strain was one against which only older people with antibodies against 1918 flu had any shred of protection.
"All that nonsense was written about 1918." Kilbourne now says. "We weren't preparing for 1918. We were preparing for 1957. Asian flu caused 70,000 deaths in 1957, and Hong Kong flu, 33,000 in 1968-69."
Federal vaccine promoters nonetheless kept raising the 1918 specter. Critics call this "unjustifiable" and "emotional."
Yet some of the most unemotional scientists indeed feared a "1918." They pointed out that the reason for the 1918 flu's great virulence is still unknown, and could not help wondering about that of related viruses.
On March 10, CDC's Advisory Committee on Immunization Practices, including Kilbourne, met and recommended that: (1) a new flu vaccine be manufactures: and (2) a plan for giving it be developed.
In three days CDC's staff developed other options for Sencer to consider. On March 13 he phoned Dr. Theodore Cooper, assistant secretary for health in the Department of Health, education and Welfare, and recommended "option 3": not merely a "plan" but mass vaccination as quickly as posible.
Most CDC staffers argued that only this "action plan" could get vaccine into people fast enough to prevent or mitigate an epidemic if one started in late summer.
"Once the CDC head made this recommendation to the assistant secretary and once it was made to the secretary, then the President, they couldn't really say 'no,'" a Cooper friend maintains. "What if your public health doctors told you to mass-vaccinate and you didn't, and then there was an epidemic? You'd go down as a Nero."
Sencer did not consult his advisory committee again before his decision.
He did phone the members - and other experts, like Drs. Jonas Salk and Albert Sabin - after the decision. Only one committee member, Dr. E. Russell Alexander of the University of Washington, said he would prefer to stockpile vaccine, then use it if more swine flu really appeared.
"I didn't say this out of any particular concerns about safety," Alexander says. "I just had a general uneasiness about doing anything you don't have good reason to do."
Two doctors who were not consulted, though they had been invited to one post-Fort Dix meeting, were New Jersey's Goldfield and his department's epidemiologist, Dr. Ronald Altman.
"I thought the Ft. Dix outbreak might well be a flash in the pan, as it's turned out," Goldfield says. "I dislike all the emotion talk about '1918' and a 'killer virus.' That young man at Ft. Dix played a considerable role in his own demise by his exertion.
"Don't get me wrong," Godfield adds. "If people like me are wrong and swine flu starts up, I'd be the first to recommend immediate resumption of vaccination, because the threat of the disease would be so much greater than any vaccine threat."
Another person who was now on the outside was Dr. J. Anthony Morris, a federal Bureau of Biologics scientist who was soon to be fired in what his superiors said was an unrelated matter for "unsubordination" and "inefficiency," a ruling he has appealed.
Morris firmly opposed the swine flu shots. He did not predict Guillain-Barre disease, the paralysis that has affected 292 vaccines and killed 10.He did tell his superiors about reports of severe nerve disease and deaths linked with flu shots.
He says now there are "something under 100" reports of such deaths in medical annals, "and there have been many more, but the facts were never gathered." Sencer and other health officials maintain that these cases were well known and repeatedly discussed in recent years - and that they become "rare" when one considers that flu-shots have been given to hundreds of millions of people.
Dr. Sidney Wolfe of Ralph Nader's Public Health Research Group also forecast that "the major disease in the U.S. this year related to Ft. Dix will not be swine flu but rather swine flu vaccine disease." He favored immunizing only the elderly and other high-risk groups.
Dr. Richard Restak, a Washington neurologist, said the shots might be "downright dangerous." Dr. Nicholas Fiumara, Massachusetts state communicable disease head, advised "test first, shoot later" - stockpile vaccine for use only if more flu was found.
Neither these nor other critics were among two dozen eminent doctors, scientists and drug industry leaders invited to meet with President Ford on the morning of March 24, Salk and Sabin, the polio vaccine pioneers, were in the group.
The President asked if anyone disagreed with his officials' recommendation to mass-vaccinate. No one did. Within minutes Ford appeared before the press flanked by Salk and Sabin to announce the program to vaccinate "every man, woman and child" against swine flu.
Sabin soon changed his mind and urged merely stockpiling vaccine. When nationwide shots started in October, Massachusetts Health Commissioner Jonathan Fielding urged that the high-risk, chronically ill and those over 65 be immunized, largely because the vaccine for this group alone would be "bivalent," including protection against both swine and A/Victoria flu.
Fielding refused to recommend or discourage swine flu shots for others. There were a few other dissenters, but the bulk of the nation's health scientists and health officers went along with the vaccination decision.
In a meeting in May, Sencer's immunization committee almost unanimously backed him, with only the University of Washington's Alexander and consultant Sabin arguing for stockpiling.
A mounting number of cases of Guillain-Barre, also known as "French polio" and "ascending paralysis," finally forced Dr. Cooper to announce the program's suspension on Dec. 16.
Newspaper editorials and commentators denounced the program as a "fiasco," and Dr. Wolfe called for Sencer's resignation.
To a critic like New Jersey's Goldfield the entire story shows "how hard it is to get anyone to speak up once the public health and academic steamroller gets going. I begged other health officers who felt the same way I did to speak up. Most refused."
Asked why, Goldfield replied, "I think they feared loss of status, or no longer being involved in decision-making, or no longer getting government money. If it hasn't been for my wife and daughter and some of my staff who urged me to speak out. I might have kept quiet too."
To a vacine scientist like Dr. Kilbourne, however, the program still represents "exactly what we should have done and should do again when a disease threatens - unless we're just going to roll over and play dead."
The Guillain-Barre is far from complete CDC and other scientists want to make sure that the vaccine really caused the disease. And they want to learn why.
Meanwhile, they worry that the unhappy incident could change the whole American attitute toward vaccinations. They fear that the uproar may start making the public shun many vaccines.
If so, this could worsen a bad situation. Doctors say that "because of public apathy" four children in 10 from ages 1 to 4 are reaching school without essential shots against measles, polio, diphtheria and tetanus. Cases of measles, often a serious disease, rose 64 per cent last year.
Some doctors says the measles toll could be worse this year just because state and local health officials had to divert time, money and people to the swine flu program.
"In public health you bet dollars against disease," says Sencer. "Sometimes you win, sometimes you lose."