What information might make the group change its mind about the decision they are about to make?

From Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It by Gina Kolata.  Page 141.   This is taking place in 1976 when President Ford faced a decision about a possible immunization campaign against the Swine Flu.  And the decision-making process was just a prone to failure nearly half a century later in 2020.  

Neustadt and Ernest R. May, a historian at Harvard University, later analyzed what they saw as crucial moments in the swine flu vaccine decision. It shared features, they said, with several other crucial moments in history, the Bay of Pigs and the Vietnam War. In each instance, they say, “the individuals who made the key decisions, or at least some of them, looked back and asked, ‘How in God’s name did we come to do that?’”

That March 10 meeting of the vaccine committee was a turning point, illustrating how the specter of 1918 overwhelmed even the experts in the field.

Neustadt and May take special note of the fact that the experts at the March 10 meeting never publicly stated what they thought the chances were that the United States would be swept by a deadly swine flu epidemic if the nation took no action to immunize the population. That, they say, was a major mistake. Forcing experts to give odds can be one of the best methods for exposing fundamental weaknesses in an argument, they note. Certainly, they argue, before making a major decision, like the decision to start a swine flu immunization campaign, federal officials should have asked the medical experts to openly state their best guess of the chance that a deadly epidemic would occur. “If the doctors and their fellow experts hesitate, we offer the suggestion of one academic colleague with extensive government experience,” they say. “Ask instead, ‘When I brief the press, with you by my side as an expert, and tell them the odds are X, will I be right? No? Then how about Y? And so forth.’

“Once differing odds have been quoted, the question ‘why?’ can follow any number of tracks. Arguments may pit common sense against common sense or analogy against analogy. What is important is that the expert’s basis for linking ‘if’ with ‘then’ gets exposed in the hearing of other experts before the lay official has to say yes or no.”

Another way to expose hidden assumptions and unstated value judgments is to pose what Neustadt and May call an “Alexander’s question,” named after one of the men at the March 10 meeting, Dr. Russell Alexander, a public health professor at the University of Washington. Alexander posed a question to the group that Neustadt and May thought so apt that, they say, if policymakers routinely asked an “Alexander’s question,” historic blunders, as well as commonplace blunders, might be avoided.

Alexander’s question was brilliantly simple. He asked what information might make the group change its mind about the need to prepare to immunize the nation against swine flu? Would it be evidence that every swine flu case was mild? Or that no one but the Fort Dix soldiers got the swine flu? Would it make a difference what the timing of the outbreaks was or where they occurred?

When Alexander asked his question at the meeting, Neustadt and May note, he “never got an answer. In the circumstances, it was the right question,” they add. “Pursuing it would have flushed out a deeper set of questions, which also did not get asked, questions about tradeoffs between side effects and flu, questions about programming and scheduled review, questions distinguishing severity from spread, questions about stockpiling, and more.”

In fact, Neustadt and May realized, “What ‘Alexander’s question’ forces into the light are causal associations thought to be validated by past experience.” It would have showed the power of the analogy of the 1918 flu and exposed the paucity of scientific data behind the swine flu decision.

Despite the way his question was avoided, Alexander nonetheless urged caution and suggested that it might be better to make the vaccine and hold it until it was clear that there was a dangerous pandemic underway. But Alexander was a quiet man who did not press his points. He gave no speeches and said relatively little. In fact, noted Neustadt and Fineberg, Alexander appeared “unimpassioned” and “so mild that other members we have seen recall but vaguely something about ‘stockpiling.’ He himself makes light of it. Known as a voice of caution in past meetings, he was easy to discount on this occasion.”

When Neustadt and Fineberg interviewed Alexander in preparation for their report on the swine flu affair, he told them, “My view is that you should be conservative about putting foreign material into the human body. That’s always true … especially when you are talking about 200 million bodies. The need should be estimated conservatively. If you don’t need to give it, don’t.”

Alexander’s worries were easily overlooked in the zeal of the moment to implement a historic public health effort, to immunize a nation against what could be a deadly pandemic. And the arguments of those who wanted to go ahead were hard to ignore.

Seal later recalled that one staff executive from the Centers for Disease Control privately told Sencer, “Suppose there is a pandemic accompanied by deaths. Then it comes out: ‘they had an opportunity to save life; they made the vaccine, they put it in the refrigerator …’ That translates to ‘they did nothing.’ And worse, ‘they didn’t even recommend an immunization campaign to the Secretary.’”