The Polio Vaccine Disaster: Precursor of the Obamacare Website Fiasco

When friends complain about evil government (e.g., NSA surveillance), I tell them “never underestimate the stupidity of government employees” — by which I mean their stupidity outweighs their self-interest. The Obamacare website fiasco is a good illustration. Everyone has heard “power corrupts” but closer to the truth is power makes you stupid.

The Obama website fiasco had many precursors. One was in the 1950s — in the details of the introduction of the polio vaccine.

Rather than staging a long series of careful field trials with appropriate scientific evaluation, Salk darted ahead on his own in the remainder of 1953 and 1954. The trials were successful. The foundation released the results to the press, and such were the nation’s expectations that from that point there was no turning back. In August 1954 the foundation ordered five drug companies to begin producing mass lots of vaccine, on the basis of a formula for inactivating the virus with formaldehyde, according to a procedure Salk himself had devised. . . . James Shannon remembered very well what happened next. At this point he had become the associate director of the NIH.  “I was working over the weekend and I got a telephone call from Los Angeles, and this is eight or nine o’clock on Friday night. It was the Health officer of the City of Los Angeles and he said they just had two reports of polio in some children who had been vaccinated nine days earlier. He wanted to know what should be done about it?”

One of the companies that contracted to make the vaccine, the Cutter Laboratories in Berkeley, California, had released several lots of vaccine that had been improperly inactivated. Live polio virus was being injected into children. The gratitude of the public turned to horror, as the cutter vaccine gave polio to almost 80 recipients; these children in turn went on to spread the disease to another 120 playmates and relatives; three quarters of the victims were paralysed and 11 died. . . . NIH’s Laboratory of Biologics Control, which had certified the Salk vaccine, had received advance warning of problems. . . .

In 1954 the rush was on. [Eddy's] lab had gotten samples of the inactivated polio vaccine to certify on a “due-yesterday” basis. “This was a product that had never been made before and they were going to use it right away,” she recalled. She and her staff worked around the clock. “We had eighteen monkeys. We inoculated these eighteen monkeys with each vaccine that came in. And we started getting paralyzed monkeys.” She reported to her superiors that the lots were Cutter’s, and sent pictures of the paralyzed monkeys along as well. “They were going to be injecting this thing into children. . . .They went ahead and released the vaccine anyway, a lot of it. The monkeys they just disregarded.”

Shannon called the Surgeon General Satur­day morning. Additional cases of paralysis continued to occur. “It seemed obvious that we had a crisis on our hands, the magnitude of which was unknown.” Late Saturday afternoon a working group of senior virus specialists, whose advice the polio foundation had started to ignore a year earlier, began meeting in Shannon’s office. Note that Shannon had completely taken charge of the crisis. “Sebrell was not the man to manage this,” DeWitt Stetten recalled. ‘James Shannon was a man of quite different character.”

Shannon had brought in the Surgeon General, who called polio chief Basil O’Connor in New York. On Monday evening O’Connor and his advisers came down to Bethesda. Shannon wanted to withdraw the vaccine, “It was a very stormy meeting,” he said. “O’Connor and the polio group in general disallowed any possibility of induced infections [as a result of the vaccine]. … So Basil O’Connor stormed out with dire warning of what he was going to do to the NIH and the Public Health Service. Further vaccination was stopped. I had many sleepless nights.”

The basic problem had really not been the carelessness of the Cutter company, which rightly or wrongly was exonerated in a later report. It was the difficulty in jumping from Salk’s lab experiments with killing (formalinizing) the virus to large-scale industrial production.

. . . Ruth Kirschstein, the director today of an important NIH institute, added, “The Cutter incident resulted in everybody up the line who had anything to do with it—very few people know this story—being dismissed because of it.” All went out: the director of the microbiology institute lost his post, as did the equivalent of the assistant secretary for health. Oveta Culp Hobby, the secretary of Health, Education and Welfare (or Oveta “Culpable” Hobby, as she was known), stepped down. Dr. Sebrell, the director of the NIH, resigned.

Whereas I think the “basic problem” was overestimating the competence of powerful people, especially powerful experts.

6 Responses to “The Polio Vaccine Disaster: Precursor of the Obamacare Website Fiasco”

  1. dearieme Says:

    An era when people who perpetrated cock-ups got the sack? “In olden times”.

  2. MikeW Says:

    The Obamacare website / polio analogy is interesting, but you seem to be perpetuating the myth that the website’s problem was scalability. Unlike Salk’s efforts, the website was sloppy work from the start, riddled with broken links, misspellings, and a confusing user interface. In this case, incompetence pervaded the whole project, from the bureaucracy all the way down to individual programmers.

  3. gwern Says:

    > In 1954 the rush was on. [Eddy's] lab had gotten samples of the inactivated polio vaccine to certify on a “due-yesterday” basis. “This was a product that had never been made before and they were going to use it right away,” she recalled…The gratitude of the public turned to horror, as the cutter vaccine gave polio to almost 80 recipients; these children in turn went on to spread the disease to another 120 playmates and relatives; three quarters of the victims were paralysed and 11 died.

    To put this ‘due-yesterday’ haste in perspective: at the time, polio was killing ~9 children & paralyzing 58 children a day in the USA, and killing or paralyzing 1300 children a day worldwide.

  4. OzMan Says:

    Thanks for sharing this little-known but important piece of vaccine history.

    It is also important to note that since the Cutter event, there have not been any vaccine reactions due to manufacturing issues – to my knowledge, please correct me if wrong. (I do not refer to known reactions such as the ~1 in million risk of getting paralysis from oral polio vaccine, or the ~2 in 100,000 who will get a bowel blockage after rotavirus, and the few other rare known serious vaccine reactions.

    But any time there are some serious events that happen AFTER a vaccine is given, the natural tendency for governments is to suspend vaccine use. Eventually, the investigation finds the deaths or other events unconnected to vaccine – and meanwhile children are needlessly put at risk of infectious disease. (Or a vaccine scare like pertussis in the UK in the 1970s or MMR-autism impact lead to massive disease outbreaks).

    How do we address these cognitive biases – and focus on fixing system failures instead of blaming individuals?

    ***
    Like others, not sure I agree this is same issue as the ObamaCare fiasco; perhaps of more substance is the what is human and financial cost of not having universal health care – even after Obamacare; and what was cost of delays in getting cover?

    And what is the accountability of our political representatives, who now seem to just represent moneyed interests…

  5. Charles Says:

    The ones designing and implementing the web site were not federal workers. It was a consulting company who had previously demonstrated incompetence at this kind of project, and should probably have never been given the project. Problems were compounded by unrealistic deadlines for all the features requested, and last-minute changes, never tested. My understanding is that federal procurement rules made it difficult or impossible to choose another contractor. That’s not the fault of federal employees other than whoever drafted the laws specifying those rules.

  6. Seth Roberts Says:

    yeah, those are fair points.