key: cord-0037177-h14o7d3z
authors: Skidmore, Max J.
title: Misguided Responses to Public Health Emergencies
date: 2016-10-12
journal: Presidents, Pandemics, and Politics
DOI: 10.1057/978-1-137-59959-9_3
sha: 05b01db5712e82013fc3f64fdfa2af0ef2bcb6fd
doc_id: 37177
cord_uid: h14o7d3z

This chapter considers some misguided responses to public health emergencies, or perceived emergencies. At one extreme was the arrest and lifetime confinement in Hawaii and elsewhere of sufferers from leprosy, or Hansen’s disease. This, of course, was not an example of presidential policy, but is included as an example of horrible overreach. An opposite approach was the refusal of the Eisenhower administration to mount a vaccination program to deal with the Asian flu pandemic of 1957. President Eisenhower was devoted to private solutions to such emergencies, and these were manifestly inadequate. There was yet another extreme example of a misguided approach, and that was President Woodrow Wilson’s militant passivity to the 1918 influenza pandemic. Disregarding advice from medical consultants, he refused to discontinue the shipment of troops abroad to fight in the Great War, which resulted in an even greater spread of the contagion because of the great numbers of men confined to small quarters aboard ships. Incompetence can always be a danger in public health emergencies. Although this was not a pandemic, the George W. Bush administration handled the health crisis caused by Hurricane Katrina so poorly that it became a national scandal. On the other hand, President Bush did move to plan wisely for a possible influenza pandemic when he ordered the creation of national stockpiles of antiviral medication.

Public health emergencies, or perceived emergencies, throughout history have brought a variety of offi cial responses. Some of these have been effective, some have not. Some have been rational, some have not. Societies have often been tempted by, and given in to, one of two dangerous extremes: over-reaction on the one hand, or inaction on the other. American history is replete with examples; it is useful to examine a few of the more relevant.

Understandably, one method that societies have often adopted is quarantine. In its long history quarantine has sometimes been effective; sometimes not. It has sometimes been warranted, sometimes not. In 2004, PBS broadcast a program on quarantine that provided a quick look throughout history. 1 In any case, regardless of whether it has been appropriate or effective, quarantine by its very nature has strong political implications.

Although it was far from typical, an extreme version of quarantine constituted one of the greatest over-reactions in American history. At the least, this sad episode should serve as a warning against the kind of excess that many people advocate when faced with newly threatening circumstances, such as HIV-AIDS, SARS, or Ebola. This particular over-reaction was the treatment of those who suffered from Hansen's disease, or leprosy. The disease "results in damage primarily to the peripheral nerves (the nerves outside the brain and spinal cord), skin, testes, eyes, and mucous membrane of the nose. Because of the visible disfi gurement…people with leprosy have long been feared and shunned." 2 The harsh treatment imposed upon those affl icted with leprosy began in 1865, when Hawaii's King Kamehameha V signed "An Act to Prevent the Spread of Leprosy." Under the act's provisions, the Board of Health was directed not only to arrest the victims of Hansen's disease but also to remove them from the general population-permanently. The colony, Kalaupapa, ultimately became the permanent prison for victims of leprosy. It was situated on the island of Moloka'i. At that time, of course, Hawaii was an independent Pacifi c kingdom, and not yet American. When the USA annexed Hawaii at the end of the century, the draconian quarantine restrictions remained in place, thus becoming perhaps the most notorious over-reaction to a disease in America's history. They remained for a time, even after Hawaii became a state.

Moloka'i is an elongated island about ten miles wide, stretching some 38 miles east and west. In the middle, the Makanalua Peninsula forms the northern shore. The peninsula is fl at, and separated from the main body of Moloka'i by cliffs reaching nearly 2000 feet in height. The peninsula's eastern section is the district of Kalawao. Kalaupapa is in the west. It is here that the Hawaiian government located its colony for those affl icted with Hansen's disease. There are no roads connecting the peninsula with the rest of the island, only a rugged mountain path. The cliffs form a substantial barrier, completing the isolation of the area surrounded on three sides by ocean. There are two places suitable for landing by water, in Kalaupapa and Kalawao, and there is now a small airstrip. Thus, practically speaking, access must be by air or sea.

Even by Hawaiian standards, the beauty is stunning. In March of 2007 I had the good fortune to visit Molokai and Kalaupapa. The following discussion is based upon, or enhanced by, my observations and conversations there at that time. The stark injustice and deep sorrow of those condemned to spend their lives in isolation-through no fault of their own-is equally stunning. So that their history will never be forgotten, the area has been given to the National Park Service. The human costs of removing its sufferers were extraordinary; as greater knowledge of the disease developed, it also became clear that they were unnecessary. Modern medical science has demonstrated that Hansen's disease "is not highly contagious, does not cause death, and can be effectively treated with antibiotics." 3 Many people had thought all along that the contagion had been exaggerated. A century ago, the writer Jack London wrote a series of articles for Woman's Home Companion magazine, discussing his fi ve-day stay in the Kalaupapa colony. "The Lepers of Molokai," the fi rst of these, appeared in January, 1908. 4 One should note that those infected with the disease consider the term "leper" to be highly offensive. 5 "Leprosy is not so contagious as is imagined," London wrote, and added, "I went for a week's visit to the Settlement, and I took my wife along-all of which would have not happened had we had any apprehension of contracting the disease. Nor did we wear long, gauntleted gloves and keep apart from the lepers. On the contrary, we mingled freely with them." 6 London decried the treatment that victims of the disease had received throughout history, and said that the "awful horror" with which they have been regarded "in the past" and the "frightful treatment" that they had received were "unnecessary and cruel." Astonishingly, though, he was still capable of writing this incredible sentence: "That a leper is unclean, however, should be insisted upon; and the segregation of lepers, from what little is known of the disease, should be rigidly maintained." It should therefore come as no surprise that he disputed accounts of shock and grief involved, and that he minimized any trauma that the victims experienced when taken from their society and relocated to Kalaupapa. Under the circumstances, it might have been expected that he would present a highly romanticized view of life in the Kalaupapa community, and he certainly did so. His articles bring to mind some of the more discreet examples of antebellum Southern apologies for slavery, and they also foreshadowed some of the arguments justifying racial segregation that came from opponents during the Civil Rights Movement.

Scientists identifi ed the cause of Hansen's disease, the bacterium "mycobacterium leprae," over a century ago, but its method of transmission is still not clear. What is clear, as indicated, is that the disease is not easily spread; it is far less contagious than originally assumed. Many people live in close proximity to sufferers from Hansen's disease, and never become infected. The disease has been known for centuries, and has never achieved pandemic status. In fact most human beings, some 95%, appear not to be susceptible to it at all. 7 It requires no conversations with any of the few remaining residents in Kalaupapa to appreciate how forcible separation from home, community, and loved ones damaged those who were its victims. The National Park Service makes available (Note: it sometimes requires persistence to retrieve it) an undated report, "Leprosy in Hawaii," describing the damage. "For the benefi t of the healthy, persons suspected of leprosy were condemned to a life of virtual imprisonment on the windward side of the island of Moloka'i. The concept of segregation was completely alien to the fundamentals of Hawai'ian society and therefore greatly resented." The report notes that many people questioned whether the disease was even contagious, and that the Board's actions in any case "were seen a penalties upon individuals affl icted by something beyond their control." The result was a "mass psychological deterioration" in the community that was detrimental to the culture as a whole. "The energetic pursuit of sick individuals was a great blow to their friends and relatives. The high degree of sociability among Hawai'ians more or less preordained that those banished to Moloka'i would be doomed to lives of despair." It should therefore be expected to read that "parents refused to let their children go, husbands and wives resisted separation, and old people implored to live out their days where they had spent their lives. Many took refuge in the countryside in ravines and caves or homes of friends, where they were sought after by the police who had been empowered by the Board of Health to seek out the unfortunates. Victims and their family and friends resorted to violence against the authorities," who eventually used violence in return. At the "end of 1866, more than one hundred victims were driven on board ship," and "descriptions of the departure of the victims are heart-rending to read." 8 Also heart-rending to read is the autobiography, or memoir, by Olivia Robello Breitha, Olivia: My Life of Exile in Kalaupapa . In a literary equivalent of folk art, she pours out her feelings. She was seventeen when a "bounty hunter" in 1934 ordered her to report to the Board of Health. 9 Eventually, in 1937, the territorial government exiled her to Kalaupapa. Although sulfone drugs were discovered to cure Hansen's disease in the early 1940s, it was not until 1969 that she, and the other former patients, was free to leave. Only then were the laws mandating exile for sufferers of the disease rescinded. Note that at this time Hawaii had been a state for more than a decade. Discovering that she had no more life on the outside, she ultimately returned to Kalaupapa, as did a number of other former patients. The state then provided for them there, and continues to do so. Breitha died at the age of 90, in 2006. 10 Fewer than three dozen former patients now reside in Kalaupapa. After they are gone, the site will become a park. In the meantime, access is rigidly controlled to protect the privacy of the residents. Except for tightly-regimented tours that the community conducts, no outsiders are permitted unless they are there by invitation from a resident. Upon landing at the small airport, visitors are warned not to leave the premises unless accompanied by an offi cial. Those who are permitted to visit may take photographs, but not of residents without their express permission. Their desire for privacy is strong, and understandable. Throughout Hawaii, there are now about twenty cases of Hansen's disease treated each year. Those infected now are treated as outpatients. 11 The Kalaupapa experience with regard to American hysteria over Hansen's disease was not unique, only the most dramatic. The USA reacted similarly on the mainland, banishing victims to a colony, Carville, in Louisiana. A release from the Smithsonian's National Museum of American History described it as follows:

On the United States mainland, the response to leprosy had national implications; in 1921 the federal government purchased the Louisiana Leper Home as a national center for disease containment and isolated care. The instatement of the Federal Marine Hospital #66, a national leprosarium, was unique. The government, under the auspices of the Public Health Service, assumed extensive fi nancial and administrative responsibility to create an institution devoted solely to leprosy's treatment and containment for the entire continental United States. Only within the last 20 years has Washington returned the Carville center to the State of Louisiana and relocated its research branch-The Gillis W. Long Hansen's Disease Center-to Baton Rouge, Louisiana. 12 Whether quarantine could ever be completely effective on a mass scale for infl uenza is doubtful, because of the extraordinarily contagious nature of the disease. Of course it can succeed in localities if applied rigorously and suffi ciently early to achieve complete isolation. During the 1918 pandemic, Gunnison, Colorado "succeeded in isolating itself. So did Fairbanks, Alaska. American Samoa escaped without a single case, while a few miles away in Western Samoa, 22 percent of the entire population died." An Army study found that most efforts were "carelessly applied," and therefore failed, but that isolation "rigidly applied…did some good." 13 For Hansen's disease, the situation is different and would appear to be more promising; quarantine might appear to be effective. Nevertheless, it was never fully effective in Hawaii. The long incubation period and the strong resistance of the population to the laws mandating exile worked against its success.

"THE MAGIC OF THE MARKETPLACE" AND PUBLIC HEALTH EMERGENCIES An example of inaction in the face of a public health emergency may be seen in the case of the Eisenhower administration regarding the impending pandemic of "Asian fl u," in 1957. The cause was a new virus that had been identifi ed in Asia early in the year, and had been circulating in the USA "as early as June-months before the pandemic mortality impact began." 14 If the volume of relevant material at the Eisenhower Presidential Library is any indication, Asian fl u was not a major issue of Eisenhower's administration. The Library's collection has only forty-fi ve pages of material, many of them duplicates or near duplicates.

On 17 August 1957, an attorney in the Bronx, Robert Himmelfarb, sent a handwritten letter to the president expressing alarm that only six companies would be producing vaccine. "It is respectfully asked that this should be increased to combat the expected fl u epidemic," he wrote, and mentioned an article in that day's New York Times. 15 The response to Himmelfarb went out on 5 September over the signature of Eisenhower's physician, Major General Howard Snyder, who indicated that President Eisenhower had asked him to reply. "The United States Public Health Service has set up a well-organized plan for the manufacture and distribution of the Asian fl u vaccine," he wrote. "Everything possible is being done to have suffi cient vaccine available to everyone at the earliest possible date." 16 A "Special Staff Note" with Eisenhower's initials, dated October 3, 1957, and marked "Administratively Confi dential" indicated that the "Public Health Service has taken all reasonable precautionary steps in preparation for the anticipated epidemics in collaboration with the AMA, state health offi cers, the drug industry, and others concerned." At the time, it said, there were an estimated 225,650 cases reported throughout the country. "It is approaching epidemic proportions in Louisiana, Mississippi, Arizona, eastern Texas, Utah and possibly other areas." Vaccine supplies "suffi cient to inoculate fi rst-priority groups" were expected within "the next few weeks." The military had 62% of the vaccine required for fi rst inoculation of all active-duty personnel, and defense agencies had been directed to "assist in establishing vaccination programs for civilian employees as supplies become available." The key provision regarding the policy was the statement that "vaccine manufacturers have agreed to voluntary distribution among States according to population, and have been asked to follow the priority recommendations of State and local advisory committees in fi lling orders. This voluntary type of distribution system cannot be expected to be uniformly effective, but more stringent controls are not recommended at this time." 17 Governor Albert Chandler of Kentucky on 24 October 1957 sent an urgent telegram to Eisenhower, indicating that Asian fl u had reached epidemic proportions in Pike County, and that vaccine was unavailable. He asked the president to intervene. The reply had originally been drafted for the signature of Eisenhower's chief of staff, Sherman Adams, but ultimately the signature was that of Howard Pyle, deputy assistant for federal state relations. The reply indicated that Kentucky was receiving the amount "of the scarce vaccine" allotted by the manufacturers, who distributed it on the basis of population. "Since infl uenza has reached epidemic stage in many areas throughout United States [ sic ], intervention by Federal Government to secure additional supplies for one area could seriously and unfairly affect others. It is suggested that you or your State health offi cer request the Kentucky outlets of the vaccine manufacturers to give special attention to fi lling orders for Pike County from Kentucky's share of new vaccine supplies." 18 According to Mike Davis, public health experts appealed to the Eisenhower administration for a mass vaccination program, but the administration "rebuffed" them. The surgeon general did provide some funds for surveillance, but (as the records clearly verify) "the Republicans in power relied upon free enterprise to develop and distribute the vaccine." This obviously was inadequate, as Snyder's reference to "the scarce vaccine" demonstrates. Davis noted scathingly that contrary to the administration's assumptions, "without government coordination classical supply-and-demand relationships work mischievously" when infl uenza is involved. Timing is among the diffi culties. "The vaccine needs to be produced in quantity for immunization at least a month before the peak of an epidemic, but most of the market demand from individual consumers comes only after the epidemic is in full course." Even though by 1957 there was a considerable range of antibiotics to treat secondary infections, and even though Asian fl u rarely produced viral pneumonia, cyanosis, and acute respiratory distress and thus was far less lethal than its 1918 predecessor, "still, 2 million people worldwide were later estimated to have perished in the pandemic, including 80,000 Americans, many of whom might have been saved by timely vaccination." 19 This is speculation, of course, but it is plausible.

Davis went on to cite the opinion of "public-health veterans" that "these deaths were the dismal price of the failure of Eisenhower's reliance upon the invisible hand of private enterprise to do the work of government," and he agrees fully with Millar and Osborne that dependence upon the "profi t-driven vaccine marketplace" with all its ineffi ciencies caused a huge and unnecessary loss of life. Among those ineffi ciencies are inadequate levels of production, and diversion of vaccine away from high-risk groups and to corporate employees in order to reduce sick days. 20 

It might appear as if the two extremes of inappropriate governmental responses to public health emergencies would be over-reaction-as in the case of Hawaii and Hansen's disease-and inaction-as in the case of Eisenhower's passivity when Asian fl u confronted the country. Unfortunately, the range is even greater. Beyond simple inaction there is an example of an even more extreme response, one that could even be termed militant passivity. In the face of the most lethal pandemic in modern history, President Woodrow Wilson not only remained inactive but took other actions that (unintentionally, of course, even if not necessarily unknowingly) made matters far worse. Wilson had strongly resisted entry into the World War, and in fact achieved his narrow re-election in 1916 campaigning on the slogan, "He Kept us Out of War!" When he reluctantly concluded that the USA must participate, however, he passionately marshaled the country's resources to throw into the war effort, and discarded many of the restraints on government that had characterized America since its beginning. Barry's description of wartime America under Wilson is chilling, and parallels the picture that Katherine Anne Porter presented so subtly, yet forcefully, in Pale Horse, Pale Rider.

The country was ill-prepared when it entered the fray in April of 1917, but hardly more than a year later "Wilson had injected the government into every facet of national life and had created great bureaucratic engines to focus all the nation's attention and intent on the war." 21 America, Barry continued, found its food supply under the control of a Food Administration, a Fuel Administration rationing its gasoline and coal, and "a War Industries Board to oversee the entire economy." Wilson controlled the railroads and many industries.

Most disturbing from the standpoint of civil liberties, "he created a vast propaganda machine, an internal spy network, a bond-selling apparatus extending to the level of residential city blocks. He had even succeeded in stifl ing speech, in the summer of 1918 arresting and imprisoningsome for prison terms longer than ten years-not just radical labor leaders and editors of German-language newspapers but powerful men, even a congressman." 22 The "internal spy network" was the American Protective League mentioned in Chapter II (p. 21) . A look at the Duluth, Minnesota chapter will provide some sense of its activities.

A history of Duluth and St. Louis County says that the "local unit of the APL had seven divisions, each of which had 'a captain and a lieutenant, and these were the only persons in each division who knew the Chief's identity, he being known as C-1.' Continuing the clandestine pattern, division leaders also were kept uninformed as to the identities of personnel and leaders of other divisions. It seems to have worked… 'The Department of Justice today [1921] has a complete record of every person living in the Duluth area who uttered words against the Government from April 1, 1917, until the Duluth division was disbanded under Federal instructions on February 1, 1919." The Duluth unit received praise for clearing up "more cases of pro-Germanism and sedition," and for causing the "greatest number of arrests and detention." 23 One person Wilson dared not touch spoke out forcefully against the repression, and almost assuredly kept it from becoming even worse. Wilson's nemesis, former president Theodore Roosevelt, condemned the administration's excesses, and dared Wilson to have him arrested. Kathleen Dalton's superb study of Roosevelt details this almost completely overlooked role that the former president played in a time of national hysteria. Most treatments of Roosevelt's activities during the Great War condemn him as acting irresponsibly. Dalton helps to correct this myopic view. She points out that " The Nation asked 'Why is Roosevelt Unjailed?' in an editorial criticizing the administration's bad habit of jailing less famous adversaries. The editorial credited the ex-president with having saved the right of free speech in wartime." 24 To be sure, Theodore Roosevelt was no absolutist on civil liberties-and certainly not on free speech in wartimebut it is inexcusable that most works dealing with his post-presidential public career tend to treat him solely as a pugnacious militarist, and ignore his role in opposing repressive government.

From the point of view of public health, the most disturbing were some of Wilson's other actions. As is customary during military mobilization, dozens of military installations sprang up, and each one increasingly concentrated thousands of personnel into a crowded area. Wilson "had injected the government into American life in ways unlike any other in the nation's history. And the fi nal extension of federal power had come only in the spring of 1918, after the fi rst wave of infl uenza had begun jumping from camp to camp, when the government expanded the draft from males between the ages of twenty-one and thirty to those between the ages of eighteen and forty-fi ve." 25 During this time, disagreements between the War Department and the Army's Medical Department brought turmoil in the midst of the pandemic. William Gorgas, the Army's surgeon general, annoyed Secretary of War Newton Baker and Army Chief of Staff Peyton March with, among other things, his demands for measures to combat infl uenza's spread. March and Baker forced Gorgas into retirement, thus dealing a blow to the Medical Department at a time when it was most needed.

Gorgas's interim replacement, Brigadier General Charles Richard, also spoke up; he warned of the dangers of continuing to ship men to Europe aboard crowded transports, while General John J. Pershing in France-who pointed out that receiving men who were ill was counterproductive-called for more medical personnel and hospital space aboard ships, and a one-week quarantine of troops before shipping. General March, however (who, as the Army's chief of staff, of course was not a physician), insisted that a physical examination of each soldier being sent to board ship would be suffi cient. He ignored, or dismissed, General Richard's assertion that no physical examination could identify those who were infected, but who had not yet displayed symptoms. 26 President Wilson was concerned, to be sure, and called March to a meeting at the White House. At this time, in October, peace already appeared to be at hand, and the carnage from the fl u was clearly evident. Crosby cites one incident prior to the meeting in which a convoy arrived in France with 24,488 men, of whom 4,147 were ill upon arrival, 1,357 required hospitalization immediately, and more than 200 had died. 27 Wilson indicated that he had been advised to halt the shipment of men abroad until the epidemic had passed, but March said that the shipments should continue. He pointed out that the men were subject to examination at their training camps, at their embarkation camps, and again before boarding ship. He conceded that epidemics on ship could still occur, but that "lives lost to infl uenza must be balanced against those which could be saved if the war could be brought to a speedy end." 28 In his opinion, no other circumstance was suffi cient to justify halting the shipment of troops.

Crosby's discussion quoted March as writing later that, after making the decision to continue troop shipment, Wilson looked sadly out the window, and said, "General, I wonder if you have heard this limerick? I had a little bird And its name was Enza… This, if true, is a damning indictment. Wilson appears to have had at least some idea of what the consequences would be. As a result of his decision, one of the military's greatest shortages came to be coffi ns for its troops who had succumbed on the voyage abroad or soon after. Pershing, himself, later implied that War Department policies promoted the pandemic, because "large numbers of cases were brought in by our troop ships." 29 However much Wilson exercised power during the war, he exerted no power to deal with infl uenza, either among the troops or among the civilian population. To be sure, there was little medically that could be done at the time (even now, our therapeutic resources are limited), but avoiding overcrowded conditions, providing adequate nursing care, and perhaps even implementing quarantine under some conditions might have assisted somewhat.

Kalaupapa resulted from an over-reaction-possibly a hysterical onebecause of ignorance. Eisenhower's response to the Asian fl u pandemic resulted from adherence to a free-market ideology that was inadequate to deal with the situation. Wilson's response to the greatest threat of all, the 1918 fl u, resulted from a single-minded preoccupation with the war that clouded his judgment. His zeal prevented him (and his key military adviser, General March) from recognizing that accepting additional infl uenza deaths by continuing troop shipments was actually detrimental to their war efforts.

There is yet another category of misguided response to public health crises, one that combines several of the reasons above-especially ignorance and ideology-and couples them to inadequate infrastructure, sheer incompetence of offi cials at the highest levels, and what seemed to many observers, however unkindly, even to be a lack of concern. This was the response of the George W. Bush administration to the disaster of Hurricane Katrina in 2005. To be sure, this was not a pandemic, but much can be learned from the government's clumsy response of things to be avoided when faced with any public health emergency, pandemics included. Note, though, that this is not the complete story with regard to the Bush administration. It performed considerably better with regard to preparation for pandemic infl uenza. Regardless of whether its Katrina experience was instructive, the Bush administration's pandemic fl u preparation was largely unheralded, probably because the country did not seem actually to be facing a pandemic at the time. Bush should receive some credit for a non-dramatic success, just as it received blame for a very dramatic failure regarding Katrina. In this instance, it appears as though his guidance came from experts in public health and related fi elds, with minimal infl uence from ideology.

On 1 November 2005, Bush announced his program of preparation, and later, in May of 2006, released National Strategy for Pandemic Infl uenza: Implementation Plan . 30 In Bush's introduction, he said that Congress in December had appropriated $3.8 billion, and that he had launched the International Partnership for Avian and Pandemic Infl uenza at the UN the previous September. The plan, he said, "describes more than 300 critical actions, many of which have already been initiated, to address the threat of pandemic infl uenza" He spoke of the need for participation of "all levels of government and segments of society." The nine chapters of the plan included a summary, two chapters on government planning and response, two on "international efforts and transportation and borders," one on "Protecting Human Health," another on "Protecting Animal Health," one on "Law Enforcement, Public Safety, and Security," and a fi nal one on institutional considerations, such as "plans by Federal, State, local, and tribal authorities, businesses, schools, and non-governmental organizations to ensure continuity of operations and maintenance of critical infrastructure."

Without acknowledging the two previous presidents (both Republicans) with relevant experience, but perhaps in consideration of lessons learned from the Eisenhower and Ford administrations, the Bush plan summarized its call for production, stockpiling, and distribution of vaccine and antiviral medications:

The Federal Government has established two primary vaccine goals (1) establishment and maintenance of stockpiles of pre-pandemic vaccine adequate to immunize 20 million persons against infl uenza strains that present a pandemic threat; and (2) expansion of domestic infl uenza vaccine manufacturing surge capacity for the production of pandemic vaccines for the entire domestic population within 6 months of a pandemic declaration. The Federal Government has also established two primary goals for stockpiling existing antiviral medications: (1) establishment and maintenance of stockpiles adequate to treat 75 million persons, divided between Federal and State stockpiles; and (2) establishment and maintenance of a Federal stockpile of 6 million treatment courses reserved for domestic containment efforts.

To accomplish these goals, we will expand Federal, and create State, stockpiles of infl uenza countermeasures, as well as expand domestic vaccine manufacturing capacity. We will make substantial new investments in the advanced development of cell-culture-based infl uenza vaccine candidates, with a goal of establishing the domestic surge vaccine production capacity to meet our pre-pandemic stockpile and post-pandemic vaccine production goals.

The Federal Government is developing guidelines to assist State, local, and tribal governments and the private sector in defi ning groups that should receive priority access to existing limited supplies of vaccine and antiviral medications. Priority recommendations will refl ect the pandemic response goals of limiting mortality and severe morbidity; maintaining critical infrastructure and societal function; diminishing economic impacts; and maintaining national security. Priorities for vaccine and antiviral drug use will vary based on pandemic severity as well as the vaccine and drug supply.

The establishment of credible distribution plans for our countermeasures is equally important. We will work with State and tribal entities to develop and exercise infl uenza countermeasure distribution plans, to include the necessary logistical support of such plans, including security provisions. 31 It was Katrina, however, that showed the Bush administration at its worst in terms of effi ciency and effectiveness. The infrastructure was inadequate, and was weakened further by an ideology of "privatization." In this instance, modern media coverage was so pervasive that contemporary America saw clearly the results of a government controlled by overly ideological offi cials who in any case gave the impression of being uncaring and unqualifi ed to deal with the disaster-regardless of whether they were so inclined. Many Americans remember the spectacle of their president, the younger Bush, viewing the destruction from the air as he passed over the stricken city. The spectacle continued. More than two years after the storm, much expensive equipment designated for housing and restoration sat unused and deteriorating, while in February 2008 news outlets around the country reported that thousands of people who had been living in many of the trailers and manufactured houses that FEMA had purchased for nearly $1 billion were being told to leave quickly, because their shelters exposed them to toxic levels of formaldehyde, a carcinogen. Even later, in March, the Associated Press reported that "years after Hurricane Katrina, tens of thousands of miserable homeowners are still waiting for their government rebuilding checks, and many complain they can't even get their calls returned." To be sure, not everyone suffered: "The company that holds the big contract to distribute that aid, however, is doing quite well for itself," a news item said. "ICF International of Fairfax, Va, has posted strong profi ts, gone public, landed additional multimillion dollar government contracts, and, it was learned this week, secured a potentially big raise recently from the state of Louisiana." 32 Historian Douglas Brinkley, who lived in New Orleans at the time of the hurricane, produced a powerful work on Katrina, the circumstances leading up to the catastrophe, and the Bush administration's failed response. 33 There have been many other comments on presidential actions and the politics of Katrina, but those that may be especially helpful in considering presidential responses to health-care disasters are a thoughtful essay in The New Yorker by David Remnick 34 and my own examination of presidential reactions to disasters in general, in The Journal of Risk, Hazards, and Crisis in Public Policy. 35 In addition to his book, Brinkley also wrote a powerful op-ed article for The Washington Post . The title was bitter, and appropriate: "Reckless Abandonment." In this piece, Brinkley pointed out that "two full years after the hurricane, the Big Easy is barely limping along," and all the "most important issues concerning the city's long-term survival are still up in the air." 36 Despite "billion-dollar band aids," he said, White House directives are "placebos." He pointed out that inaction, itself, can and often does result from a deliberate policy decision. Almost the only people working to restore the city at that time were volunteers, and they tended ultimately to become cynical, disillusioned, and exhausted from their efforts. "Katrina," Brinkley wrote, "exposed all the ills of urban Americaendemic poverty, institutionalized racism, failing public schools and much more. New Orleans," he said, "is just a microcosm…" America is faced with a decision, and that is whether "the current policy of inaction is really the way we want to deal with the worst natural disaster in our history."

Fortunately, America's responses to public health emergencies have not always been misguided. Some have been excellent, and others have been better than generally supposed.

The Most Dangerous Woman in America

Merck Manual

Woman's Home Companion

Honolulu: Arizona Memorial Association, 2003; this was verifi ed by my discussions on Moloka'I and in Kalaupapa during the period of 3-10

Leprosy in Hawaii

Feeling Out Leprosy

Oh Say Can you See: Stories from the National Museum of American History

Revisited: Lessons and Suggestions for Further Inquiry

Pandemic Infl uenza and Mortality: Past Evidence and Projections for the Future

Eisenhower Presidential Library, Records as President, White House Central Files, Offi cial File Box 606 OF 117-T Asian Infl uenza

Eisenhower Presidential Library, Records as President, White House Central Files, Offi cial File Box 606 OF 117-T Asian Infl uenza. 17

Eisenhower Presidential Library, Records as President, White House Central Files, Offi cial File Box 606 OF 117-T Asian Infl uenza

The Monster at Our Door: The Global Threat of Avian Flu

Precursors of the Scientifi c Decision-Making Process Leading to the 1976 National Immunization Campaign

Moose Crossing: Portland to Portland on the Theodore Roosevelt International Highway

A Strenuous Life

Fever of War: The Infl uenza Epidemic in the U.S. Army during World War I

America's Forgotten Pandemic: The Infl uenza of 1918

Homeland Security Council, National Strategy for Pandemic Infl uenza: Implementation Plan

Survivors of Katrina Wait for Aid

The Great Deluge: Hurricane Katrina

Letter from Louisiana: High Water: How Presidents and Citizens React to Disaster

Anti-Government is Not the Solution to Our Problem, Anti-Government IS the Problem: Presidential Response to Natural Disasters, San Francisco to Katrina

Reckless Abandonment