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Introduction

  • Max J. Skidmore
Chapter
Part of the The Evolving American Presidency book series (EAP)

Abstract

This book examines major threats from disease to the people of the USA, and the ways in which American presidents have responded to such threats. It describes pandemics, and looks at several presidents. It looks critically at two, Woodrow Wilson and Dwight Eisenhower, and at their inaction when faced with influenza. It looks especially at Gerald Ford’s scorned National Influenza Immunization Program (NIIP, or the Swine Flu Vaccination plan), and concludes that—in contrast to the conventional wisdom—there is much to be learned from Ford’s efforts.

It discusses major achievements in combatting infectious diseases in the twentieth century, such as the eradication of smallpox, and the virtual eradication of polio and of so-called “childhood diseases,” such as measles, that at one time were almost universal but are threatening to return because of the irrational refusal of many parents to immunize themselves and their children.

Above all, the book demonstrates that efforts to impose severe limits on the size, scope, and expense of government are dangerous. Government, and that means presidential action, often provides the best, and sometimes the only, method of protecting the population.

Keywords

Pandemics Presidential power Irrationality  Vaccination Influenza National defense 

This book examines major threats from disease to the people of the USA, and the ways in which American presidents have responded to such threats. It will look critically at two presidents who had direct roles to play in pandemics, Woodrow Wilson and Dwight Eisenhower. It will look most extensively at another who faced what appeared as though it might develop into a horrendous pandemic, but did not materialize. That president was Gerald Ford, whose National Influenza Immunization Program (NIIP) sought to vaccinate all Americans against a swine flu virus that many experts thought was impending. Without a pandemic to fight, his program was derided as a fiasco. Officials from the incoming Carter administration were triumphantly scornful of the defeated President Ford, and their scorn was exceeded by that from the forces of Ronald Reagan, who had sought to seize the nomination from the sitting president of their own party, but had failed to do so, and thus seethed with disdain for Ford’s policies. This study will offer a rather favorable assessment of President Ford’s program, one that is rare for reasons that it will make clear. It will consider the health policies of Presidents Clinton and Obama favorably, and will give a mixed assessment to the policies of George W. Bush: highly critical for the most part, but surprisingly favorable in others. Above all, it will make the case that guarding against pandemics is and must be an integral part of national security. Despite the book’s title, now and then it will look beyond pandemics when it seems that doing so will help to evaluate presidential actions that would be relevant if the situation involved were a pandemic.

Presidents and Pandemics will argue that we must learn from past experience—mistakes and successes—in preparing for the future, and that future preparation is vital to the maintenance of civilization, here and elsewhere. As critical as terrorism is in the modern world, including bioterrorism, an even greater threat comes from natural causes. It will be necessary to overcome the tendency to respond only to the most dramatic danger—the obscenities, say, of a scowling enemy decapitating a helpless captive, attacking innocent schoolchildren, or snarling evil intent that might take place here—as opposed to preparation also for what assuredly will take place here: ever more virulent pandemics.

An examination of this kind obviously has implications not only for this country but for the rest of the world as well. The role of government will be key to national efforts; presidential understanding, commitment, and action will be prerequisite to effective government. Therefore, presidents are crucial to successful public policies.

At one time, there was little the world’s population could do in the face of pandemics. Modern medicine has given us many tools to employ. The decades since the beginning of the twentieth century have been characterized, time and again, by outbreaks of new and deadly diseases that either are or have the potential to become major threats to humanity. The greatest of these to date was the misnamed “Spanish Flu” of 1918 during World War 1, a swine flu pandemic that, with a death toll of some 675,000 for this country alone, killed more Americans than even the 600,000 of the Civil War, the conflict most lethal to its citizens. Worldwide, as later chapters make clear, the pandemic’s deaths exceeded those of any other cause in world history, upward of 50 million, sparing virtually no part of the planet in which there were human beings. Decades later, pandemics resulted first from Asian flu, and then from Hong Kong flu, each less lethal than its predecessor. Later in the century, despite being far less easy to transmit than influenza, came the march of HIV-AIDS. It was slower than the explosion of influenza, but its many tragic deaths were accompanied by sweeping cultural effects that were as serious as those of the wartime pandemic.

With the twenty-first century came SARS. According to the Centers for Disease Control (CDC), “Severe acute respiratory syndrome (SARS) is a viral respiratory illness caused by a coronavirus, called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003. The illness spread to more than two dozen countries in North America, South America, Europe, and Asia before the SARS global outbreak of 2003 was contained.” Fortunately, since 2004 there have been no reported cases of SARS anywhere. 1

In June of 2015, according to both official reports and the press, South Korea was facing the largest outbreak of MERS that had ever taken place outside of the Middle East. MERS, says the CDC, is “Middle-East Respiratory Syndrome,” a severe coronavirus infection affecting human beings. The earliest reports described MERS as having been identified in 2012 in Saudi Arabia, but later corrections indicated that there had been a case a few weeks earlier in Jordan. MERS spreads from one person to another “through close contact,” although the exact mechanism of transmission is not clear. It causes fever, coughing, and difficulty breathing. “About 3–4 out of every 10 patients reported with MERS have died.” 2 Citing a report from The World Health Organization (WHO), the Washington Post said that the South Korean government was implementing “strong control measures,” and that the virus—which gave no indication that it was increasing its ability to spread from one person to another—in South Korea had remained completely confined to hospitals and treatment centers. 3

At roughly the same time there was a widespread incidence of bird flu in the USA that was causing a serious egg shortage severely affecting American restaurants. Prices escalated, and in some locations sellers began limiting egg purchases, that is, in effect they were implementing rationing of eggs. 4 USA Today reported that the outbreak was “especially damaging in Iowa, the nation’s largest egg-producing state, with 40% of it egg-laying hens lost to the disease.” 5 Government in the USA seems always to be a prime target for complaint from all segments of the political spectrum, so under the circumstances, it is hardly surprising that there was considerable criticism of the government as having done too little, too late. A spokesman from the Department of Agriculture, John Clifford, “USDA’s chief veterinary officer,” defended the agency before an investigating committee of the US Senate, and said that despite difficulties, the response had been quick and decisive. Also, he said, USDA had learned from the experience, and will be able to respond in ways that will “minimize the effects of this disease going forward.” Iowa’s two conservative Republican senators, Charles Grassley and Jodi Ernst, according to USA Today’s article, “have said the federal government needed to respond more quickly and offer more resources to combat the disease.” 6 This is reasonable, but it seems poorly compatible with the attitudes of “small-government Republicans,” especially those of Senator Ernst, who ran for office condemning dependence upon government.

This illness was not infecting human beings, but influenza affecting human beings has emerged from other animals, and seems most often to have originated among birds. Avian flu, in fact, poses perhaps the most serious potential threat that humanity faces, along with those of climate change and environmental degradation. The New Yorker magazine, among all the publications directed toward the most literate and highly educated segment of the reading public, seems to be most likely to deal with issues of general concern, and to do so in a thoughtful and appropriate manner. In the matter of bird flu, it did so in an article under the rubric of its occasional “Annals of Medicine.” 7

The article began with the death in Hong Kong, on 21 May 1997, of a three-year-old boy from influenza. In itself, that was not unusual, in that influenza viruses “kill hundreds of thousands of people every year. Hong Kong is among the world’s most densely populated cities, and pandemics have a long history of first appearing there or in nearby regions of southern China, and then spreading rapidly around the globe.” 8 What quickly became unusual, though, was the nature of the virus. An “international team of virologists,” after three months of attempts, finally identified it as H5N1, an avian influenza that had killed hundreds of millions of chickens, but had not previously been known to infect a human being, even those who worked with poultry. By the end of the year, eighteen people had contracted the infection, and six had died, a “remarkably high mortality rate.” Hong Kong officials worked speedily, slaughtering all the chickens in the area, and bird flu seemed to have disappeared. Officials involved included those from Hong Kong, the WHO, the CDC in Atlanta, and elsewhere. They could only have felt great relief that a worldwide pandemic had not taken place. Then, the virus appeared once more, this time in Thailand. As of 2012, it was known to have infected 587 people, killing 346 of them. This made “H5N1 one of the deadliest microbes known to medical science.” 9

The core of the piece in The New Yorker was a discussion of the work of a Dutch virologist, Ron Fouchier, who had succeeded in causing mutations in H5N1 that made it extremely easy to transmit, both to mammals and from mammal to mammal. Was the mere existence of this transmittable virus so dangerous to the health of the world that it should never have been created—however stringent the security imposed to keep it well contained in vaults the laboratory? Did its creation enhance potential knowledge of how to combat the virus enough to justify the creation of such a deadly organism? Critics have pointed out that dangerous organisms have escaped from the most secure facilities. Fouchier responds that nature can easily do what he did in his laboratory, and says moreover that it inevitably will do so. He concedes that bioterrorists might find ways to acquire, or create, the organism, but argues that the threat from nature itself is far greater.

Before the reports regarding the outbreak of MERS in South Korea, and bird flu in this country, there had been hysterical headlines, articles, news broadcasts, and general fear about a possible Ebola epidemic in the USA. There is no doubt regarding the deadly nature of Ebola, and there was legitimate concern about an epidemic in 2014 that raged in several West African countries, becoming the largest outbreak in history.

The serious nature of the disease, however, did not justify rampant speculation in the press and elsewhere that the virus was easily transmitted, with implications that a pandemic was inevitable. A CBS News report pointed out that much of the fear in the USA was based on misinformation and false alarms. Citing several incidents, perhaps the most extreme was that of a “schoolteacher’s trip to Dallas” that was “enough to cause a panic in Maine. She was placed on medical leave after attending a conference 10 miles from the hospital where Ebola patient Thomas Eric Duncan was treated.” 10 Ultimately, there were only four cases of Ebola infection in the USA, and only one of these resulted in death. 11 Because of vigorous and effective action on the part of the WHO, the governments of the African countries most affected—especially that of Liberia—and the CDC in the USA, the epidemic has been stabilized, and in Liberia actually eradicated. Nearly all the cases had occurred in only three countries, Guinea, Sierra Leone, and Liberia, and as of June 2015 those totaled fewer than 30,000. Only about 35 cases involving 15 deaths were in other countries, and on 9 May 2015 the WHO declared Liberia to be free of Ebola. That status is achieved when 42 days, or two incubation periods, have passed “since the last Ebola patient was buried.” 12 Subsequently, there was another. “On June 29, routine surveillance detected a new confirmed case of Ebola in Liberia—the first confirmed case since March 20.” 13

Twentieth-Century Successes

As the twentieth century neared its end, the CDC issued a report, “Achievements in Public Health, 1900–1999 Impact of Vaccines Universally Recommended for Children—United States, 1990–1998.” The report is a succinct history of improvements in public health, and contains information that should be widely recognized and appreciated.

The first vaccine to be developed was that for smallpox, and that came as early as 1796. Nevertheless, a full century later it was still not used sufficiently widely to control the disease. As the twentieth century began, vaccines against rabies, typhoid, cholera, and plague had recently been developed, but also were not yet in widespread use. As of the date of the CDC report, vaccines for twenty-one other diseases had been developed and were available, eleven of which had “been recommended for use in all U.S. children.” The CDC report contains a table identifying the targeted diseases, and specifying those vaccines that had been recommended for universal childhood immunization. “National efforts to promote vaccine use among all children began with the appropriation of federal funds for polio vaccination after introduction of the vaccine in 1955. Since then federal, state, and local governments and public and private health-care providers have collaborated to develop and maintain the vaccine-delivery system in the United States.” 14

The results have been highly—even dramatically—successful. Smallpox has been eliminated, and thus the vaccine, which itself presents dangers, has been withdrawn. Polio and its associated deaths and disabilities declined dramatically, and no longer appear in the Western Hemisphere. “The last imported case caused by wild poliovirus into the United States was reported in 1993. The remaining 154 cases were vaccine-associated paralytic polio (VAPP) caused by live oral poliovirus vaccine (OPV).” It is extremely rare for OPV to cause polio, but it was unnecessary to have any risk at all. To eliminate risk entirely, OPV has not been used in the USA since 2000, only the inactivated polio virus (IPV) which cannot cause the disease. 15 Polio has thus been eliminated from the USA, and is close to being eliminated elsewhere. It is possible, though, for the disease to be re-introduced into the country by someone who has acquired it outside the country. That has happened, but not since 1993. 16

Also declining dramatically are those that once were called “childhood diseases,” such as chickenpox, mumps, and measles. Previously, these were assumed to be an almost inevitable part of growing up. Parents sometimes would have such gatherings as “chicken pox parties,” or “measles parties” to expose their children to others who had the disease, and “get it over with.” That obscured the danger of such infections, especially measles, which can cause permanent disabilities such as deafness, blindness, and brain damage; it can even cause death. Measles is one of the most contagious of all diseases. With regard to measles vaccine and the extent of transmittability, the CDC says, “Measles spreads when a person infected with the measles virus breathes, coughs, or sneezes. It is very contagious. You can catch measles just by being in a room where a person with measles has been, up to 2 hours after that person is gone. And you can catch measles from an infected person even before they have a measles rash. Almost everyone who has not had the MMR shot will get measles if they are exposed to the measles virus.” 17 “MMR” refers to the combined vaccination for measles, mumps, and rubella. It is responsible for one of the largest improvements in public health overall. In 2000, the USA had achieved “measles elimination,” although a few cases continued to occur from importation of the virus by travelers. 18

A Disturbing Development

Although there is no question regarding the enormous improvement in public health that has resulted from the widespread use of vaccines, an anti-vaccination movement has developed reflecting two different themes. One is religious belief, often supported by anti-government attitudes that oppose government intrusion into personal practice and belief. The other has coalesced within better-educated groups who nevertheless base their conclusions on poor science, and emotionally-charged arguments. The Internet has been a major factor in spreading misinformation.

If a child is autistic and has been vaccinated, there is a tendency for its parent to be receptive when someone argues that “vaccinations cause autism,” a connection for which there is no scientific evidence whatever. In response to the scientific argument that no evidence exists to suggest a link, it is easy to twist logic to say that no proof exists that vaccines do not cause autism, ignoring all questions regarding proof of negatives. Other allegations for which there is no scientific evidence are that vaccines cause autism and other ailments by “overloading” a child’s immune system, or that somehow “natural” immunity is better than the immunity that bodies develop in response to vaccines.

There can be a community of interest here between right-wing groups who oppose government social programs in principle and left-leaning groups who favor the idea of such programs, but who fear the influence of large corporations and other financial interests, their influence on government, and their control of established institutions. One does not have to be a leftist to decry the influence of the powerful. It was, after all, no radical but an essentially conservative American president and five-star general, Dwight D. Eisenhower, who warned in his farewell speech about the “military-industrial complex.” Such an awareness of the influence of anti-democratic forces is rational. It is even essential to maintain democracy, but it does not justify complete cynicism. It is highly irrational to conclude that the obvious influence of money on politics must mean that all information from any official source or institution is invalid, or that any action must be self-serving.

Such a view becomes what the late historian Richard Hofstadter called “the paranoid style” in American politics. 19 His point was that of course there are conspiracies in history, but it nevertheless is irrational to the point of delusion to believe that the whole of history is a conspiracy. The characteristics of much of the literature generated by the anti-vaccination groups and the writings that influence them are uncomfortably close to those generated by groups that most intelligent observers would have to classify as cults.

There are many thoughtful analyses of the controversy, but one of the most cogent is by Peter Salk, in The Atlantic, “The Anti-Vaccine Movement is Forgetting the Polio Epidemic.” 20 Peter Salk is a distinguished medical researcher himself who is the son of the originator of the polio vaccine, Jonas Salk. One should remember that Jonas Salk could have patented the Salk vaccine, and made literally billions of dollars from it. He did not even consider doing so, though, because he believed the vaccine should belong to the people.

With regard to measles, the USA in 2015 had its first fatality from the disease since 2003. In late 2014, an outbreak of the disease took place in California as a result of exposure at a theme park. It was responsible for 117 cases in several states; the total measles cases in the first six months of 2015 came from five outbreaks and appeared in 24 states, and amounted to 178 (including the 117). 21 As a result of the diminishing number of people being vaccinated and the increasing number of measles cases, California, on 30 June 2015, passed a strict new vaccination law requiring vaccinations for schoolchildren and eliminating exemptions because of personal belief or religious reasons; only medical reasons can now justify an exemption. Upon signing the bill into law, Governor Jerry Brown remarked, “The science is clear that vaccines dramatically protect children against a number of infectious and dangerous diseases,” … “While it is true that no medical intervention is without risk, the evidence shows that immunization powerfully benefits and protects the community.” California thus joined only two other states, Mississippi and West Virginia, in requiring all schoolchildren regardless of religion or personal belief to be vaccinated unless there are legitimate medical reasons that justify exempting a child. 22 Outraged by the new law, parents and others who oppose vaccination indicated that they would immediately begin a campaign to repeal the new statute.

The Importance of National, and Presidential, Action

We are dealing here with no less than the essential elements of national (and worldwide) defense. Most of these principles are self-evident, and many are being employed here and elsewhere. The connection between health and national defense should be self-evident. An interesting article by Chuck Brooks of the Xerox Corporation makes clear the roles already played by the “many organizations that play significant roles in warning, treating, and protecting against infectious outbreaks. The World Health Organization, Centers for Disease Control and Prevention, the Health and Human Services and Defense Departments are all experienced with the challenges that may arise when dealing with worldwide pandemic events.” 23 Brooks, in his capacity at Xerox as Vice President/Client Executive, works directly with the Department of Homeland Security (DHS), demonstrating the close ties between public and private organizations with regard to protecting the population.

The mission of the Department of Homeland Security concentrates upon defense against terrorism, but its activities are relevant to natural threats as well. Brooks describes the segments within DHS of the Office of Health Affairs, and the Chemical and Biological Defense Division of Science and Technology Directorate, which “provide comprehensive analysis of threat characterization,” and the like. Examples of relevant programs include “Foreign Animal Defense Vaccines and Diagnostics,” which works in cooperation with the Department of Agriculture and the National Bio-and Agro-Defense Facility in Manhattan, Kansas; Underground Transportation Restoration, aimed at maintaining transportation capabilities after biological events; and risk assessments. Broadening beyond military considerations, he recognizes natural threats as relevant, and mentions infectious Ebola as demonstrating “the threat of pandemics and bioterrorism” (italics added). Earlier recent threats of possible epidemics came in 2002 and 2003 from SARS, possible terrorist attacks came in 2001 from Anthrax scares, “and the 2004 ricin letters. Many forget,” he wrote, “that the 1918 Spanish Flu influenza pandemic killed more than 50,000 [sic; this likely was a misprint from 50,000,000] people. We are all vulnerable and the vigilance to bio threats are [sic] necessary and should not be taken lightly.” His final sentence sums it up: “Pandemics, whether they are generated by nature or terrorists need to be addressed through interagency preparedness, training, and communication…” 24 The additional point around which this book revolves is that we must learn from past experiences, and view them objectively rather than from partisan or ideologically tainted perspectives.

The greatest rejection of the need for a strong government role is likely to come from within the USA, where there is resistance to scientific findings on such things as vaccination and climate change, and where scientific issues such as these have been made into political issues.

In summary, given the nature of biological threats, governments must take the lead in developing and implementing strategies to protect the world’s populations. Official international organizations also must employ their resources fully. Regarding national defense, protection against pandemic illness is at least as urgent a matter as is military preparedness. This is true regardless of the source of the threat, but the greatest threats are from nature itself.

Of all the world’s countries, the USA is the most powerful, and has the greatest resources. Therefore, America’s government must take a lead in marshaling protective forces, developing and implementing strategies, and creating and encouraging the creation of the knowledge required to deal with potential catastrophes.

The unique nature of America’s government is such that it requires a strong, active, and dedicated president and executive branch, if it is to be effective. It is not by accident that one author titled his work on the presidency “The Ferocious Engine of Democracy: A History of the American Presidency.” 25

Because of this, the traditional American disdain for government must give way to a recognition that, although controls on government are essential, a strong and active government is also essential. The acceptance by one of America’s two major parties of former President Reagan’s firm belief that “government is not the solution,” and that government, itself, is the problem, is potentially a greater threat to the people of America and elsewhere than are the actions of terrorists. The assumption that keeping taxes low is more important than any government responsibility and function must be recognized as irrational.

Notes

  1. 1.

    Centers for Disease Control and Prevention, “Severe Acute Respiratory Syndrome (SARS),” http://www.cdc.gov/sars/; retrieved 11 July 2015.

     
  2. 2.

    Centers for Disease Control and Prevention, “Middle East Respiratory Syndrome (MERS),” Page last updated June 5, 2015; http://www.cdc.gov/coronavirus/mers/about/; retrieved 3 July 2015.

     
  3. 3.

    Kim Tong-Hyung, “WHO: MERS Not Spreading Outside S. Korea Hospitals,” Washington Post (13 June 1015); http://www.washingtonpost.com/world/middle_east/who-mers-not-spreading-outside-s-korea-hospitals/2015/06/13/9995f426-1230-11e5-a0fe-dccfea4653ee_story.html; retrieved 3 July 2015.

     
  4. 4.

    Roberto Ferdman, “Egg Rationing in America has Officially Begun,” Washington Post (5 June 2015); http://www.washingtonpost.com/blogs/wonkblog/wp/2015/06/05/the-largest-grocer-in-the-texas-is-now-rationing-eggs/; retrieved 4 July 2015.

     
  5. 5.

    Christopher Doering, “Egg, Poultry Groups Criticize USDA’s Handling of Bird Flu Outbreak,” USA Today (8 July 2015); http://www.usatoday.com/story/news/nation/2015/07/07/senate-committee-considers-impact-of-bird-flu/29823229/; retrieved 10 July 2015.

     
  6. 6.

    Ibid.

     
  7. 7.

    See, Michael Specter, “The Deadliest Virus,” The New Yorker (12 March 2012).

     
  8. 8.

    Ibid.

     
  9. 9.

    Ibid.

     
  10. 10.

    Carter Evans, “Ebola Panic Spreading Much Faster than Disease in U.S.,” CBS News (18 October 2014); http://www.cbsnews.com/news/ebola-panic-in-us-spreading-much-faster-than-disease/; retrieved 4 July 2015.

     
  11. 11.

    Centers for Disease Control and Prevention, “2014 Ebola Outbreak in West Africa – Case Counts,” (updated July 2, 2015); http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html; retrieved 4 July 2015.

     
  12. 12.

    Ibid.

     
  13. 13.

    Centers for Disease Control and Prevention, “2014 Ebola Outbreak in West Africa – Outbreak Update,” (1 July 2015); http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html; retrieved 4 July 2015.

     
  14. 14.

    Centers for Disease Control and Prevention, “Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children—United States, 1990–1998” (2 April 1999); http://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm; retrieved 14 July 2015; vaccines identified in Table One.

     
  15. 15.

    Centers for Disease Control and Prevention, “Polio Disease – Questions and Answers,” (11 August 2014) http://www.cdc.gov/vaccines/vpd-vac/polio/dis-faqs.htm; retrieved 14 July 2015.

     
  16. 16.

    Centers for Disease Control and Prevention, “Polio Elimination in the United States” (29 May 2015) http://www.cdc.gov/polio/us/index.html; retrieved 14 July 2015.

     
  17. 17.

    Centers for Disease Control and Prevention, “Vaccines and Immunization” (7 April 2015) http://www.cdc.gov/vaccines/vpd-vac/measles/fs-parents.html; retrieved 14 July 2015.

     
  18. 18.

    Centers for Disease Control and Prevention, “CDC Advisory,” HAN (Health Alert Network) 23 January 2015 http://emergency.cdc.gov/han/han00376.asp; retrieved 15 July 2015.

     
  19. 19.

    Richard Hofstader, The Paranoid Style in American Politics, Cambridge: Harvard University Press 1964; available in numerous subsequent editions.

     
  20. 20.

    Peter Salk, “The Anti-Vaccine Movement is Forgetting the Polio Epidemic,” The Atlantic (28 October 2014).

     
  21. 21.

    Centers for Disease Control and Prevention, “Measles Cases and Outbreaks,” (30 June 2015) http://www.cdc.gov/measles/cases-outbreaks.html; retrieved 15 July 2015.

     
  22. 22.

    Adam Nagourney, “California Mandates Vaccines for Schoolchildren,” The New York Times (30 June 2015). P. A 19.

     
  23. 23.

    Chuck Brooks, “The DHS’s Role in Confronting Pandemics an Bioterrorism,” Federal Times (22 December 2014; originally published 4 November) http://www.federaltimes.com/story/government/dhs/blog/2014/12/22/dhs-role-in-confronting-pandemics-and-bioterroreism/20770335/; retrieved 15 July 2015.

     
  24. 24.

    Ibid.

     
  25. 25.

    Michael Riccards, The Ferocious Engine of Democracy: A History of the American Presidency, 2 volumes, New York: Madison Books, 1995.

     

Copyright information

© The Author(s) 2016

Authors and Affiliations

  • Max J. Skidmore
    • 1
  1. 1.Political ScienceUniversity of Missouri-Kansas CityKansas CityUSA

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