Public health, defense, what will *really* make us safer

I generally don't discuss a lot of politics on here. It's not that it's a topic I'm uninterested in; it's just that, for the most part, other people do it so much better than I do, so I leave a lot of it to them. There are, of course, exceptions. Intelligent design is much more of a cultural and political issue than a scientific one, despite the protestations of its advocates. There are others that occupy a similar niche. The idea that abortion causes breast cancer, for example, is one that has made its way into information packets that must be given to women contemplating termination of their pregnancy in a number of states, despite the actual science of that "connection" being refuted by a number of large studies. It's no longer a scientific issue; it's a political one.

Alas, this is the case with our health as well. And despite the lip service paid to making this country "safer" in the aftermath of 9/11, the measures put in place show that protection of our health has become almost exclusively a political issue, and the science is again being ignored.

Allow me to provide a bit of background here. When the history of healthcare in America is discussed, 1969 is often mentioned as a hallmark year. An oft-cited quote (which should be noted is somewhat murky in origin) by then-Surgeon General William Stewart stated that it was time to "close the book on infectious diseases." Antibiotics had been successful in treating many deadly infections (though resistance was already a problem); vaccination had made scourges such as polio and measles less of a threat; smallpox had been eliminated from America for decades, and a campaign to eradicate it world-wide had begun. With these infectious killers turned into tame kittens, the focus was shifting to diseases of aging and lifestyle, such as cancer and heart disease. Infectious disease was a non-issue, and since communicable disease had long served as a main reason for public health funding, public health infrastructure began to be neglected. Nixon declared a "war on cancer" in 1971, which led to valuable insights into carcinogensis at the price of infectious disease research and surveillance. As noted in this story:

But as new research money poured in, funding for infectious disease control programs dried up, as did budgets for public health agencies. As a result, facilities and equipment became outdated, staff training waned and personnel shortages became the norm. Between 25 and 50 percent of the nationâs estimated 500,000 government public health workers are expected to retire in the next five years and no replacements are in the pipeline, mainly because of low pay.

A 2003 report, "The Future of Public Health," by the Institute of Medicine found that the nation's "governmental public health agencies, the backbone of any public health system, still suffer from grave underfunding, political neglect and continued exclusion from the very forums in which their expertise and leadership are most needed to assure an effective public health system. This calls for urgent action."

One can see that we're still paying the price for this shift in funding today, and it's going to be a helluva lot more difficult to re-build from the remaining skeleton than it would have been if it had been maintained in the first place.

So, okay. Our public health system is broken. So what?, you ask. I have insurance; I don't need public health. What many people, including I'd guess most politicians, don't realize is that public health is vital to our national security, and having a strong public health system (and associated emergency response plans) in place will protect us not only from an aerosol release of smallpox, but also from another Katrina-esque disaster.

Don't get me wrong; action has been taken. Those in power occasionally get a wake-up call, and respond accordingly. Bioterrorism money surged following the 2001 anthrax attacks (still unsolved, by the way). But it funded projects in a narrow spectrum of areas: paying for research for a tularemia vaccine, for instance, and to jump-start smallpox research as waning immunity and an entire generation of unvaccinated individuals has left us open to an attack with this agent. This is great, in the unlikely event that there's a bioterrorist attack with tularemia, smallpox, or the other select agents which were funded. But the money allocated did little to aid our local public health departments in actually doing their jobs, nor did it provide enough funding to establish a surveillance network that would greatly improve our abilities to actually detect the release of a biowarfare agent--or the presence of a new pathogen introduced by Mother Nature rather than a rogue nation.

And if it's bad in the US, imagine the situation in other countries where even basic necessities are more difficult to come by. This was highlighted last year in an international exercise called "Atlantic Storm," role-playing a fictional release of smallpox that spread across Europe and then to the United States.

In the aftermath of the exercise, it was noted that "we have a globalized economy and globalized society, but we don't yet have globalized effective institutions to deal with the questions that come out of the globalization process." Nothing highlights this more than a pandemic. Acting during Atlantic Storm as the Swedish Prime Minister, Jan Eliasson, former Deputy Minister of Foreign Affairs of Sweden, noted that "What we see now is that health and security go together, so we have to combine them, and I think the lesson we should draw from this...is that we don't have the organizational structures to deal with new threats." To fix this, nations need to not only improve their own internal preparedness plans, but also to consult and collaborate with neighbors and other allies to form a more robust plan, including what will happen at the borders. As former German Deputy Minister of Foreign Affairs Werner Hoyer said, "it is not the idea to secure borders in the sense of making them tight. The idea must be to make crossing borders safe. Otherwise, we are going to destroy our economies within a few weeks."

Border security isn't the only reason to work as partners with the international community. In a summary published in EMBO reports (link above), the authors point out:

It is in the explicit interest of any nation to ensure that there are as few "weak links" as possible in the international community's ability to mount an effective public health response. The developed countries are only as strong as the worldâs weakest public health system--even the health systems in many advanced countries like the USA are largely unprepared for an international attack using infectious disease.

This goes to a question Kevin over at No Se Nada raised:

Is it the federal government's responsibility to make sure the local public health infrastructure is up and running, or should local/state gov's bear the responsibility?

To this end, I'd argue that this is something that needs to go up to the national level, to eliminate as much as possible the weak links mentioned above. We need a cohesive, centralized system. As it stands right now, we have underfunded, understaffed departments doing what they can, but there's simply not enough money or personnel. If something big does happen, there's no surge capacity, and no clear chain of command. This was something many states did receive funding to improve after 9/11, and some public health workers were able to receive training in bioterrorism/emergency response, but it's still not enough. Additionally, each department is supposed to have a response plan, but the local and state ones are only part of the larger, national picture--and the pandemic plan leaves much to be desired, while Homeland Security remains a mess.

What about international control? Many assume that in the event of a pandemic, the World Health Organization (WHO) will step in and come to everyone's aid. But the truth is that, despite its big reputation, WHO is tiny, underfunded, and understaffed (seeing a theme here?). In 2004-5, their total budget was only $2.8 billion, and most of that comes from donations from governments, international organizations, and private sources--funding that can't be guaranteed in the event of a pandemic severe enough to potentially destabilize world economies. Additionally, many of the important questions that may arise are simply ones they cannot answer, such as "who has priority when it comes to scarce vaccines and/or medicines?" These are sticky issues that should be discussed as much as possible before they come up in a real life event.

The EMBO report also notes:

The absence of medical countermeasures such as medicines, vaccines and diagnostic tests, the inadequacies of health information systems, and the lack of efficient distribution systems for medicines and vaccines will limit most nations' capacities to deal with large-scale epidemics. Much more can--and should--be done now to build up these resources and give international leaders more options when they are faced with a large-scale bioterrorist attack or natural pandemic.

So, what can be done? Four priority areas have been suggested for research and funding.

Numero uno, we need information systems. National and international ones. Fast ones. Right now, government officials have a tough time finding out about cases in real time. We need to get this information quickly so we know where to target interventions.

One thing that can aid in achieving his goal is a controversial topic (in the U.S., anyway): universal health care. Too many in our population are unable to afford primary care. They don't go to the doctor for routine infections. If they are seen by the health care system, it's when they're already seriously ill. Therefore, these individuals can act as incubators of infectious disease that won't show up on our radar. One example: the homeless and immigrants lacking insurance are two groups that contribute to the incidence of multi-drug resistant Mycobacterium tuberculosis in the United States. Not having access to health care (and therefore treatment) allows them to be infectious longer, potentially spreading the bacterium. Therefore, having some kind of national health care in conjunction with better and quicker disease reporting will work to increase the safety of all of us.

Two, we need to be able to produce drugs and vaccines--fast. Stockpiling just isn't good enough. For one, we can't stockpile a vaccine against a pathogen we've not yet encountered, so this does nothing to protect us from emerging diseases. It's also not helpful for something like influenza, which is highly mutable and changes from year to year.

C, better diagnostics. Even for something as high-profile as avian flu, look how long it takes us to determine whether 1) it's actually influenza, and 2) if it's the high-pathogenicity H5N1 strain. We need to be able to figure this out much quicker. This will help not only in emergency situations, but also in everyday practice. And this could help distinguish bioterror attacks from naturally-occuring epidemics as well. Look at the mess that was this past summer's tularemia detection in Washington, DC. It took days for it to be confirmed, and then longer for docs to get the message to be on the look-out for cases. In the meantime, many of the people in the affected area never even heard about the situation. This is completely unacceptable.

IV, develop systems to deliver the above-mentioned drugs, vaccines, and diagnostics. Quickly. As mentioned in the article, this could make the difference between a community coping and fragmenting while fighting over scarce resources.

Note that these areas need not be limited to bioterrorism, nor even to naturally-occurring infectious disease. These same information systems put in place to report on disease cases can also provide up-to-the-minute information during other types of disasters and life-threatening situations, and having a fully integrated system for disease surveillance will inform us not only of a bioterrorist attack, but also of a multi-state foodborne outbreak of E. coli O157:H7. The same systems put in place to quickly provide medicine and vaccines to affected areas can also be used to deliver food, water, and other supplies in the event of a hurricane, or earthquake, or tornado.

We need to integrate public health and national security communities in ways that allow us to deal with new challenges. What we've done so far is to put a bunch of band-aids on this situation, when we require much more than a fix for boo-boos. Instead, this calls for an overhaul from the ground-up. We need to stop compartmentalizing disasters, and to take an all-hazards approach to disaster management. Public health, fire, police, EMT, hospitals, etc. all need to be adequately funded and working together. It doesn't matter if the Next Big Thing is the avian flu or a giant earthquake in California. We need to have the capability to respond quickly and to have a well-defined chain of command, so people know who to report to, who to ask questions, who's in charge and what everyone's individual roles are. I highlighted last week the poor state of many of our emergency departments--improving these will benefit us whether we're struck by an airborne Ebola virus unleashed by a crafty bioterrorist, "bird flu," or another major hurricane hitting the Gulf coast. Improving our surveillance for infectious disease will likewise allow us to detect new pathogens early, ideally before they become widespread. And spending money on new vaccine technologies and manufacturing centers will allow us to respond quickly to any introduced microbe, whether it's sent by Al-Qaeda or Mother Nature.

Problem is, this ain't easy to do. It's much easier--and politically expedient--to throw money at the pathogen of the week. And don't get me wrong; this funding is great, and it has allowed us to uncover new insights into infectious processes in a number of pathogens. But it's a short-term solution, and every time we spend money this way, we lose another chance to do what's really needed to improve the health and safety of our citizenry. It's like indulging a child who throws a temper tantrum in public. It's easy to just give them the toy they want: it quiets them down and gets people to stop staring at you like your child is the spawn of Satan. It's much more difficult to stand your ground and do what is going to be more beneficial over the long-term. What we need is someone with enough balls to make this a priority from the national defense angle, and spend more money where it will really improve our welfare, instead of chasing ghost WMDs in countries halfway across the world and then declaring America to be "safer" as a result.

This is the reason why so many of us who've written on avian flu do so. This is why so many were worried about SARS, and were relieved when the measures taken to prevent its further spread worked. This is why new emerging diseases make news, even if they don't seem to cause as much death as predicted in the long run. While H5N1, for example, is indeed a potential threat (and looking worse every day), the danger goes far beyond just that virus, right to the heart of our national (and international) vulnerability. It shouldn't require millions of deaths from a pandemic to get our leaders' attention, but I fear that's what it will take. And even worse, I fear that still might not be enough.

public health, Bioterrorism, Disaster planning, Influenza