Rough Beasts & Public Health
“Some rough beast, its time come round at last,
Slouches toward Bethlehem, waiting to be born”
William Butler Yeats
In early June, a patient checked into a Contra Costa County Health Department outpatient clinic in Richmond, Ca., with a fever of 101.2, flu-like symptoms, and a cough. The man sat in a waiting room—the clinic serves hundreds of thousands of people each year—until the physician could see him. Because the patient could not speak English, the doctor called in a Vietnamese interpreter. The rest was drill: blood pressure, ear and throat examination, listen for congestion.
But then a bell went off in the doctor’s head.
She had the translator ask the patient if he had recently traveled. Yes, he replied, he had just returned from Vietnam, presently ground zero for avian flu, a particularly malevolent virus that has killed more than 60 people and decimated chicken populations throughout Asia.
The doctor put a mask on the patient, moved him to a room by himself, and called the Health Department. Blood samples were drawn and county and state health labs went into overdrive, scanning for a molecular code designated H5N1-A. For a few scary days it looked like Richmond might be the first U.S. beachhead for the disease, but in the end it turned out to be a standard Type A influenza.
On one hand the incident demonstrated the strengths of public health. “The businessman who returns from Vietnam is going to see a private doctor,” says Dr. Wendel Brunner, Director of Public Health for the county’s health services. “A private doctor has about 12 minutes to see a patient, four of which are filling out insurance forms. They aren’t going to ask the patient’s travel history, and they are not likely to call the health department.”
On the other hand, Brunner is facing a $5 million cut in his $60 million budget, and high on the list of cuts are translators, who not only interpret, but also accompany nurses who conduct house visits. Without a translator, the Richmond doctor would never have asked the travel question.
The arrival of the next great pandemic has always been a “when” not an “if,” and firewalls for stopping it are getting thinner.
“Nobody knows how bad it [the pandemic] will be,” says World
Health Organization (WHO) General Director, Lee Jong-Wook, “but we can’t be optimistic.”
So far, H5N1-A is only a threat to those exposed to infected birds, although there are scattered cases of person-to-person transmission. But the virus has spread from domestic fowl to wild ducks and domestic pigs. The latter are worrisome, because pigs have served as a viral bridge to humans before. If avian flu mutates into an easily transmissible form, the world could be in considerable trouble
H5N1 presently has a startling mortality rate of between 47 percent and 83 percent, but most experts think it unlikely that it will maintain that level of lethality. People in Asia have tested positive for the flu’s antibodies without exhibiting symptoms, indicating that not everyone who contracts it gets deathly ill. Nevertheless, WHO estimates that such a pandemic would hospitalize 30 million people and kill eight million.
Other researchers, like Michael Osterholm at the University of Minnesota, say the death toll could range from 180 million to 360 million worldwide, including 1.7 million in the U.S. Olsterholm is the Director of the Center for Infectious Disease Research and Policy and an associate director of the Department of Homeland Security.
Even if avian flu has only the fatality rate of the 1918-19 pandemic—2.7 percent— it would have a catastrophic effect. That pandemic killed 675,000 Americans and anywhere from 50 to 100 million people at a time when the world’s population was less than a third what it is today, and when populations were far more isolated.
“If you want to see why a pandemic today will be far greater than the 1918 flu, ” says Dr. Donald Francis of Global Solutions, “just sit in a European airport and watch all the costumes walk by.” Francis, whose firm is trying to generate money for vaccines, was one of the earlier identifiers of HIV, and part of the WHO/Center for Disease Control (CDC) team that finally cornered and eliminated smallpox in 1977.
But at the very time avian flu is threatening to mutate into a worldwide killer, public health budgets in the U.S and across the globe are being systematically starved of funding.
Budget problems like Brunner’s are hardly limited to Contra Costa County.
“Each budget year those of us in community clinics have to fight for our very existence,” says San Francisco’s Nancy Lewis, FNP, MSN. “We are considered expendable,” she says bluntly. She calls the cutbacks of public health facilities and personnel “alarming.”
County and state health budgets have been declining for years, and Congress plans to cut Medicaid by $10 billion over the next five years. Medicaid is the nation’s largest health insurance program, covering some 50 million low-income people.
That will have a cascading effect on the states, many of which are already cutting recipients from the rolls. Tennessee is dropping some 300,000 people, and Missouri is cutting 90,000. For those still covered, states are proposing higher co-payments.
“State and local governments are in such a budgetary crisis that they are forced to cut things that they know are good for the public,” says occupational physician and former president of the American Public Health Association (APHA), Dr. Barry Levy.
According to public health officials and epidemiologists, cutting health care creates the perfect breeding ground for pandemics.
Public health funding seems almost designed to create a crisis. For instance, according to health writer and Pulitzer Prize winner, Laurie Garrett, one of the key things hospitals need to respond to a pandemic is ” surge capacity,” or the ability to double their ability to treat patients.
Garrett says, “What’s happened with managed care is that hospitals have eliminated surplus beds and surplus personnel. So, far from being ready to deal with surge capacity, we’re actually understaffed and we have massive nurse shortages all across the country.”
Asked about “surge capacity,” Brunner just laughs. “We don’t have surge capacity for a bad winter.” He goes on to explain that private insurers calculate that “It is cheaper to turn patients away than have empty beds.”
According to the American Hospital Association, between 1980 and 2000, some 900 hospitals were closed nationwide in the name of “efficiency.”
A scarcity of beds has consequences. The Society for Academic Emergency Medicine found that delays in getting patients into hospital beds meant greater medical complications, more patients ending up in expensive Intensive Care Units, and higher mortality rates.
If anything, the international situation is worse.
Countries like China, according to Calcutta based journalist P. Sainath, have largely defunded their health care programs, as the recent SARS outbreak demonstrated. “The Chinese saved tens of millions by closing down rural clinics, and then lost billions because of SARS,” he said. “Everywhere the rights of the poor are being whittled away, and we will all end up paying a price for it.”
During the 2003 SARS outbreak, Chinese villagers told Garrett that they didn’t seek medical care because a single day in a hospital represented a year’s income.
SARS eventually infected some 8,000 people, killing 800 of them.
According to the May 6-7 WHO conference in Manila, early intervention is the key to stopping or moderating a pandemic: “if action is delayed…it will be too late to implement effective local, national, or regional responses.”
WHO recommended a crash program on developing a vaccine and stockpiling the anti-viral drug, Tamiflu.
According to the Financial Times, however, only 12 countries have made a serious attempt to stockpile, and the U.S has only enough Tamiflu for about 1 percent of its population. In contrast, France and England can cover about 20 percent of their populations.
Nor is Tamiflu a magic bullet. “It is not clear that Tamiflu is effective,” says Brunner.
On developing a vaccine, Levy agrees with WHO’s recommendation, but warns that “We are way behind where we should be on vaccine development.”
Vaccines also have their own difficulties. “The problem with vaccine development is that vaccines don’t make money,” says Francis, illustrating his point with a chart indicating that while worldwide sales of vaccines brought in just a little over $6 billion in 2001, Lipitor and Prilosec sales alone earned pharmaceutical companies $12 billion.
When private industry does get involved, it can be costly. In 1970, WHO paid about 1 cent per dose for smallpox vaccine. When the Clinton Administration asked Dynport, the company that manufactures smallpox vaccines for the military, to ramp up production for civilians, its price was $25 a pop.
There were lessons learned from the 1918-19 pandemic. In his book,
“The Great Influenza,” John Barry notes that a Public Health Service post mortem on the disaster found, “What could help, more than doctors, were nurses. Nursing could ease the strain on a patient, keep a patient hydrated, calm, provide the best nutrition, cool the intense fevers. Nursing could give a victim of the disease the best possible chance to survive. Nursing could save lives.”
But the U.S. has a major shortage of nurses at the bedside, as does much of the world. According to Rockefeller Foundation estimates, Africa is short one million health workers and Europe has a crisis that parallels the U.S. Add to that the shortage of hospital beds, and Osterholm’s projection may not be far off the mark.
“We’re not in the preventive mode here,” says Lewis, “but the let’s-fix-them-after-the-fact mode of hospital care. Under such circumstances it would be very difficult to care for the tens of thousands of patients who would not get a necessary influenza vaccine on time.”
Keeping nurses healthy will also be a problem. “Medical workers are at risk,” says Brunner, “because they are literally in people’s faces.” He points out that the first SARS victim was a medical worker.
“New strains of influenza, particularly things like the avian flu, are the most worrisome to me and many nurses,” says Lewis. “This is especially so in light of last year’s debacle when the influenza vaccines were contaminated.”
According to Gina Johnson, RN, public health case manger at the Rolling Meadows Clinic, Cook County, Il., not enough has been done to prepare medical workers for what they may face in a pandemic. “We need to start getting education about Asian avian flu, SARS and new strains of tuberculosis as soon as possible (so that) we don’t get it thrown at us at the last minute.”
She adds, “nurses want to be given the proper tools and protection as soon as possible so in the advent of an emergency we don’t get burnout and feel overwhelmed.” Johnson has been in public health for 12 years in Illinois and Iowa.
In a pandemic situation, Osterhold predicts that “healthcare workers would become ill and die at rates similar to, or even higher than, those in the general public.”
One recent influx of money for public health comes from the Department of Homeland Security to prepare for bioterrorism. Brunner estimates the county receives about $1 million from Home Security, which he is happy to get because he says “it helps the Health Department deal with all communicable diseases.”
But others worry that Homeland Security’s concerns end up diluting the mission of public health.
“Bioterrorism distracts public health from its true mission,” says Dr. Victor Sidel, Distinguished University Professor at Montifiore Hospital in New York, and past president of the APHA. Sidel calls the spending on biowarfare “wasted funds” and says the real problem is that “public health has been starved, and is being starved.”
Brunner also wishes there were the same kind of focus and funding on “what is really killing our people, which are chronic diseases, like cancer, HIV, diabetes, cardiovascular problems, not to mention violence.” He also worries that the bioterrorism focus may “divert attention and intellectual resources from public health issues that are more important.”
Sometimes the problems seem almost overwhelming.
Francis says that “there is not the in-hospital or in-public health capacity to deal with a flu pandemic,” and Brunner agrees that the inability of U.S. medicine to respond in the way it should “is built in.”
Besides the insufficiency of beds in the U.S., according to Osterholm, there are only 105,000 mechanical ventilators, between 75,000 and 80,000 of which are in constant use. Ventilators are particularly important if a pandemic takes on the characteristics of the 1918-19 flu, in which a major killer was acute respiratory distress syndrome (ARDS).
Lewis says “The bottom line is that we are about as ready as they were in 1918 when millions died here in the US. But they had an excuse. There wasn’t much of a public health infrastructure and no vaccine. We have no excuse for not fully utilizing the resources that are available to us today.”
Levy argues, “We are in a major crisis and we need something on the order of a Manhattan Project,” adding, “the greatest threats out there to us are not military, they are disease.”
For Sidel, the solution is long-term: “What we need is a decent medical care system, a universal system that unites public health and medical care,” and points to U.S. Rep. Barbara Lee’s HR 3000 as a step toward creating a system that “will prepare us for what will surely come.”
In the meantime, Brunner successfully lobbied to keep his Vietnamese translators, and the Supervisors “restored most the cuts in Health Care.” So Contra Costa has dodged yet another bullet—for now.