Reflections on Pandemic Illness: Practical preparedness for here (and abroad)

November 1, 2006 at 11:44 am (AE Beacon's Posts)

Over the past fifteen years the federal government has spent billions of dollars on something that does not exist; bird flu. Despite less than 20 known human to human transmissions, none of which having occurred in the wildfire fashion envisioned by public health experts, considerable funding has gone into fighting this supposed menace. At this very moment several million doses of Tamiflu, the supposed cure for bird flu, are parked in warehouses outside of several major US cities awaiting distribution. Further, a half dozen manufacturers have promised the ability to ramp up production in case of a large scale outbreak.

Unfortunately these solutions neglect the dynamics of disease spread and our ability to respond to widespread public health emergencies. Recent successes with polio, mumps, measles and a variety of other illnesses have perhaps contributed to an overwhelming sense in our culture that we can triumph over illness through medicine. Though successful in certain instances, modern diseases like HIV/AIDS have proven to be more divisive and adaptable than we are prepared to handle through drugs alone. Even if we had a cheap vaccine tomorrow, how long would it take to inoculate the millions infected and the billions at risk? Ask any of the millions of men, women and children living with polio right now and they will tell you it takes a long time.

So what can we learn from HIV/AIDS? Perhaps the most important lesson is that medicine, while perhaps the ultimate cure for a given illness, is only part of the answer. The effective control of any pandemic illness requires the simultaneous action of medicine and public health. Through public health the spread of disease can be slowed enough to provide researchers with the time to develop medicines that either cure or dramatically reduce the spread of disease. This approach gives the added advantage of providing health officials with the crucial medico-demographic data that will later enable medical interventions to effectively target sick and at-risk populations.

What does a public health intervention entail? Good public health includes four main tenants: rapid medical reporting, centralized outbreak analysis, locally accountable health personnel and public awareness. Our current system lacks reliable rapid response reporting or personnel, our infrastructure is divided into a host of semi overlapping uncoordinated provider networks and Americans are armed with all the fear of pandemic disease but none of the tools to protect ourselves individually or communally.

Back to bird flu. In reality whether bird flu hits or not is irrelevant. A pandemic illness is bound to strike and I predict strike within our lifetime. The sheer number of people (and animals) combined with the rapidly evolving nature of viruses guarantees that one of the trillions of latent and perhaps low impact disease strain already in existence will mutate into a fatal, easily transmittable killer.

Evolution, however, is not the only factor competing for our health. One need not watch Twelve Monkeys to realize the realistic and disastrous potential of bioterrorism. A genetically engineered virus will likely have a long infectious but symptom free latency and resistance to most if not all known therapies. In the event of a bioterrorism attack drug research and development will not be the determining factor in who lives or dies. If we cannot manage to get people out of harms way quickly during an infectious disease emergency, in three to six months there will be few left to inoculate.  

Our public health infrastructure demands immediate practical and ideological change. First, we must decentralize healthcare. Illness happens at home, at school and at work. We must have our health workers as close physically and mentally to where illness occurs as possible. Increased connectedness between these spheres through in house, in school and at work contact with health workers will increase the likelihood of obtaining rapid and relevant care. Second, we must implement electronic reporting. This should be done through a private-public partnership. Currently we have a variety of reporting systems at several hospital systems around the country. This is great but community or even regional systems lack the tremendous benefits of a national system. The government must step in to standardize electronic reporting, make it affordable for small practices and ensure that people use it. Tax incentives, grant support and fines will directly ensure that health workers are providing the best in care for patients locally and nationally. Further, rewards to private companies for developing a suitable technology must also be implemented. A million dollar DOD grant initiated a few years ago resulted this year in a car that could drive for hours without any input from a person. Let’s challenge industry to come up with the same innovation in electronic healthcare reporting. Finally, integrate public health education into elementary school education. I doubt a fourth grader in San Francisco can tell you anything about plate tectonics but she certainly knows what to do during an earthquake to save her own life. Pandemic disease is frightening but, by providing simple information on what to do during an outbreak to our future generations, each of us will be able to act against disease and panic. By taking these steps we can offer ourselves the best chance to survive a natural or malicious outbreak.

When a pandemic disease finally does emerge, it will be able to affect most countries in the world in a matter of days. It will affect most major cities and it will affect the human way of life. However, pandemic illness will not kill us all. By pairing medicine with public health, vaccine research with systemic and cultural preparedness, Ho with Gerberding, we offer ourselves a chance to survive. Pandemic disease requires our immediate attention and our immediate preparation. Let’s act.  

Æ Beacon

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3 Comments

  1. misarita said,

    You give some concrete ideas for what we can do under the current US structure. I was struck by the sentence “When a pandemic disease finally does emerge, it will be able to affect most countries in the world in a matter of days.” While many of your solutions seem feasible in the US, they are massively more than can be expected in developing countries. Given the example of SARS, I think it is pretty clear that control of a potential pandemic hinges on global transparency and surveillance. This seems like a clear example of how the weakest link in the global chain could have hugely detrimental effects on the entire world.

    So, the question to me seems to be how we can mobilize some of these really good ideas on a global scale. What are the minimums that need to be met? Or, perhaps a better question is how can we make the best surveillance systems accessible under less than ideal circumstances?

  2. msoule said,

    Sarah, I think that the issue you raise is the same one that Sam was having trouble with last month. How is the research he is working on (a project that will immediately benefit those who can afford a cool new tagging procedure) going to affect global health? Well, when the technology is perfected here and used for some time, people will work to make an affordable and equally powerful version of it that will be accessible. Hopefully, the measures that Mr Beacon suggests (many of which I agree with heartily in theory but am sadly slightly sceptical about in practice) will be put in place long before developing countries need them.
    So Sarah, I guess my reply is that the question you raise is one that will be better answered once we have a viable model in the US. I am optimistic that the Internet Age is bringing wildly faster connectivity. It’s just a matter of getting the right conduits set up so that they can be used in an optimal way. I am also optimistic that as computing hardware and software gets cheaper and more widespread, these systems will be easily exportable once designed.
    Speaking of optimal electronic record-keeping, my Big Public Hosptial uses an electronic records system but the attendings in my clinic hate it. So we need computer scientists and interface designers to create good systems that providers and support workers can intuit easily so as to expedite the sharing of the right information in the most useful form. In other words, it’s easy to say we need it, but harder to get it right. I think a government program to build a communication system is a bad idea but a grant to build one is a FANTASTIC one.
    Let’s get legislating.

  3. sstolper said,

    Michael, I have not previously stopped to think about the possibility of user dissatisfaction with electronic record-keeping. I have heard a tiny bit about this from Daniel Beswick, who works for a company that implements an allegedly efficient computerized record-keeping system, but I just figured the gains to be had were so obvious that it would not fail to satisfy clinicians. I will ask him about this and see if he can shed some light.

    Is it widely agreed that the government would be better suited to give out the money for global health projects than to actually construct the projects itself? Are there particular fields where this is definitely or definitely not the case?

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