Saturday, November 12, 2005

PlanFlu, III: stillborn

At a recent symposium on bird flu, one of the participants noted that in War the first casualty is Truth, but in a public health emergency, the first casualty is The Plan. Something to keep in mind as flu experts from around the world met in Geneva this week to share national plans and frame an international strategy. The level of seriousness with which the situation is regarded was signaled by the participation of world financial institutions, including the World Bank.

Unfortunately the problem is not amenable to a crash program. The goal of having enough capacity in the US to vaccinate the entire population cannot be achieved in less than five years, according to officials, and there is as yet no production of any H5N1 vaccine. The experimental version required such high doses to achieve antibody titers even plausibly protective that it is infeasible to produce in any quantity. Nor do we know the nature of a pandemic strain, if one does emerge. We'd have to start from scratch with the relevant virus. In addition, there is still not enough production capacity for antivirals, given the demand. That, too, will take time, and the efficacy of antivirals for controlling a pandemic (as opposed to treating individual cases) has been questioned. Finally, the ability to distribute vaccines and antivirals is limited in the developing world and in the United States, which alone among the developed nations has no national health care system.
"There are distribution dilemmas," admits US health secretary Mike Leavitt. Most pandemic plans spell out priority groups: healthcare workers, people in essential services, vaccine plant workers, and in the US "key government leaders". The draft US list included priority vaccination for 1.5 million soldiers. This disappeared from the plan published last week, but will return "should the military be called upon to support civil authorities".

They may be needed. Public-health experts privately express fears of massive civil disorder if people with dying family members not on the list struggle to get drugs from people who are, while people who have drugs may share them, resulting in no one having enough. (New Scientist)
Indeed, this is symptomatic of a deeper problem with most of the flu plans, especially the US one. Most of hte burden falls on local communities. An influenza pandemic will essentially be a local affair and depend on the leadership, resources and ingenuity at that level to cope with the consequences of a possible 30% to 40% absenteeism rate over an extended period. That is a community planning problem that takes time and resources. Our communities have neither. And with no effective public health infrastructure, even the vaccine (which doesn't exist) wouldn't save us. This sad predicament is the result of the social policies of the last twenty years.

It is fine to have a political slogan that each person knows better what to do with their money than the government does. But if you give me back $500 in a tax cut, I can’t buy better public health with it, or better fire protection, or better teachers. I can only do that when I put my $500 together with someone else’s $300 and someone else’s $900 and so on. Tax cuts, so popular at election time, are now coming back to hurt us. A terrible harm that has been done to public health (and public service in general) by an attitude that implicitly looks down on public servants as unnecessary.

And if a pandemic strikes, make no mistake, we will be a world of hurt. From my perspective as a public health professional you can’t view the massive potential problems a pandemic can cause to the lives of ordinary people, their livelihoods, their businesses and their future without saying clearly that the social policies of the last decades have left us more vulnerable and defenseless to the threat of infectious epidemic disease.

The Flu Plan is not a casualty to come. It is stillborn.