Thursday, April 13, 2006

Report card time

The circus in the UK where top government scientists are issuing conflicting messages about bird flu, suggests we take a quick look at how the US government health leadership is doing. The Report Card is mixed.

The top public health leaders in the federal government are the Secretary of Health and Human Services, Michael Leavitt; the Director of the Centers for Disease Control and Prevention (CDC), Dr. Julie Gerberding; the Surgeon General, Dr. Richard Carmona; and the Director of the National Institutes of Health, Dr. Elias Zerhouni. Dr. Anthony Fauci is Director of one of the NIH institutes, the National Institute for Allergy and Infectious Diseases (NIAID) where much of the earmarked research funding for bioterrorism and influenza has come to rest, so he has become the principal NIH voice on the subject. He has also been one of the most visible of the four.

Considering how miserably the Bush Administration has done on public health issues of all kinds -- in effect, pushing an already tottering system over the cliff -- it is surprising how well most of these people have done in presenting the bird flu problem to the public. Two stand out, for different reasons: Leavitt, for his tireless tour of all fifty states to send the message that this is serious business. And Carmona for his virtual absence from the scene. (Most public health professionals would be hard pressed to even name the person who is the Surgeon General, much less listen to what he has to say, which is very little).

Fauci and Gerberding have shown themselves skilled communicators, providing relatively accurate information, delivered without much spin. A typical example is Fauci's recent interview with AP:
Bird flu is not likely to change overnight so that it spreads from person to person, nor is it likely that a sick bird migrating to the US will trigger human illness, the government's top bird-flu scientist said.

"One migratory bird does not a pandemic make," Dr Anthony Fauci, the National Institutes of Health's infectious disease chief, said in an interview Tuesday with The Associated Press.

What are the odds that the H5N1 strain of bird flu will spark the next worldwide influenza epidemic? There is no way to know, Fauci said.
Reassuringly, it must undergo a series of genetic changes before it could become contagious among humans instead of just birds.

Scientists might see those signs while studying the virus itself, but an early warning would be if doctors or nurses caring for someone who caught H5N1 from a bird in turn got sick, Fauci said.

"It is entirely conceivable that this virus is inherently programmed that it will never be able to go efficiently from human to human," he said.

"Hopefully the epidemic (in birds) will burn itself out, which epidemics do, before the virus evolves the capability of being more efficient in going from human to human."

But the government must prepare for the worst - "it would be unconscionable not to" - as officials gear up in case bird flu does spark a human pandemic, he added.
Admittedly this is pretty heavy on the reassurance side, but not beyond the pale. Nothing he said is inaccurate, a welcome difference with some other attempts to reassure. And it contains the important message: Not to prepare for the worst would be unconscionable.

Of course there is also an unconscionable failure to support and augment the nation's public health infrastructure, for which the Bush Administration is now accountable (and before it the Clinton Administration to a lesser extent). That is where Fauci and Gerberding, also a skilled communicator, have failed. It is hard to know what battles are being fought (and lost) within the Administration, but both Fauci and Gerberding (particularly the latter) have carried a lot of water for this incompetent and malicious Administration. Under Fauci NIAID's research portfolio has been hijacked by the bioterrorism nutcases and CDC has been so mismanaged that its effectiveness and morale are now seriously impaired. Leavitt has also done some significant damage on the environmental and social services fronts, so his performance in alerting the states regarding bird flu doesn't net out positively when you consider the additional requirement for resilient community structures to respond to widespread illness. He simultaneously warns the states that there is a threat but that they will be on their own, while not significantly helping them get the resources to meet the threat.

I think a dispassionate view gives decent marks for public presentation and a sober and accurate picture of challenge. It gives low marks for providing a federal response that is substantively helpful to local communities. The UK is the reverse. They are making a mess out of the public presentation and response, but they possess something we don't: a functioning national health care system, imperfect as it is.

So what should the health leadership report card say? "Plays well with others. Needs to get homework in on time."