We still don’t know if we are experiencing a lull in flu or the virus has burned itself out for the season, but it’s as good a time as any to reflect a bit on where we’ve been and where we still need to go. Being otherwise occupied (I’m sure you are sick of hearing about my grant writing obsession but not half as sick as I am about having it!), I’ll start with something relatively straightforward: how CDC did on the epidemiology and surveillance front. Historically this is the agency’s strong suit and so it is expected they would have acquitted themselves well. And pretty much, they did. A lot of good epidemiology got done and the surveillance system more or less worked to provide important information. But this doesn’t mean there isn’t room for improvement.
As for epidemiology, it was an “all hands” effort, but one wonders if the system could have sustained a much more severe event. If there had been a lot of absenteeism and a much bigger demand a lot of work that would have been desperately needed probably would not have gotten done. As it is a lot of non influenza work didn’t get done. One reason for the heavy load on CDC was that the states were not in good shape. State and local public health is where the rubber meets the road in US public health and the road definitely was full of potholes, detours and closures. CDC has a lot of expertise but a thin reserve and there is no way it can be the nation’s health department. So I’ll give them a B, realizing that there wasn’t much they could do to raise their grade. Too much homework and not enough time to study.
The influenza surveillance system was augmented and provided critically important information. But it is a jury rigged system, a mosaic of different sources of information and heavily dependent on state and local health departments (see above). It really needs an overhaul and if Obama’s Electronic Medical Record (EMR) initiative goes forward CDC needs to be at the table. Maybe they are, but somehow I suspect if they are, they aren’t a major player. The EMR is being touted as a major cost saver and rationalizer of medical care, although I am extremely skeptical about those claims. On the other hand it could be an extremely important way to get timely medical information for surveillance purposes, but only if CDC makes sure it is designed to include this need. It’s not just a matter of harvesting information collected for other purposes. The system has to be constructed in such a way that it can be used by CDC. This would include making sure it generates useful information for surveillance and allows it to be gathered in a form that doesn’t compromise patient confidentiality or run afoul of HIPPA or other reasonable privacy concerns. It would be a shame if the information was there but couldn’t be accessed.
As we’ve had too many occasions to remark, however, surveillance in general is always the unsexy poor sister of routine public health. It goes on in the background, can be costly and sometimes feels burdensome and of little value — until you need it. So investing in good health surveillance takes leadership and some fortitude to stick to it in the face of what will certainly seem to be — and will indeed truly be — urgent competition for resources.
Just deciding to surveillance isn’t enough. You have to do it in a smart way but CDC has not always done it intelligently. On occasion they have turned design and implementation of surveillance systems for states over to private contractors who produce rigid, poorly designed, content ignorant and cumbersome systems looking more like research instruments than the kind of simple and flexible systems that CDC’s own surveillance guidelines dictate. That’s CDC’s fault. I’m a researcher, so I’m not against research, but surveillance isn’t research, even if it can be used to do research. Surveillance systems are meant for routine use. A surveillance system needs to be simple and useful and readily implemented by states without costing a fortune and it must be continuously supported, not with start and stop and varying funding. And you can’t demand that they produce visible results immediately. They aren’t that kind of “immediate pay off” affair. That’s just the way it is.
So while the surveillance system sort of worked during this not catastrophic pandemic, I have the feeling that as with the heroic epidemiological effort, we dodged a bullet.
So far. Or until next time.