Influenza A/H5N1 (bird flu) bubbles away this year much as in past years and public health professionals continue to wait with bated breath for the other shoe to drop. It could happen this year, next year or not at all. That's the way the world is. Betting on "not at all" isn't considered prudent by most people in public health, despite the fact that it's possible. So given the uncertainty, what is the best strategy?
It is a bit disconcerting to see that the overwhelming preponderance of resources to pandemic preparedness resources are going into influenza-specific counter-measures, particularly vaccines and antivirals. If a pandemic doesn't materialize not all of it is wasted. The boost that the threat of a pandemic has given to vaccine technology is real and significant and will pay off in the long run for diseases other than influenza for which vaccination is a reasonable preventive. So that's good. Antivirals are more narrowly specific to influenza. Both are narrowly conceived, however, and are framed in terms of an uncertain event. But they are not the only reasonable response, nor even the ones where, if we were gaming out the possibilities, the likelihood of biggest pay-off would come. What are we suggesting?
In our view the biggest benefit comes with investment in public services which strengthen the community's response to health threats of all kinds. Investment in routine public health -- vital data and surveillance, substance abuse, elder care, maternal and child health, infectious disease control, human resources, social service support for the ill in the community and all the rest of it -- is the place where we would put most of the money. If national planners are reluctant to give up the "magic bullet" approach of vaccines and antivirals then we are talking about additional investment. Given that every dollar invested in infrastructure is almost certain to pay off in multiple dollars of saved expense, we can afford this. And if a pandemic does come, it will pay off handsomely there, too. Vaccines and antivirals still depend upon the public health system. They don't work at a distance.
We've been saying this for three years. It is not a change in attitude occasioned by a new threat assessment. On the contrary, our threat assessment has not changed at all. Only the virus changes. Whether the viral changes we are seeing is bringing us closer to a pandemic, farther away from one or are neutral in that regard we don't know. So we have to respond in the most rational way.
The strategy of vaccines and antivirals appears to us a public health Maginot Line. Effective if the enemy comes that way. But if it goes around it and our communities are helpless and undefended, well, you finish the thought.
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A beautiful piece or writing!!
Thanks.
Whether we like it or not...the unique threat potential of H5N1 makes Public Health a matter of National Security.
Be careful what you say, or the idiots managing our 'National Security' will try to take over public health as well.
that Maginot Line is uncertain to hold, even if the
enemy comes that way. Invest more in spying
Now this one I can buy into Revere. One of your best.
The only thing I can see is that we are going to have to pony up money again and again for this and that is the one acknowledgement that we can all agree upon. What are the answers? Vaccine it would seem is likely totally out of reach in all circumstances for any more than a small fraction of the population of the world, if at all.
So I wonder if spending billions for anything other than preparations would be efficacious? Do we continue to bolster lightly the preparations and look for the magic bullet with billions? We spend the money on vax research, then we get to pay for it again. Right now it seems that we are paying for stuff that wont be worth anything in a panflu and arguably we are 10 years or more before the first molecular level vax comes along?
BTW-one of your best posts in recent history.
As always, I'm still a bit confused...but I find myself surprised that I'm agreeing with Randy on at least one thing. I would concur on his opinion of your post. An excellent post Revere.
Portland's Peak Oil Task Force is considering the impact oil shortages will have on public health:
"Vulnerable and marginalized populations are already among the most at-risk members of society. They are also the least likely to have information or understanding about Peak Oil. They have the fewest resources to deal with any increased cost from Peak Oil and are currently struggling now to pay for $3.00/gallon gas. They are also not well represented in policy and planning discussions. The GAOs recent report focuses on the need for strategies for addressing Peak Oil, but even they didnt focus on the people affected.
Will we catch on before a large segment of our community gets left behind? My hope is that we will. The awareness of a future decline in world oil production needs to be incorporated at the local level in public health systems planning. Here in Oregon, Portlands Peak Oil Task Force is the first in the nation to identify likely impacts from Peak Oil and then to recommend mitigation strategies for the broader community. Vulnerable populations, emergency preparedness, the abilities for public health and social services to provide services to all who may potentially be in need, and the lack of awareness of peak oil impacts were all concerns of the Task Force.
For Portlands Task Force and the City Council, there had been some expectations regarding the obvious impacts--personal transportation availability, increased costs of freight transportation, population shifts, increased food prices, increased need for local agriculture, decline in the availability of a variety of foods--but peak oil impacts on the citys vulnerable and marginalized populations had never been previously considered."
The public health community had better wake up fast. As oil becomes more and more expensive, it could have a devastating impact on public health.
Oil production peaked in 2006 and will declline by 3% per year. So oil is not going to be cheaper in the future.
What happens during a bird flu pandemic when then is a drop in the supply of oil?
I don't know what the best strategy for H5N1 is, but shouldn't we spend a little bit more time and money forecasting the type of disasters we can expect, and the defense strategies that would mitigate those different types of disaster.
We could then draw up common action plans that applied to the different types of disaster, rather than just throwing money at narrow defenses that might have worked very well for the last pandemic disaster, but might not work against the next disaster (like the Maginot line was useless against Panzer attacks through Belgium).
As a f'rinstance, providing people with material & strategies for survival as small communities without anything but local trade and transport would be useful preparation against a major geophysical event, a meteor strike, WWIII and most Pandemics.
On just the narrow topic of pandemic preparation for my small suburban/rural community (~40,000 souls) I'd be happy to get a one-time mailing of concise, well written emergency planning information in English and Spanish and enough postage to mail information to critical local businesses.
Or host a seminar specific to their needs. Or just the clout (which could be free) to mandate police, fire, rescue and department of public works prepare a response plan using DHHS planning assumptions.
Then again, my day job is at a large university hospital in Center City Philadelphia. I'd be tickled to see an uninsured patient get an appointment to see a doctor at one of the low cost/free district health centers in less than three or four months. Or that the D.O.T. department (for TB) can see a new case in less than 2 weeks...or.....
Economic losses of the SARS outbreak has been estimated at about 50 billion, H5N1 has already cost the Asian poultry industry more than 10 billion. A 2% global economic loss during a pandemic outbreak would be an estimated 800 billion and losses likely would be greater than 2%. The global spending for pandemic preparedness is nowhere near any of these amounts. Surveillance in most countries affected with the disease in non-existent and there's only a handful of individuals with expertise. I'd be surprised if the global investment in pandemic preparedness was 1% of the SARS cost.
Much of the money being spent on influenza-specific counter-measures is being spent on production capacity. So, like you said Revere, this investment "will pay off in the long run for diseases other than influenza..." And, I entirely agree that investment in public services is essential to enhance the community response. But I would argue that additional investment is needed in all areas of pandemic preparerdness, especially in surveillance of the disease and training of new experts.
This post is a masterpiece.
I totally agree with you, Revere.
In Italy Local Public Health Services are underpaid and would be in big trouble if a pandemic comes. In a paradoxical situation we could have vaccines but difficulties to build a mass distribution campaign or to face nominative lists of persons falling under priority categories and establish methods for a periodic updating of such lists. Why those things are difficult? Because there is nobody to do them. First thing we need: human resources.
You had the Twin Towers disaster and Katrina. Canada had SARS. Sometimes I wonder if we have to wait for a plane that crashes on the Colosseo in Rome or a Tsunami that destroys Venice to have some investment in public services
I'm sure that my response doesn't appear to be public health-related, but it really is: I'll keep my preps maintained, and encourage others to do so. If the Bird Flu happens, we eat a lot of canned foods and get a wee bit tired of looking at each other for a few months. If it doesn't happen,then we eat canned foods--albeit less often--learn how to rotate stored foods, enjoy the fact that we've bought a lot of groceries at last year's prices, and finally share a lot of food with the local food bank. There's no downside to prepping.
Here's the core of the public health aspect of this: The whole is the sum of its parts; each family who is prepared is one entire family that doesn't need to be bailed out, hospitalized, ventilated, or buried.
I understand that TPTB want to discuss which agency will respond, and how each agency will handle its response. My concern is that if the manure hits the ventilating device, the virus isn't going to stand around tapping its little viral "whateverpods" on the ground, waiting until TPTB have definitive answers. These discussions have been going on for at least three years, and my town is absolutely no better prepared--even if my state has great information on its "official flu website"--than it was before.
Planning at the international/national/state level does not equal preparation on any level, especially local. Just ask all of the families of the dead.
When a local govenment rep comes to my home, hands me a box with a list of specific preps, websites, local meeting dates, a laminated quarantine sign ("just in case"), a list of farm wells in the county, and a list of dates to purchase cheap groceries with others, THEN I'll believe that someone here is taking this seriously.
That's my take on public health, and as an R.N., I've done public health.