DemFromCT's interview with us at DailyKos

On Sunday my friend and colleague from Fluwiki, DemFromCT, did me the honor of interviewing me on the front page of DailyKos. That's a pretty tall platform, being the most visited blog in the known universe (and beyond), so it's best to be absolutely clear when saying things there. I"m not sure I quite met that standard, but I'll let you judge for yourself, as I am cross-posting the interview below the fold. But this also gives me an opportunity to clarify one point that drew some justified comment. Here's something I said in the interview:

In the past I downplayed individual prepping for a pandemic for a political reason. I wanted to keep the pressure on government to play an appropriate and meaningful role and I thought that placing the burden on individuals to protect themselves and their families was the wrong message.

We've only downplayed individual prepping here by not discussing it much. In the comments I've admitted I'm not a prepper myself, at least not specifically for flu. We do have the usual emergency plans and paraphernalia in the house in the event of some event where we need to subsist for a few days or so, but nothing elaborate and I never got myself a personal stash of Tamiflu. The reference to government policy, though, was not well phrased, so I'd like to clarify. We consciously did not want to encourage a kind of survivalist response to a pandemic, where it's everyone for themselves. In my youth there was plenty of that around nuclear issues, with people building bunkers in preparation for a post apocalyptic Mad Max world. When we say government response this was in the broadest sense the organized community. Our concern was to encourage responses that assumed we we were all in this together and if we were to get through it we'd need to help each other, not hide from each other. It was the collective response, not the individual response we wanted to talk about. We are, after all, public health professionals.

So with that, here's the interview as it appeared at DailyKos (the first part of what DemFromCT plans to be at least two parts, perhaps more):

The reveres at the ScienceBlog Effect Measure are public health scientists and have been commenting about public health for as long as I have been blogging (i.e. since 2003.) I got one of them sit sit down and talk about where we have been and where we are going, in the context of seasonal flu, pandemics and public health in general. This will be a two part interview, with part III today and part IV next week.

For flu background, see Flu Basics: Science And Threats from 2006 and H5N1 And The Long War Against Flu from 2008, or the Flu Wiki science section which the reveres organized and edited.

DemFromCT: We started Flu Wiki together with the late Melanie Mattson in 2005. Are we any better prepared now for a pandemic than we were then?

Let me take this in two parts: the public response and the government/public health response. As far as the public and the news media goes, there's a lot of "flu fatigue" out there and with all that's going on it's more and more difficult to get their attention except with scare headlines. But I'm going to surprise a lot of people and say I think in terms of public awareness, the short answer is "yes," we are better off. As usual, it requires a longer answer to make clear the limitations of a "yes" answer. We are better off because a lot of people have been thinking about this and trying to visualize the consequences of a pandemic. When you, Melanie and I started Flu Wiki in June 2005 only a handful of people, and almost no one in the blogosphere, talked about this problem in a serious way. Since then there has been a lot of effort devoted to "pandemic planning" and there's been a significant amount of dedication and creativity in the flu world's version of the netroots. Thanks to you and other denizens of flublogia there is a network of knowledgeable citizen advocates distributed in many communities here and abroad. In the past I downplayed individual prepping for a pandemic for a political reason. I wanted to keep the pressure on government to play an appropriate and meaningful role and I thought that placing the burden on individuals to protect themselves and their families was the wrong message. I am optimistic the new administration will be more receptive to the task of rebuilding public health infrastructure, both its human capital and its material substance, and will revive the idea of fulfilling the mission of public health. If this happens and combining it with a new spirit of public service I think there is less risk of letting government off the hook by pushing individuals and communities to take up the burden. But there is still a long way to go. Preparedness advocates are still a marginalized minority in their communities and often feel extremely frustrated at their inability to convince others of the potential danger.

Let me make a small digression here, because I think it's useful for Daily Kos readers and bears on what we are talking about. I've spent many decades in academia, most of it in a major School of Public Health where I am a Professor and researcher and was a longtime Department Chair. I was an anti-war activist in the sixties and remain one today and because of that I've spent a lot of time organizing on peace and other justice issues within schools of public health and schools of medicine. My personal experience has been that it is much easier to organize in a school of medicine than in a school of public health. This sounds counterintuitive because students and faculty in schools of public health are intimately occupied with access to care, environmental contamination, the plight of our society's least advantaged and much else intimately connected to social justice. Many are passionate advocates for their particular specialty areas, like substance abuse or reproductive rights. In describing them, however, I have deliberately used the word "advocate" rather than "activist," because that's what they are. They work tirelessly and effectively for their particular area but quite often have blinders and little time for any other issue. Their area is the most important. The citizen preparedness advocate is often of this stripe (there are many exceptions, of course, but I am trying to make a general point). If you couple a tendency to cleave toward advocacy rather than activism (meaning a more general progressive political stance that crosses issue boundaries) with the fact that the main employers and institutions public health students identify with are in the public sector, it becomes understandable that mobilizing them against government actions on issues outside of their area of interest is not something that comes easily. Medical students, on the other hand, often feel independent, empowered and self confident enough to question government actions. They start out poorly disposed to the government in the first place and as students they are still idealistic enough so there is a reasonable yield of activists amongst them.

Preparedness advocates are sometimes pejoratively referred to as the "flu obsessed" but they should more properly be thought of as the kind of passionate advocates like my students and colleagues in our School of Public Health. They tend to be very bright and they know a great deal about flu, often much more than their doctors. But they aren't activists and they don't organize easily. They will be a tremendous resource, if and when, and because they exist I think we are better off than four years ago when they didn't.

As far as government response, however, I am not confident we are better off. There has been a lot of planning on paper, but like a military plan that never survives the first engagement with the enemy, the pandemic plans on paper will be out the window in the first week of a catastrophic disease outbreak. This always happens, but it will be more severe today than four years ago because of the deterioration of local and state public health and its distorted priorities during the Bush years. There has been a lot of stockpiling of antivirals (Tamiflu and Relenza), but whether they will work for bird flu or whether the virus will quickly develop resistance we don't know, although the signs are that this could be a big problem. There is as yet no vaccine matched to a pandemic strain because we don't know what that strain will be, and in any event the time to produce a vaccine is long enough so that we will have to endure at least one wave of a pandemic and after even after that, if a vaccine can be produced there will not be enough to go around or adequate ability to distribute it. That's a consequence of the lousy shape our health care and public health systems are in. And they continue to get worse.

DemFromCT: So speaking of flu pandemics, what are the chances we will have a catastrophic flu pandemic in the near future?

No one can predict this. I don't take it as a given and never have. It's true that pandemics happen at intervals, although there is no rhyme or reason governing how long the interval is. We don't understand the dynamics of this virus well at all and the world has changed in many ways. Most of the ways the world has changed involve a closer interconnectedness that would make spread easier and more rapid, so I'm not heartened by the fact that the world is different than it was in 1918 or 1957 or 1968, the years of the last three pandemics. But we also don't understand what makes some years much worse than others and some pandemics much worse than others. We don't even know the major mode of contagion and for some flu virus subtypes, like H5N1, we can't be confident we know all the current or potential reservoirs in nature.

We've learned a lot since H5N1 returned in full force in 2003, but much of what we've learned is that what we thought we knew we were wrong about. This is a wily and dangerous enemy and it's a race between gaining effective knowledge to treat and control it (which we don't have at the moment) and the continual experimenting the virus is doing to find ever new ways to make copies of itself, its only meaningful activity from the virus's perspective.

I think it is quite plausible we will have another pandemic from some influenza subtype humans have no immunity to that will still be non-catastrophic, more like 1968 or 1957. Those were bad but not like 1918. On the other hand, it is also perfectly plausible we could have a truly terrible pandemic with high mortality and horrendous social disruption. It doesn't have to be H5N1. There are other flu and non-flu possibilities in a world where the most remote spot is not more than an incubation period from an international airport. Given that, it would be prudent to build our public health and social service systems like brick houses instead of the houses of straw and stick we have today.
DemFromCT: We have often talked about ‘rebuilding public health infrastructure’. Last week we discussed one aspect of that (the lab capability). What else does ‘rebuilding public health infrastructure’ mean?

Over at Effect Measure we've been saying for years that the best way to prepare for an influenza pandemic is not with antivirals or vaccines (although both have important uses) but by strengthening the public health and social service infrastructure to make it robust and resilient. Our view is that preventing a pandemic is technically difficult or impossible so the main task is to prepare to manage the consequences. The consequences of a large proportion of our population being sick or dying extends to almost every part of our society.

It’s the Three Little Pigs principle. The piggies’ mommy sent them out into the world to “seek their fortune,” but the world is full of danger. The first pig invests little effort in getting settled and builds a house of straw, only to get eaten when the wolf blows it down with ease. The same thing happens to pig number two, who tries to do better but doesn’t make a sufficient commitment, building a house of sticks. Only pig number three escapes because she had enough foresight to build her house of bricks. Pig number three would have survived not only the wolf but a hurricane or a fire or a blizzard. The brick house symbolizes a sound public health and social service infrastructure.

Unfortunately it is a superficial if seductive analogy. One of the reasons I have not responded to your insistent and well founded requests over the years to spell out what I mean by rebuilding the public health infrastructure is that every time I sit down to do it I run into unexpected difficulties. It turns out not to be as simple as waving a nursery rhyme under the noses of policy makers.

Consider, for example, the meaning of the word “infrastructure.” There is a halo effect from the use of this word for bridges and roads and electrical grids but when applied to public health it doesn't transfer easily. Infrastructure is the “structure” that is below our vision, the stuff we take for granted, don’t know is there or don’t understand but that nevertheless makes many other things possible by supporting them. Infrastructure doesn’t produce anything but is part of society’s capital. This seems straightforward, but isn’t. If you try to stipulate what part of the public health or social service or any other system is infrastructure not everyone can agree. Bank of America is not infrastructure but the banking system is part of the economy’s infrastructure. A state public health laboratory is not part of the public health infrastructure but most of us consider the laboratory system to be an essential element of infrastructure. Similarly for our disease surveillance system, which provides us with the “situational awareness” we need to make decisions about disease outbreaks or resource allocation. It's public health infrastructure. But being infrastructure doesn't automatically make it good. There are things that are infrastructure but have no particular public purpose or that facilitate some private one (the wave of armory building in the wake of the 1877 railroad strikes is a historical case in point but there are many others).

Then there are things of ambiguous status. What about the vaccine production system? A no-brainer you’d say? I had a long discussion about this with a like-minded colleague over the lunch table but we couldn’t agree. He is an economist who doesn’t consider the vaccine system to be part of infrastructure, whereas I argued it was. I'm less sure about the nation's drug manufacturing capacity.

DemFromCT: There's more about infrastructure I want to talk about, but that will need to wait until next week.