Saturday, March 6, 2010

By: Æ Beacon

Part I: October 25th, 2007

Over the past fifteen years the federal government has spent billions of dollars on something that does not exist; bird flu. Despite few known cases of human to human transmissions, none of which having occurred in the wildfire fashion envisioned by public health experts, considerable funding has gone into fighting this purported menace. At this very moment several million doses of Tamiflu, the antiviral with supposed action against bird flu, are parked in warehouses outside of several major US cities awaiting distribution. Further, a half dozen manufacturers have promised the ability to ramp up production in case of a large scale outbreak.

Unfortunately these solutions neglect the dynamics of disease spread and our ability to respond to widespread public health emergencies. Recent biomedical successes with polio, mumps, measles, smallpox and a variety of other illnesses have perhaps contributed to an overwhelming sense in our culture that we can triumph over illness through medicine. Though successful in certain instances, modern diseases like HIV/AIDS have proven to be more divisive and adaptable than we are prepared to handle through drugs alone. Even if we had a cheap vaccine tomorrow, how long would it take to inoculate the millions infected and the billions at risk? Ask any of the men, women and children still living in areas with endemic polio, a full half century after the development of two effective, cheap vaccines, and they will tell you it takes a long time.

What can we learn from viruses? Perhaps the most important lesson is that medicine, while perhaps the ultimate cure for a given illness, is only part of the answer.
The effective control of any pandemic illness requires the simultaneous action of medicine and public health. Through public health the spread of disease can be slowed either enough to provide researchers with the time to develop medicines that either cure or sufficiently to extinguish the spread of disease. This approach gives the added advantage of providing health officials with the crucial medico-demographic data that will later enable medical interventions to effectively target sick and at-risk populations.

So what does a public health intervention entail? Good public health includes four main tenants: rapid medical reporting, centralized outbreak analysis, locally accountable health personnel and public awareness. Our current system lacks reliable rapid response reporting or personnel, our infrastructure is divided into a host of semi overlapping uncoordinated provider networks and our citizens have been endowed with a fear of pandemic disease but none of the tools to protect ourselves individually or communally.

Back to bird flu. In reality whether bird flu hits or not is irrelevant. A pandemic illness is bound to strike and I predict strike within our lifetime. The sheer number of people (and animals) combined with the rapidly evolving nature of viruses guarantees that one of the trillions of latent and perhaps low impact disease strain already in existence will mutate into a fatal, easily transmittable killer.

Evolution, however, is not the only factor competing for our health. One need not watch Twelve Monkeys to realize the realistic and disastrous potential of infectious man-made weapons. For thousands of years state and non-state actors have shot, dropped, spread and dispersed toxins and diseases in human populations. No longer limited to simply refining or concentrating the more virulent agents available, advances in biomedical technology have given scientists the tools to engineer distinct biological organisms. By purposely or accidentally eliminating the weaknesses of viruses like the rapid course of Ebola, the low case fatality rate of influenza or the transmission route of HIV, a scientist could fundamentally restructure the future of human life.

In the wake of such an event, drug research and development will not be the determining factor in our survival. If we cannot manage to respond systematically and comprehensively, there will be few people left to medicate.

Our public health infrastructure demands immediate practical and ideological change.

First, we must decentralize healthcare. Illness happens at home, at school and at work. We must have our health workers as close physically and culturally to where illness occurs as possible. Increased connectedness between these spheres through in house, in school and at work contact with health workers will increase the likelihood of obtaining rapid and relevant care.

Second, we must implement electronic reporting. This should be done through a private-public partnership. Currently we have a variety of reporting systems at several hospital systems around the country. This is great but community or even regional systems lack the tremendous benefits of a national system. The government must step in to standardize electronic reporting, make it affordable for small practices and ensure that people use it. Tax incentives, grant support and fines will directly ensure that health workers are providing the best in care for patients locally and nationally. Further, rewards to private companies for developing a suitable technology must also be implemented. A million dollar DOD grant initiated a few years ago resulted this year in a car that could drive for hours without any input from a person. Let’s challenge industry to come up with the same innovation in electronic healthcare reporting.

Finally, integrate public health education into elementary school education. I doubt a fourth grader in San Francisco can tell you anything about plate tectonics but she certainly knows what to do during an earthquake to save her own life. Pandemic disease is frightening but, by providing simple information on what to do during an outbreak to our future generations, each of us will be able to act effectively against disease and panic. By taking these steps we can offer ourselves the best chance to survive a natural or malicious outbreak.

When a pandemic disease finally does emerge, it could affect urban and rural population centers throughout the world in a matter of days. However, unlike disease, we have the capacity to predict, plan and prepare for the future. By pairing medicine with public health, vaccine research with systemic and cultural preparedness, Sabin with Snow, we offer ourselves a chance to survive. Pandemic disease requires our immediate attention and our immediate preparation. Let’s act.

Part II: February 25th, 2010

Over the past year we witnessed a new derivative of influenza overrun health systems worldwide. Relying on obsolete, often passive reporting systems, H1N1 was on our doorsteps before we knew where it came from. One step behind, officials world-wide scrambled to counter the threat of mass casualties and widespread panic.

Heterogeneous messages, policies and restrictions left individuals and families confused and frightened while insufficiently mitigating our risk of disease. Existing interventions, such as hand sanitizer, were quickly deployed despite the inconsistency between the main mechanism of influenza spread, through respiratory droplets, and the anti-fomite based action of such sanitizers. Meanwhile, effective mechanisms of respiratory disease control like masks and social distancing were inadequately adopted further exacerbating the spread of disease. In the end, luck if nothing else, played the largest role in what now appears to be a dwindling threat to our health and safety. Although actual mortality numbers are unknown, reporting systems in the US and elsewhere were quickly overwhelmed, the early projections of a high case fatality rate were never met.

We can learn from this near miss. In a generation where the term “viral” encapsulates both the cause and solution to some of the most important threats to individual and state security, we have a unique opportunity. The tools we employ everyday to track traffic, photos, phone calls, goods, our friends and our enemies must be brought to bear on disease. Tracking disease at home is not enough. Real leadership at the state and local level, real collaboration between governments, and real commitment to health intelligence are the only way forward.

Armed with timely and accurate information, we will be better equipped to strike hard, strike accurately and strike first at future disease threats.

As I’ve said before, let’s act.


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