Priorities

by hilzoy

I never did write more about bird flu. (Short version: the person in charge of the federal response is unqualified; despite the fact that the GAO has been urging (pdf) the government to finish its response plan since 2000, it still isn't finished; and the NYT, which has seen a copy of the latest version of the plan, reports that it "shows that the United States is woefully unprepared for what could become the worst disaster in the nation's history", as well as failing to address such crucial questions as who would be in charge. Great.)

Tonight, I want to write about an important background issue: public health spending. Via Effect Measure, here's an article in Government Health IT:

"As state and local health departments gear up to battle a possible avian flu outbreak, they face a sharp cut in funding from the Department of Health and Human Services. However, the loss could be fixed through funds intended to cover the costs of controlling a pandemic, added as an amendment to the 2006 Defense Department Appropriations bill.

“Critical funding is shrinking just as public health agencies are being required to expand their work in pandemic influenza preparation and response," said Dr. Rex Archer, health director of Kansas City, Mo., and president of the National Association of County and City Health Officials (NACCHO).

The Bush administration, in its proposed 2006 HHS budget, slashed funding for public health preparedness by $129 million -- from $926 million in 2005 to $797 million. The House version of the 2006 HHS bill appropriates $853 million while the Senate bill sticks with the$797 million requested by the administration.

Donna Brown, government affairs counsel at NACCHO, said those state and local preparedness funds provided by the Centers for Disease Control and Prevention (CDC), an HHS agency, are used for a wide range of activities by local health departments, including information technology and disease surveillance systems.

“We need robust electronic information systems to detect disease outbreaks," Brown said, including surveillance systems that can alert local public health officials to potential flu symptoms. Those would be critical to helping combat a pandemic.

Congress should not be cutting preparedness funds as “we face a potential health emergency," Brown said. He believes Congress should reverse any cuts proposed by the administration. The Senate and House HHS bills are still in conference and need to be passed by Nov. 15, when a continuing resolution to fund government operations in fiscal 2006 expires."

Well, no, of course it shouldn't. But, also of course, it is.

Public health spending, especially spending on infectious disease monitoring and control, has always seemed to me to be a no-brainer. (For any of you who have read or seen And The Band Played On, remember those initial reports about puzzling diseases in gay men that came into the CDC? That's surveillance. Remember Selma Dritz, the character played by Lily Tomlin? She's a public health worker doing her job. And remember the scenes in which Don Francis of the CDC tries to set up a functioning lab in a broom closet? That's the underfunding of public health.)

Infectious disease surveillance and control protect us against things that can kill us just as surely as any bomb, in many cases without our having done anything whatsoever to bring death or disease on ourselves. Moreover, it doesn't make sense to think that each of us should be solely responsible for protecting ourselves from infectious disease. Obviously, we should do what we can, and equally obviously, someone who fails to take available precautions to protect herself from infectious disease is being stupid. But there are things -- like a network for monitoring disease outbreaks -- that we cannot provide for ourselves individually, and that are exactly the sorts of things that we should provide collectively -- that it, through our government. I have never understood why exactly the same sorts of considerations that lead people to support increased spending on national defense should not also lead them to support increased spending on public health, or why the former is normally regarded as tough Republican spending and the latter as squishy liberal spending.

Despite that fact, we have been cutting public health funding, except for specific bioterror programs. This is a mistake even if we're only thinking about bioterror, not about public health more generally: having a decent system of infectious disease surveillance and control is essential to detecting and coping with bioterror attacks, and funding for specific bioterror programs needs to supplement, not replace, funding for public health more generally. A report (pdf) by the Century Foundation on the effectiveness of bioterror spending puts it this way:

"The response to a biological attack demands expertise in the detection and containment of epidemics. This core capability, and others that are vital components of a working public health system, have eroded over past decades. If Congress and the administration intend to decrease the country’s vulnerability to potential domestic bioterrorist threats—or other acts of terrorism that could result in mass casualties—they must commit to a longterm investment that rebuilds the public health system as a whole. Bioterrorism preparedness cannot be funded as a “categorical” initiative. What is called for are not only specific tools, training, and practices but also a critical corps of specialists and professionals and basic public health capacities that cut across traditional public health categories. Durable competencies against bioterrorism, naturally occurring disease outbreaks, and other potential disasters will not be achieved through fragmented program support."

Moreover, the cuts have come at a time when states, which are responsible for a lot of public health work, have been facing serious budget deficits of their own. Here is a report (two years old) from OMB Watch; it says:

"Public health departments are now charged with new responsibilities for bio- and chemical terrorism preparedness. However, in this era of budget cuts at federal, state and community levels, any increases in funds for the new responsibilities posed by terrorist attacks are being offset by cuts in other programs. Ironically, the infusion of new federal money since 9/11 has, in many cases, weakened the public health infrastructure more than before. The availability of new federal funds for bioterrorism has become an excuse for states, desperately trying to balance their budgets, to make cuts in public health financing. Resources are being diverted from the vital core services of public health departments to the narrower (though essential) role of preparing for a terrorist threat. The costly federally mandated smallpox vaccination effort also has depleted funding."

Or, in other words: just when the states really needed federal help, what they got was a costly new mandate and budget cuts in everything outside bioterror. And the cuts continue: spending on infectious disease control is essentially flat, despite the threat of avian flu; as mentioned above, funding for improving state and local capacity in public health is being cut by $130 million; the CDC budget as a whole is being cut by nearly half a billion dollars, and that understates the problem, since it includes a $203 million increase in stockpiles of medicine. (A good thing, but that means that the cuts to the rest of public health are more like $700 million.)

Here's Revere from Effect Measure sums it up:

"So what's the deal? Bush reads The Great Influenza and then cuts funds for public health?

Yes and no. The cuts are independent of the concern for influenza. They are a consequence of the wrecking-ball policies of the Bush Administration and the Republican-controlled congress (and shame to the democrats who helped). You don't stop a wrecking-ball in mid-swing. It has too much inertia and will continue to destroy critical infrastructure even as bandaids like supplementary avian flu funding try to cover the worst of the damage.

It's not just public health. It's dams, bridges, levees, the shredded safety-net for our most vulnerable neighbors. While pursuing military adventures abroad and obsessed with terrorists at home, the BushCo's left us defenseless and dangerously vulnerable in our own homes, workplaces and communities.

Enough is enough."

Revere is right.

Comments

[hilzoy]

Note: I just changed this. In the original, I said that the person in charge of the federal response to avian flu was an idiot. I changed it because I don't know that; what I do know is that he has no obvious qualifications for his job. (I plead sleepiness.) The New Republic:

"According to his official biography, Stewart Simonson is the Health and Human Services Department's point man "on matters related to bioterrorism and other public health emergencies." Hopefully, he has taken crash courses on smallpox and avian flu, because, prior to joining HHS in 2001, Simonson's background was not in public health, but ... public transit. He'd previously been a top official at the delay-plagued, money-hemorrhaging passenger rail company Amtrak. Before that, he was an adviser to Wisconsin Governor Tommy Thompson, specializing in crime and prison policy. When Thompson became HHS secretary in 2001, he hired Simonson as a legal adviser and promoted him to his current post shortly before leaving the Department last year. Simonson's biography boasts that he "supervised policy development for Project BioShield," a program designed to speed the manufacture of crucial vaccines and antidotes. "That effort, however, has by most accounts bogged down and shown few results," The Washington Post reported last month."

[togolosh]

He'd previously been a top official at the delay-plagued, money-hemorrhaging passenger rail company Amtrak

I dunno, Hilzoy - he has experience with plague and hemorrhage, so perhaps he's better qualified than you think.

[bob mcmanus]

"...or why the former is normally regarded as tough Republican spending and the latter as squishy liberal spending."

Perhaps liberals view gov't as essentially an insurance, spreading the costs of risk among its citizens. The amount necessary should be able to protect the least able and affluent and the most vulnerable.

Conservatives think the amount necessary should be only what is necessary to protect Bill Gates when his personal resources are not sufficient, e.g., national defense.

[alex]

Investing in 'public health' inevitably means that sooner or later you're going to give some poor people things they couldn't afford to buy on their own, even if it's just vaccine or a simple HIV test.

This is sensible medicine, but incompatible with current Republican ideology. The proverbial pound of cure seems to be the preference, particularly if it can be purchased via a no-bid contract.

[Tim]

I have little doubt that the plan has actually been finished, but expecting to see "The plan is we keep the Tamiflu for ourselves and you guys are on your own." is probably unrealistic.

[cleek]

Neil Boortz didn't have anything to do with this plan, did he?

[John Thullen]

Tangentially relevant, which is close enough for me, but Brad Delong has a post up savaging George Will regarding the absence of some sort of taxypayer-funded universal health care in America, the Delphi/General Moters debacle, and the utterly, willfully, ignorant, purely innocent and destructive idea among the powers that be that real people who signed contracts should be screwed because the elegant concept of "comparative advantage" says so.

Except that comparative advantage for Honda, Toyota, and Mercedes includes basic, government-provided and decent healthcare in their home-countries.

Yeah, I know, they open factories here, because costs are lower. Nice that we bring out the best in people.

Side note to the side note: Here in Colorado, the folks (non-human Douglas Bruce, the Gingrich-Delay spawn John Andrews, Independence Institute funny boy/mass murderer Jon Caldera, all backed by Norquistian and Dickarmy national money) who are campaigning against Amendments C and D, which loosen the strictures of the draconian anti-tax Tabor amendment, passed without my permission in the early 1990s,
are quoted in yesterday's Rocky Mountain News
backing the idea that the poor, none of them, the sods, should receive government-backed healthcare (not even vouchers).

The election is close. A defining moment.

We (not me, Kemosabe) are very close to choosing death for the poor.

It will be a national model, Bush hopes.

[dr ngo]

FWIW - If avian flu hits, you may not be able to get your "Tamiflu," but cheer up! Tamiflu may not even work!! I quote a press release from the University of Wisconsin:

Date: Fri, 14 Oct 2005 22:13:12 -0600
>From: Kevin and Tammy Naze
>Subject: [wisb] Off topic: Avian influenza virus
>UW-Madison release today:
>
>An avian influenza virus isolated from an infected Vietnamese girl has
>been determined to be resistant to the drug oseltamivir, the compound
>better known by its trade name Tamiflu, and the drug officials hope will
>serve as the front line of defense for a feared influenza pandemic.
>
>Scientists from the University of Wisconsin-Madison, working with
>colleagues in Vietnam and Japan, report in a brief communication in next
>week's edition (Oct. 20, 2005) of the journal Nature that a young girl,
>provided with a prophylactic dose of the drug after experiencing mild
>influenza symptoms, developed a strain of the virus that was highly
>resistant to the drug.
>
>The finding suggests that health officials - now stockpiling millions of
>doses of the drug to forestall a global outbreak of influenza and buy time
>to develop and mass produce a vaccine - should also consider other
>options, according to Yoshihiro Kawaoka, an international authority on
>influenza and the senior author of the Nature paper.
>
>Recent reports indicate the federal government may spend billions of
>dollars to stockpile as much as 81 million courses of Tamiflu to forestall
>a possible influenza pandemic. The government has already stockpiled an
>estimated 12 to 13 million courses.
>
>"This is the first line of defense," says Kawaoka, a professor in the
>UW-Madison School of Veterinary Medicine who holds a joint appointment at
>the University of Tokyo. "It is the drug many countries are stockpiling,
>and the plan is to rely heavily on it."
>
>The drug would be used to slow the spread of influenza until a vaccine is
>developed, which may take up to six months.
>
>Tamiflu is delivered orally and works to impede the spread of the virus by
>binding to and inhibiting one of the surface enzymes the virus uses to
>exit infected cells of a host. Once inside a host cell, the virus
>commandeers the cell's reproductive machinery to make new infectious
>particles that go on to take over other cells. When the drug is at work,
>Kawaoka explains, "the virus is still able to replicate inside a cell, but
>is unable to get out and infect other cells."
>
>Oseltamivir, which Kawaoka describes as an "amazing drug," is one of three
>compounds proven to be effective against influenza. One class, derivatives
>of the compound adamantine, would be less effective, as some flu viruses
>have already evolved resistance to it. The other drug, zanamivir, which
>was developed prior to oseltamivir, is effective, but is formulated as a
>powder and requires that a clinician provide instructions for use. Thus,
>it is more cumbersome to administer than the orally delivered Tamiflu.
>
>These flu-fighting drugs, says Kawaoka, are by no means a replacement or
>alternative to a vaccine. Effective vaccines can confer immunity,
>preventing the virus from gaining a toehold in the body. But it is
>unlikely sufficient quantities of a vaccine can be produced and stockpiled
>prior to the emergence of a new virus in human populations.
>
>If avian influenza does emerge and becomes infectious from human to human
>- and nearly all experts agree that will happen at some point in the
>future - an outbreak similar to the 1918 influenza pandemic could occur.
>That pandemic killed as many as 50 million people, more than died on all
>the battlefields of World War I. Scientists and vaccine manufacturers
>would be in a race against time to produce enough doses to forestall
>disaster. Drugs like Tamiflu, used in combination with quarantine, would
>be intended to slow the spread of the disease until a vaccine is produced.
>
>Kawaoka says there may not be enough Tamiflu to go around even though
>countries are stockpiling it. The Wisconsin scientist says that will
>create a risk of patients sharing the drug and using smaller doses, which
>could accelerate the emergence of virus resistant to the drug and hamper
>efforts to contain the spread of the disease.
>
>He says health officials should consider stockpiling zanamivir and
>recommending that only the therapeutic dosages of Tamiflu be administered
>to patients.
>
>"We've been watching for this change (in the virus)," Kawaoka says. "This
>is the first, but we will see others. There's no question about it."
>
>

[Wade Schuette]

Well, you say "We (not me, Kemosabe) are very close to choosing death for the poor."

Alas, their choice is akin to being ecstatic because the idiot we're competing with at the other end of lifeboat just drilled a hole though the bottom of the boat on HIS end!

Perhaps the history will be written to show how the virus came, and took hold among the 45 million without health insurance, in a winter in which they couldn't even afford to heat their apartments any more, and, like Katrina, developed a huge momentum, like a spark falling on gasoline-soaked rags in the basement. In 45 million guts it evolved and perfected itself, a new generation every 20 minutes, 3 an hour, 72 generations a day to try to find the winning combination, times 45 million poor, times 10 trillion cells per person.

As Mike Osterholm quotes at the start of his book "Living Terrors", quoting the IRA - "You have to be lucky all the time - we have to be lucky just once."

And then, in full fury of an F1 epidemic turned into an F6 pandemic by that social choice we all made or stood by and watched being made, it leapt every silly barrier the very wealthy thought they had to keep it at bay. As if the virus would care who was rich and who was poor, who had Tamiflu and who didn't.

If there is one thing we can be sure of, is that it might start with the poor, but it won't stop there.

No, come to think of it, there's a second thing we can be sure of - it's that the mental model behind that social policy simply, totally, cannot conceive of the idea that poor and rich are genetically identical, in every way that matters to a virus.