Looking for the perfect metaphor for the ills of the American health care system? Look no further than H1N1. Or so says Dr. Michael Osterholm.
If anyone is in a position to draw such a conclusion it is Dr. Osterholm. Dr Osterholm is the director of the Center for Infectious Disease Research and Policy (CIDRAP), director of the NIH-supported Minnesota Center of Excellence for Influenza Research and Surveillance (MCEIRS). In June 2005 Dr. Osterholm was appointed by Michael Leavitt, Secretary of the Department of Health and Human Services (HHS), to the newly established National Science Advisory Board on Biosecurity. In October 2008 he was appointed to the World Economic Forum’s Global Agenda Council on Pandemics and currently serves as chair of that council. In a nutshell, Dr. Osterholm tracks pandemics and reports on our ability to respond to both expected and unexpected disease outbreaks. Recently he has turned his attention away from bioterrorism to the H1N1 pandemic. At a recent presentation coordinated by the Health Law Institute of Hamline University’s School of Law Dr. Osterholm presented a sobering state of American readiness. According to Dr. Osterholm, today more than any time in the history of monitoring infectious disease, whether or not a person will be affected by a disease outbreak depends entirely on where you live and what resources you have access to.
Current estimates by the Center for Disease Control suggest that about 25-30% of the world has been infected with H1N1, and as of November 12, 2009 the CDC had counted about four thousand deaths from the disease. But those numbers alone suggest nothing unusual, and in fact, track standard seasonal influenza outbreaks. So then, what has Dr. Osterholm so worried?
For starters, decades in epidemiology has taught him to expect the unexpected. So while his estimates suggest that H1N1 infection has peaked in this country news of outbreaks in China of a new, more virulent flu strain suggest that the season is far from over. But it’s not disease or disease mutation that’s the issue. It’s the response.
Or more accurately, it is the ability to respond to these outbreaks that keeps Dr. Osterholm awake at night and busy on the national speaking circuit. A health care system that is chronically underfunded and stressed by overflow emergency care simply cannot handle the patient surge that accompanies these kinds of outbreaks. The best hospitals have, at most, thirty-days of cash reserves on hand. That means there is no stockpiling of supplies, no ability to meet payroll demands of care providers working overtime to respond to an influx of incoming patients. That’s just the problem within our borders.
When news of H1N1 first hit and it appeared that the disease had manifested and spread from Mexico many called for a temporary close of the border as a means to try and curb its spread. But those calls came without any understanding of the interconnectedness of our global economy and that sealing the border with Mexico would have a drastic and immediate impact on American health care providers. You see, the flexible plastic tubing used in respiratory ventilators is made almost exclusively in Mexico. With hospitals running on bare-bones cash supply, sealing the borders would mean that within weeks hospitals would not be out of respiratory ventilators–a real problem when combating a disease that at its worst manifests as a lethal respiratory infection.
Perhaps a more startling example involves the development and manufacture of influenza vaccine. Current estimates place about 80-90% of vaccine manufactured outside of the United States, primarily in China and India. Should anything happen to destabilize those regions American vaccine supplies would become instantly at risk.
Given the critical need for jobs in this country and the well-established biotechnology industry the obvious solution to this instability of supply would be manufacture vaccines at home. A fantastic solution according to Dr. Osterholm, but one that is not happening. Last year alone American vaccine manufacturers threw out over 25 million doses of flu vaccine. Simply put, these companies see vaccine development as a terrible return on investment and refuse to foot the bill for technological upgrade. Despite all advances in medical technology, vaccine technology has not changed at all for over fifty years.
So despite our ability to create a universal vaccine that would be resistant to every known combination of flu strains we currently lack the infrastructure to take on such a campaign. This is, Dr. Osterholm believes, one of the single most imperative public health policy issues facing the entire globe–creating the infrastructure that would allow for global influenza vaccination.
Because private industry will not, and in many ways cannot, foot the bill entirely on its own to develop the required infrastructure, government must step in. Governments need to be willing to bear the costs of maintaining vaccine levels for its citizens because, in a free market, we cannot expect private companies to be ready and willing to ramp up, then down, vaccine production at a moment’s notice.
Government also needs to rethink its current antiviral distribution policies. For example, when faced with mounting H1N1 deaths among otherwise healthy pregnant women, Argentina revamped its Tamiflu campaign. The country handed out supplies of Tamiflu to all women in their third-trimesters with instructions to begin taking the antiviral at the first onset of flu-like symptoms. The results were staggering as overall deaths from the disease plummeted.
So where does that leave us as this country heads into the winter months? Despite all the bad news Dr. Osterholm was very supportive of the efforts of both the Obama administration and private industry. As to the administration Dr. Osterholm’s strongest critique came from the fact that it overpromised what it could deliver. Approximately 33 million doses of vaccine have already shipped–a staggering feat given how quickly the outbreak spread, and a testament to both government and the private sector working around the clock to meet demands. But the government said it could do more, so 33 million doses looks like a failure. But, by no means should we consider the response anything short of a phenomenal success.
If we want a better response, we have to be willing to pay for it. And that means an understanding that vaccine development and maintenance should be part of an ongoing and systemic public health infrastructure. Because even as bleak as this picture is, places like Ukraine and Belarus are grappling with an H1N1 mortality rate at least twice that of the United States, Australia, and the UK with no hope of access to future vaccine short of intervention by the global health community. So even if we take head on this piece of the health care crisis, a global vaccine shortage remains.
Just think what a little investment in a public health infrastructure could create. Today we have the ability to vaccinate for influenza, whatever the strain, much like we vaccinate for smallpox but are simply unwilling to pull the trigger despite overwhelming evidence that such an infrastructure would protect not only against virulent influenza, but global bioterrorism. What’s the disconnect?
What is missing is an understanding and acceptance of health, and access to health services, as a basic and fundamental human right. Some things are best left out of the private market, and some things are best not commodified. Disease prevention and return on investment do not belong in the same thought unless our vision is expanded to see global public health as an economic measure. Unfortunately today that is not the case and it looks like we may be unwilling to undergo such a paradigm shift until its too late.
photo courtesy of alvi2047 via Flickr