Health Scare: Swine Flu and the Need for Public Health Reform

Lewis and Judith Leavitt on the Swine Flu

AS THE Mexican government begins to reopen its factories and restaurants in light of the recent ebb in Swine Flu cases, the questions of how appropriately the U.S. government responded and what political action, if any, we as citizens should undertake remain important.

First, the biology: Influenza—or the flu—is a respiratory illness caused by a virus that has afflicted humans throughout recorded history. There have been a number of worldwide influenza epidemics (pandemics) that have historically caused many millions of deaths. The influenza virus can cause disease in a number of different animals such as birds and pigs; there are three major types: A, B, and C. Each tiny virus is covered with proteins that determine its proclivity for specific animals and the nature of injury that it can cause its host. These proteins are classified by a letter H or N and a number. (Thus, the current swine flu is caused by the A/H1N1 strain.)

Influenza is typically a seasonal disease in humans. Each fall and winter usually brings some genetic modification of the virus’s H and N proteins. There is much genetic interplay among the bird, pig, and human versions of the virus. In 1918-19, a type A/H1N1 influenza virus proved to be extraordinarily lethal. Historians estimate that it killed on the order of 50 million people worldwide and 675,000 in the United States (190,000 Americans died in the month of October 1918 alone).

In April, an influenza-like illness began to spread in Mexico. A number of deaths were reported, and when laboratories typed the virus associated with these cases, they identified the virus as influenza type A with an H1N1 subtype. This H1N1 subtype has the protein characteristics of viruses that typically infect pigs and birds. Although it is of a type broadly similar to the 1918 strain, no one has even partial antibody protection to this strain. In addition, we have no idea what to expect in terms of how infectious or dangerous this virus may be or how it will evolve.

The initial data from Mexico suggested a mortality rate as high as 7 percent. Although this is almost certainly an artifact of not knowing the proper denominator (how many people in total had the disease), it was very alarming. As well, initial data in Mexico suggested that the deaths occurred in young adults as well as the very young and elderly (the two age groups that are typically most affected by flu). This effect on young adults was a notable characteristic of the 1918 pandemic and not characteristic of typical seasonal influenza. During the past week, H1N1 flu (Swine Flu) has been diagnosed in the United States, Europe, and Asia, but death rates have been (so far) less that 1 percent.

Here is where we need to integrate biology with political and public health issues. First, infectious disease epidemics in general and influenza in particular are worldwide problems. Global travel means that an infected individual in any area of the world may arrive in almost any other area of the world within twenty-four hours. Influenza in Mexico, Indonesia, or Ghana has implications for us in the United States. Surveillance of influenza cases is therefore an important part of our planning and response to a potential epidemic. The many under-resourced countries of the world do not have the infrastructure or budget to maintain and effect countrywide surveillance for influenza and must respond to possible epidemics in a hastily organized, ad-hoc manner. The United States and other well-resourced countries have an interest in fostering the public health infrastructure of poorly resourced countries.

In the United States, health departments at the local and state level have been severely depleted of funds by the previous administration and continue to be financially distressed in the current economy. Ironically, an $870 million infusion of funds that would have supported local public health infrastructure and personnel was removed from the recent economic stimulus bill because senators—including Susan Collins and Charles Schumer—identified these funds as inappropriate “pork.” The Obama administration’s $1.5 billion for public health epidemic measures is a step in the right direction. The World Health Organization (WHO), which has been very active in coordinating member country response to epidemics, is limited by the infrastructural public health deficits in many countries. Moreover, in the United States, although the Center for Disease Control and Prevention (CDC) as a federal agency leads our national surveillance effort, the individual states are the key agents in instantiating the day-to-day work and retain their legal obligation to protect the public’s health. State health departments are currently very stretched in resources available for all of their programs.

Our current data indicate that the H1N1 flu is sensitive to treatment with the antiviral medications oseltamvir and zanamivir. These medications may moderate the course of the disease as well as protect close contacts from succumbing to the disease. Stores of these antivirals, however, are currently inadequate to address a worldwide epidemic should it occur. They are manufactured under patent protection by two European-based pharmaceutical companies and the current price is beyond the resources of much of the world. This issue is part of a larger worldwide problem of access to affordable medicines under the current regime of patent protection. Manufacturing and distributing antivirals at an affordable price should be a programmatic political effort of the United States and Europe in cooperation with the WHO and World Trade Organization.

Of course, in the United States the egregious situation of roughly 50 million medically uninsured people emphasizes the link of health care reform to the problem of a flu epidemic.

Many of us have become used to the annual autumn call for a flu shot. But we can’t just give everyone a new flu shot to prevent this new flu. First of all, because this is a totally new flu, a brand-new vaccine must be developed and produced. Under the most optimistic scenario this production of millions of doses would take four or more months. The U.S. government is particularly wary of proceeding with the vaccine because, in 1976, confronted by a somewhat similar scare (although with far fewer infected people), it did develop a vaccine and administered it preventively to 40 million Americans. In the end, there was no epidemic, but 525 people developed a form of nervous system injury, possibly associated with the vaccine, resulting in 25 deaths. There was, understandably, a great public outcry, and the U.S. government paid many millions of dollars in compensation. Once bitten, twice shy. The current approach of the Obama administration to develop and produce a vaccine but withhold its distribution until the nature of the epidemic becomes clearer is quite reasonable.

SO HOW should we proceed?

1) This new H1N1 flu strain is cause for worry but so far does not seem different in severity from typical flu. (We must remember that typical flu causes about 36,000 deaths yearly in the United States)

2) We need active public health surveillance in the United States. Public health departments need funding. The proposed $1.5 billion emergency funding is a good idea, but attention to a continued stream of funding is necessary.

3) Infectious disease is a worldwide phenomenon. Support of WHO programs and public health infrastructure in poorly resourced countries is in our own national interest.

4) Begin developing a vaccine for this new influenza strain.

5) This new “health scare” can help energize political pressure to effect universal access to health care and to ensure that the World Trade Organization emphasis on patent protection for pharmaceuticals does not prevent access to appropriate medications for people worldwide.

It is also a timely moment for us to reexamine our current reliance on factory farms in which hogs are kept in such high density that they must stand in place. These conditions provide an outstanding incubator for the development of new influenza virus strains, not to speak of the heavy use of antibiotics that promote the development of antibiotic resistant strains of bacteria (a problem that is increasingly taxing medical therapy).

We have argued elsewhere that public fears can be used as fuel for the engine of public health reform. The current fear engendered by our 24/7 new media may be useful, if substantive reform and funding of public health is presented as part of the needed barrier against future epidemics. This has not yet been part of the news or analysis but it should be. It needs to be emphasized that even if this present epidemic does not turn out to be devastating, it is quite possible that there will be a more serious one in the future. In 1918, a short lived wave of flu was followed some months later by a tsunami of an epidemic. This harbinger wave phenomenon worries public health officials and should temper our elation if this current wave of flu benignly ebbs. If it does turn out to be benign, we need to be ready to counter a possible public backlash at “wasted effort” and “wasted funds” for public health measures.

Despite some initial reluctance to face the implications of a serious epidemic, Mexico has risen to the occasion. The Obama administration appears to have learned from the consequences of information suppression as seen in China’s handling of the SARS epidemic of 2003. Historical studies have shown that even during the devastating epidemic of 1918, cities that used containment strategies–case isolation and the closing of large social venues–did better than those that did not. It may become necessary for health officials to use these measures. Preparing communities by providing regular candid reports and timely communication can promote public cooperation, keeping involuntary isolation rare and as a last resort.

Whether or not we are at the beginning of a dangerous epidemic, there is work to be done. The Obama administration has addressed the initial problems well. It needs to be pressed for the follow through. Tying epidemic management to public health funding, universal access to health care, and safety of food and farming can be accomplished by educating a public made very attentive by the fear engendered by the words epidemic and pandemic, and a strange new virus.

Lewis A. Leavitt is professor emeritus of pediatrics at the University of Wisconsin and has been involved in international programs in child health. Judith W. Leavitt is professor of the history of the medicine at the University of Wisconsin and is the author of The Healthiest City: Milwaukee and the Politics of Health Reform and Typhoid Mary: Captive to the Public’s Health.