We are not immune:
Influenza, SARS, and the collapse of public health

Death is inevitable, but not disease. The difference may be as simple as washing our hands or keeping the wastes of industrialized farming out of the water supply, but it is often much more complicated. Bacteria and viruses are no mean adversaries, nor are they easily defeated. If we fail to be watchful or to protect those most at risk, a public-health catastrophe is inevitable, and yet somewhere within the span of the last thirty years the idea of the common good has disappeared from our national consciousness, giving way to the misconception that we no longer need concern ourselves with the welfare of our fellow citizens. It is a dangerous conceit, and it leads us toward a future infected with unprecedented and unnecessary disease.

We have grown not so much complacent as narcotized, lulled into a sense of security by the almost daily pronouncements from corporate medicine and the pharmaceutical industry of ever better drugs and more “breakthrough” treatments. The spectacular progress of twentieth-century medicine, most recently the sequencing of the human genome, sponsors the widespread fancy that disease might someday be conquered, that genetic manipulation or nanotechnology or some other science-fiction marvel might bring with it a cure for death. Long forgotten are the days when the loss of a child to diphtheria or whooping cough or yellow fever was a commonplace event, the days before widespread vaccination and government safety and health regulations; we no longer remember life before publicly funded sewage-treatment plants and the passage of the clean-air and -water acts. Public health is often invisible and unremarked when it works well; when it fails, our neighbors sicken and die.

A public-health system is only as strong as its weakest link; an epidemic enforces, in the most rigorous fashion, the American credo that all men are created equal. If we allow one segment of our society to suffer and perish from preventable disease, little stands in the way of collective doom. Yet today, 44 million people in the United States are without health insurance; those who can afford to pay for it generally receive inferior treatment, despite the fact that Americans spend $1.4 trillion annually for their health care. Public-health departments across the country have never recovered from decades of cutbacks, despite injections of funding in response to specific emergencies such as AIDS or the threat of bioterrorism. Purchases of newer and more reliable diagnostic-testing equipment have been deferred; technical staff and other employees needed to support epidemiologic and testing programs have been downsized; vital on-site bacteriological and viral laboratories have been closed and the testing outsourced to the lowest bidder or simply abandoned.¹1. More than 3,000 hospital beds and 35 hospitals have been eliminated in Minnesota over the last twenty years; the state has 16,511 licensed beds, of which only about 7,000 are staffed, and most of these are occupied every day. Nationally, between 1980 and 2000, 1,000 hospitals shut their doors. State and local early-childhood services, prenatal care, immunization campaigns for the poor, alcohol-abuse and smoking-awareness campaigns, monitoring programs for lead and arsenic levels, as well as HIV/AIDS treatment programs, have been curtailed as health departments shift around available monies and reassign what few permanent staff members they have left in an attempt to keep the most critical programs in operation. Prevention becomes secondary to simply keeping people alive. Nor must we concern ourselves simply with the state of American public health; as distances collapse and human populations grow ever more mobile, so also new and deadly diseases (among them Ebola and the Marburg virus) find their way across deserts and oceans. AIDS took decades to escape its origins in central Africa; we should not expect the next simian retrovirus to take so long. SARS made its way from Asia to Toronto in a matter of weeks.

Medical historians describe the last few decades as the age of “the emerging plagues.” Overpopulation, poverty, ecological devastation and global climate change, chemical pollution and industrial agriculture—all of these factors conspire to create the conditions for unprecedented death by infectious disease. Between 1977 and 1994, twenty-nine previously unknown human pathogens emerged, and it is estimated, moreover, that we have identified only 1 percent of the bacteria and 4 percent of the viruses on the planet. Tuberculosis, a disease that should have disappeared decades ago, has reemerged as an epidemic, and drug-resistant strains continue to spread throughout our cities. In 1995, 1.7 million American patients contracted hospital-spread infections; 88,000 of these patients died; 70 percent of the infections were drug-resistant.²2. The failure of antibiotics to control common infections such as staph and strep is one of the most chilling of recent developments, one hastened by the reckless overprescription of physicians and by massive application of antibiotics to livestock that would otherwise perish in the lethal miasma created by industrial agriculture. Each year an estimated 76 million Americans fall ill to food-borne illnesses resulting in approximately 325,000 hospitalizations and 5,000 deaths. Influenza infects 10 to 20 percent of the U.S. population every year and kills 36,000; a virulent avian flu could kill millions. Such numbers, a mere sampling of those available, paint a grim portrait, and the view does not improve if we narrow the perspective.

During a two-week period in 1993 one of Milwaukee's two water- treatment plants malfunctioned. This waterworks supplied treated drinking water directly from Lake Michigan to at least half the population of Milwaukee and nine of its suburbs. The investigation that eventually followed revealed unprecedented increases in the density levels of the supposedly treated water during that two-week period. The gauges designed for continuous measurement of water purity had clearly not been functioning properly for periods as long as eight to twelve hours at a time. The precise reason for the failure remains obscure, but what is clear is that no alarms went off, no backup systems were brought online, and no one noticed the increases in turbidity that led to the largest waterborne epidemic ever to occur in the United States.

Within days of the plant's malfunction and continuing for an additional month, more than 403,000 people in the Milwaukee area developed fever, vomiting, and diarrhea. One hundred people died. The cause of the illness was Cryptosporidium, a single-celled microorganism that survives in bodies of standing water and has been known as a cause of diarrhea, abdominal cramping, nausea, vomiting, and fever since the 1970s. There is no medical treatment for the infection, and in otherwise healthy individuals the disease is usually self-limiting, though in a minority of cases the disease can lead to weeks of disability. In patients on immunosuppressive medications, those undergoing chemotherapy, or those with AIDS, the infection can be ruthless, unrelenting, and fatal.

The seriousness of Cryptosporidium in an immune-suppressed patient became clear at the beginning of the AIDS epidemic when physicians first found this strange and unexpected parasite in the blood and bone marrows of infected patients. Knowing that the organism was basically a disease of herd animals, the doctors contacted the preeminent expert on Cryptosporidium in the department of agriculture at the University of Iowa. When the professor was asked how infected sheep were treated, he hesitated. “There is no treatment,” he answered. “We shoot them.”

There are well over 1,400 documented microorganisms that can infect humans, of which fully one half first caused disease in animals. Cryptosporidium made the transfer to humans through the contamination of surface waters by runoff from farmlands and drainage ditches. Unfortunately, the cysts that spread the infection are highly resistant to chlorine and even remain viable in the laboratory after exposures to full-strength household bleaches. You can't kill the Cryptosporidium cysts, and while alive they remain astonishingly infectious. Disease has been known to occur through ingestion of as few as thirty cysts, and experimental data have shown that even a single cyst can pass on the disease to uninfected sheep as well as to humans. The only means of prevention for a contaminated water supply are filters of less than one micron placed within water-purification systems that physically remove the millions of heavy, dense cysts before they reach the household taps of public water supplies.

The failure of the main safety and backup gauges in Milwaukee was clearly a disaster, but the most unnerving aspect of the Wisconsin epidemic was not the astronomical numbers of affected people or even the deaths; it was the fact that, in the midst of the worsening epidemic, it was not the federal government or any state or local health department or surveillance program or emergency-room database or managed-health-care reporting system that alerted the public that an epidemic was in progress. It was a pharmacist, who happened to notice unusual sales of over-the-counter diarrhea medication. The local media reported the outbreak days before the health department took action, almost a week after the alarm was first raised.

The outbreak of Cryptosporidium in Milwaukee was more than the simple malfunction of a few gauges in a midsized American city; to those concerned about the nation's ability to treat its people and control disease, it was a clear sign that our infectious-disease and medical surveillance and prevention programs were no longer working. Although the Milwaukee disaster was unusual for its size, waterborne outbreaks of disease are not uncommon. The Centers for Disease Control maintain a database on the subject, but the statistics are not very reliable because they depend on the voluntary reporting of state and local health officials. Some states choose not to make these reports; some states do not even have active disease-surveillance systems. But local failures can often have far broader consequences, as we learned from the 1999 outbreak of the West Nile virus in New York City. Mosquito surveillance and control was a local budget casualty that led to a national epidemic, and by last year West Nile had appeared in every state but Washington, Oregon, Alaska, and Hawaii; 14,163 people are known to have been infected and 564 have died. The discovery in 2002 that the virus was transmitted via organ transplantation, and possibly by blood transfusion, has led to fears that the national blood supply could be contaminated. Testing for West Nile raises the cost of blood by $4 to $7 a unit. And even as the virus spreads across the continent, federal funding is being cut; in 2004 the Mosquito Abatement for Safety and Health Act received zero funding, and none has been requested for 2005.

The United States has no single agency responsible for public health and thus no coherent policy. As Laurie Garrett suggests in her monumental study, Betrayal of Trust: The Collapse of Global Public Health, it is no exaggeration to say that we simply lack a public-health system per se; what we do have is best described as “a hodgepodge of programs, bureaucracies, and failings.”

The great public-health victories of the nineteenth and early twentieth centuries over yellow fever, cholera, encephalitis, smallpox, puerperal fever, and a host of other infectious diseases were largely the result of preventive measures enacted by visionary public officials: improved sanitation and nutrition (safe water and food, decent housing, paved streets, sewers), vigorous powers of quarantine to prevent contagion, mosquito control and the installation of window glass, and the creation of vaccination programs. Few advances were as important as the realization that merely washing one's hands could prevent the spread of disease. Life expectancy in the eighteenth century for an average male was about thirty years; by the early 1970s, it was seventy-five years. And as Garrett points out, most of that progress occurred prior to the invention of anti-biotics, and “less than 4 percent of the total improvement in life expectancy since the 1700s can be credited to twentieth century advances in medical care.” Ironically, the medical revolutions of the twentieth century have contributed to our overconfident and complacent neglect of the public-health infrastructure. We spend vast sums to lengthen the lives of terminally ill patients by a few days and refuse to make modest investments that would prevent millions of needless illnesses and deaths.

The peculiar dynamics of American politics, with its periodic spasms of irrational antigovernment hysteria, have ensured that few effective public-health policies fail to attract powerful political enemies, enemies that more often than not have succeeded in weakening the agencies charged by Congress with the responsibility for the health and well-being of the American people. Not even the CDC is immune from the virus of partisan politics; despite an overwhelming medical consensus, the agency has refused to take a position on the use of condoms to prevent AIDS and has curtailed the printing or distribution of any data on the control or treatment of sexually transmitted diseases that might offend the most conservative Christians. In response to political pressure from the NRA and threats from Congress to withhold funding, the CDC has also discontinued its definitive research documenting the public-health costs of handguns.

The Food and Drug Administration presents the same self-defeating pattern of regulatory behavior. In May of this year, the agency refused to approve a morning-after contraceptive pill for over-the-counter use, even after its own expert advisory panel recommended it. Far worse is the degree to which the FDA panders to its industrial constituency. Drugs receive approval without adequate testing; the agency dithers when patients begin to die; eventually it turns out that adverse findings were ignored or suppressed. Often more concerned for the well-being of the pharmaceutical industry than for the health of American citizens, the FDA challenges states that seek to purchase cheaper Canadian drugs for their citizens and ignores the ongoing concentration of drug and vaccine production into the hands of fewer and larger companies, which has led to greater consumer costs and vaccine shortages. The agency has shown no inclination to pressure manufacturers into adopting new technologies that would allow the timely and safe development of new vaccines in response to emerging diseases. Not too long ago the FDA supported the pharmaceutical industry's wish to give antidepressant drugs to children despite the agency's own finding that such drugs might cause them to commit suicide.

Faced with alarming outbreaks of food-borne illness, the Department of Agriculture has refused to enforce the use of any of the more definitive and reliable, though admittedly more costly, bacterial tests of meat and meat products to replace the pathetically ineffective “poke and sniff” test used in all government-monitored and -approved slaughterhouses and meat-processing plants. E. coli, salmonella, listeria, shigella, have all caused outbreaks of disease. What is astonishing is not that a million pounds of hamburger can be contaminated from one infected cow but that the federal government demands only “voluntary” recalls. Confronted with proof that mad cow disease has infected the American food supply, the agency has prohibited the routine testing of American cattle for the disease, using the newly available tests only in obviously diseased animals and then allowing the animals to be slaughtered and put into the food supply before the results of those tests are available. The USDA has dismissed the recommendations of some of the nation's most prominent professors of agriculture and veterinary medicine to institute a more rigorous and scientific method of testing for this disease, usually citing as an excuse the meat industry's concern that any testing will add an additional three to five cents a pound to consumer prices. The USDA is not so much a regulatory agency as it is an arm of the meat-industry lobby.

Americans, we know, pay too much for their health care, and compared with other countries we receive a very poor return on our investment. The reasons are many, but they are not hard to understand: in essence, we have tended historically to view health care as a commodity like any other. But health is not a product; it is a public good. The evidence is clear that even when viewed through the reductive lens of purely economic self-interest, market-based, entrepreneurial medicine is a failure. Healing people after they fall ill is vastly more expensive than preventing the illness in the first place: every dollar spent preventing diphtheria, for instance, saves $27; every dollar spent on measles, mumps, and rubella saves $23. Yet policymakers have consistently preferred the most expensive and least efficient models of health care, proving once again that the apostles of privatization are motivated not by hard-nosed economics but by an incoherent ideology that is little more than a brittle mask concealing the most irrational species of self-interest.

For the last quarter century, especially after the election of Ronald Reagan and his declaration that government itself is the problem that afflicts us, the public-health infrastructure of this country has been eviscerated. Between 1981 and 1993, public-health expenditures declined by 25 percent as a proportion of overall health spending; in 1992, less than 1 percent of all American health-care spending was devoted to public health. That trend has continued, even after the anthrax attacks of 2001, when politicians suddenly realized how vulnerable the nation was to biological attack.

Since then, it is true, the federal government has appropriated about $2 billion for bioterrorism response, an undertaking that if it were actually carried out would necessarily involve improving the public-health infrastructure. In theory, the bioterrorism money is channeled through the CDC, which distributes it to the states, which in turn disperse money to local health departments. Superficially, the gains are impressive: the CDC's budget for “public health preparedness and response for bioterrorism” increased from $49.9 million in 2001 to $918 million in 2002 and $870 million in 2003. Yet strangely enough, state and local public-health budgets have continued to decline. Public-health laboratories in California could lose 20 percent of their funding this year; the Alabama Department of Public Health expects to fire 250 people and to close regional labs and cut back on its flu-vaccination programs. State funding for AIDS prevention in Massachusetts has been cut by 40 percent over the last two years. Larimer County, Colorado, where last summer 500 people contracted the West Nile virus, received $100,000 in federal funds but lost $700,000 in state money. Overall, thirty-two states cut their public-health budgets between fiscal years 2002 and 2003. Michigan cut its spending by 24 percent, Massachusetts by 23 percent, and Montana, which received more federal bioterror money per capita than New York, cut its public-health budget by 19 percent. Many states, facing huge budget deficits, apparently took the federal money and simply cut their own appropriations. This should come as no surprise: in 2003 the states collectively faced a $66 billion shortfall, and in 2004 state deficits are estimated to be $78 billion. Federal investment will do no good if state politicians, struggling to cope with the economic effects of other federal policies, use those funds to reduce their own deficits.

The Trust for America's Health (TFAH), a nonprofit group that monitors public-health policy, in December released a comprehensive study of what the state health departments have accomplished with their “increased” funding. TFAH found that only twenty-four states had spent at least 90 percent of their 2002 bioterror funds, and only seventeen states had passed at least 50 percent of the money along to local health departments. Much of the money is mired in bureaucracy. A February GAO report revealed that the states were not much better prepared for bioterrorism (and by extension, a natural epidemic) than they were in 2001.

Of course, state health departments can hardly be blamed for their inability to correct a quarter century of neglect with what amounts to a mere $2,000 for every staffed hospital bed in America. Bioterrorism funds are being used simply to keep the lights on, and no one who has carefully observed the Bush Administration would expect it to follow through with its promises to rebuild the public-health system. In fact, the President's 2005 budget proposal calls for a $105 million decrease in state and local bioterrorism funding. The new budget also cuts $1.1 billion from the “Function 550” account, which finances disease-prevention programs and other public-health initiatives, and the federal Public Health Improvements Programs were cut by 64 percent.

Secretary of Health and Human Services Tommy Thompson has claimed that preparing for bioterrorism will enable the government to respond to influenza and other infectious diseases; in fact, the reverse is true. Bioterrorism is a remote threat and a massive attack is very unlikely, but it captures the imagination of weak-minded politicians and a populace raised on movies starring Bruce Willis. The truly imminent biological threat, which all public-health experts agree will inevitably strike, is an influenza pandemic. The 1918 pandemic killed 550,000 Americans and 30 million worldwide. A virulent flu would thus be much worse than a bioterrorism attack, and it would strike every part of the country more or less simultaneously. These facts are well known and understood, yet TFAH found that only thirteen states have a plan or at least a draft of a plan to confront an influenza pandemic. Amazingly, the CDC itself has yet to release a federal plan for such a pandemic; nor does the CDC require states to report flu cases or even flu deaths.

Every year influenza epidemics emerge from areas such as the Guangdong region of China, where large populations of farmers, pigs, and poultry share their species' various strains of the influenza virus. When multiple strains of the virus infect the same host, they begin to share genes, creating new mutations; when a new strain emerges for which humans have no immunity, a pandemic can occur.

In response to a 1997 avian influenza outbreak that began to infect humans but stopped short, for some reason, of becoming an epidemic, the World Health Organization significantly expanded its flu-prevention activities and set up its Global Agenda for Influenza Surveillance and Control, a program whose four main objectives are to monitor the spread of influenza in animals and humans, to identify each year's newest infective strain, to accelerate global pandemic awareness, and to increase usage and speed development of an effective vaccine. Each year the WHO surveillance program puts its infectious-disease teams along with its worldwide network of more than one hundred laboratories on alert, hoping to detect outbreaks before they spread around the globe. Such generalized surveillance is difficult and expensive, but the danger of emerging infections and the continuing influenza threat have left the world health community with little choice.

In February 2003 the WHO issued a report about a group of patients with severe influenza in Hong Kong. The index case was a physician from Guangdong province in China. A global alert was soon issued concerning similar illnesses in Singapore and Hanoi. The WHO sent Dr. Carlo Urbani, an Italian infectious-disease specialist, to Hanoi to investigate. Urbani swiftly determined that the disease was something unusual and that it was highly contagious and virulent. Unlike influenza, which always begins with a runny nose, waves of generalized aches and pains, and weakness, followed by days of fever and an increasing cough before the onset of pneumonia, this disease progressed almost immediately to severe pneumonia, respiratory collapse, and, for many, death. We now know that these alerts were describing the SARS outbreak, which nearly became a global pandemic. Working closely with the Vietnamese authorities, Urbani and other specialists from the WHO, the CDC, and Doctors Without Borders were able to contain the disease in Hanoi, though tragically Urbani himself contracted SARS and died in a makeshift isolation ward in Bangkok. It was not long before the disease spread to Toronto. By late March, 6,800 people there had already been quarantined, with another 5,200 health-care staff working “in quarantine” at facilities that public-health officials had quickly set aside for treating suspected SARS cases. In the United States public-health officials were simply holding their breath and hoping for the best. Not only have cutbacks stripped rural areas of their hospitals and clinics but even the major cities now lack the number of acute-care and infectious-disease beds—not to mention the nursing staff, technicians, and isolation units—to deal with a bad year of influenza much less a full-fledged disease with what appeared to be the staggering demands of SARS.

What happened next was unprecedented: researchers quickly determined that the disease was caused by a new type of virus and very rapidly isolated the cause as a previously unknown coronavirus that had apparently jumped from an animal species to humans. It was not lost on the world's infectious-disease experts that what had taken physicians and scientists almost four years in the case of AIDS was accomplished for SARS in less than four months. It is no exaggeration to say that the billions of dollars so reluctantly pushed into viral research as a result of the efforts of AIDS activists in the 1980s and 1990s enabled the WHO to quickly find the cause of another viral plague. And it was the ability to share accurate information in real time via email and the Internet that allowed the WHO to hold the disease in check.

In the midst of all the tracking of potential contacts, the increased hospitalizations, the thousands of people in quarantine, the disease simply vanished at virtually the same time all over the world. Coronaviruses thrive in cold weather, and, like influenza, they spread during the winter months, which accounts for the yearly outbreaks of colds and upper-respiratory infections. The realization that SARS is a cold-weather virus is troubling, because it means that there has been no real victory, only a reprieve. It has to be assumed that SARS is still out there waiting for another winter.

The lesson of the SARS outbreak was that preparation, surveillance, and decisive action from public officials can prevent epidemics. The WHO response was exemplary—training, staffing, equipment, and funding were all in place, ready for an emergency—but we still lack a truly global early-warning system. In the United States we continue to be without an effective national warning system. As Lancet editor Richard Horton writes in Health Wars, his scathing critique of contemporary medicine, “No single agency—CDC, WHO, the military, or a nongovernmental organization (such as Médecins Sans Frontières)—currently has the resources, staff, or equipment to act as a rapid-response strike force during a civilian health emergency.” If SARS had come to the United States, there is little hope that it could have been contained.

Today, we are no better prepared for a SARS epidemic than we were last year. “Homeland security,” curiously interpreted to exclude the most plausible and deadly threats facing our population, has remained the priority. The massive smallpox immunization program in 2002 was little more than a distraction and waste of precious funds. Meanwhile, we are afflicted with a government that has waged war all across the world to avenge the deaths of 3,000 terror victims, far fewer than die of influenza in a mild year; a government that insists on spending $50 billion to build a missile-defense system that does not work, a military-industrial make-work project designed to meet a threat that does not exist. The war in Iraq consumes almost $4 billion a month, twice the amount we have largely squandered on bioterrorism since 2001. We have grown so foolish and so incompetent that perhaps we do not deserve to survive. Perhaps it is simply time to die.

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We are not immune: Influenza, SARS, and the collapse of public health

We are not immune:
Influenza, SARS, and the collapse of public health