by revere, cross-posted at Effect Measure
Yesterday Flu Wiki founding editor and DailyKos frontpager DemFromCT reviewed three recent report cards on public health, one each by the American Public Health Association (APHA), The Trust for America’s Health (TFAH) and the American College Of Emergency Physicians (ACEP). It was a great a service in two ways. The first is to remind us that “health reform” is hollow without making sure the public health infrastructure is sound. And second, he reviewed these reports so the rest of us don’t have to. Believe me, that’s a service in my eyes. My patience gets pretty short when I see these tomes, full of platitudes, generalities or special pleading from a public health establishment that has lost its way, its mission and its ability to think out of the box. Too many years in the wilderness, perhaps. I’m guilty, too. I’ve been carrying on for years (literally) that the way to prepare for a pandemic is to shore up the public health and social service infrastructure.Dem and others have gently pressed me for some specifics, but I have resisted, mainly because I am not completely sure what I mean. It’s hard to explain things you don’t understand yourself (although teachers do it all the time).
I know I can’t do it alone. When I started the Effect Measure blog four plus years ago, just after the Bush re-election catastrophe, I hoped it would be a gathering place for serious discussion about public health from a progressive viewpoint. Specifically I wanted to begin a rethinking of public health, from the ground up, questioning all assumptions, ideological and practical, and not settling for the kind of slogans we in public health had been ritually mouthing for years (e.g., “prevention pays”; what if id din’t? does that mean we wouldn’t do it?). One of my very early ideas was to view public health through a specific lens and I decided to use the potential for an influenza pandemic with H5N1 as concrete example to focus things. I was among the first in the blogosphere to talk in any depth about bird flu, although I soon discovered two others, DemFromCT and the late (and much missed) Melanie Mattson of Just a Bump in the Beltway blog. The three of us, with the technical expertise of pogge, started The Flu Wiki in June 2005 and it has remained one of the “go to” sources for pandemic prep information since then (without much help from me, I might add). As time went on bird flu became the tail wagging the dog (pardon the mixed animal images). We still write about bird flu here, but it is time to put our shoulders to the wheel and start re-thinking public health. The three reports Dem discusses brought this home to me. All three sounded like tired nonsense.
Take APHA’s view, for example:
During the 1990s, health improved at an average rate of 1.5 percent per year, but improvements against national health measurements have remained flat for the last four years. Smoking, obesity, and the uninsured are the nation’s three most critical challenges…
No doubt those are three important health problems. But this strikes me as extraordinarily shallow thinking. I wasn’t any happier about the TFAH report:
“The economic crisis could result in a serious rollback of the progress we’ve made since September 11, 2001 and Hurricane Katrina to better prepare the nation for emergencies,” said Jeff Levi, PhD, Executive Director of TFAH. “The 25 percent cut in federal support to protect Americans from diseases, disasters, and bioterrorism is already hurting state response capabilities. The cuts to state budgets in the next few years could lead to a disaster for the nation’s disaster preparedness.”
This made me gasp. “Progress since September 11”? As Jon Stewart might say, “And do unicorns talk in your world, too, Dr. Levi?” The public health infrastructure — meaning the sinews and muscle of our state and local health departments haven’t been in such bad shape in my 40 year career in medicine and public health. TFAH is so narrowly focussed on disaster response they can’t see the trees for the leaves, much less the forest. The influx of federal funds for disaster preparedness has been one of the problems, not one of the solutions (we have made that point here before).
I am a little more forgiving of ACEP’s narrow Report Card. Representing the nation’s emergency room physicians they are on the front line of the crisis in health care, public health, social services, the economy and everything else that is falling apart around us. They viewed things in a characteristically narrow way:
The overall grade for the nation across all five categories is a C-. This low grade is particularly reflective of the poor score in Access to Emergency Care (D-). Because of its direct impact on emergency services and capacity for patient care, this category of indicators accounts for 30 percent of the Report Card grade, so the poor score is especially relevant.
At the moment I admit I can’t do better. But we have to do better. These “reports” are not much more than demanding we do more, and again, what we did in the past that didn’t work.
So let’s start over in thinking about this. The easy stuff, first. Public health and social services are an essential part of the country’s infrastructure, as much or more than roads and bridges. We have been disinvesting in them. We need to start re-investing in the routine stuff: substance abuse programs, maternal and child health, surveillance and vital records, environmental health and the rest of it. We need to do the same for social services. Yes, this is more of what we did before, but the first step in investing in our physical infrastructure (which should include the water and sewer systems, by the way, not just roads and the electrical grid) is to keep the bridges from falling down and the roadway from developing huge potholes.
But we don’t want to just recreate the old transportation infrastructure and we shouldn’t want to recreate the old public health system, either. It was based on different premises in a different world than the one we are heading into. The economic meltdown is a catastrophe but it is also an opportunity. All the cards have been thrown in the air and will come down in a different configuration and we should be prepared.
What’s the goal of public health? Surely it isn’t simply that I should be thinner and not smoke and be able to buy medical care. Surely it can’t be that we are ready for a bioterrorist attack. Can it possibly be that it is that I get seen much faster in the emergency room? I know these are caricatures, but not by much. What else do we want?
If I am an ordinary person, I don’t want to have to think about public health. I want it to work well but in the background, like the water system. I’ve got too many other things to think about and worry about. But if I am not looking at it all the time I also want to feel confident that those who are thinking about it are (a) competent, (b) making judgments and decisions for the welfare of the community. In substance, I want a system that is going to keep me and my family and my community as safe as they know how, all things being equal. Especially (but not solely) in the Bush years we couldn’t be assured of either of these elementary desiderata. Somehow we have to restore trust in the system.
What else? When I or the community have a problem, I want somebody to fix it. If it’s a health problem, that might or might not mean paying for expensive technology. Expensive health care is not always the best health care. We should be asking, for health problems, what is the best way to solve them. If the only way is very expensive, then so be it. But the system is now designed and favors expensive over less expensive solutions, and not necessarily because they are better. We have let the private sector drive the technology, as a matter of ideology. It has worked in some ways but failed miserably in others. We need to rethink the system of licensing and patenting of publicly financed research and we need to put public monies into finding the best solutions. When I say this I am saying something different than, “The best solutions, no matter how expensive they are.” I am saying, “The best solutions, no matter how cheap they are.” We currently do the former, not the latter.
That’s the merest of starting points: Make my world as safe as you can make it, all other things being equal (and that might mean taking other high priority factors into account), and when I get sick, help me to get well. But the starting point is not, how do we get people to stop smoking (although doing that is part of making their world safer) or thinner (although doing that is part of making their world safer) or giving them health insurance (because insurance is only a means to another goal, so let’s talk about that goal instead).
When I started the blog we were pretty much alone in the public health blogosphere. Now we have a steady readership in health departments all over the world, and more important, there is The Pump Handle, where this is cross posted and which I hope will become the lunch table around which public health professionals can start to talk seriously about what the hell we are doing and what the hell we want to do, without any preconceived notions.
The Pump Handle 
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December 15, 2008 at 10:03 am
Annie
This is an important post, and I hope you will forward it to Maggie Mahar of the Health Beat blog.
I’ve noticed an almost identical trend in professional nursing, only more hidden and more unreported and blogged at all. There is essentially no academic and research-based professional nursing blogging occurring. THere is no community of developing consensus in this field, either as it teeters ever more precariously on the precipice of catastrophic failure.
However, one of the trends I notice is that in healthcare reportage, there are “the big four” players referenced to the exclusion of everyone else. They are physicians, hospitals, big pharma and commercial insurers. I fear that public health is relegated to invisibility cloaking status as is nursing.
What I have done is to use Google search to look for references to nurses and nursing in every major (national) healthcare story and then to write to the reporters to explain the role that professional nursing plays and why it’s critical to report on it. More and more, reporters are responding and are asking follow-up questions.
Perhaps, too, there is a need to introduce new media into the curricula of basic public health and nursing programs. In nursing, the average age of faculty is in the upper forties and doctorally educated faculty have an even higher average age. So they may not rely on blogging and new media, and they are most likely not encultured to use new media to disseminate and germinate ideas. Is this occurring in public health?
I have been extremely disappointed in remaining so isolated in the blogosphere . I perceive an extreme degree of segregation and ostracism by most of the healthcare blogosphere. Identifying myself as a nurse, in particular, has brought outright hostility from both nurses (because I’m educated beyond the basic licensing mandated credential) and physicians (because I ask direct questions and argue for issues outside the mainstream point of view).
So now I pretty much ignore fellow nurses and physicians and write for the public, government and US and international students (who appear to be the three biggest segments of my readership). But in a heartening way, I get more and more hits from media sources around the world.
I submit pieces to a health policy blog carnival, but I no longer participate in healthcare blog carnivals, as that readership has almost no interest, and an inversely proportional degree of contempt.
What comes through is how little respect nursingcommands as a profession. And I wonder, again, if the public health field doesn’t have some degree of that as well, within the healthcare community?
I have many more questions than solutions or answers, but that’s where analyzing some of the demographics has led me.
(I routinely send a link to the Pump Handle to reporters, by the way.)
December 15, 2008 at 10:24 am
Annie
Part two of my rant:
Since it’s Monday and the coffee hasn’t kicked in yet, please also know that last year, Mike Leavitt ran a bogus health leadership blog, and DemfromCT shilled and covered for him in all good faith (seat at the table, open discussion, etc.) while Leavitt did nothing except to use and abuse him. My comments critical of the HHS blog’s PR firm, Ogilvy’s, heavy handed moderation of dissenting views, incurred their wrath. Since then I monitored John Agwunobi, an HHS Asst Sec who posted wrong and misleading information on that blog, and since resigned going directly to Wal-Mart as its “Health and Wellness Director” I alsoposted essays critical of Leavitt establishing his own blog on the HHS website at taxpayers’ expense where he freely opined unscientific and religious dogma-based political partisanship that undermined the health of large swaths of the US population with abstinence only drivel, the rule change to allow providers to deny or not offer appropriate options to women who have reproductive health and pregnancy questions, etc. I know of no other blogger who has been watching Leavitt’s and the behavior of the HHS agency heads relative to science, partisanship and using new media as propaganda tools.
But DemFrom CT won’t link to my work and won’t reference it. Before he posted this latest piece on Daily Kos I had emailed him explaining that I submitted an idea to the Change.org website about establishing a universal healthcare system based on public/primary and preventive healthcare which is accessible, affordable and appropriate and asking him for critiques. His one word response was, “thanks.”
I tied the public health infrastructure to the development of local community health centers that use baccalaureate prepared nurses to serve as patient case managers and disease/end-of-life case managers, while also mandating that school nurses become federalized in the USPHS so that all K-12 schools receive health services from a baccalaureate prepared nurse for developmental and disease management needs. I specifically addressed the public health infrastructure and role around surveillance, prevention and containment. I thought that should merit at least a mention. It almost seems as though DailyKos doesn’t want the word to get out….
Again, there’s that contempt issue.
December 15, 2008 at 11:25 am
Liz
“If I am an ordinary person, I don’t want to have to think about public health. I want it to work well but in the background, like the water system.”
Part of the problem may be that people don’t have to think about things like clean water, so they take them for granted and don’t factor them into their political decisions. The anti-big-government tactics gain traction because people forget that government provides many important services, from sanitation to drug review, that are extremely valuable and require lots of personnel and infrastructure.
This is why I was pleased when the Center for American Progress started running ads reminding people that we have government to thank for clean water, Social Security, and oversight of drug and toy safety. I don’t know whether CAP has continued to push that idea, which was part of an effort to rally people behind the “progressive label, but it’s a valuable thing for them and others to be doing.
It’s an uphill and ongoing struggle to remind people to be grateful for the easy-to-overlook public health services they have, let alone rally support to put more funding into infrastructure that they didn’t realize was broken. Has the Minnesota bridge collapse spurred more support for road and bridge repair? I can’t tell, so I’d be interested to hear from folks who might know.
Emergency-room problems might help people understand why prevention and capacity building are important. I think most people will recognize that they expect emergency medical services to be there when they need them, and most of us have heard a horror story from a family member, friend or acquaintance about a long ER wait and/or inadequate ER treatment. We need to explain to people how inadequate funding of the healthcare system causes inadequate ER capacity, and link that to inadequate funding of other kinds of public health infrastructure.
Increasing public awareness of public health services provided by the government is one step toward achieving goals (like more getting more money for water and sewer infrastructure and hospital capacity), but it might also be a goal in and of itself. If we can achieve and maintain a higher level of awareness of all the ways government contributes to our health, we’ll have better luck creating and sustaining leadership and consistent funding for public health priorities.
December 15, 2008 at 12:01 pm
Catherine Mitchell
If I am an ordinary person, I don’t want to have to think about public health.
I agree with Liz, this is the crux of the problem.
Sometimes we have to think about the things that we want to pass off to others to think about. The answer isn’t in thinking less, engaging less, it is in the exact opposite.
We have been disengaging far too much. Our busy, stressful, lives are not to blame they are our excuse. We do not do, we do not look at, we do not engage ourselves in what is unpleasant.
We leave that to others.
Put the public back in public health. Unfortunately, it just may take a pandemic to do that, and that simply grieves me.
December 16, 2008 at 1:29 am
Dipl.-Ing. Wilfried Soddemann
Many infections are transmitted by water also by the public water supply
CUT THE CHAIN OF INFECTIONS ! Spread of avian flu by drinking water:
Proved awareness to ecology and transmission is necessary to understand the spread of avian flu. For this it is insufficient exclusive to test samples from wild birds, poultry and humans for avian flu viruses. Samples from the known abiotic vehicles as water also have to be analysed. Proving viruses in water is difficult because of dilution. If you find no viruses you can not be sure that there are not any. On the other hand in water viruses remain viable for a long time. Water has to be tested for influenza viruses by cell culture and in particular by the more sensitive molecular biology method PCR.
Transmission of avian flu by direct contact to infected poultry is an unproved assumption from the WHO. There is no evidence that influenza primarily is transmitted by saliva droplets: “Transmission of influenza A in human beings” http://www.thelancet.com/journals/laninf/article/PIIS1473309907700294/abstract?iseop=true.
There are clear links between the cold, rainy seasons as well as floods and the spread of influenza. There are clear links between avian flu and water, e.g. in Egypt to the Nile delta or in Indonesia to residential districts of less prosperous humans with backyard flocks of birds and without a central water supply as in Vietnam: http://www.cdc.gov/ncidod/EID/vol12no12/06-0829.htm. See also the WHO web side: http://www.who.int/water_sanitation_health/emerging/h5n1background.pdf. That is just why abiotic vehicles as water have to be analysed. The direct biotic transmission from birds, poultry or humans to humans can not depend on the cold, rainy seasons or floods. Water is a very efficient abiotic vehicle for the spread of viruses – in particular of fecal as well as by mouth, nose and eyes excreted viruses. Infected humans, mammals, birds and poultry can contaminate drinking water everywhere. All humans have very intensive contact to drinking water. Spread of avian flu by drinking water can explain small clusters in households too.
Avian flu infections may increase in consequence to increase of virus circulation. Human to human and contact transmission of influenza occur – but are overvalued immense. In the course of influenza epidemics in Germany, recognized clusters are rare, accounting for just 9 percent of cases e.g. in the 2005 season. In temperate climates the lethal H5N1 virus will be transferred to humans via cold drinking water, as with the birds in February and March 2006, strong seasonal at the time when (drinking) water has its temperature minimum.
The performance to eliminate viruses from the drinking water processing plants regularly does not meet the requirements of the WHO and the USA/USEPA. Conventional disinfection procedures are poor, because microorganisms in the water are not in suspension, but embedded in particles. Even ground water used for drinking water is not free from viruses.
In temperate regions influenza epidemics recur with marked seasonality around the end of winter, in the northern as well as in the southern hemisphere. Although seasonality is one of the most familiar features of influenza, it is also one of the least understood. Indoor crowding during cold weather, seasonal fluctuations in host immune responses, and environmental factors, including relative humidity, temperature, and UV radiation have all been suggested to account for this phenomenon, but none of these hypotheses has been tested directly. Influenza causes significant morbidity in tropical regions; however, in contrast to the situation in temperate zones, influenza in the tropics is not strongly associated with a certain season.
In the tropics, flood-related influenza is typical after extreme weather. The virulence of influenza viruses depends on temperature and time. Especially in cases of local water supplies with “young” and fresh influenza-contaminated water from low local wells, cisterns, tanks, rain barrels, ponds, rivers or rice paddies, this pathway can explain H5N1 infections. At 24°C, for example, in the tropics the virulence of influenza viruses in water exists for 2 days. In temperate climates with “older” water from central water supplies, the temperature of the water is decisive for the virulence of viruses. At 7°C the virulence of influenza viruses in water extends to 14 days.
Ducks and rice (paddies = flooded by water) are major factors in outbreaks of avian flu, claims a UN agency: Ducks and rice fields may be a critical factor in spreading H5N1. Ducks, rice (fields, paddies = flooded by water; farmers at work drink the water from rice paddies) and people – not chickens – have emerged as the most significant factors in the spread of avian influenza in Thailand and Vietnam, according to a study carried out by a group of experts from the United Nations Food and Agriculture Organization (FAO) and associated research centres. See http://www.un.org/apps/news/story.asp?NewsID=26096&Cr=&Cr1
The study “Mapping H5N1 highly pathogenic avian influenza risk in Southeast Asia: ducks, rice and people” also concludes that these factors are probably behind persistent outbreaks in other countries such as Cambodia and Laos. This study examined a series of waves of H5N1, a highly pathogenic avian influenza, in Thailand and Vietnam between early 2004 and late 2005. Through the use of satellite mapping, researchers looked at several different factors, including the numbers of ducks, geese and chickens, human population size, rice cultivation and geography, and found a strong link between duck grazing patterns and rice cropping intensity.
In Thailand, for example, the proportion of young ducks in flocks was found to peak in September-October; these rapidly growing young ducks can therefore benefit from the peak of the rice harvest in November-December, at the beginning of the cold: Thailand, Vietnam, Cambodia, Laos – as opposed to Indonesia – are located in the northern hemisphere.
These peaks in the congregation of ducks indicate periods in which there is an increase in the chances for virus release and exposure, and rice paddies often become a temporary habitat for wild bird species. In addition, with virus persistence becoming increasingly confined to areas with intensive rice-duck agriculture in eastern and south-eastern Asia, the evolution of the H5N1 virus may become easier to predict.
Dipl.-Ing. Wilfried Soddemann – Epidemiologist – Free Science Journalist soddemann-aachen@t-online.de http://www.dugi-ev.de/information.html