Neglecting the Swine Flu Frontlines

Tuesday morning, I walked into our university hospital for a meeting. I was stopped at the door by a police officer. He didn't check my ID, he pointed to a bottle of hand sanitizer. As I scrubbed, he gave me a card telling me what to do if I had a fever or other symptoms. That's good. Chicago has had some likely cases of H1N1 flu. We aren't panicking, but we are paying attention.

Such experiences remind us that local institutions are at the real front lines in addressing public-health emergencies. The capacity of state and local governments to coordinate and mobilize these efforts is a crucial, and readily overlooked, variable in the current flu challenge. Unfortunately, these components of our nation's public-health infrastructure are less prepared and less capable than they would otherwise be, thanks to that small but critical group of Senate moderates who controlled Senate votes on this year's stimulus bill.

Perhaps these votes would have gone differently had H1N1 arrived three months sooner. With HIV/AIDS providing a notable exception, Americans are generally unaccustomed to the whiff of fear that still accompanies infectious diseases in most of the world. More precisely, we are used to the occasional bursts of panic caused by local outbreaks of Legionnaires' disease, Methicillin-resistant Staphylococcus aureus (MRSA), and other nasty things. After the initial panic fades, an ignorant and fickle public quickly returns to its apathetic or non-evidence-based stance regarding most public-health concerns. Yet for billions of people around the world, well-grounded fears of deadly or burdensome epidemics are a daily reality. This flu should remind us of what we take for granted.

No one can really say how widespread or how severe the H1N1 pandemic will be. So far, it does not seem likely to cause many U.S. deaths, though some will surely occur. We can say for certain that the pandemic has altered our national conversation about the role and importance of public health.

During the presidential campaign and after, I was one of many activists trying to attract greater attention and resources to government investments and regulations that can improve population health. This fight continued during congressional debates over the economic stimulus. 

The final stimulus bill financed valuable and necessary projects. It established a $1 billion prevention and wellness fund, provided $2 billion for community health centers, and infused $500 million in resources to train primary-care providers. Despite these achievements, we lost too many key battles. In the arena of public health, the end product was welcome but thoroughly unimaginative legislation. A huge opportunity was therefore missed.

Throughout, our key opponents were moderate senators who had no problem supporting the usual giveaways to powerful constituencies, yet who balked at spending small amounts on useful but unsexy measures to prevent sexually transmitted infections, promote family planning, help people quit smoking, finance substance-abuse treatment, and, yes, prepare to fight pandemic flu. In a $2.4 trillion health-care economy dominated by personal medical services, it once again proved nearly impossible to channel public investments into population-level activities that are often much more cost-effective.

To take one example not quite at random, Medicaid will pay a doctor or nurse practitioner to dispense antiviral medications to eligible patients who need these medicines. Medicaid will not pay for the services of a public-health nurse who, through careful searching of medical records or through shoe letter casework in the community, identifies an infected person in the first place. For reasons of history and habit, cash-strapped state and local governments are often left to their own devices in performing such essential public-health tasks. Many of these functions are badly underfunded and are readily cut when budgets are tight.

Republicans Susan Collins and Olympia Snowe -- not to mention those new and old Democrats Arlen Specter and Ben Nelson -- were some of these nay-saying Senate moderates. Three months later, Collins finds herself in the particularly awkward position of having to explain why her Senate Web site brags about her leading the charge to strip $870 million in flu preparedness funds from the stimulus bill.

It would be political malpractice for liberals not to pounce on this, and quite a few bloggers have. Not surprisingly, Sen. Collins calls this a cheap shot. This Monday, her communications director, Kevin Kelley, released a statement "in response to blog reports":

Claims that she is opposed to increased funding for pandemic flu research are blatantly false and politically motivated. In fact, in December 2008, Senator Collins joined in a letter to Senate leaders requesting a $905 million increase for the Public Health and Social Services Emergency Fund at the Department of Health and Human Services.

During negotiations of the economic stimulus package, Senator Collins always maintained that, though very worthwhile, pandemic flu research funding should go through the regular appropriations process since it did not meet the test of stimulus spending. And, in fact, the Omnibus Appropriations bill that was signed into law in March, less than a month after the stimulus bill, contains $156 million for pandemic influenza research, which is $1.4 million more than the Fiscal Year 2008 level.

He has a point, though Sen. Collins' fastidiousness about funding worthwhile initiatives through regular appropriations did not extend to other bigger-ticket items in the stimulus bill. Much of the $870 million was aimed at future pandemics. Had this money been appropriated, it would now be winding its way through the budgetary pipeline. It is certainly true that the United States has already spent a lot of money on the molecular biology of flu immunology and vaccines. We have stockpiled tens of millions of doses of antiviral medications. These particular disputed flu monies would have bolstered our capacity to address an epidemic in 2014. It's dicier to claim that they would have directly addressed our current difficulties.

But those evil liberal bloggers still picked the right targets, just not for the reasons you would initially think. The fiscal conservatives' most immediately damaging misdeed was not to oppose specific flu monies. It was to fight, in the name of fiscal conservatism, against measures to preserve the state and local government infrastructure we now rely upon to address a serious and unexpected public-health challenge.

If this pandemic becomes more serious, our nation will face several difficulties. We have no vaccine, and we might conceivably stress our stockpiles of key antiviral medications. These are the most obvious challenges in addressing a pandemic. They are not the only challenges or even the most difficult ones.

Suppose the pandemic were -- or later becomes -- more serious than it right now is. Suppose tens of thousands of Americans became seriously ill across the country, requiring both medical attention and tough decisions about isolating infectious people to minimize the threat to others. Suppose, further, that manufacturers were ready, willing, and determined to follow a crash program to produce an effective vaccine for 300 million people.

Who would identify and serve sick patients in the greatest need? Who would decide when to close and reopen local schools and businesses? Who would decide and then implement policies to isolate infectious people? Who would be responsible for allocating scarce antiviral medications? Who would answer the phone when people wonder whether they should buy protective masks or whether it is safe to walk to the supermarket?

Some of the people likely to face the greatest risks -- Mexican farm laborers, for example -- are poorly connected with traditional health services. Who would reach out to these men, women, and children? Who would identify, recruit, and vaccinate individuals at the highest risk? Who would provide medical care for these individuals if they become ill?

These logistical questions underscore an essential point that is often lost. Although many federal officials appear on television talking about flu, state and local governments are where the rubber meets the road in responding to any true public-health emergency. Are the strained capacities of our local public-health infrastructure sufficient to mount an effective response?

Two things we know:

First, we know that state and local public-health departments are laying off thousands of people precisely when they are most needed in the current economic crisis. A revealing New York Times report by Kevin Sack suggests that even more job cuts are on the way, even as these organizations face ever-increasing burdens arising from a growing uninsured population and from new threats such as bioterrorism. As health departments desperately shift people from other tasks into addressing the logistics of managing an unfolding flu epidemic, there are simply fewer available bodies to handle routine, but necessary, procedures.

Second, we know that these layoffs are more severe than they had to be, because that same group of moderate Senate fiscal conservatives tried to eliminate -- and did successfully reduce -- key stimulus provisions intended to infuse money into state and local government.

The details are complicated because they reflect the arcana of intergovernmental relations. To make a long story short, the stimulus package included a State Fiscal Stabilization Fund intended to quickly infuse money into state coffers and to finance specific priorities, mainly in education but also in health care and other areas. Local governments had much at stake in this legislation, given their reliance on state governments for contracts and fiscal aid.

Not surprisingly, House Democrats included an expansive fund. Things got stickier in the Senate, which passed a bipartisan amendment offered by Ben Nelson of Nebraska and one Susan Collins of Maine, cutting the proposed Fiscal Stabilization Fund by $40 billion.

The fine print looks worse. Within the fund, House Democrats proposed a $24 billion "flexible" account to bolster the capacity of state governments to directly or indirectly provide key services given cyclical declines in state tax revenues. As Ed Kilgore relates at The Democratic Strategist, this provision harkened back to 1970s general revenue sharing, whereby the federal government shared resources with state and local government.

The Nelson-Collins amendment provided zero dollars in flexible state funding. One-third of the House proposal ($8 billion) was restored by the conference committee. Despite this partial reprieve, Nelson-Collins sharply reduced a key vehicle to rapidly help state and local government. In this time of deep recession, government layoffs and service cuts are therefore worse than they had to be. As Kilgore notes, this undercuts the goal of economic stimulus. It also undercuts the capacity of state governments to address critical tasks.

Pandemic flu presents many challenges, some of which are beyond our present control. We hope for, but can never count on, the warning time afforded by pandemics that affect other countries before they appear here. We hope, but can never guarantee, that the biological properties of the relevant pathogen favor the design of an effective vaccine and that the virus promotes mild illness and is inefficiently spread. We hope that an epidemic emerges in ways that spark public concern and concerted action without causing panic.

There is one thing, though, we can definitely control: We can maintain a strong and capable public-health infrastructure that commands the required resources to tackle unexpected problems -- not just to protect against flu but to competently and effectively respond to a broader range of equally important public-health challenges that attract less notice. Sen. Collins is embarrassed now because she opposed stimulus money labeled "pandemic flu." She should be more embarrassed that she took such pride in withholding resources state and local officials now surely wish they had.

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