At Risk: The Dangers of an Eroded Public Health System

An interview with Dr. Irwin Redlener

Irwin Redlener, M.D., is associate dean, professor of clinical public health and director of the National Center for Disaster Preparedness at the Columbia University Mailman School of Public Health. He speaks and writes extensively on national disaster preparedness policies, pandemic influenza, the threat of terrorism in the U.S. and related issues.

Dr. Redlener, a pediatrician, is also president and co-founder of the Children's Health Fund and has expertise in health care systems, crisis response and public policy with respect to access to health care for underserved populations.

Dr. Redlener is author of the forthcoming Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do, to be published by Alfred A. Knopf.

Multinational Monitor: How worried should people in the United States be about avian flu?

Dr. Irwin Redlener: Let me differentiate between worrying and panic, and taking relevant preventive actions around a potential risk. We're not dealing with something we need to panic about. But I do think that we as a society - both on the governmental level and on the personal level - need to be aware that a pandemic is eminently possible and that we are extraordinarily not prepared to deal with a pandemic flu.

Our health and public health systems are so fragile and have been so degraded over the past decades that we're just not ready to deal with any big biological catastrophe like a pandemic. This is an opportunity to shine a long-needed spotlight on the condition of those systems and on what we need to do to make us stronger from a health and public health point of view.

MM: Particularly focusing on H5N1, how seriously do you assess the risk for the U.S. population?

Redlener: There will be birds with H5N1 influenza in the United States within the next few months. That is virtually inevitable because there are so many infected birds throughout the world and the migratory flight patterns of wild birds is such that it is impossible to conceive of a situation where they won't be arriving in the United States. That said, the question remains as to the risk of it going from a problem for birds to becoming a pandemic public health catastrophic situation for human beings. That possibility is not really fully understood, in terms of being able to predict how or when it might happen.

MM: If there were a mutation of the virus so that it was easily transmissible among humans, what are the prospects of containing it?

Redlener: Zero. If it becomes robustly transmissible among people, then there is no chance of containing it.

The answer you'll get from the World Health Organization is that when it breaks out in Southeast Asia or some place, they'll rush resources there and try to contain it. There will be attempts to encircle it, treat the people who have been contacted or who have gotten sick and hopefully keep it in one geographic area.

That is not going to happen. We're not going to find out about it quickly enough, and there's so much movement of people on the village level, in urban areas and across national borders, that I don't think we can realistically depend on containment as a full strategy. We'll try containment, but the purpose of containment is more to slow it down, if that's possible, so that other countries can get ready for it. But containment is no kind of panacea here.

MM: What has been the Bush administration's preparatory response to bird flu?

Redlener: The Bush administration response is the usual response: too little, too late. It's something that we should have been preparing for well before we really engaged in this, which was basically around the summer of 2005. That's when the rhetoric started appearing within the administration that this might be a problem, and that was amped-up through the fall. As of last November, the U.S. Department of Health and Human Services (HHS) put out a 400-page national pandemic flu plan, and the Secretary of HHS has been crisscrossing the country and forthrightly saying the country is not prepared. So from a rhetorical perspective, the Department of Health and Human Services is now there. But from a resource perspective, we are not there - the President asked for $7.1 billion last fall for next year's budget to support the pandemic flu plan. The Congress approved $3.8 billion for the first year. Of that $3.8 billion, about $3.5 billion is designated for developing rapid technologies to produce vaccine and for developing and stockpiling anti-viral medications like Tamiflu. That left only $350 million to bolster the health and hospital systems around the country so they would be ready for flu.

This is one of the great weaknesses in both the national plan and the state plans collectively: there is not enough money to support the efforts within the health and public health systems that will be needed to care for people who are going to get sick, and in large numbers at a point where we don't really have enough vaccines or anti-virals. $350 million is supposed to be distributed among the 10,000 hospitals and public health agencies, and this is just not going to work.

MM: What should the United States be doing to enhance preparedness for avian flu?

Redlener: What we are doing is fast-tracking the development of technologies to allow us to rapidly produce vaccine, and I think we're probably doing that about as fast as we can. I'm not sure that more money would actually facilitate or accelerate that process.

What we're not doing and what we should be doing is putting significantly more resources into bolstering the health and public health systems. Probably 10 times the $350 million is what we need. That money would go to help hospitals develop the capacity to handle surge demand, to buy ventilators and face masks, to create alternative treatment sites, and many other things that are going to be needed if we're actually going to deal with a major healthcare crisis like this.

MM: The administration has proposed as part of its preparedness plan potential involvement of the military in case of an outbreak or pandemic. What is your assessment of that?

Redlener: A few months ago, Bush somewhat casually in a press conference declared - or mused would be better put - that the military might be deployable to enforce a quarantine locally in cities and wherever needed around the United States. I responded publicly that I thought that was outrageously inappropriate. We cannot have U.S. soldiers under the president's direction roaming around fully armed in cities enforcing local public health policies. That would be a major intrusion into the space that is properly occupied by civilians and civilian law and order.

MM: If the United States does everything you would like but the rest of the world doesn't, how prepared would the United States actually be?

Redlener: Pandemic flu is the great equalizer, on some level. You can't protect the borders from the possibility of really dangerous diseases crossing from one country to the next. We're all in it together, basically. The weaker the links are in some of the less affluent countries, the more dangerous it is for the whole world. We would like to have some means to equalize countries so that all could make the diagnosis and intervene appropriately and have enough Tamiflu, but we probably won't.

I think the implication of your question is quite true; we can't pretend that we're not part of the world here by creating a policy that is somehow only restricted within our own national borders.

MM: To what extent are the weaknesses you are highlighting in the U.S. public health system specific to a possibility of a flu pandemic and to what extent are they really just reflections of the overall state of the system?

Redlener: Since we're in a phase where we don't have the ability to rapidly manufacture appropriate vaccines at the quantity that they might be needed; and since Tamiflu is going to be difficult to stockpile; and since we still don't know whether it's going to be effective if it is used widely, that leaves us in a very odd and dangerous situation.

We don't have the vaccine to prevent, we don't have the Tamiflu to treat, all we have is the capacity of our health and public health systems.

If we got a serious pandemic, we would be dependent on our local systems to take care of us, since there is no way we're going to be able to get vaccines to prevent us from getting the disease.

The problem is that the health system - I hesitate to even call it a system, it is such a mess - has been so undermined and distorted that its ability to respond when needed to a major emergency is extremely limited.

We've been living with this "problem" for the past couple of decades, and in a sense almost getting used to the system being difficult to maneuver, very expensive, excluding lots of people, and with real quality issues. To a certain extent, we have become used to this, and we simply do not expect too much. But if, on top of those chronic worries, we someday have to cope with a pandemic, we're going to pay a very, very steep price for the inadequacies of our systems.

MM: Are things getting worse, or have public health systems always been neglected in the United States?

Redlener: Over the past 20 or 30 years, there has been a deterioration of the health care system. It's become more bureaucratic, while excluding large numbers of people, without enough accountability and without enough quality control.

MM: Your forthcoming book has as part of its subtitle: "Why We Are Not Prepared For Megadisasters." Is there an explanation for why policymakers are not doing what ought to be done?

Redlener: There are lots of reasons why we have so much trouble coping, but here are two. First of all, getting prepared for megadisasters is fundamentally about prevention, about making investments now in systems - or ourselves for that matter - that will pay off later. And we seem to constitutionally have a problem with making investments in the present even if they have large payoffs later. We barely do it for our own health, and we're certainly not doing it for preparedness for the country.

Secondly, there are problems with decentralization. Congress may appropriate money to accomplish something - whether it's in homeland security or disaster preparedness or pandemic flu readiness - with distribution through federal agencies. But because we're living in an increasingly federalist society, it goes to the states.

Then states have their own discretion about what's going to happen with the dollars and how they go to local communities.

By the time the money gets down to the level where something is actually going to be done with it, we have far less money than we need, we have very little guidance for how that money should be sent, and a minimal amount of accountability. This creates an environment where it is extremely difficult to make progress.

That is not to say that we don't spend any money, because we do. Billions of dollars have been spent on preparedness issues, but we have very little to show for it.

MM: To what extent is a privatization impulse underlying the problem? Do wealthier people simply believe things will work out for them, they can buy the Tamiflu if it's needed, they can get to a good hospital, they can do whatever they need to do?

Redlener: That may be true. I don't know if there is data to support that.

I think a lot of people, whether we're talking about terrorism or pandemic flu, prefer just not to think about it at all. That's probably a bigger factor than having some level of confidence that they are going to get taken care of. My anecdotal experience is that nobody feels very comfortable about this situation and very few people feel confident that the government or anyone else will do what they have to do to take care of things.

MM: Is there anything that individuals or families can meaningfully do in the face of this kind of threat or others like it?

Redlener: First of all, individuals need to keep the pressure on government to really make sure that the country is exploring appropriate strategies and investments to make us stronger and better able to cope with such a disaster.

On a personal level, it is important that families really have some plan of what they would do in the face of a major disaster.

Specifically for pandemic flu, there are a lot things that we want to make sure that families are aware of in terms of appropriate personal hygiene and ways of staying healthy in times of a pandemic. It is important to ensure conditions are taken care of as much as they can be. Anything we can do to make us healthier will also make ourselves stronger in terms of facing a major infection. Since the pandemic H5N1 virus gets deep into the lungs, for example, it would be better for people not to be smoking for as long as possible before the pandemic comes.

Also, there may be periods of time when you have to remain in your house or apartment. The Department of Health and Human Services is recommending that people stockpile food and supplies and medications in case people have to remain in the house for two or three weeks.