a citizen’s journal by Thomas Nephew

Public health for the common defense

Posted by Thomas Nephew on December 28th, 2001

Yesterday and today, Jeff Jarvis has been listing a number of homeland defense recommendations for Tom Ridge to consider. Of all of them, the ones I think would reassure me the most would be the public health related items, such as getting information about new disease threats and diagnoses out pronto,. Foremost among the public health measures should be to have plans and infrastructure capable of handling surges of new patients. Look up “patient surge” and “smallpox” on Google, and you’ll find articles like this one by Monica Schoch-Spana, Ph.D, in the March 2000 Biodefense Quarterly: “Hospitals Buckle During Normal Flu Season: Implications for Bioterrorism Response.” Dr. Schoch-Spana writes:

The prevalence of crowded emergency rooms and ambulance diversions around the country during the 1999-2000 influenza season might suggest that an unusually potent virus was at work, sending sick people to the hospital in droves. Epidemiological data, however, made it clear that the recent flu outbreaks were nothing more than the annual appearance of a familiar respiratory illness, only appearing earlier than expected.

That patients’ urgent demands outstripped the ability of many hospitals to respond with prompt and, in some cases, adequate care was less a result of the disease than underlying pathologies within the healthcare system. Beset with pressures to reduce costs and facing regional nursing shortages, hospitals today lack the flexibility to deal with even nominal upswings in demand, let alone the potential health crisis of a biological attack or pandemic influenza. […]

Influenza is an annually occurring outbreak of an infectious disease with comparatively low morbidity and mortality rates, and an active vaccine campaign. That it creates profound hardships for U.S. hospitals is worrisome from a bioterrorism preparedness perspective. Appraising the 1999-2000 flu season, the President of the Maryland Nurses Association, Mary Beachley, concludes, “If a major super bug hit, we’d be in trouble. Our response in the short-term would be okay, but long-term care with large numbers of critically ill patients [would] be a problem.” The efficiencies achieved through reduced bed capacity, staffing levels, and equipment ownership – survival strategies within a competitive health care industry – have left hospitals ill-equipped to deal with a mass casualty scenario.

There simply is no “give” in the current health care system, “no excess capacity or flexibility to handle things outside the norm, even the slightest blip,” according to Virginia Hastings, Director of Emergency Medical Services for Los Angeles County. Efforts to prepare the country for a potential bioterrorist attack must include a severe accounting of the present state of hospitals – namely the fiscal conditions that have fostered profound inelasticity.

Luckily, there’s a political model for fixing this I assume both fiscal conservatives and bleeding heart liberals can love: the Interstate highway system. That system, built on the public dime, was sold by Eisenhower as a military preparedness measure, to better allow tanks and other military hardware to be ferried hither and yon across these United States; many of the segments of that interstate system make little short-term economic sense, but as a whole, they ensured that military needs (however unlikely) for quick overland transport and relocation of heavy equipment could be met.

Likewise, I think we should consider a major public health initiative, that subsidizes and sponsors hospitals and hospital workers from doctors to nurses to paramedics, with the goal of higher preparedness for patient surges from bioterror attacks. Just as with some stretch of interstate highway in North Dakota or West Virginia, the beds and workers thus subsidized might not meet the strictly economic tests usually applied to a business proposition. But this isn’t just a business proposition; it’s providing for the common defense, against some of the plausible worst threats evil minds can conceive. We know those minds are at work. Let’s provide for some homeland defense — and not let the day-to-day benefits of a less precarious public health infrastructure bother us too much.

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