One of the concerns of public health is indeed preparing for and responding to infectious disease outbreaks and epidemics. However, I fear that we at Kos have put far too much emphasis on this small slice of a big field and the result has been a huge missed opportunity to frame some strong progressive messages. Influenza control is a wonky issue that is pretty thin on political resonance compared to most of what public health is all about.
Public health is the endeavour -- more than a scientific discipline, or a profession, it's a unifying philosophy -- that treats human health at the level of populations rather than individuals. The latter is the province of medicine. Many people think that public health means "providing medical services to poor people." Not so. In fact, the intersection between medicine and public health is fairly narrow on both sides. The fact is, medical services – I think that “health care” is a misnomer – make only a modest contribution to our health and longevity. By the time we get to the doctor, it’s already too late.
Now, as for the prospect of a flu pandemic, let us suppose that the absolute worst case scenario that anybody is imagining really does happen, in other words, something very unlikely. Right now, there’s no evidence that this novel virus is actually any more dangerous than ordinary seasonal influenza – outside of Mexico, everybody who has been infected seems to have had a normal course of illness and to be recovering just fine. What’s going on in Mexico is unclear. And the latest indications are that after all the hoopla, this is actually a fairly mild strain of flu.
But let’s say just for the sake of argument that it really does turn out to be unusually dangerous, like the 1918 bird flu. And let’s say it continues to spread and ultimately infects hundreds of millions of people – highly unlikely, in my view, given the season, that would be behavior from a flu virus we have never seen before. But let’s just say it happens anyway. The whole thing will be over in a year. It is unlikely that the fatality rate would be as high as the 1918 incident, given several factors including the availability of antiviral medications, antibiotics to treat secondary pneumonia (the real killer in most cases), and more effective isolation and quarantine measures to limit transmission, followed by the availability of a vaccine by late fall. It also helps that we aren’t in the middle of World War I. But let’s just say for the sake of argument – and this will not happen – that 50 million deaths worldwide are attributed to the episode, including 400,000 in the U.S. – in other words that it really is comparable to 1918. (Of course the population is much larger now, and I’m not blowing it up proportionately, because of all the reasons stated above.)
That will indeed be bad. That magnitude of death toll globally would be close to matching the ongoing number of yearly human deaths, which is about 56.5 million. (WHO figures are here.) Now, that doesn’t mean the death rate will actually double, because some of those people who die of influenza would have died of something else anyway. But once our imaginary flu pandemic burns out, we’ll be back to normal. Here’s some of what’s normal (handy reference here):
- 11 million little kids – 5 and younger – die every year from easily preventable infectious diseases and malnutrition. That’s more than 30,000 every day. That holocaust is going on right now.
- 300 million people have malaria and 1 million of them die every year. An insecticidal bed net costs $5, lasts 4 years, and cuts the risk of a child dying by 25%. But poor families in Africa don’t have 5 bucks .
- More than 30 million people are infected with HIV and 2 million of them die every year. Only about 1/3 of the people who should be receiving anti-retroviral treatment according to current guidelines are getting it. And really, the guidelines are out of date – there are probably 15 million people going untreated who should be treated. It costs about $90 a year to provide the basic regimen, thanks to deals that were beaten out of the drug companies.
- About half a million women die in childbirth every year, almost all of them in poor countries, of course
I could go on but you get the idea. And here in the U.S., we spend twice as much or more on health care than every other country in the world, but we are about the least healthy of all the rich countries. Why is this? Well, it’s a little bit to do with the 15-17% of the population who don’t have health care coverage, but it’s a lot more to do with tobacco, and obesity, and social inequality. Life expectancy at birth for white men in the U.S. is about 74 years; for black men, it’s 8 years less. The unhealthiest place in the U.S. is the poverty stricken portion of Appalachia. And why do you think we have so many tobacco addicts, and so much obesity? Tobacco companies spent decades aggressively marketing their product and paying phony scientists to dispute the truth about its dangers. Food companies aggressively market nutritionally poor, calorie dense foods to children, and agribusiness has won huge subsidies from congress to grow corn for sugar. As a result, fresh produce has increased in cost relative to inflation in the past 20 years, while sugar has gotten cheaper and cheaper.
What do all of these issues have in common? They are political issues – issues of justice, inequality of wealth and power, the structure of society, who has access to the basic stuff we all need and who doesn’t. Influenza, on the other hand, is an absolutely equal opportunity disease, albeit you’re worse off in a poor country where you can’t get medical care if you do get really sick from it.
So why do we spend so much attention here to pandemic flu and so little to what public health is really all about? That’s an interesting question which I will address anon- assuming anybody cares.