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Swine Flu Hearts Our Health-Care System

PH2009081300398.jpgThe President's Council of Advisors on Science and Technology released its big report (pdf) on H1N1 on Tuesday. Some of the news was pretty sobering: The council estimates that swine flu could infect up to half of the population this year, hospitalizing 1.8 million and causing as many as 90,000 deaths — about double what we'd expect from an average flu season. And that's assuming there's not a dangerous mutation that makes the virus either more lethal or more communicable. Matters aren't helped, unfortunately, by our fractured and inefficient health-care system.

Because the most severe outcomes appear to be concentrated in certain groups, based on data thus far with 2009-H1N1, it is logical to assume that focusing mitigation efforts on those groups will have disproportionate public health benefits. In addition to accelerating the availability of vaccine, it is important to develop clear guidance about the means of access and appropriate use of vaccines and anti-viral drugs for these groups and to communicate that guidance to them and their health care providers promptly and effectively (discussed in Chapter 7). We note that the complex and distributed nature of the U.S. healthcare system poses logistical challenges in accomplishing these goals, which will require considerable planning.

We have a tendency to judge the health-care system primarily by its capacity to deliver extremely sophisticated and advanced care for traumatic injuries and catastrophic illnesses. The sort of stuff you see on "House," say. But we think much less about its role as a public health infrastructure — its ability to deliver flu shots, and make sure that all of the country's inhabitants have a trusted medical professional they can see if they're sick.

On those measures, our system performs terribly. It's simply too fractured to do anything different. Almost 50 million Americans have no insurance. Many more are underinsured. Many don't have a particular doctor or even medical center where they feel comfortable receiving care. Many are uncertain about what is and isn't covered in their health plan. Many have recently been uninsured, and so have no regular contact with the medical system and haven't established an obvious way to begin having some.

The backstop to all this chaos is that you can go to an emergency room when things get really bad. That's fine for a car accident. It's not good for preventing the spread of the flu. You don't go to the emergency room when you're a bit sick. You go when you've become really ill. Which not only increases the likelihood that you wait until you get really sick, but with the flu, that you infect many others along the way. That in turn gives the flu more opportunities to mutate into something much worse. And let's not even talk about our insistence on keeping the illegal immigrants who prepare our food and clean our homes from seeing the doctor, as if H1N1 can't be transmitted by people who don't have a green card.

Photo credit: By Mark Humphrey — Associated Press

By Ezra Klein  |  August 25, 2009; 4:31 PM ET
Categories:  Health Coverage , Health Reform  
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the ramifications of this flu are really frightening, from every perspective....there are already some very intense strains of flu that are making people very ill this season.
i cant help wondering, could one more bad/terrible thing fall on obama's watch?
if i were barack obama, i would be tempted to stay on martha's vineyard indefinitely, planting heirloom tomatoes and taking many afternoon naps.

Posted by: jkaren | August 25, 2009 5:26 PM | Report abuse

This post makes little sense, because the flu is a terrible example to use. Ezra posits some preferred public health outcome where people go to the doctor when they're just a bit sick with the flu -- to do what? There's little that can be done to treat a virus, except when it gets so bad that the symptoms have to be addressed as an emergency. In other words, a scenario where people make a lot of useless visits to their doctor is not the best pro-reform argument to make.

One compliment: this post was a useful reminder that illegal immigrants are indeed a live issue in health reform.

Posted by: tomtildrum | August 25, 2009 5:32 PM | Report abuse

This post needs a fact check.

President Ford ordered nationwide H1N1 vaccine administration on 24 Mar 1976 at a cost of $135 million. Mass illness from the flu was, in large part, avoided; however, the vaccine had side-effects and taxpayers were ordered by the Courts to pony up funds to the families of those injured by the vaccine.

There are several sources of factual information on the matter, not the least of which is "The Swine Flu Affair: Decision-Making on a Slippery Slope" (National Academies Press, 1978).

This is an issue that shouldn't be made political: it has to do with a potential public health emergency, not the routine health care system.

Posted by: rmgregory | August 25, 2009 5:45 PM | Report abuse

It's about time someone said that it is better to provide health care (and education for that matter) to everyone in the country regardless of their immigration status. If TB started to take hold in the immigrant community, wouldn't it be better for them to have options for treatment? Or should we let it fester and grow into a full epidemic in the documented, full US citizen population before public health officials get involved?

Wouldn't it be better for kids, regardless of their immigration status, to be in school instead of on the streets getting into gangs and committing crime?

Posted by: srw3 | August 25, 2009 5:47 PM | Report abuse

In my opinion, the healthcare debate can be summed up by looking at two opposing camps:

--I've got mine, don't mess with it. If I ever get really sick I want the latest PET scan, nuclear this or that, and I want it pronto.
--what is good for the largest percentage of the population. This captures the public health argument Ezra is making here.

Without universal care, public health is at risk. This is not really debatable if you look at the journals. This is why our relative health stats are not up to par with other industrialized countries.

What people are afraid of is the large catastrophic expense where you need the PET scan and the latest nuclear gadgetry pronto. That fear, and the fear that someone will tell them they can not have it, is driving the hysteria. Of course, the rationing feared exists is just based on income or a health insurance company is doing it to you.

Health care expenses in this country are mainly comprised of primary care (eg I go to the doc for my tennis elbow for a NSAID, etc) and chronic care (I go to my doc for my diabetes, asthma, etc). The catastrophic creates a good story, but is not the driver.

I read an article today about a guy in GA who went to a townhall to politely protest reform because his wife had had breast cancer (he had employer sponsored healthcare) and he did not want anything to mess with that system. He was afraid that anything we did would cause rationing. Of course, a large portion of his wife's treatment was not covered, but that was not seen as rationing. He acknowledged that the safety net did not really exist, but that was OK because he was getting what he needed. How screwed up is that?

Posted by: scott1959 | August 25, 2009 5:50 PM | Report abuse

"This is an issue that shouldn't be made political: it has to do with a potential public health emergency, not the routine health care system."

Shorter rmgregory: the "routine health care system" in the US can't cope with public health.

Posted by: pseudonymousinnc | August 25, 2009 5:56 PM | Report abuse

To add to that: rmgregory just basically backed up TR Reid's formulation that healthcare in the US -- calling it a system is an insult to systems -- is a patchwork quilt with a large expanse no different from that found across the third world.

Posted by: pseudonymousinnc | August 25, 2009 5:59 PM | Report abuse

This H1N1 flu looks like another opportunity to prove America's exceptionalism: We're the best!

We'd rather rail against even a nickle being spent on undocumented immigrants (or any immigrants at all, bottom line) than consider that having the triage nurse (with citizenship) at the ER may have 10 relatives at home with no docs and near fatal cases of flu that she carries to work each day on their clothes. Or the MD with Pilgrim ancestors picking the flu up on the bike rack and generously spreading it from exam room to room. It just doesn't enter the mind that viruses and other bugs don't give a damn about heritage, income, social status, or skin color.

So, we'll be the best, again: at ensuring that the highest percentage of folks are exposed and untreated for a highly contagious bug. Then we can all say: "I've got mine", and really mean it.

Posted by: JimPortlandOR | August 25, 2009 6:11 PM | Report abuse

In Ontario, seasonal flu shots are free to everyone. The infrastructure developed for seasonal flu shots can be adapted for H1N1 shots.

Can I get a free shot from my doctor? Sure. Can my company have a private nurse come around and give shots? Yes, but the company will have to pay for the nurse. Can I go to a public clinic and get a flu shot for free? Yes.Can I go to a shopping center on a certain day and get a free flu shot? Can my brother the doctor get supplies and inject a bunch of us at family gathering? Yes.

I should mention that at the Shopping Center the staff asked all the right questions before I got the shot.

I've gotten a flu shot everyway above except at a regular public clinic. Except with my brother, for billing purposes, they ran my health card through a scanner.

If you don't have a health card because you're an illegal immigrant here's what the government says:
"The flu vaccine is available from your family doctor and walk-in medical clinics. The flu shot is free for anyone six months of age or older who lives, works or attends school in Ontario."

The government wants everyone to get the seasonal flu shot. A side-effect of universal free flu shots has been a drop in the inappropriate use of antibiotics as fewer people show up with the flu asking for useless antibiotics--which should slow the development of antibiotic resistance.
(google and find the recent study)

As for H1N1, the vaccine will be free to everyone. Shots will be given out with priority to health care workers, the elderly, those in contact with elderly first.

Unfortunately, the idiocy of the largely American anti-Vaccine movement is everywhere in Canada. There are many "health" care workers who won't get the shot. Maybe this year will be different.

If you're anti-vaccine and read this, here's something to think about. Flu vaccines don't work that well with the elderly. Much of their safety depends on the non-elderly people around them having gotten the shot and therefore cannot pass the flu onto to the elderly. If you're not getting a shot, stay away from the vulnerable.

Posted by: shelgreen | August 25, 2009 11:14 PM | Report abuse

Flu shots are $20-$30. They should be covered with direct payments, not insurance.

Trips to the doctor with the flu are generally useless, and one of the main reasons for the over prescription of antibiotics, as patients demand "something" from the doctor.

If you want to cure the flu, make Tamiflu and its competitors available over the counter and it will be profitable to make enough and for it to be cheap enough for everyone to afford.

Or you could set up a government bureaucracy to drive up the the cost by removing competitive pressures, reduce the convenience, and reduce the chance of people getting the jab.

Posted by: staticvars | August 26, 2009 12:10 AM | Report abuse


I agree. It should be sent to local pharmacies across the country as well as doctors offices but why get it from a doctor when a nurse at a pharmacy can administer it similar to how its done with the regular flu in any other year for many of those without insurance or whose copay's are greater now than the cost of the shot. If we're going to start having nurse practitioners handling this type of routine care here is as good a place as any to start.

Posted by: visionbrkr | August 26, 2009 12:51 AM | Report abuse

While going to the doctor for mild flu symptoms is to be discouraged, there are recomendations for certain high risk patients who are ill and high risk contacts who have been exposed to H1N1 to get antiviral medications: pregnant women,
kids under 5, people with obesity and chronic illness. Anyone with direct contact with a baby under 6 months should get the H1N1 vaccine when it comes out because the baby is too young to get vaccine, and of course all the other high risk people mentioned above as well as health care workers should be first in line for the new vaccine. We are talking about a lot of people at risk who are going to need more than tylenol and hand sanitizer and it will be a disaster if this kind of care takes place only in ER's, because heart attacks, strokes, trauma do not take a break during flu season. Making Tamiflu over the counter is a ridiculous idea; the last thing we need is drug resistance and med shortages. I am afraid that our non-system will make this harder than it needs to be.

Posted by: CarlaKakutaniMD | August 26, 2009 1:02 AM | Report abuse

"And let's not even talk about our insistence on keeping the illegal immigrants who prepare our food and clean our homes from seeing the doctor, as if H1N1 can't be transmitted by people who don't have a green card."

I think the bigger problem is actually that we don't have adequate, or in most cases any, paid sick leave for service occupations, regardless of employees' immigration status. I can't really blame anyone for coming in to work sick if 20% of their weekly pay would be lost otherwise, but these are the workers who are in casual contact with more people in a day than I'd usually deal with in a month. But what's truly important is that marginal low-wage workers are reminded that they're marginal by their lack of benefits, and desk jockeys like myself can feel superior taking a week off when we're infected with the workers' flu during a weekday lunch... because that's how we know who in this country's important and who's not.

Posted by: latts | August 26, 2009 1:23 AM | Report abuse

Check out: Conservatives To Reject Government-Run Swine Flu Vaccinations -

Posted by: SandboxReport | August 26, 2009 5:28 PM | Report abuse

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