Swine flu pandemic tests patchwork health system

Posted: Monday, October 12, 2009

When the federal government began shipping pandemic flu vaccines last week, the Centers for Disease Control and Prevention said vulnerable groups such as children and pregnant women, who are most likely to die from the virus, should be given priority in being inoculated.

The District of Columbia had other ideas.

The D.C. Health Department decided that it would start giving vaccines to many public school kids on Oct. 19, but, as The Post's Nelson Hernandez reported, it would make private school kids who live in the District of Columbia wait two more weeks to get their shots - as if the flu somehow infected children based on tuition payments.

Inside a 13-page draft of D.C.'s flu strategy were more oddities. In addition to the CDC's priority groups, the city decided to add in its own priorities, including "essential District personnel" and "incarcerated persons." This suggested that pregnant women and children might have to compete for the shots with healthy bureaucrats and prisoners, who aren't at high risk for complications.

Federal health officials got wind of this strange plan and placed a call to the D.C. health director, Pierre Vigilance. He was home sick, as it happens - with the flu. District of Columbia officials, who say that the plan wasn't finalized and that it was never their intention to vaccinate prisoners before kids, revised their plan and are now in line with the CDC recommendations.

The episode, and the pandemic-flu response generally, point to the many problems with the nation's patchwork of a public health system. There are more than 2,500 state and local health departments in the nation, and they are plagued by huge disparities in funding and competence. A study by Glen P. Mays of the University of Arkansas found that the top 20 percent of communities had public-health agency spending 13 times greater than those in the lowest quintile. And even the best are in bad shape: The National Association of County and City Health Officials reports that local health departments cut 8,000 jobs in the first half of 2009 and 7,000 in 2008.

The swine flu vaccination program shows the strain and the disparities. The shots are paid for and shipped by the federal government, so Americans should, in theory, have equal access. But children in Illinois, New York, Utah and elsewhere started getting the vaccine on Oct. 6. Children in Prince George's County, Md., started the vaccination on Oct. 9. But children in the District of Columbia won't see their first vaccines until Oct. 19 - if all goes well.

Other measures of pandemic preparedness are equally lopsided, but in a different order. The District of Columbia has adequate supplies of antiviral medicines, but half of the states don't have enough to cover more than 25 percent of their population, according to the Trust for America's Health. Colorado is the worst off, having only enough medicine for 14.9 percent of its residents.

This hasn't mattered much, because the pandemic flu strain, mercifully, has proven to be relatively mild so far. So we can consider this a drill; had this been an actual pandemic, or a biological terrorism attack, we'd all be in deep trouble. And even in the absence of such a menace, we're being ill served every day by a public health system across the country that can't keep up with obesity, diabetes and the rest of Americans' ailments.

The good news is that there's a provision in the House version of the health-care reform bill, written by Rep. Henry Waxman, D-Calif., that would fix much of the problem. Now, state and local public health departments get federal grants only for specific diseases and conditions, which makes it difficult to maintain a core public health infrastructure. Waxman would solve this by spending $1.3 billion a year on overall public health - and in exchange for the cash, state and local health departments would have to meet minimum standards for such basic things as laboratories, disease surveillance and vaccine delivery. A national accreditation board would enforce the standards.

"Is there a minimum core capacity that every American should expect their local health department can deliver? We think the answer is yes," said Jeffrey Levi, director of the Trust for America's Health. "The federal government has been more reluctant than it ought to be in ensuring some kind of consistency."

As this fall's pandemic response shows, it's time to shed that reluctance.

• Dana Milbank is a reporter for The Washington Post.



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