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Talking Public Health With Obama

Posted: 12/19/08 04:13 PM ET

Any politician who tries to talk about science runs the risk of looking like a lounge singer attempting to rap.

It can get ugly. And for all the talk about the Republican war on science, party affiliation doesn't tell you much about who actually knows their stuff. Plenty of Democratic officials are clueless about science and health policy.

But President-elect Barack Obama seems to be one of the good ones. I interviewed Obama in October 2005 about the threat of pandemic flu and the broader problem of public health preparedness. I had written for years about various strains of avian flu, and Obama was more knowledgeable on this subject than any elected official I'd met, with a good sense of how to put that knowledge into practice.

[Although a couple of Obama's quotes made it into a front-page Chicago Tribune story on pandemic preparedness that I wrote with fellow reporter Tim Jones, this is the first publication of the interview transcript.]

The interview, done more than a year before Obama announced his presidential run, gives some insight into his governing instincts, especially his awareness of how a public health disaster could overrun a president's agenda. He touched on threats ranging from pandemic flu to terrorist attacks and a massive earthquake - "The Big One" - hitting California. Aptly for someone who talks about reducing partisan rancor, the two politicians Obama singled out for praise were both Republicans.

Obama showed an appreciation of how public health problems tie the world together, through economic fallout and the international spread of infections. He talked about the outbreaks of avian flu in Asia through the prism of his early years spent in the developing world - an experience that seems sure to influence how Obama views a range of global issues.

Given his new job, the most reassuring part of our talk was Obama's eagerness to think deeply about the most catastrophic threats facing the nation - an instinct that also showed in his collaboration with Sen. Richard Lugar on preventing nuclear proliferation. Hurricane Katrina was fresh in everyone's minds when we spoke. The lesson of that calamity, Obama said, is that government can never rest easy about potentially nation-shattering risks, however unlikely they seem.

Fears of pandemic flu have eased in the last couple of years, but the threat is real - estimates are that an outbreak could kill more than 60 million people worldwide. So it's a bonus that the next president already has educated himself on ways of keeping such a disaster from ever happening.

Q: How did you get interested in the problem of pandemic flu?

A: I already had an interest in ordinary flu vaccines and the challenge of producing adequate supplies. In the course of that I came across an article on the avian flu, and some of the reports that were already starting to come out of Asia. I lived in Jakarta, Indonesia for five years when I was a kid. And ...

Q: You knew that part of the world.

A: I knew that part of the world, and I was very familiar with how the livestock operations are. They're in people's backyards. As a consequence of that constant contact and population density, the possibilities of this avian flu mutating I think were more significant. And then I guess the other aspect of this was just my general interest in public health, and the fact that we tend to have underserved communities not only in the inner city but also in rural areas. All these things just made me concerned about how well we could adapt to a pandemic situation like this.

Q: How serious do you think the threat is?

A: I think it's very serious. I think I would distinguish between the particular threat of the H5N1 [avian flu strain], and the threat of pandemic generally. I think that there are reasonably high probabilities of this particular avian flu mutating, and the potential results would be so catastrophic that we have to do everything we can to prepare for it now. The probabilities of some sort of pandemic striking in the next decade are extraordinarily high. And we have to prepare for those circumstances, so that if we make an investment now in creating the infrastructure for vaccine production, strengthening the distribution system and the relationship between federal, state and local governments, those investments won't be wasted even if we're lucky and this particular strain of avian flu doesn't mutate, because we'll then be in a position to deal with whatever pandemic comes down the road.

Q: You took some of your first steps back in March [2005], but I get the sense that more people have gotten on the bandwagon since then.

A: Absolutely. I mean, nobody was really paying attention at that point. I was able to garner some interest from Sen. Dick Lugar, the chairman of the foreign relations committee, and we wrote an op-ed piece together, and he co-sponsored some legislation to allocate more money for surveillance activities in Asia. But beyond that this wasn't receiving a lot of attention.

I think what really changed the climate was Katrina. Because it made people realize that when you have some probability of a completely catastrophic event occurring, and you choose to ignore those probabilities, a catastrophe really can happen. And I think it scared the administration into looking at what other potential catastrophes were out there. And obviously terrorism continues to be at the top of the list. As well as the Big One in California. But I think at that point people became aware that pandemic should be at the top of the list as well.

In fairness, to give credit where credit is due, one individual in the administration who had been on this issue for some time was actually Tommy Thompson, the previous head of Health and Human Services. And he spoke about this while he was in the department, and in his exit interview before he resigned from being secretary, he actually said this was the single largest health threat facing the American people. But nobody was really paying attention at that time.

Q: One of the researchers who does modeling of pandemics for the CDC told me that over 20 yrs the likelihood is almost certain that something like this will happen. In any single year there might not be a high likelihood. But if it happens on your watch, it's the only thing you'll be remembered for.

A: No, absolutely. And I think the administration suddenly realized that if this happened during the next three or four years of the Bush administration, I mean, not only would it be a complete tragedy, but it's hard to see how ... I mean, the political fallout would obviously be enormous. The country hasn't seen the scale of what could happen in a pandemic since the last pandemic in 1918. It's just beyond the memory of most people.

Q: What are the best things we can do to prepare, both as a country and individually? Is there anything individuals can do?

A: Well, I mean I'm sure that an Internet market in Tamiflu has erupted over the last month, although I would caution people against trying to purchase Tamiflu over the Internet. You have to assume there's going to be a lot of counterfeit drugs sweeping through the market as people try to make a quick buck.

I think that people just having a good awareness of how quickly something like this could occur, having a plan for accessing public health facilities quickly, and frankly treating this as they would any other significant catastrophe in which you might have panics, and things might shut down in ways that would require to have basic provisions and supplies and so forth. All those things are relevant.

But frankly this is one of those areas where government has to carry the load. We have to purchase large stockpiles of Tamiflu. Because we did not get on this quickly enough we're at the back of the line compared to France, Germany, Japan and other countries. Right now we have a million doses, we'll probably have 2 million fairly soon, but we need 80, to 90 or 100 million. And then the government's got to set up an infrastructure to produce vaccine.

Q: There's no surge capacity right now. People say even in a normal year if you had a surge in demand there would be no way to meet that need.

A: Absolutely, I mean right now we're still using egg-based technology to produce vaccine, and we're going to have to move to cell-based technology, which is going to require investments in infrastructure. Now the private sector is going to have to be involved, but the government's going to have to incentivize the large capital investments that will be required in order to manufacture sufficient quantities once a vaccine is identified [for a given strain of avian flu].

Q: Do you think that medication is key? My sense is you can do things once a pandemic hits, but without medication you're basically going to be ameliorating rather than really stopping the outbreak.

A: Yeah, well even Tamiflu is not 100 percent effective. It helps your odds of surviving. But it's not a full-blown cure. But it can strengthen your immune system in fighting the disease.

Now the third thing we really have to focus on is surveillance, and assisting other countries and creating the kind of networks tat allow us to catch this as quickly as possible when you start seeing if there's been human to human transmission.

Q: It's hard enough to get ourselves prepared for this, but people do say we have to take a global view. We'd be pretty lonely if we only protected ourselves.

A: The nature of public health problems like this is that there are no boundaries. A flu virus is not going to check to see whether you're a U.S. citizen or a Nicaraguan citizen, or a Cambodian citizen. And given today's air travel patterns, it's likely that wherever this occurs, it will be in the United States within 4 to 6 weeks. The other thing to keep in mind is that assuming you set up quarantines or try to block entry of people and goods from let's say Asian countries, the cost economically to this country would be enormous. Even when the SARS scare struck, the losses were in multiple billions of dollars. And that proved to be a false alarm essentially. If something like this genuinely occurred, you'd see global trade come to a standstill. And in addition to obviously the loss of life, the breakdown of our health systems, the economic consequences would be huge.

Q: The president mentioned the idea of regional quarantines last week. The sense I get is that that's not a realistic thing once it's slipped through Southeast Asia.

A: No. I mean, you might be able to slow it.

So, you hate to be Chicken Little on this thing - no pun intended. But this is actually one of those situations where getting people a little scared, and certainly getting our government a little scared is probably a useful thing. And as I said, whatever investments we make are not going to be wasted, because the likelihood of pandemic is so high, even if it isn't this particular pandemic.


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