In June of 2008, researchers from the Tohoku University School of Medicine in Tokyo warned, in a report re-published by the CDC, well before the masked and panic-laden Spring Break of 2009 images from Mexico City emerged, that mortality rates from a future pandemic would likely be higher in countries where:
- Its citizens lack access to adequate medical care
- Its public health infrastructure is weak
- Conditions, including housing and population density, contribute to spread of disease
- Host factors exist, including nutritional status and co-existing medical conditions; and
- Its citizens experienced a high HIV/AIDS prevalence.
The researchers from Japan were profiling the potential impact of the next influenza pandemic in developing countries, well before H1N1 burst on the scene. And, in the end, they may be right -- deaths associated with H1N1 will likely be considerably higher in developing countries than in high-income countries.
But how will the United States fare against other industrialized countries that offer adequate health care to all of its citizens? Already we are observing death rates in children and teenagers early in the year. Indeed, as of October 9, we had already seen over 75 deaths in children, a figure that is higher than the rate typically seen for seasonal flu over an entire season, and winter hasn't even begun.
And could these heartbreaking deaths, many of them affecting otherwise healthy children, have been avoided in the United States, still the richest country in the world?
We must ask our policymakers whether some children died in the U.S. because a) care was delayed or refused because of cost, b) there weren't enough providers to diagnose and treat , c) whether too many of our children have underlying diseases, including diabetes and asthma, because of health and reimbursement policies skewed away from prevention and/or chronic disease management and/or d) our public health infrastructure has been significantly impacted because of thousands of layoffs in the last two years. We must also ask about vaccine production, but more on that later.
Consider the following information, because for good or ill, California is often a harbinger of what's to come for the rest of the country.
- Since the recession began, 661,000 Californians have lost their employer-based coverage, resulting in an uninsured statewide rate of over 26%.
- Even for those who have coverage, access to care is no guarantee -- scores of hospitals and emergency departments have closed throughout California leaving long lines, and delay of care to critically ill patients. Many of these facilities closed because of bankruptcy driven by increasing numbers of uninsured patients and patients on public plans with low reimbursement rates.
- In the poorest parts of Los Angeles, citizens with the highest rates of diabetes, asthma, cancer and HIV in the country, have a difficult time obtaining access because of high rates of un-insurance and limited numbers of healthcare providers, thus placing an even greater burden on the remaining provider community.
- Even if we expand coverage, the American Academy of Family Physicians reports that we do not have enough primary care practitioners to treat everyone who needs care, and estimates that we will face a shortage of 40,000 family practice physicians by 2020 just when the baby boomers' health care needs spike. Estimates are that California's shortfall alone will exceed 4,200 by that time. This means that even for families with healthcare coverage, the emergency room has become the 'primary care' default office, once again leading to long lines and delayed care. The numbers of medical students going into primary care has declined by more than 50% since 1990, in great part, because the reimbursement rates from both commercial and public payers is much lower than those paid to specialists.
- And finally, a strong public health infrastructure is integral to a nation's ability to respond to a public health disaster. The U.S. has been preparing for such an occurrence, particularly since 2002, and has taken many steps to protect its citizens. The recession, however, has taken its toll, at exactly the wrong time. In 2008 alone, over 12,000 public health workers were laid off.
Policymakers initially indicated that distribution of H1N1 vaccine to high-risk groups and healthcare workers would begin by mid-October with an anticipated delivery of 40 million vaccines. Instead, we are learning about delays of approximately 25% of promised vaccines, amounting to delays of 10 to 12 million doses.
Perhaps the delay is warranted because of the time it takes to develop and distribute a safe vaccine. Clearly, many concerned parents are worried about safety, and some are indicating that they will not have their children vaccinated even when the vaccine becomes available.
But the question must be asked as to whether companies charged with the production of the H1N1 vaccine are setting aside production of, say, more profitable drugs, in order to get needed vaccines to our high-risk groups and/or are refusing to commit more resources to expediting delivery. Indeed, GlaxoSmithKlein, the only manufacturer licensed to develop H1N1 vaccine for Canada, has already been challenged and, as of August 19th, has apparently refused to commit more resources to packaging the vaccine in order to facilitate its delivery.
Hospitals are typically required to comply with surge capacity protocols, including the diversion of ambulances and cancellation of elective procedures when disasters strike, even though this means the potential loss of millions in revenue. Are pharmaceutical manufacturers privileged to do business in the United States similarly required to expedite the safe manufacture and distribution of antivirals and vaccines, even if doing so means more profitable business lines are placed on hold, and/or the cost of meeting pre-established delivery dates is higher than originally contracted?
If the answer isn't yes, then policymakers should act fast to create the appropriate remedy to protect our most medically vulnerable populations.
Thus far, it should be painfully obvious, even to families who haven't been affected by H1N1 yet, that policies skewed toward the maximization of profits for health insurance and, quite possibly, pharmaceutical companies, may not be good for American families.
As the healthcare reform debate continues, we must ask whether our country's collective 'Katrina' movement has arrived. And have we served our children well?