Ill

10.03.13

How the Shutdown Could Make You Sick

Flu vaccines won’t be affected by the shutdown, but we’re not out of the woods yet. Dr. Kent Sepkowitz on the most critical public-health task that’s not getting done.

The government shutdown has created a series of hardships and dangers for citizens coast to coast. One that is featured prominently is the threat to individual and public health. The stories of children prevented from receiving life-saving treatments, seniors who no longer can rely on certain services to maintain independence, and the plight of a scientific community unplugged are heartbreaking, embarrassing, and hopefully of sufficient emotional pull to force a resolution to this self-inflicted crisis.   

Another danger—the threat of a runaway influenza epidemic unable to be contained by a crippled public-health complex—is also often featured on the list of scary potential consequences. But here, the impact, while very real, isn’t as simple as it may seem.

Unlike the sequester, which diverted money from actual vaccination programs, the shutdown disrupts an altogether different aspect of public health. The vaccine, for the most part, already has been made and purchased. Vaccinators, from the local doc to the local drugstore, are not really affected. Neither are most local vaccine clinics and school vaccination programs, which are paid for by local government. Yes, a few vaccination hotspots that will be shuttered and lives potentially affected, but the danger is larger than this.   

The real threat is that the Centers for Disease Control and Prevention’s magisterial surveillance system, which monitors the rate and types of influenza, the rapidity of spread, the drug-resistance profile—all of it—will not be able to function. But surveillance is a strictly back office sort of activity—far from the sexed-up Hollywood allure of Contagion and Outbreak and all the other movies that brought together hot actresses and lethal viruses.  

No, surveillance is decidedly unsexy, but it is the key to the system. Without it, the U.S. public-health program is on par with that of Somalia. Oh, alright, Uruguay then, but bad, crippled, near useless. One need only recall the controlled chaos that accompanied last year’s flu epidemic or the great H1N1 epidemic that started one day in 2009 with teenagers from Queens, New York, returning from a spring break bash in sunny Mexico. More than 60 million Americans developed infection from the novel H1N1 strain, an almost unbelievable number. And a number known only because of surveillance, that relentless bean counting that must be done to build any basic understanding of a situation, medical or otherwise.  

Tales from the back office never make the headlines unless there’s a screw-up.

Over the years, the CDC has developed and adjusted its influenza surveillance program to follow the inevitable appearance of influenza from its first few cases to its final tally. (It has parallel surveillance programs for countless other diseases that also will be frozen in place till the shutdown ends.) With the information gathered quickly and calmly, the CDC is able to make adjustments in mid-air, advising local health departments on where to push vaccines and where to worry a little less, on whether it’s time to close a school or unbottle widespread preventative therapy with oral medication. For example, the recognition that the novel H1N1 influenza strain caused fatal infection in pregnant women led to a real-time recommendation to obstetricians across the country to vaccinate their patients. It’s an intervention that, like so many, has no clear measurable outcome because of the countless moving parts of epidemics, but surely saved lives.  

What makes a great and effective public-health program, like any effective government program, is information (obligate Edward Snowden comment deleted)—lots and lots and lots of information. Without it, we are like an Army marching into the battlefield with enough bullets perhaps, but no idea which way the enemy is coming from and no idea if they number a hundred or a hundred thousand.   

But tales from the back office never make the headlines unless there is a screw-up. So the value of the CDC and of surveillance itself is lost in the discussion, or at least blended into a “loss of the influenza vaccine program” headline that doesn’t quite say what’s what. Admittedly, there is the problem that people who are passionate—really passionate—about surveillance (and I proudly count myself as one) are usually excruciatingly boring to talk to. The details that make it critical—how many cases in the last 24 hours, whether the local ER in a rural town has enough culture media for a week’s worth of tests, if the snow will mess up collection of specimens from upper Michigan—these critical pieces can, when pieced together, make the Weather Channel seem like the final episode of Breaking Bad.    

But that's the point: excellent public health, like excellent government, is the simple sum of its parts, the product of countless people doing thoughtfully organized, meaningful work towards a specific goal without particular attention to who gets on the 6 o'clock news. It's the real thousand points of light—not small sparks of American genius scattered across the terrain but rather the thousand sexless data points that collectively point the way to informed decisions.

As the current carnival demonstrates, however, when emotion and feral hatreds guide the country rather than bland, boring information, everyone loses.