Be very afraid

So in addition to the lack of defensive medicine, the missing public health defenses in the Third World represent a breach in the walls.

No one in Washington has proposed funding resources that would allow East Africans to match the level of surveillance that Southeast Asia has. And while all this has been happening, the basic work of defending humanity against infectious disease, which involves continual development of new antibiotics, vaccines and antivirals, has been totally abdicated by the pharmaceutical giants. Those companies have no interest in making antibiotics or vaccines or antivirals because they are unprofitable. Infectious diseases don't create lifelong, expensive demand for medicines the way that chronic conditions like diabetes or heart disease do. Nor are they as profitable as culturally defined illnesses like erectile dysfunction, the darling of the pharmaceutical industry. There is one drug for diabetes that earns more than the revenue from all vaccines and antivirals put together.

Should the government be stepping in? Bush's recently announced plan earmarks money for this kind of research -- not enough, and it's about time, but is that a step in the right direction?

There's a few of us old enough to remember that, for instance, the influenza vaccine was originally developed by Jonas Salk for the U.S. Army in the Second World War. It was manufactured by the federal government, which used to actually make drugs, but no more. The Bush administration has now offered billions of dollars in subsidies to [Big] Pharma, which strikes me as inherently ridiculous. The most that any politician in Washington, Democrat or Republican, can think of doing apparently is to lay billions of dollars in guaranteed profits at the feet of the pharmaceutical companies, to waive all questions of liability for the vaccines and products, and then beg them to produce these vaccines and antivirals. The old-fashioned socialist in me wonders, Why shouldn't the federal government, in association with the public universities that produce most of the raw research that gets turned into these products, not produce lifelong medicines for free -- as a human right?

Some people ask why we should worry about a disease for which we know of fewer than 200 human cases. When we live in a world where millions of children die each year of diarrhea, malaria and even a lack of clean water, isn't this a fantastically rare disease?

And some people ask whether Bush's invocation of the avian flu wasn't just a plot to give money to the drug companies and divert attention from other issues. It is a reasonable question. The reason there should be real alarm is simply the experience of 1918. That was an influenza almost entirely novel to the human immune system, and it killed about 2 percent of humanity. Likewise, H5N1 is entirely new. And, more startling, researchers recently reconstructed the genome of the 1918 influenza and brought the virus itself to life for study, and they discovered that it was also a bird flu that jumped species, just like the emergence of the H5N1 avian flu of 1997.

Let's talk a bit about the public health issue. The public health infrastructure in the United States is suffering. We've seen the HMO revolution reduce the number of beds, and it's very clear, as we saw in Toronto with SARS, that in the case of even a small, localized outbreak, our public health system would be overwhelmed instantly. As a policy matter, massive public health revitalization ought to be at the top of the agenda. One of the things I kept wondering last year when I was covering the presidential campaign was why the Democratic side never equated all the resources spent on Iraq with the missed opportunities to make a sort of national security preparedness effort. The $200 billion thrown at Iraq could have been so much more efficiently spent on the public health infrastructure. As politics, it seems to be a no-brainer, a twofer: Invest at home, and address national security at the same time.

You talk about this a little bit in the book -- how the amount spent on these kinds of public health preparedness in the last three years was a just couple of billion dollars, less than we spend in 10 days in Iraq. Even before September 11th, everybody in the security sector was talking about how the biggest single thing we could do defensive-wise was to rebuild the public health infrastructure. But people really balked at the price tag: $40 billion. Now we've spent hundreds of billions in Iraq. With that kind of money, we could rebuild the entire public health system from the ground up. We could make the whole country like Switzerland, with transformer mountains that turn into hospitals, robots dispensing vaccines, everyone equipped and trained with lifesaving techniques. So I'm asking you to address the clear politics of the avian flu.

That's true, and more. The politics of public health anywhere begin with nutrition, and even right here in California we have a shockingly large number of children who go to bed hungry every night. We have malnourished children and malnourished adults. Fifteen percent of the children in Los Angeles have suffered from malnutrition. If the first level of public health is nutrition, the second level is basic immunization. Immunizations and vaccines should be an absolute human right in this country, freely available to everybody. The third level is our local health facilities, which have been closed by the thousands across the United States in the recent years. The fourth level is hospitals and, above all, intensive-care facilities. Think about what would happen in the case of pandemic influenza, where you need to hospitalize an enormous number of people in intensive care and some degree of isolation. Los Angeles has lost something like 17 percent of its hospital beds since the year 2000, largely due to HMOs, which operate on the "just in time" system of closing hospitals, getting rid of hospital beds and raising the profit margins -- as if epidemics, and surges in intensive-care cases, will never occur.

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