Outbreak could reveal socioeconomic divide

November 03, 2005|By HILLEL W. COHEN

Will preparations for pandemic flu incorporate important lessons from Hurricane Katrina?

President Bush unveiled a $7.1 billion plan Tuesday that concentrates on expanding production and stockpiles of vaccine and antiviral medicine. It may still fall far short of what is needed.

The Bush plan has prioritized protection of pharmaceutical company profits with broad protection against liability suits but did not suggest how low-income families without prescription medicine coverage will pay for medications. Conspicuously absent was a proposal for emergency licenses for generic versions of antiviral drugs to increase supplies at lower cost.

Moreover, while vaccines and antivirals undoubtedly have an important role in preparing for an epidemic, to believe that acquiring and stockpiling medicine will answer the problem is to believe that the Katrina evacuation failed because the country had too few vehicles to transport all the residents of New Orleans.

Similarly, the desperate conditions in the Superdome and Convention Center did not come about because the United States doesn't have adequate supplies of food, water and sanitation facilities. The problem was not lack of resources, but rather an infrastructure and government unable to make those resources available in a timely manner to those who needed them most. And at the root of this problem, as the television images made starkly clear, were issues of race and class.

During Katrina, race and class determined who had the resources to evacuate in time. In the event of an outbreak of pandemic flu, race and class will impact how the pandemic spreads and how effective the response will be.

Socioeconomic factors, particularly race and class, are almost always among the top predictors of who gets sick and who dies of infectious diseases like flu, tuberculosis and AIDS or chronic illnesses such as heart disease, cancer and diabetes. Race and class identify those who have the weakest immune systems, those who live in environments with the unhealthiest conditions, those who have the least resources to cope with crises and those who have the least access to health information, preventive care, medical services and medications.

For example, Mr. Bush directed the public to a Web site to get advice but didn't suggest how people without internet access will be informed.

In a serious flu outbreak, people may be instructed to stay home. But what about workers who don't get paid sick leave? Where will those who live paycheck-to-paycheck get money for food, rent and heat? Families with higher incomes have cupboards filled with groceries and supplies. Poorer families will run out in a day or two. People with cars might get to food and medicine distribution centers. Those who require public transportation will be forced to risk greater infection rates in the closed quarters of buses and trains, assuming these are even available.

If businesses remain open but schools are closed, who will watch the kids of working parents? When emergency rooms are overwhelmed, who will have access to private physician offices? Despite increased production, will there be enough antiviral medication, and at what cost? Will an underground market quickly emerge to make medicine available only to those with the most cash or connections? Will government distributions consciously or unconsciously prioritize the wealthier, more politically powerful communities?

The government could mandate employers to pay sick leave for workers who are ill or must care for children. Food stores could be mandated to distribute subsidized food and medicine where needed.

In light of harsh criticism of the delay in federal response to Katrina, Mr. Bush last month proposed rapid military involvement in the event of a pandemic. But such a proposal is more frightening than reassuring? Is the administration making contingency plans for what could be tantamount to martial law? If so, martial law could itself be an incalculable disaster to public health as well as civil liberties. A photo of flooded New Orleans in which whites were carrying groceries was captioned "Getting provisions" while an identical one with blacks was captioned "Looting." Will armed soldiers react to similarly prejudiced perceptions?

It is too soon to tell whether H5N1, or avian flu, will transform into the human pandemic that many fear or whether it will pass like the 1976 swine flu. But it is already clear that failure to account for racial and economic inequalities can have deadly consequences in the event of any public health emergency.

Epidemics and natural disasters are inevitable, but repeating mistakes and ignoring lessons are not. For decades, public health infrastructure has been allowed to crumble and frantic catch-up measures will be too little and too late if the lessons from Katrina are not learned. Recognizing the role of race and class in disease and enrolling and empowering local communities to overcome the effects of social inequality must be part of any effective pandemic preparedness plan.

Hillel W. Cohen is an associate professor of epidemiology and population health at Albert Einstein College of Medicine in New York City. His e-mail address is hicohen@aecom.yu.edu

Baltimore Sun Articles
Please note the green-lined linked article text has been applied commercially without any involvement from our newsroom editors, reporters or any other editorial staff.