What Would Romney Do?
As the national elections enter their final laps in the United States it seems reasonable to ask how the respective candidates would respond to a pandemic threat. As was the case in 2008, as Barack Obama and John McCain slugged out the last election, swine flu is brewing right now, and warning signs are obvious, even alarming. (More on that, below.) When the 2009 H1N1 “Swine Flu” pandemic broke out the Obama Administration had no Secretary of Health and Human Services, no permanent leader for its Centers for Disease Control, and generalized disarray in its response. We were lucky – the virus was a comparative influenza wimp. But what if it had been a virulent killer strain?
Given the mountain of federal documents and academically-published papers released since the 2009 pandemic – we count more than 1,000 of them so far – it’s clear a massive collective learning experience has transpired inside public health and government circles. The mea culpas and analyses have been issued from Geneva,Mexico City, Washington, Bangkok and every other power center in the global health world. The failures and mistakes have been listed, and the bottom lines are clear:
- There weren’t enough vaccines to go around, and there never will be unless completely novel methods of designing and manufacturing immunizing compounds are developed. Though many potential products are in the pipeline, no innovations can possibly be available for general use during this decade, as radically new forms of vaccines remain in early stages of R&D. Therefore, we must assume that should a flu pandemic erupt on the watch of the next President of the United States, the world’s vaccine supply would miss needs levels by more than 90 percent, and the vast majority of vaccine would reach people after their region’s epidemic had already peaked.
- The populations that suffered the highest hospitalization and death tolls in the 2009 pandemic werebabies, pregnant women and young adults aged 15-35 years. Most of the estimated 285,000 deaths caused by H1N1 were of people less than 65 years old (80 percent), living in Africa or Southeast Asia (51 percent). In no country in the world were public health and medical systems prepared to mobilize for these population groups, as typical influenza mortality hits hardest among the elderly and individuals suffering immune-compromising chronic diseases. Though improvements have been made since 2009, most flu systems remain best prepared to mobilize on behalf of the elderly.
- Worldwide the populations least likely to receive timely vaccines and treatment for flu in 2009 werethe very poor – indigent populations within richer countries, and the entire citizenries of poorer nations. The political repercussions of vaccine and pharmaceutical battles on the international stage wereenormous and contentious. Nothing has changed that picture.
- The U.S. was compelled to bid against other countries for positions in the vaccine and drug queues as our own domestic pharmaceutical production capacity proved woefully inadequate, and the primary flu drug, Tamiflu, is Swiss-made. Little done since 2009 would change this conundrum. Therefore, should another influenza pandemic occur, the survival of Americans would literally be dependent on the ability of our Federal government to out-bid other nations, drawing billions from our national coffers to buy our way to the front of the vaccine and drug queues of companies located all over the planet. Given the fiscal constraints and budgetary battles on Capitol Hill, conjuring hundreds of billions of dollars to out-bid Europeans and Asians for meager vaccine supplies might prove problematic in 2013.
- Local public health responders were ill-equipped and understaffed in most of the country. Hospitals were swamped with ailing flu patients and worried-well, over-taxing not only their bed and staffing capacities, but also budgets, as many of the patients were uninsured.
THE OBAMA STANCE
The Obama Administration has issued its flu plans, pandemic schemes, and stacks of documents detailing how it might better respond the next time. Its positions are, therefore, clear. Moreover, Secretary of Health and Human Services Kathleen Sibelius, who stepped into her job midway through the 2009 pandemic, has repeatedly addressed these issues and tied preparedness to the Affordable Care Act (aka “ObamaCare”), arguing it will offset much of the cost of responding to an epidemic as more of the nation’s patient population will be insured and hospitals will be better reimbursed for their efforts.
Overall, the Obama Administration considers pandemic threats an element of National Security. Response therefore entails an all-hands-on-deck Federal mobilization of not only health agencies, but Homeland Security, the military, and multiple other agencies – all working in partnership with the states and their responding entities. Protecting the American people against epidemics, and assisting other countries in their epidemic responses, are duties of Government, in the Obama worldview.
But what do we know of the Republican candidate, Mitt Romney, and his likely Presidential responses to a pandemic?
THE ROMNEY STANCE
To date Romney has only once addressed the pandemic issue, in response to a list of questions from Scientific American, sent to both candidates. While acknowledging the genuine hazard of epidemics, Romney emphasized pharmaceutical innovation and deregulation as keys to preparing America:
“Unfortunately, the Obama Administration has taken numerous steps that are stifling medical innovation. He has imposed new taxes on innovative companies. He has empowered bureaucrats to manage the marketplace. His FDA has slowed the drug development process and inserted requirements that drive up the cost of developing new antibiotics. A robust public health system is only as strong as the tools available, and I will empower the private sector to pursue the breakthroughs that will equip society for the health challenges of the twenty-first century.”
Neither Romney nor Vice Presidential running mate Paul Ryan have indicated whether they would support the pandemic plan created in 2006 by the Bush Administration. Under President George W. Bush, the State Department placed global preparedness for influenza and international cooperation high on its priority list. But the 2012 GOP leadership hasn’t stipulated its positions either on domestic or global pandemic response.
We are left to sift for clues to likely responses from more general statements. Romney and Ryan have vowed to repeal the Affordable Care Act immediately upon taking office, but have not indicated what precisely they would replace ACA with. Congressman Ryan favors creation of lump sum pools of health funds allocated to the states, based on an unstated distribution algorithm, to be used to pay for healthcare as the individual states deem appropriate. Some states in this scheme might choose to create epidemic response teams or hospital reimbursement plans, but it is more likely most cash-strapped local legislatures would dump the funds into general health coffers in hopes of paying existing salaries and bills.
Governor Romney strongly opposes “big government” and Federal spending, supports Ryan’s scheme to slash most public goods spending and radically reduce the U.S. budget, and favors deregulation over most forms of Federal oversight of business and social activity. He has never stated how he would reconcile plans to diminish government with the exigencies of epidemic control and response.
In 2009 the threat of a flu pandemic was greeted with partisan response on Capitol Hill. Two months before the pandemic was recognized, President Obama introduced an economic stimulus bill that included nearly $900 million in flu preparedness funding. Maine’s Senator Susan Collins famously rejected the flu funding saying, "Does it belong in this bill? Should we have $870 million in this bill? No, we should not." Republican Party strategist Karl Rove applauded Collins’ actions and denounced as “disturbing” Obama’s inclusion in the original stimulus bill of, "$462 million for the Centers for Disease Control, and $900 million for pandemic flu preparations." The GOP voted against the pandemic money, and it was dropped from the stimulus bill.
Two months later H1N1 swept across America and Wall Street clamored for flu spending, fearing massive productivity losses and stock-outs amid widespread illness. Wisconsin Democrat Senator Dave Obey seized the opportunity to attack Collins and fellow-Republicans, charging, "We have been trying to get adequate funding to prepare the nation for a pandemic outbreak since 2005. We tried again as recently as January in the economic recovery package. Whether or not this influenza strain turns out to have pandemic potential, sooner or later some strain will."
As Swine Flu spread across America, Congress shifted its view, and the price tag soared. The White House asked for $1.5 billion in emergency funds for pandemic response. On May 14 Congress passed the Supplemental Appropriations Act, providing $1.85 billion for the “Public Health and Social Services Emergency Fund,” to address Swine Flu. Among those voting for that spending were Sen. Collins and Wisconsin RepublicanCongressman Paul Ryan. In the end Congress spent more than twice the originally rejected pandemic request.
America has become a “patchwork nation” divided by hundreds of issues, and governed by highly disparate models of leadership. In one county, located in one state, the government may be well-funded and highly proactive, engaged in an enormous range of local health activities. But the next county down the road or the abutting state may offer little health leadership, have a far larger uninsured population, and feature no capacity to respond to a biological threat, natural or manmade. Our public health patchwork reflects differences in economics, politics, religion, and the general notion of “government responsibility,” leaving the fifty Governors with tremendous personal authority in epidemic crises. Such was the case in 1918 when the Great Influenza swept the world, and as John Barry has demonstrated, the various afflicted states had wildly divergent reactions, laws and police actions: There was no National response to the deadly flu.
As Governor of Massachusetts, Romney demonstrated that he viewed biothreats as government responsibilities, and drew heavily on Federal funds to support bioterrorism preparedness in his state, flu planning, and hospital response capacity. It’s hard to know whether his past experience reflects Romney’s likely White House actions, as Candidate Romney has dodged most discussions of his Massachusetts health efforts.
Among the inner circle of Romney advisors are former HHS Secretary Mike Leavitt, who led the Bush Administration’s responses to H5N1 “bird flu” threats, Jamie Burke (former Bush White House liaison to HHS) and current Louisiana Governor Bobby Jindal – widely rumored to be at the head of the GOP line for HHS Secretary. Leavitt and Burke demonstrated during their service in the Bush Administration serious concern about influenza, and the national preparedness plan was written on their watch.
Jindal, in contrast, has been the poster boy of GOP/state opposition to the ACA, refusing to implement“ObamaCare” provisions. He denounced ACA by saying that the Federal government was interfering in individual lives, and it “raises the question of what's next, what's allowable. Taxes on people who refuse to eat tofu or refuse to drive a Chevy Volt…It's a huge expansion of federal power," he said in July. Rhetorically, at least, Jindal is against sweeping Federal authority over health matters, though he has never stated how a poor state like his would/should fight off a pandemic on its own. Because of the 2005 Hurricane Katrina disaster Louisiana received an unprecedented $51 billion in unique stimulus aid from Congress in 2009, making it per capita the most Federally-dependent state in the nation. “No other state in the nation has been blessed with such generosity from Congress and the American people,” boasted Jindal’s aide, Paul Rainwater. These funds came to his state under the same act from which the Republican Members of Congress axed the original pandemic provisions.
THE QUESTION IS NOT ACADEMIC
Since July of this year, 309 people in the United States have contracted new forms of Swine Flu, involving mutated strains of viruses that have jumped from pigs to humans. Most of these cases have involved novel types of H1N1, H3N2 or H1N2 influenzas that have circulated among livestock hogs in Midwestern farming operations. Sixteen of these cases have required hospitalization, one woman has died. So far the mutant strains have not shown the ability to spread widely from person-to-person, but neither did the 2009 H1N1 virus in 2008, when it caused a few isolated human infections in the Midwest among people that worked in pig farming. This summer many of the cases have been children that visited local agricultural fairs, where they had contact with pigs.
One of the new mutant strains (Swine H1N2) is a mixed-up virus that contains some of the genes from the 2009 flu, and could potentially jump from human-to-human. Raising anxiety levels among flu specialists is this month’s study of a very similar mutant pig virus H1N2 found in South Korea. Analysis reveals the mutant is actually a genetic mosaic of three different flu viruses. When laboratory ferrets were exposed to the mutant they quickly became infected, and all died within days. The group of international researchers also showed that caged ferrets could pass the mutant flu among themselves by coughing and sneezing – no physical contact was necessary for spread.
“It shows that there are very nasty viruses being generated in swine,” Robert Webster of the St. Jude Children’s Research Hospital in Memphis, Tennessee, one of the study’s senior authors told Scientific American. “And these viruses are coming out of apparently healthy pigs.”
Whether or not one of these pig flu viruses will break through to spark another global pandemic in coming months cannot be forecast. It’s all a game of probabilities and guess work – which, of course, is why the Bush Administration thought America needed a pandemic plan, and the Obama Administration sought funds to back it up.
In a pandemic the entire world would turn to the flu experts at the U.S. Centers for Disease Control – the top influenza team on Earth. But the CDC is already in budgetary trouble. Its capacity to respond to biological threats is diminished, and it will likely take further cuts in 2013 Federal budget battles. If Congress is unable to agree on an FY13 budget before March and goes into sequestration, the CDC and all other health agencies of the Federal government will realize significant cuts in all their programs, including those aimed at pandemic preparedness.
AND THEN THERE’S THE 47 PERCENT
This week’s big election news is that candidate Romney was surreptitiously filmed telling supporters that 47 percent of Americans are "dependent upon government, who believe that they are victims, who believe the government has a responsibility to care for them, who believe that they are entitled to healthcare, to food, to housing, to you name it -- that that's an entitlement. And the government should give it to them." Romney went on to stipulate: "[M]y job is not to worry about those people. I'll never convince them they should take personal responsibility and care for their lives."
Presumably Mitt Romney does not believe that “personal responsibility” should rule the day in a pandemic. We certainly hope not. But somebody should ask him.