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Why the Public's Trust and Help Matter in Emergencies D.A. Henderson, MD, MPH Speaker biography | Summary | Audio | Q&A transcript | Q&A audio Transcript
Tara O'Toole:
Now, my next responsibility is to introduce the gentleman to my left, D.A. Henderson. Introducing D.A. is always a challenge because he has so many accomplishments and because he has lived so many lives, that reading a litany of them would take a half an hour, but you know him of course as the man who led the World Health Organization's campaign against smallpox. He has served three presidents, including the current president; he was the advisor to the secretary of HHS and president Bush on bio-terrorism, having been drafted back into the government after the 9/11 attacks. He served for almost two decades as the dean of the School of Public Health at Johns Hopkins University. And he has, of course, a generation-long wealth of experience in dealing with public health crises, of many kinds and in many settings. D.A. has deep stores of intellectual knowledge and direct experience with disease and the efforts to fight it. He is a guy who, I can tell you, is always focused on what is practical and what is possible and what will work and how to get it done. He is an unstoppable force when aroused, as many of us have discovered. And, he is a true hero of public health. Ladies and gentlemen, D.A. Henderson. D.A. Henderson:
Well thank you very much Tara, and may I say that it is a great pleasure for me to be here with you because the subject you are discussing, I think, is one of the most important aspects of dealing with some of the problems we face. And certainly as Tara has noted, epidemics of disease do not behave in any way like post-explosive events or hurricanes or what have you. They have a particular life all their own, and they are all very different and very problematical. Now over the past half century, we in North America have had only a very limited experience in dealing with epidemic disease. We had flu pandemics in 1957 and again in 1968, but neither of these proved to be a serious test of our health system. The hospitals were full, but then we had many more hospital beds at that time and the disease itself was substantially milder [than during] the 1918 influenza. Now certainly the patients were considerably less severely ill than those we are seeing now, suffering from the H5N1 disease in Asia. In the 1950s, there were outbreaks of poliomyelitis and you have seen the dramatic pictures portraying rooms full of people in respirators, but I think many people don't realize that in the peak polio year, there were only 25, 000 cases of paralytic disease and only a small proportion of those actually had bulbar polio, requiring a respirator. Though there were problems, [they were] very focal, very limited. We had outbreaks of hepatitis and west nile; we have encephalitis, whooping cough, salmonosis, and we could go on and on with a whole host of different outbreaks that we have dealt with, but most of them have been short term in duration. Few of them have seriously tested our system and virtually all of them have been handled pretty much solely by existing authorities of public health and medical care people, sometimes with support from the Red Cross, but not too often. So seldom has there been real involvement or need for involvement, as it would seem, of the community. However useful it might have been, this has been, some would say, somewhat of an alien concept, involving broadly, community participation. Now for some 12 years, ending in 1967, I was on the Atlanta CDC staff, with the broad responsibilities for surveillance in the epidemic intelligence service, but the staff was small and we acquired a considerable amount of practical shoe leather experience, in dealing with epidemic problems. But as time has gone on, the CDC staff has grown substantially larger, the number of infectious disease outbreaks have diminished. Expertise at CDC accordingly has greatly diminished, simply not having the practice. And at the same time, state and local health departments have until recently shifted their focus to more chronic [diseases], and no less in our academic centers, where indeed we have had very little experience frankly-[and only limited] expertise in the infectious diseases. And all of this became evident when we were dealing with the anthrax attacks of October 2001. As you will remember, the anthrax [letter] attack-like so many outbreaks of an uncertain nature-was characterized initially by apprehension, completely out of proportion to the inherent risk. We had senior health officials assuring everyone that all was okay, [that] the situation was under control, not to worry when in fact it was apparent to everyone that it was anything but under control, and nobody knew what was happening. There was a tidal wave of press coverage which surprised us more, much as we had anticipated, with far more than anybody ever thought it would be. And much of this was covered by, as you recall, so-called "beat reporters," rather than science reporters, and they were not well informed particularly about science, and very frequently they were communicating with a variety of people who were quite willing to be quoted and who knew even less than the beat reporters about what was happening. Meanwhile, we had a first responder community who was well trained to decontaminate persons of chemical weapons [attacks]. And so, as you know, for a number of people where powers were-[INAUDIBLE]-they were unceremoniously taken out into the back lot, stripped down, hosed down, isolated, and goodness knows what else. We could not have had more inappropriate behavior if we had tried. We had very little guidance on this as to what should be done. And all of this was covered immediately, and in Technicolor by CNN. So it was not, I would say, one of our more distinguished periods, the anthrax event. In many cities today, pandemic flu could generate a similar response, because indeed few municipalities have really given serious thought to the preparation that may be necessary to deal with that. And I don't know how many have yet tried to digest the 250-page National Influenza Plan, to try to understand this and what it means to them. Little thought has been given to the predictable tidal wave of patients that we will see. And little thought has been given as to who is going to care for them, given the fact that we will have a certain amount of illness in the medical and public health community. It is not rocket science that you need to run through what you might [see], how many patients [that might be expected] based on present assumptions, and to recognize there is going to be a critical need for volunteer groups with elementary training in some medical procedures.... There will be large-scale needs to assure that supplies are delivered, that phone banks are manned to answer the many questions [that will arise], and I could go on and on... There are still serious challenges barely addressed. And I should add that were a pandemic of H5N1 to begin person-to-person transmission, and as Tara has noted, right now, we are looking out over events, and smartly, with considerable apprehension. A rapidly spreading [active?] epidemic could appear on our shores as early as September, and if we look back to 1957 and we look back to 1918, those two outbreaks really began towards the end of August, early September, and basically spread across the country in roughly two to three months. Over the past 40 years I have been deeply engaged in dealing with control and eradication of the disease of smallpox, and from 1985 the control and attempts to eradicate a second disease called polio. For the smallpox program we had a World Health Organization budget that was considered quite generous at the time. It was $2.5 million per year, and that was intended to conduct programs in 40 countries. It wasn't enough to buy the vaccine we needed, so we sought donations, but it was a problem. Primarily the endemic countries were the poorest of the poor. They had few resources to contribute. Whether we thought a broad public involvement in this program was a good idea was irrelevant. There was simply no choice but to draw into the program many volunteers from local areas and in many different ways. For the large-scale vaccination, the technique that we used throughout Africa and other parts of South America was to have a two-person team moving to visit the target areas and seeking [out] the village headman, or the principal religious leader and the school principal in a discussion of how the vaccination program might be conducted, and where it might be held, and what they might do to help organize that, and [to] schedule with them. And it was remarkable, the organizational capabilities they showed. And so in Africa for example we counted on every vaccination. [We were] averaging 500 vaccinations per day, per person with the organization with which they were doing [just] in the villages themselves. We also found, as time went on, that it wasn't too long before we could train vaccinators in the villages to do the vaccination, and it took a period of maybe 15 to 20 minutes. And then you had expanded your team's capacity very quickly. What I found very interesting was how responsive and enthusiastic and reliable so many of these people were. They had never been asked to do anything like this before and the only thing we could pay them with was a "thank you" at the end of their time. There was no money involved. For the detection of cases we came to rely on schoolchildren. This was done by an individual going into the school classroom, showing a picture of smallpox and then asking the children was there anything like this in their village? What was truly remarkable was how much nine to 12-year-olds know of what is going on in the community, and how willing they are to tell you everything they do know, whether they are supposed to or not. And so, this turned out to be almost more efficient than the reports from health centers and hospitals; it was very useful. There are a couple of important caveats which we learned very early in the program, and generally apply. The first was never to use the police or the military to enforce vaccination. Any civil authorities were eager to get good coverage, and were eager to have everybody comply. But once [one] brought the military or police in, we found that large numbers departed for the woods or engaged in active fighting with the vaccinators. What we really had that was very effective, was simply further support from the key religious leaders and the school principals and the headman of the village to say that this was a good thing, and compliance was very good. I think the caveat of not involving the police of the military is appropriate today. The second caveat was never to impose quarantine. That is, forcing contacts with patients who are otherwise well, to be sequestered in their homes or the building. The isolation of patients-that was done routinely. But so far as the families were concerned, we vaccinated them, checked them daily for symptoms, but otherwise they went about their business and moved about freely. When we made efforts to quarantine families, this usually resulted in them hiding cases because they did not want to be quarantined and they would not report cases. And this meant, with greater transmission, we had less chance of containing the outbreak. Interestingly, talking with some of those in Canada unofficially, who worked on the SARS program where they did try to quarantine families, and were moderately successful, there were a few key people including a couple of the hospital [workers] themselves who had found they had a fever and respiratory illness, but made the decision that they were so key to the continuation of what they were doing at the hospital that they themselves came in and worked. One can imagine what this might mean if you tried to extend the quarantine to large numbers of families, and how many people, how many professions feel that they are really key and are we going to stay home, or are we going to quarantine, and I would say this is not a good idea. And in fact, I think the suggestion that quarantine had no practical role to play in epidemic control is right, and I think that this is true today. I think this is counter to certain recommendations of the National Influenza Plan which advises that it might be useful to quarantine families or close schools for three to six months, or close nurseries. It is a provocative idea, but having worked here now for 40 years on outbreaks and wondering how best to control them, I think it is quite clear that quarantine is a concept that is perhaps 50 years out of date, and as we learn from practical experience and understand how diseases transmitted, that this is something that we can happily set aside. The importance of public involvement in disease control could not be better illustrated than what has taken place with respect to polio and [INAUDIBLE]. The historical importance of the March of Dimes, and the impetus provided by [INAUDIBLE] in raising funds for treatment of polio research will be, I am sure, vividly portrayed today at lunch by Dr David Oshinsky who has written his most remarkable book-the best book I know on polio. As you all are well aware, that set a pattern so that many citizens have banded together to raise funds, in disease research and care for many different diseases. And they are not only donating or seeking the donation funds, but they have made an important contribution in identifying priorities and setting priorities for research through the political process. But there is a quite extraordinary series of events that [they] relate to, and these pertain to polio control and the eradication program. An interesting approach to vaccination emerged in the 1960s, soon after the oral polio vaccine was licensed. It was an unusual vaccine, such as we had never had before. It was one that required only two to three drops of the vaccine to put on a sugar cube, and then to be put into a child's mouth. There was no needle or syringe required, and the question soon arose as to why such a vaccine could not be administered by any lay person. And this did not make the organized medical community happy, that that might be raised, because it was felt that to administer a product such as this there should be minimal supervision. But it is hard to see how you could go too far wrong with two drops, and if it were six drops it didn't make any difference. So it was at that point that the [plan set] forth was "Yes, lay people can administer a polio vaccine." The concept, however, that was proposed was to introduce vaccine by setting up a program to vaccinate all the children under 10 years of age in all of the major municipal areas in the country. Our health departments, at that time, regularly protested that they did not have the personnel to do it, and how could they possibly manage this? When suddenly the Junior Chambers of Commerce, a national club for young executives, volunteered their services and they began working with the health departments. It [became] somewhat of an unusual, tense relationship. Health departments do not work like an industry, and the Junior Chambers of Commerce industry people like to carry things on in a little different way, but it worked. And so began what were called "SOS programs," Sabin-on-Sunday programs, in different parts of the country, and these reached between 80 and 90% of the target population. Now, mass vaccination campaigns countering epidemics are certainly nothing new, but mass vaccination campaigns for a preventive vaccination such as this was an entirely new concept. Now in the 1980s, Albert Sabin advanced the argument that to control polio, it would be a great advantage in a lot of other countries to vaccinate children throughout the country on a given day. And his argument was that if this vaccine, which grows in the intestinal tract, was widely enough disbursed, it would prevent the wild virus from spreading and thereby it would have a very profound effect. Meanwhile Albert, in his persuasive way, went to Rotary International and garnered the full support of Rotary in helping to deal with polio. And Rotary agreed, and decided, and set a goal of $100 million that they would raise by the hundredth anniversary of Rotary (which as I recall came up in 2004.) Meanwhile Brazil was dispensing polio [vaccine] in health centers and hospitals regularly, and they were reaching about 60% of the population. The Brazilians decided to undertake a national program and to vaccinate all of the children that were under five years of age on a single day. This inevitably required participation of a huge number of volunteers, and a whole new set up such as they had never had before. And it was quite remarkable-I suggested that there is something peculiar genetically in the Brazilian constitution, because they can organize programs like this like no other group can do, and they are quite remarkable. They got about 90% of the population. They did it a second time and they have been doing it every year with a great deal of festivity; it is a festival atmosphere. And my colleagues in Geneva in the World Health Organization insisted that no one could keep this up: "It will fall apart, people will lose interest, and you cannot keep this up." Well, year after year it has been kept up, and one of the Brazilians said to me puzzled, "Well, we have carnivals every year, why can't we have vaccination every year?" There is no answer to that. Meanwhile, the Rotarians have played an important role, initially in providing money in helping the publicity, and also in getting involved in the logistics and providing transportation and many of the door-to-door campaigns; it has been very active. Polio vanished from Brazil. The other Latin American countries began to do something similar, and in 1991, under the direction of the Pan-American Health Organization, and a remarkable physician by the name of Ciro De Quadros, polio vanished from the Americas. This has been taken up by many other countries now, and in fact, the largest number given on any one day was in India which exceeded 100 million vaccinations in one single day. Meanwhile, Rotary's contributions have now gone over $500 million in support. This is a heartening story and encouraging, I think, to others. However, I still have the feeling that public health and medical care staff are still somewhat leery of voluntary organizations and have difficulty, very often, in accepting them as full partners in policy formulation, strategy development and so forth. Significantly, I believe, the problem lies in the fact that we have allowed a public health infrastructure to wither in most parts of the country. And as curative medicine has dominated the calendar, public health departments are now typically understaffed, underpaid, and understandably not so receptive to taking on some special efforts that need to be explored, let alone put in place special, significantly different, programs that involve greater communication and involvement with the public and voluntary groups. But this is changing: In response to national security concerns, the Federal government has begun funding at state and local levels in a broad-based development program for "public health emergency preparedness." This amounts to about $1 billion per year. That sounds like a very generous amount, although they spread this across 50 states and all the municipalities. It does not amount to huge amounts of money in any given area but it does amount to significant sums more than were there before. Many are responding well. I'm optimistic that more opportunities are there now than there were before, and more will emerge, that will provide closer and more effective relationships between citizens and the public health and medical communities. Thank you. Proceedings of the May 23, 2006 Summit: Disease, Disaster, & Democracy Transcription by CastingWords |
