Global public health mobilizes to confront H1N1 flu outbreak: Disease brings preparedness to forefront
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* Kim Krisberg

While the average person is often — and unfortunately — unaware of public health’s place in daily life, its indispensable role is occasionally thrust in the spotlight, as was the case in late spring when a new flu strain quickly spread around the globe.

Initially called “swine flu,” the H1N1 flu strain brought the international pandemic alert to one of its highest levels, shut down hundreds of schools in the United States alone and transformed the threat of a new pandemic flu strain into a reality practically overnight.

The H1N1 flu strain took front-page headlines beginning in late April after reports of illness and deaths in Mexico, but the strain was, in fact, identified more than a week earlier when officials with the Centers for Disease Control and Prevention determined that two children living in southern California were infected with the virus. According to the April 21 issue of CDC’s *Morbidity and Mortality Weekly Report*, the viruses from the two California cases were “closely related genetically…and contain a unique combination of gene segments that previously has not been reported among swine or human influenza viruses in the United States or elsewhere.” Six days later, Mexican health officials notified the Pan American Health Organization that several cases of H1N1 flu in humans had been confirmed.

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A Washington Metro Area Transit Authority worker disinfects the inside of a bus in Hyattsville, Md., in late April.

Photo by Win McNamee, courtesy Getty Images

In the following days, World Health Organization officials called on countries to activate their pandemic preparedness plans, President Barack Obama called on all Americans to adopt longtime prevention techniques such as handwashing, and the nation’s top public health officials became regular faces on the nightly news. Along with keeping the public up to date on the numbers and locations of confirmed cases — as of May 19, CDC reported almost 5,500 confirmed and probable cases in almost every state — health officials also reminded viewers that the U.S. public health system had for some time been preparing for the possibility of a new deadly pandemic flu virus that passes easily from human to human.

“This is moving fast, but I want you to understand that we view this more as a marathon,” said then-acting CDC Director Richard Besser, MD, during an April 26 news conference. “We do think that this will continue to spread, but we are taking aggressive actions to minimize the impact on people’s health.”

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Christine Arroyo sits with her son, 10-year-old Patrick, as they wait to be evaluated in a triage tent set up for possible H1N1 flu patients outside of the emergency room at Sutter Delta Medical Center in Antioch, Calif., on April 30.

Photo by Justin Sullivan, courtesy Getty Images

In addition to igniting widespread concern — and in some corners, panic and hype — the H1N1 outbreak created some positive reaction as well: schools and businesses revisited and in some cases updated their reparedness plans; more Americans began washing their hands more frequently; and the need for a robust and well-funded public health infrastructure once again was recognized. While the U.S. public health system has received millions in federal funds for emergency and pandemic flu preparedness since 2002, such funds have dwindled in the last few years and only worsened as states slashed their budgets to compensate for an ailing economy.

According to Jeff Levi, executive director of Trust for America’s Health, state and local health departments have not received federal pandemic flu preparedness funds since fiscal year 2006, even though at least $350 million is needed annually just to maintain pandemic preparedness capacity. During an April 27 Trust for America’s Health news conference, Levi called on policy-makers to complete funding to implement the National Strategy for Pandemic Influenza, which began under former President George Bush, who originally requested $7.1 billion to support research and development for vaccinations, medicines and medical devices to confront a possible flu pandemic. Funding that would have completed Bush’s request was included in, but eventually eliminated from, both the fiscal year 2008 budget proposal and fiscal year 2009 economic stimulus package. However, shortly after the U.S. H1N1 outbreak, Obama asked Congress to provide $1.5 billion in emergency funds to address the public health emergency. According to the White House, the funds would be used to supplement antiviral stockpiles, support vaccine development, and ensure monitoring, diagnostic and public health response capacity. For many public health advocates, the additional funds couldn’t come too soon.

“So far, the swine flu crisis has not tested the limits of our response system,” Levi said in late April. “This outbreak is a reminder that it’s better to be safe than sorry. This funding is a down payment on what is needed to help protect Americans from the swine flu and other pandemic flu strains that may emerge.”

Paul Jarris, MD, executive director of the Association of State and Territorial Health Officials, noted that the annual $350 million preparedness request is only a baseline needed to plan for a pandemic — that it is “clearly” not enough in the event of a fully realized pandemic. Millions more in funding is needed to complete state antiviral stockpiles as well as to purchase antivirals for health care and other critical infrastructure workers, he said during the Trust For America’s Health news conference. At an April 28 briefing before the Senate Subcommittee on Labor, Health and Human Services, Education and Related Agencies, Jarris emphasized that state and local health departments “will do everything humanly possible” to contain the H1N1 outbreak, but in the face of substantial employee layoffs, job vacancies and budget constraints, the United States does not have the public health work force it had just two years ago. He told Senate policy-makers that while every state has developed, practiced and now activated their pandemic flu plans, the public health system is at a critical juncture in terms of funding.

Karl Moeller, MPA, executive director of the Campaign for Public Health, said national health reform presents the perfect opportunity to broaden understanding of public health’s critical role and, in turn, the need for sustained funding not only to support preparedness, but overall public health activities. It is unfortunate, he said, that public health is often subjected to “these fits and starts” of funding that come and go with widespread public health emergencies and frontpage headlines.

“It’s nice to see the term ‘public health’ in the newspaper and to have people more aware that there is this incredible and very beneficial system out there protecting people’s health,” Moeller told *The Nation’s Health*. “But it’s important to remember that the same person in your town who’s responsible for responding to a pandemic flu is also the person who makes sure that restaurants are serving safe food, it’s the same person who educates children about preventable diseases, it’s the same team who’s doing all the public health work in that local community. But, there are not an unlimited number of people doing these jobs.”

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[Figure3](http://www.thenationshealth.org/content/39/5/1.1/F3)

A college student in Mexico City in May washes her hands before her first day of class since the outbreak of H1N1 flu shut down many activities throughout the city.

Photo by Jam Media, courtesy LatinContent/Getty Images

APHA’s Executive Director Georges Benjamin, MD, FACP, FACEP (E), also pointed to the critical need for a well-supported public heath system in dozens of media interviews related to the H1N1 flu outbreak. In addition, APHA created a special page dedicated to the outbreak on its Web site. The page, which can be accessed from [www.getreadyforflu.org](http://www.getreadyforflu.org), includes a regularly updated map of the outbreak, prevention fact sheets, a free chapter on flu from APHA’s “Control of Communicable Diseases Manual” and Q&As with experts in the field. It also features materials from APHA’s Get Ready campaign, which works to help Americans prepare themselves, their families and their communities for all health hazards and disasters, including pandemic flu, infectious diseases and other emergencies.

“Although it is far too early to know the degree to which the current swine flu outbreak warrants alarm, the number of cases and the speed with which the virus has spread around the globe serves as an opportunity to spread the message of the critical nature of preparedness,” Benjamin said.

For more information and to stay updated on H1N1 flu activity, visit [www.cdc.gov](http://www.cdc.gov), [www.who.int](http://www.who.int) or [www.apha.org](http://www.apha.org). To take action on public health preparedness funding, visit [http://action.apha.org/site/PageNavigator/Advocacy](http://action.apha.org/site/PageNavigator/Advocacy).

*   Copyright The Nation’s Health, American Public Health Association