Leavitt: We're overdue for a pandemic
Health and Human Services Secretary Michael Leavitt delivered remarks at the health summit about the country's preparation for a pandemic. Following the presentation, U.S. News Chairman and Editor-in-Chief Mortimer B. Zuckerman moderated a question-and-answer session.
SECRETARY MICHAEL LEAVITT: Thank you to U.S. News & World Report for this distinguished opportunity.
My subject today is a difficult one to talk about. Can we just acknowledge that? Pandemics are difficult to talk about because anything you say in advance of a pandemic feels alarmist, but anything we have done once a pandemic starts seems inadequate.
So this is a function of trying to find a balance in preparing: learning to speak about this in ways that will inform but not inflame; learning to inspire communities to prepare, but not to panic.
The fact of the matter is, we – when it comes to pandemics, we are overdue, and we're underprepared. And it's necessary that we speak with candor about it and that we move with dispatch to prepare.
Pandemics are a biologic fact of life. They're part of the microbial world of viruses and bacteria and microbes that are constantly mutating, constantly adapting. They are aggressors, constantly seeking more fruitful hosts.
The history of pandemics is not so much the history of public health as it is the history of mankind, because it has been a pandemic disease that truly has – have reshaped entire nations, that have affected cultures and politics and prosperity of entire continents. As far as human history has been recorded, whether it is secular history or biblical history, the evidence of these ravaging diseases become prominent.
I go back to Athens, as far back as 400 B.C. Twenty-five percent of that great city wiped out because of a disease. We're not 100 percent sure what it was, but we know it changed the future and course of that entire region.
Roll forward periodically through every century – 1400 A.D., the best-known pandemic, Black Death. Twenty-five million people on the continent of Europe died. It reshaped nations. It completely changed their culture. It affected their politics. It affected their prosperity.
Pandemics happen. We've had 10 pandemics in the last 300 years. In the last 100 years, we have had three pandemics: 1968, 1957 – both relatively minor pandemics on a scale of pandemics. A lot of people became sick. They were highly efficient, but not many people died. They were not particularly virulent.
However, in 1918, we had what was clearly – what has to be considered clearly the world's greatest medical disaster of all time: some 40 million people across the globe perished as a result of this pandemic.
If we were to have in the United States and across the world a pandemic of similar proportion today, 90 million Americans would become ill; 45 million Americans would become sick enough that they would require some kind of serious medical attention, whether that was a clinic visit or a hospital stay. Regrettably, roughly two million people would die.
This is a very serious matter. I am not talking about a Stephen King novel here. I am talking about what happened in 1918 in this country and across the world. The fact is pandemics happen.
Now, we're concerned today because the H5N1 virus, the virus we're concerned about now, is sweeping across the world on the back of wild birds carrying this virus.
Not only are we concerned because of its broad proliferation, we're concerned because of its genetic character. Using samples that we were able to retrieve in a rather remarkable way, we've been able to use reversed genetics to identify that that virus, the 1918 virus, has great similarity to the H5N1 virus that we now see spread across the world. Should it achieve human-to-human transmissibility, which it has not in a widespread way, it would be an aggressive killer. That's why we're concerned.
So it's important that we begin to talk about it, but it's important also that we not focus entirely on this H5N1 virus because pandemics happen, and if it's not the H5N1 virus, it will be another virus at some point in the – in time, and the reality is, because they happen and because we are under prepared, we must begin to think of pandemic preparedness in its larger context, not simply the H5N1 virus.
I've become somewhat of a student in my – of the 1918 pandemic. I've begun to focus on what happened around the country. Many of you will have read John Barry's account of the 1918 pandemic called The Great Influenza. It made me curious to go to my own hometown to find out what happened there. I grew up in a little town in the southwest corner of Utah called Cedar City. In 1918, it had about 3,000 people. There was a doctor there by the name of L.W. MacFarlane. I'm not sure that he was the only physician in town, but he was clearly the most prominent. The mayor had made him head of public health. He wrote a history of his life; a major portion of it was devoted to this event. In the long professional career, this was clearly the most prominent experience he had.
I found his history. You'll be interested in this. He said, "Quite a group had gone from Cedar City to attend a conference and the State Fair in Salt Lake. They returned home bringing unexpected gifts with them. By the time they got back to Cedar City, Mr. and Mrs. Don Coppin and their son Billy and Mrs. James Anderson and their daughter Ethel and Mell Corlett had definitely developed the flu. Before many days," he said, "the influenza swept like a fire through Cedar City and the surrounding communities."
I went to the little weekly newspaper, read every issue from September of that year, 1918, until December, a week after he described the – the Iron County Record carried the first recorded death in my hometown, a woman by the name of Mrs. George Foster. She died leaving what the newspaper called "a husband and a little motherless child."
The mayor and this Dr. MacFarlane issued a proclamation, doing what turns out happened in virtually every community in America during that period – they banned public gatherings. The schools were closed. The college was closed. The only building turned into what was a makeshift hospital. Everyone was required to wear a gauze mask 24 hours a day when they were out of their – if they were out of their home. Dr. MacFarlane noted about the gauze masks, he said the masks were annoying to everyone, but particularly galling to members of the community who were addicted to chewing tobacco. [Laughter.] One elderly member of this fraternity is recalled whose mask was tied on sure enough, but it just hung around his neck, leaving his nose and his mouth well uncovered and served only to rescue whatever tobacco juice failed to clear his chin.
But despite those efforts in my hometown, the influenza changed everything. It wasn't just my hometown. It wasn't just your hometown. It was every hometown.
In the state of Massachusetts, the great pandemic struck. On August the 27th, the first cases were found – two sailors at Commonwealth Pier. The next day, there were eight cases. The day after that, there were 60 cases. Within two weeks, 2,000 people were suffering with the influenza. On the 8th of September, it struck Camp Devens, where there were 50,000 soldiers.
I found an account by a physician whose name only I know to be Roy. I don't know any more about him, but he obviously was there to attend soldiers who had been struck. I'd like to read something from his journal, and I'd like to tell you, this is a rather graphic description, but it's important to understand that what we're talking about here isn't just the flu. This is a killer disease.
He said this epidemic started four weeks ago and has developed so rapidly that the camp is demoralized and all ordinary work is held up till it passes. These men start with what appears to be an ordinary attack of influenza, and when they're brought to the hospital, very rapidly they develop the most vicious type of pneumonia that I have ever seen. Two hours after admission, they have mahogany spots over their cheeks. In a few hours you can begin to see the cyanosis extending from their ears all over their face until they can hardly be distinguished from the colored men – when you can hardly distinguished the colored men from the white.
It's only a matter of hours until death comes, and it's simply a struggle for air until they suffocate. It is horrible. One can stand to see one, two or 20 men die; but to see these poor devils dropping like flies sort of gets on your nerves. We've been averaging about 100 a day, and it just keeps coming.
By the time the pandemic had stopped in Massachusetts, 45,000 people had died.
In Kentucky, the first influenza cases came in the last – the second week, rather, of September as well, in 1918. The first week – when it ended – the first week ended, they had a thousand cases.
I found a journal of a – it was actually an oral history of a man out in Pike County, Kentucky, a little mining town – man by the name of Temus Bartlet, a very colorful man, talked about going to visit his brother. These are his words.
"Nearly every porch – every porch – I'd look at had a casket a- sitting on it. The mines had to be shut down, and there wasn't nary a man there that was working. There wasn't a miner running a lump of coal or running no work. Stayed that way for six weeks." He said later that he saw four or five miners' family die in one night.
This is hard to hear, but it's not a Stephen King novel. This is what happened in 1918.
In Vermont, at a little power company just outside of Montpelier, a man by the name of Frank Eastman recorded in his journal – he said – he recorded that there were nine men sick. The next day he recorded five more. And two weeks later he used these words: "Carpenter Willie died this morning, and the switchboard operator this afternoon."
It touched hometowns in Illinois. It was – Chicago at that point was the second-largest city in our country. It was a hub of a transportation, and obviously the influenza struck there quickly.
It was reported in Chicago on the 27th of September. Within two weeks it was an epidemic throughout the entire state. More than 2,100 residents of Chicago died during the second week of October and 2,300 more the third week. The city ran out of hearses. It put signs up prohibiting any kind of an open-air – any kind of a closed funeral and prohibited any more than 10 people to attend a funeral.
It reached hometowns in West Virginia. Charleston had the first cases, seven cases in September, on the 28th, and within two weeks they had more than 2,000 cases. I found the journal of a man in – an account, rather, in Martinsburg, West Virginia. There's a fellow there by the name of James Horvet, who was accused of a $40 forgery. They took him to the jail, and he caught the influenza, and on Monday they held his trial. Within three days three of the attorneys who had been in the trial had died. The judge, a clerk and an assistant were all sick, as were their families. It's easy to understand that the courts weren't functioning there, nor were they – was the power company in Montpelier, Vermont, functioning, nor was the city functioning in Chicago.
These have profound cascading consequences. Nearly every family had some kind of loss during that period. They knew people who had been lost. We know people who were affected. A story of a young North Carolina mother who passed away; her baby adopted by her parents who moved from North Carolina to West Virginia. The little baby grew up to be Senator Robert Byrd of West Virginia. I told that story to Governor Manchin of West Virginia. He said, "My grandfather died of what I heard was the flu. I didn't understand it until now." This wasn't just the flu. This was a killer disease.
My point is that it touched every hometown in America. Go to an Internet site when you're interested and put in "Spanish flu 1918" and the name of your hometown, and you'll see that it reached, literally, your hometown in ways that you didn't know about because we are a couple of generations hence. We have been fortunate as generations to have experienced pandemics that were not virulent, but highly efficient. We don't know what the next one will be, we don't know when the next one will be, but what we do know is that pandemics happen, that they are part of biologic life. It is – this is a fact of life, and we need to be prepared.
May I suggest to you that local preparedness for the reasons that I have described is the foundation of pandemic preparedness. If there is one message on pandemic preparedness that I could leave today that you would remember, it would be this: Any community that fails to prepare with the expectation that the federal government or for that matter the state government will be able to step forward and come to their rescue at the final hour will be tragically wrong, not because government will lack a will, not because we lack a collective wallet, but because there is no way that you can respond to every hometown in America at the same time.
Now we will talk much about emergency preparedness in this conference, but it's proper and fitting that we start with pandemic. I had a chance to walk through medical shelters throughout the region of the Gulf Coast after Katrina for weeks. I saw a remarkable thing happen as people moved from all over America to come to that region to help. We learned powerful lessons from Katrina. We learned, first of all, that what you do in advance of the disaster is more important even than what you do after. We also learned that you have to think about the unthinkable because occasionally it happens, and you have to be prepared.
We also learned the difference between a pandemic and any other kind of disaster. In a pandemic, people could not rush to the Gulf Coast because they would be in their own hometowns. A pandemic would not be three hellish days and then moving into recovery. It would be literally a year. Life will need to go on. People have to have food. They will have work. They'll have – the court system will have to operate. We have to think about this now because what we do now will be dramatically important should it occur.
We don't know what a pandemic would look like, we don't know when it will come, but we do know we're overdue and underprepared. Now, that's the reason that the president has asked that we mobilize the country in preparation. I have committed to hold on his behalf 50 summits around the country. We have now accomplished 43 of those. We'll continue to the 50. There will be one in each state and some of our major cities. Over 25,000 people who are health professionals, who are school officials, who are business officials representing local and state governments, representing faith communities, have attended those, and we are now mobilizing as a nation. But we are far from prepared yet.
The president has asked the Congress for $7.1 billion. We have not had a science initiative like this, or a preparation initiative like this since the Manhattan Project in this country, because we're investing substantial portions of that to invent new technologies that will provide vaccines, that will provide new antivirals, new diagnostics. We're mobilizing as a country to prepare. We're also developing check lists that will inform our collective thinking, and we're working to practice and to exercise our plans. Plans and check lists have the effect of – well, they reveal our weaknesses, but it is our weaknesses we seek, because until we know our weaknesses, we cannot improve.
A prepared nation will be a nation where every community, every business, every tribe, every community organization, every hospital, every clinic, every school, every college, every day- care center, every ambulance service, every household and family has a plan.
Now, I suspect that every one of you are asking the same question I think that we all ask ourselves. Is this Y2K? Is this something we're going to get all worked up over and then it won't happen? Let's hope so. There are some things we prepare for because we know they will happen. There are other things we prepare for because if they happened and we weren't prepared, they could change the nature of our society in ways that we could not respond to adequately. A pandemic is both. We need to prepare. But even if a pandemic does not happen soon, we'll be a stronger and a healthier nation because the pandemic preparation is the same preparation that we would make for a bioterrorism event. It's the same preparation that we would make for a medical disaster brought on by a natural consequence, like a hurricane or a tornado. It's the same kind of preparation we would make if we were to have a bioterrorism – or a nuclear event. Pandemic preparedness will make us a safer and a healthier nation. May I suggest that this is a time for real focus and one that will require our best efforts.
It was mentioned in the introduction that I was governor of my state prior to serving in this role and others. I'll tell you, one of the great things about being governor is I got terrific seats at the 2002 Winter Olympic Games. [Laughter.] I often think of a moment that – at the games; there was a young skater by the name of Sarah Hughes who skated out onto the ice on the final night in fourth place. No one really expected, I think, she would win. There were great skaters in front of her. She was young, inexperienced, not well known. She started to skate. Something magical happened. There were 25,000 people in this arena watching her, a billion people around the world. There was a harmony about the way she skated that soon the audience began to feel it. She stopped, the music was done, her arms went out, her head went back. You could tell she had done exactly what she had hoped to.
The next day I witnessed a news conference where this 16-year-old girl, who the day before had been studying for her SAT exams, was facing a wall of 300 cameras asking her questions: How did you feel? She said, "I, first of all, felt pride in being able to skate in the uniform of the United States." Then she said, "Most of all, I felt gratitude for being able to skate at all. Most people don't get a chance to skate the performance of their life, and I did."
I would suggest to you that this is a moment when we need to skate the performance of our life because our lives and others could depend on it, and future generations. We have an opportunity to be the first generation who truly can have enough information that we can not change the course of the pandemic, but change its effect, because pandemics happen and we must be prepared.
Thank you. [Applause.]
ZUCKERMAN: Thank you very much. That was an extraordinary talk, and the attention of the audience and the silence of the audience I think is just a commentary on how your words struck home.
The secretary has agreed to answer a few questions. And I wonder if I could –
(Unidentified speaker) – Mort, I would just ask if everyone could please identify themselves and your affiliation, just for our viewers at C- SPAN and other media, if you would. So we can ask a few questions. Anybody here.
ZUCKERMAN: Nobody has to ask the first question. Would somebody like to ask the second question? [Laughter.]
We have here – please.
Q: Yeah, Dr. John Lowe from the University of Prague. In 1918, could you comment on the fact that the country was preparing – just going into war, and how that might have had an effect on being able to deal with the pandemic, having not had any preparedness?
LEAVITT: Historians have pointed to the interaction with war as being an important contributor. I mentioned The Great Influenza that John Barry wrote. He believes that essentially the government's unwillingness to focus on the flu so as to not distract from the war effort contributed substantially to the lack of preparation or at least the lack of awareness that was occurring.
I think that's something that we simply cannot, will not allow to occur again to the extent that it happened then.
I think it's also important to recognize that the vector, if you will, of spreading the disease was in large measure soldiers. There's no firm understanding of where the flu of 1918 started. It's widely attributed to be in an Army base in Kansas, and as soldiers were transported all over the world, it began to move. And I don't know the – I'm not in a position to evaluate the scientific basis of that, but what I think you can say is that we wouldn't need soldiers. We have a world that's much different now, where there is – where people are essentially traveling on an unlimited basis.
Our belief is that if we were to see person-to-person transmission of this disease – and we have not yet, and we don't – I need to emphasize that – if we were, however – if it happened anywhere, there is risk everywhere. That is our doctrine. If we see it in a remote village in Laos or in Turkey or in Cambodia or in China or wherever, and we can confirm that it is person to person, we are going to begin to activate our National Response Plan in appropriate and aggressive ways.
Question over here.
Q: Maggie Fox with Reuters. Secretary Leavitt, there have been a couple of surveys published recently that show that a large proportion of health care workers would be afraid to come to work if there were a pandemic. Are you doing anything specifically to address that?
LEAVITT: Yes. I will say, first of all, that it won't be just health care workers. If the – if history – if past is prologue, we will see every sector of the economy affected in those ways.
It will be true for police officers. It could well be true for school personnel. It could be true at colleges, anywhere where people begin to in fact accumulate. And that's the kind of planning that needs to be done. It's the reason every business needs a plan. It's why every school needs a plan. It's why every college needs a plan. It's why every news organization needs a plan.
In 1918 many of the major newspapers in our country for extended periods of time were not able to publish – big papers.
It's very possible that if we got into a severe pandemic – and I – what I've outlined today is the most severe we have ever known; it's the worst case – it's very possible that if we had a pandemic disease, it could be substantially less than that, but we prepare for the worst.
But if you have the worst, it's not inconceivable at all that news organizations would be required to help us teach people how to care for others in their homes, because – think about the pandemic surge.
Now, a pandemic generally will roll out in two or three waves of six to eight weeks each. They have a shape that looks like that. I mean, the surge is immediate. It's viral, literally.
The goal of a pandemic planning is not to eliminate or to avoid the pandemic, because that's impossible. It's to reshape the response of the pandemic or to reshape its impact. Instead of looking like that, hopefully it can look like that. And in other words, it can be a shorter peak; more people can get health care, more people can feel the certainty.
But we may well be dependent upon on each other for things like caring at home and how – and using the media for that. So it'll be every part of the community that needs to have a plan.
Q: Secretary Leavitt, I'm Ronald Kahn from the Joslin Diabetes Center. And I appreciated very much your description, but one thing that has changed considerably between 1918 and the present time is also the health insurance agencies. So we have doctors and nurses and public health officials and the media and hospitals all trying to do emergency preparedness. But so many individuals depend on certain health plans which are hard to move around, hard to move the information around.
I wonder if you could comment how the health insurance and the health insurance provider group is being incorporated into the emergency preparedness thoughts.
LEAVITT: Well, the financial impact of a pandemic, the cascading consequences, if you will, of a pandemic are endless. Health insurance is one sector that you can begin to think about. There are many others.
Now, we have, through the Department of Treasury, begun to initiate those conversations. They have begun to initiate those conversations. It's like any other potential disaster; it's good planning to be thinking about that at the corporate level. And we are encouraging them to do that.
The reality is no government, whether it's a federal government or a national government or a local government, can anticipate every potential ramification of this. And that's why a prepared nation gets down to prepared individuals and prepared families and prepared businesses and prepared churches and prepared schools and prepared hospitals.
Surge capacity, ventilators is something that one needs to worry about in a situation like this. I had a – I read a comment by a very well thought of public health official who said what the federal government doesn't understand is that we count on the federal government for ventilators in times of nuclear events or biologic events or serious medical needs, and we would all be calling – what they don't seem to understand is we're all going to be focusing on the same stockpiles at the same time.
That's exactly what we do get. And the reason we're saying to local communities: If you don't have enough ventilators in your hospital, if you have insufficient capacity to respond in this kind of a situation, maybe you ought to be thinking about more ventilators instead of remodeling the swimming pool. Public health needs to be put onto the same budget platform as other community efforts and initiatives. I'm just suggesting that the health insurance industry is just one. Virtually every part of a community would be affected.
ZUCKERMAN: We have time for just about one more question, Mr. Secretary, if I may.
Q: (Unidentified – off mike) – from the NewsHour. You mentioned the importance of plans. And in recent days there have been news reports, and yesterday Dr. Nabarro referenced at the World Health Congress that the president's going to be coming out with a more comprehensive plan. Can you tell us what that will entail?
LEAVITT: Did you say the president?
Q: Yeah. He said that the White House is going to be putting out a –
LEAVITT: Yes. What the White House has assembled – we first put out in November a strategy that basically laid out our basic strategy, and then we have been working together as federal agencies to come up with a integrated plan for the federal government.
Now, the federal government has a clear set of unique roles. We need to develop vaccines – the federal government needs to do that, and we are. We need to be involved in stockpiling antivirals and medications, and we will do so, and have done so. We need to be involved in the development of communications plans so that the best information is available. We also need to be involved in international and domestic monitoring to assure that we have the best available information. Those are unique roles of the federal government. If we were to have a person-to-person transmission, people will look for us to do screening at the borders. There are lots of things that the federal government can and must uniquely do. Every federal agency will need to be involved in that process, and the plan that you've heard spoken of is the integration of the division of labor.
But there are also needs for local plans. And I want to emphasize again that the foundation of pandemic preparedness is local planning. It has to be. It's the nature of a pandemic.
ZUCKERMAN: One quick question. I wonder if I could ask a question, take advantage here. Almost everybody that I speak to says, "Boy, I would like to get some Tamiflu." What is the status of this – [laughter] – of the supply of Tamiflu and similar medications? This is one thing that could be done at a very local level.
LEAVITT: Tamiflu is an antiviral medication. It is one type of antiviral that has shown effectiveness against the H5N1 virus. It's important to understand its virtues and its limits.
First, its virtues. It has shown in large – in circumstances that if it is given within 24 to 48 hours at the time a person begins to manifest a system, that it has a substantial impact on the length of time people have symptoms and the nature of their symptoms. That's all very good.
The – in terms of the potential downsides, there is no guarantee that Tamiflu will be effective under the mutated version of the virus, whatever it is that ultimately triggers a pandemic, and therefore, there's another – it's important that it be recognized as a treatment and not as a prophylaxis. It does have a preventative quality when it's taken every day, but that would mean a person, in order to have protection, would have to take one Tamiflu tablet every day for a year. We have no idea what type of impact that would have on a human body. There's no certainty that that would be safe, and there's no certainty that it would ultimately have the desired impact.
So our strategy has been to stockpile Tamiflu and other antivirals to an amount sufficient that we could provide it to 25 percent of the national population if they became ill. Now, why 25 percent? As we have studied previous pandemics, we've identified that as the percentage roughly that every pandemic has in the last 100 years has affected. Some of them have been more virulent than others, but they've always been about 25 to 30 percent. Now, I will tell you that we are at the point of having about 26 million courses that will be in our stockpile by the end of this year, and we will have the 25 percent by the end of '07.
Having said that, it's important to realize that Tamiflu and antivirals does not equal preparedness. It simply is one piece of a comprehensive plan, and I will also tell you that having it isn't the hard part; distributing it is where victory is one. And we're a lot closer to having it than we are having adequate plans to distribute it.
ZUCKERMAN: Mr. Secretary, I have one – promised one last very brief question here.
Q: Nelson Jacobson. I'm actually one of the CERT team trainers here in Washington, D.C., and you keep talking about the community level. Are we going to see another push in getting CERT, which is the Community Emergency Response Team, training out, because how we're going to prepare our communities is through this, is my understanding.
LEAVITT: Yes. Recent recommendations coming out of Katrina, for example, would be to have the DMAT or Mobilization Medical Teams that would be going from Homeland Security back over to HHS where we can begin to focus on that effort. We do see that an important part, and the local training and being able to integrate in an efficient way the teams you've spoken of and other emergency teams as well as the revitalization of a wonderful asset in this country called the Commission Corps, which is a – literally a – 6,000 professionals plus additional medical professionals who are – who need to be trained in units.
And that's a major part of the future of our emergency training.
Thank you very much.
ZUCKERMAN: Thank you very much. [Applause.]
Mr. Secretary, you carry the hopes and fears of this country as we go forward and face these kinds of issues. Thank you very much for your talk today, and we wish you well in everything you do.