The Age of Plagues

It wasn't that long ago that medicine declared a victory over infectious disease. Now a raft of new and mutating bugs are at the door, and a declining public health system is in no shape to fight them.

"My parents grew up before the antibiotic era," is how Osterholm puts it. "I have lived in the antibiotic era. And my children--any children born now--will be living in the post-antibiotic era."

Russell and John (not their real names) are tearing through the corridors in the Hennepin County Community Services building like extremely healthy 4- and 7-year-olds. They bypass the big toy basket and head straight for the nurse's desk, where they pick candy out of a bag she keeps in the drawer. Back in the waiting room, their mother listens to Dr. Linda Hedemark explain the treatment regime.

Both kids have to take several types of antibiotics a day for several months, and the youngest has a problem keeping his meds down. The mother has tried squirting the liquid into his throat with a syringe, mixing it into his baby bottle, and finally feeding him through a tube. Nothing has worked too well. There are also problems with the way the medications are mixed at different pharmacies; it's not easy to keep all the dosages straight.

The kids have tuberculosis, and they were "very, very sick" when they first came in, Hedemark says. The youngest was hospitalized right away, and the county team has been staying in close touch with the family ever since. They do this for about 80 people every year, some of them in worse shape than Russell and John. Often outreach workers go looking on the streets for patients who haven't been showing up. Sometimes they help them get housing, food, bus tokens, chemical-dependency treatment. Occasionally they need to find translators; some 50 percent of the county's TB patients are foreign-born.

This clinic is a rare thing. Most general hospitals around the country can't even keep track of patients as they pour into the emergency room, much less follow up on individual cases, let alone help with needs other than direct medical care--even when that would help avoid the next emergency-room visit. And even here, this kind of close-up care is available only to TB patients, whose disease has received special funding attention from Congress.

The resource crunch applies to most of the things that, according to health professionals, could prevent a lot of the basic infections. Vaccinations must reach at least 80 percent of a population to prevent epidemics; in some Minneapolis and St. Paul neighborhoods fewer than 25 percent of preschoolers get the recommended childhood shots. Regular medical checkups are unavailable for lots of people who are uninsured or underinsured; thus diseases, as in the case of the Minneapolis bar patron, often aren't spotted until they're full-blown and have been passed on to others. And some epidemiologists are starting to worry that managed care, with its emphasis on cutting costs and "unnecessary" tests, may be missing many infectious agents.

Though the poor are generally the first to fall through the health care cracks, microbes are one social scourge not even the rich can get away from. In California, certain outbreaks have been reported among wealthy homeowners who caught bugs from their domestics. And in woodsy Twin Cities suburbs like North Oaks, researchers follow Lyme disease as it makes its way from deer ticks to humans on the five-acre lots.

Infection, in other words, is the most public of all health problems. Bugs shrug off boundaries of class, race, culture; they cross city lines, national frontiers, and oceans. And the only way to spot, let alone treat or prevent outbreaks, is through a system that reaches as many people as possible--public health. The bad news is that that system is pretty well in shambles.

Two months ago, a government research group convened by the State Department released a report on "emerging and re-emerging infectious diseases." The report was couched in the usual subdued language, but between the lines you could spot the bureaucratic equivalent of desperation. The cover featured a map of 17 major global outbreaks in the 1990s: Diphtheria in the former Soviet Union. Lassa and Ebola in Africa, dengue in Australia. An aggressive, continent-spanning cholera that reached Latin America in 1991 and has since been found in the U.S. border regions. And those, the report's text warned, were just the outbreaks that got noticed.

"At the present time there is no government agency or group that has the mandate, the flexibility, or the funds necessary to respond to infectious disease emergencies," the document said. "[Officials and doctors] scramble to find resources and solutions on an ad-hoc basis. Response is made even more difficult by the occasional occurrence of widespread shortages of drugs, vaccines, and antisera." (Drug companies have little incentive to make vast quantities of drugs for people who may or may not be able to pay.) "Moreover, there is virtually no surge capacity for producing many of the unique medical supplies needed on an emergency basis."

And finally, "the component of the public health system that protects the public from infectious microbes has been neglected both here and abroad. Federal, state, and local efforts to control communicable diseases are concentrated on a few targeted illnesses [AIDS, cancer, and other diseases that have advocacy groups], with few resources allocated to address new or re-emerging diseases. This limits the ability of the U.S. medical community to detect and respond to outbreaks."

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