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C A L I F O R N I A N U R S E N O V E M B E R 2 0 0 5 15 H5N1 presently has a startling mortality rate of between 47 percent and 83 percent, but most experts think it unlikely that it will maintain that level of lethality. People in Asia have tested positive for the flu's antibodies without exhibiting symptoms, in- dicating that not everyone who contracts it gets deathly ill. Nev- ertheless, WHO estimates that such a pandemic would hospitalize 30 million people and kill 8 million. Other researchers, like Michael Osterholm at the University of Minnesota, say the death toll could range from 180 million to 360 million worldwide, including 1.7 million in the United States. Olsterholm, director of the Center for Infectious Disease Research and Policy and an associate director of the Department of Home- land Security, reported his estimates in the May 5, 2005 New England Journal of Medicine. Even if avian flu has only the fatality rate of the 1918-19 pan- demic—2.7 percent—it would have a catastrophic effect. That pandemic killed 675,000 Americans and anywhere from 50 to 100 million people at a time when the world's population was less than a third what it is today, and when populations were far more isolated. "If you want to see why a pandemic today will be far greater than the 1918 flu," says Dr. Donald Francis of Global Solutions, "just sit in a European airport and watch all the costumes walk by." Francis, whose firm is trying to generate money for vaccines, was one of the earlier identifiers of HIV, and part of the WHO/Cen- ter for Disease Control (CDC) team that finally cornered and elim- inated smallpox in 1977. But at the very time avian flu is threatening to mutate into a worldwide killer, public health budgets in this nation and across the globe are being systematically starved of funding. Budget Crisis at Every Level Budget problems like Brunner's are hardly limited to Contra Costa County. "Each budget year, those of us in community clinics have to fight for our very existence," says San Francisco's Nancy Lewis, FNP. "We are considered expendable," she says bluntly. She calls the cutbacks of public health facilities and personnel "alarming." County and state health budgets have been declining for years, and Congress plans to cut Medicaid by $10 billion over the next five years. Medicaid is the nation's largest health insurance pro- gram, covering some 50 million low-income people. That will have a cascading effect on the states, many of which are already cutting recipients from the rolls. Tennessee is drop- ping some 300,000 people, and Missouri is cutting 90,000. For those still covered, states are proposing higher co-payments. "State and local governments are in such a budgetary crisis that they are forced to cut things that they know are good for the public," says occupational physician and former president The arrival of the next great pandemic has always been a "when," not an "if," and firewalls for stopping it are getting thinner. By Conn Hallinan and Carl Bloice And what rough beast, its hour come round at last, Slouches towards Bethlehem to be born? — William Butler Yeats I n early June, a patient checked into a Contra Costa County Health Department outpatient clinic in Richmond, California, with a fever of 101.2°, flu-like symptoms and a cough. The man sat in a waiting room—the clinic serves hundreds of thousands of people each year— until the physician could see him. Because the patient could not speak English, the doctor called in a Vietnamese interpreter. The rest was rote: blood pressure, ear and throat examina- tion, listen for congestion. But then an alarm went off in the doctor's head. She had the translator ask the patient if he had recently traveled. Yes, he replied, he had just returned from Vietnam, presently ground zero for avian flu, a particularly malevolent virus that has killed more than 60 people and decimated chicken populations throughout Asia. The doctor put a mask on the patient, moved him to a room by himself, and called the health department. Blood samples were drawn and county and state health labs went into overdrive, scan- ning for a molecular code designated H5N1-A. For a few scary days, it looked like Richmond might be the first U.S. beachhead for the disease, but in the end it turned out to be a standard Type A influenza. On one hand, the incident demonstrated the strengths of pub- lic health. "The businessman who returns from Vietnam is going to see a private doctor," says Dr. Wendel Brunner, director of pub- lic health for the county's health services. "A private doctor has about 12 minutes to see a patient, four of which are filling out in- surance forms. They aren't going to ask the patient's travel histo- ry, and they are not likely to call the health department." On the other hand, Brunner is facing a $5 million cut in his $60 million budget, and high on the list of cuts are translators, who not only interpret, but also accompany nurses who conduct house visits. Without a translator, the Richmond doctor would never have asked the travel question. The arrival of the next great pandemic has always been a "when," not an "if," and firewalls for stopping it are getting thinner. "Nobody knows how bad [the pandemic] will be," World Health Organization (WHO) General Director Lee Jong-Wook told the Fi- nancial Times, "but we can't be optimistic." So far, H5N1-A is only a threat to those exposed to infected birds, although scattered cases of person- to-person transmission have been reported. But the virus has spread from domestic fowl to wild ducks and domestic pigs. The latter are worrisome, be- cause pigs have served as a viral bridge to humans before. If avian flu mutates into an easily transmissible form, the world could be in considerable trouble.