National Nurses United

of the American Public Health Association (APHA), Dr. Barry Levy. According to public health officials and epidemiologists, cut- ting health care creates the perfect breeding ground for pandemics. Current public health funding seems almost designed to cre- ate a crisis. For instance, according to health writer and Pulitzer Prize winner Laurie Garrett, one of the key things hospitals need to respond to a pandemic is "surge capacity," or the ability to double their ability to treat patients. Garrett, appearing on the Dec. 30, 2004, "Jim Lehrer News Hour" on PBS, said, "What's happened with managed care is that hospitals have eliminated surplus beds and surplus personnel. So, far from being ready to deal with surge capacity, we're actu- ally understaffed and we have massive nurse shortages all across the country." Asked about "surge capacity," Brunner just laughs. "We don't have surge capacity for a bad winter." And how did hospitals lose their surge capacities? According to the American Hospital Association, some 900 hospitals were closed nationwide between 1980 and 2000 in the name of "effi- ciency." A scarcity of beds has consequences. The Society for Acade- mic Emergency Medicine found that delays in getting patients into hospital beds meant greater medical complications, more patients ending up in expensive intensive care units, and higher mortality rates. A Global Pox on All Houses If anything, the international situation is worse. Countries like China, according to Calcutta-based journalist P. Sainath, have largely defunded their health care programs, as the recent SARS outbreak demonstrated. "The Chinese saved tens of millions by closing down rural clinics, and then lost billions be- cause of SARS," he said. "Everywhere the rights of the poor are being whittled away, and we will all end up paying a price for it." During the 2003 SARS outbreak, Chinese villagers told Garrett that they didn't seek medical care because a single day in a hospi- tal represented a year's income. SARS eventually infected some 8,000 people, killing 800 of them. According to a report by the May 6–7 WHO conference in Manila, early intervention is the key to stopping or moderating a pandemic: "if action is delayed…it will be too late to implement effective local, national or regional responses." WHO recommended a crash program on developing a vaccine and stockpiling the anti-viral drug Tamiflu. According to the Financial Times, however, only 12 countries have made a serious attempt to stockpile Tamiflu, and the Unit- ed States has only enough Tamiflu for about 1 percent of its pop- ulation. In contrast, France and England can cover about 20 percent of their populations. Nor is Tamiflu a magic bullet. "It is not clear that Tamiflu is effective," says Brunner. On developing a vaccine, former APHA head Levy agrees with WHO's recommendation but warns, "We are way behind where we should be on vaccine development." Vaccines also have their own difficulties. "The problem with vaccine development is that vaccines don't make money," says Francis. He illustrates his point with a chart indicating that world- wide sales of vaccines brought in just a little over $6 billion in 2001, while Lipitor and Prilosec alone raked in $12 billion for pharma- ceutical companies. When private industry does get involved, it can be costly. In 1970, WHO paid about 1 cent per dose of smallpox vaccine. When the Clinton administration asked Dynport, the company that manufactures smallpox vaccines for the military, to ramp up pro- duction for civilians, its price was $25 a pop. The Nursing Imperative Lessons learned from the 1918–19 pandemic should be reviewed. In his book The Great Influenza, published in February 2004, John Barry notes that a public health service postmortem on the disaster found, "What could help, more than doctors, were nurs- es. Nursing could ease the strain on a patient, keep a patient hy- drated, calm, provide the best nutrition, cool the intense fevers. Nursing could give a victim of the disease the best possible chance to survive. Nursing could save lives." But the United States has a major shortage of nurses at the bedside, as does much of the world. According to Rockefeller Foundation estimates, Africa is short 1 million health workers and Europe has a crisis that parallels this nation's. Add to that the shortage of hospital beds, and Osterholm's projection may not be far off the mark. "We're not in the preventive mode here," says Lewis, "but the let's-fix-them-after-the-fact mode of hospital care. Under such circumstances, it would be very difficult to care for the tens of thousands of patients who would not get a necessary influenza vaccine on time." Keeping nurses healthy will also be a problem. "Medical work- ers are at risk," says Brunner, "because they are literally in peo- ple's faces." He points out that the first SARS victim was a medical worker. "New strains of influenza, particularly things like the avian flu, are the most worrisome to me and many nurses," says Lewis. "This is especially so in light of last year's debacle when the in- fluenza vaccines were contaminated." According to Gina Johnson, RN, public health case manager at the Rolling Meadows Clinic, Cook County, Ill., not enough has been done to prepare medical workers for what they may face in a pan- demic. "We need to start getting education about Asian avian flu, SARS and new strains of tuberculosis as soon as possible [so that] we don't get it thrown at us at the last minute." She adds, "Nurses want to be given the proper tools and pro- tection as soon as possible so in the advent of an emergency we don't get burnout and feel overwhelmed." Johnson has been in 16 N O V E M B E R 2 0 0 5 C A L I F O R N I A N U R S E "We're not in the preventive mode here but the let's-fix-them-after- the-fact mode of hospital care. Under such circumstances, it would be very difficult to care for the tens of thousands of patients." —NANCY LEWI S, FNP

• Cover