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**sharon sanders** · March 14, 2009, 06:45 PM

Re: Flu and You

<table class="mainTable"><tbody><tr><td> Flu And You - Part II

by: DemFromCT

Sun Jan 18, 2009 at 09:00:00 AM EST

</td> </tr> <tr> <td> Last week in Flu and You Part I we talked about CDC's weekly data pointing to potential seasonal flu resistance this year to the commonly used anti-viral tamiflu, as well as preliminary reports of vaccine-to-circulating virus mismatching of the Influenza B component of this year's flu shot. Both of these situations are newsworthy (see here and here), and highlight the importance of lab surveillance of influenza and other infectious diseases. It's not just a cable tv worry; infectious disease problems like the current 43 state salmonella outbreak will continue to occur, and timely lab confirmation and identification will continue to be needed to fight them. Small scope problems occur all the time, both in humans and animals. Larger outbreaks - the analogy would be to category 5 hurricanes - don't happen as frequently, but can be devastating when they do.
The new President is aware. This is an excerpt from the prologue to Barack Obama's The Audacity of Hope (for more Obama statements on pandemics, follow the link):

"... I suggest how we might move beyond our divisions to effectively tackle concrete problems: the growing economic insecurity of many American families, the racial and religious tensions within the body politic, and the transnational threats - from terrorism to pandemic - that gather beyond our shores."

</td> </tr> <tr> <td>Here's a Voice of America article also spotlighting one of the potentially big problems, an influenza pandemic (a worldwide outbreak of a novel flu virus capable of infecting humans everywhere.)

The United States is concerned that the ongoing outbreaks of H5N1 avian influenza in birds, or bird flu, have the potential to turn into a human influenza pandemic. Whenever or wherever a pandemic begins, everyone around the world will be at risk. To fuel a pandemic, a virus must be able to easily spread from person to person. And although currently the H5N1 virus does not spread easily from human to human, its mortality rate in humans is so high-over 60 percent-that we cannot take the chance that it will not do so in the future. Several influenza pandemics have occurred during the last century. The pandemic in 1918-1919 spread to every continent, and caused at least 40 million deaths world wide.
The effects of a pandemic can be lessened if preparations are made ahead of time. Working through the International Partnership on Avian and Pandemic Influenza, the U.S. Government and others in the international community have developed national and international programs to prevent, detect, and limit the spread of the avian flu virus.
Central to that effort is building infrastructure, including laboratory capacity and international rapid response mechanisms; a global surveillance and warning system; a coordinated plan of intervention; and of course, the development of vaccines. The U.S. has pledged $ 949 million in support of these efforts.

We are between pandemics, the last having occurred in 1968. Birds, however, are experiencing the equivalent, a panzootic infection of H5N1 (aka "bird flu", a misnomer because birds get all kinds of flu) with the latest outbreak in Nepal. I bolded the part about laboratory capacity. What's that mean, exactly, for seasonal flu, for pandemics, and in general for infectious disease? These are some of the tools that public health people use to track disease, and this is where at least some of your tax dollars go. And for you long time readers, when we speak of infrastructure, this is part of the package.
To help clarify this, we asked Dr. Scott Layne of the UCLA School of Public Health to address some issues about lab infrastructure.

DemFromCT: Scott, you're the Director of the Center for Rapid Influenza Surveillance and Research and High Speed, High Volume Laboratory Network for Infectious Diseases at the UCLA School of Public Health. Can you tell us what that is? Let's start with some perspective and rationale for our work. The world faces several enormous challenges (global warming, population overgrowth, food insecurity, monetary instability) and one of them is from infectious diseases. At present, infectious diseases kill 16 million people (mostly children) per year worldwide, and an unpredictable pandemic could dwarf these numbers. And the situation will only get more challenging as the world's population increases to 9 billion over the next few decades.

Given this situation, we need new tools and transformative capabilities to deal with major infectious diseases threats. It starts with the ability (on a worldwide scale) to have near real-time information (situational awareness) on emergence, outbreaks and spread of infectious diseases, and to have accurate and useful ("actionable") information for public health decision making (warning, control and containment). Our efforts combine worldwide surveillance of infectious diseases (starting with influenza, mainly in animals so far) with high-throughput laboratory automation, testing and analysis capabilities. The goal is to collect samples fast and to test and analyze them fast for effective awareness in our ever increasing fast-paced and connected world.

DemFromCT:: Who are your partners in making this happen?
Our work involves a close collaboration between UCLA and the Los Alamos National Laboratory in New Mexico. UCLA enables the public health part. Los Alamos enables the technology part. We currently supported by congressionally-directed and CA Office of Homeland Security grants for high-throughput laboratory development, and a NIAID Center of Excellence contract for national and international surveillance work.

DemFromCT:: When will you be up and running?
The high-throughput laboratory facility will be contained within the appropriate Biosafety Level 3-enhanced (BSL3e) space at UCLA. This containment space is scheduled for completed in May/June 2009. In parallel, several high-throughput laboratory systems (that perform all the various sample receiving, processing, testing and storing operations) have been designed and are being built. Some of these systems will be installed in May/June 2009. The remainder will be installed over the subsequent six to nine months. We will have core operations by mid 2009 and full operations by mid 2010. As we bring these capabilities on line, we will have the ability to perform increasingly penetrating testing, analysis and comparison of infectious disease samples.

DemFromCT:: Does the lab service the entire country?
Yes, in fact, the laboratory is intended to have an even broader reach, as discussed below. We will have two modes of operation. The first is everyday surveillance (scientific research, monitoring) mode. The second is emergency surveillance (outbreak, pandemic) mode. At present, the laboratory surge capacity of our country is unknown but much to limited. We need to considerably strengthen its resilience, connectedness and capacity to handle outbreaks and pandemics.

DemFromCT:: Last week I wrote about the twin issues of Influenza A H1N1 resistance and Influenza B vaccine mismatch. Will the lab you run help us to more quickly know what A sub-types and B families are circulating in CA and the rest of the country?
Yes, that is one of its important goals. Rapid, accurate and comprehensive information on circulating strains of influenza (in humans and animals) will support better decision making for vaccine selection and antiviral usage, and ongoing escape from these remedies. The primary concept is better information improves public health and health security decisions. Better information in fast-paced emergency (pandemic) situations is also essential - and for the first time we can build capabilities to save lives.

DemFromCT:: Are there more rapid tests on the horizon for the community to use or is everything to be sent to UCLA?
The high-throughput laboratory at UCLA takes advantage of economy of scale, much like large clinical testing laboratories take advantage of economy of scale. However, we are also developing rapid tests (molecular-based dipsticks) that are inexpensive, disposable and intended for community use. Overall, we need a hybrid approach to near real-time surveillance of infectious diseases. We need distributed point-of-care testing for simple diagnosis and on-the-spot decision making. We need centralized high-powered testing for penetrating analysis and widespread (national, global) decision making. This hybrid strategy is the wave of the future.

DemFromCT:: Will you have international reach? What do other countries do?
There are major two goals and measures of success for our work. The first is the high-throughput laboratory at UCLA performs as planned. The second is that our work serves as a (paradigm shifting) model and catalyst to build other like laboratories around the world. Humans tend to interact in "zones of cooperation" and so we need high-throughput laboratories situated in each of these zones - Asia, Eurasia, Middle East, Africa, Europe, South America, and North America. It is easy to imagine a global high-throughput laboratory network that focus on a number of serious infectious disease threats (influenza, HIV, tuberculosis, SARS-like emerging diseases) and that work together in a time of crisis, for example, during an influenza pandemic.

DemFromCT: What should we do in the meantime, given that the lab is not up and running?
Right now, we can do quite a bit. We can lead by example and invite the world to consider our new paradigm for global infectious diseases surveillance. The incoming (Obama) administration in Washington, DC appears to understand that more complete and rapid information enables better decision making and planning. I am therefore hopeful that our work will have renewed traction within our government (including HHS, DHS, DoD) as the high-throughput laboratory becomes operational in 2009. In addition, I am hopeful that other opportunities will arise in this new era. For example, the Internet-based surveillance at Google.org (Predict and Prevent) is very complimentary to our laboratory-based surveillance, and new interest at the Gates Foundation in influenza could help with development of our envisioned global network.

More background on the UCLA high throughput lab can be found here. If you want to track whether people are searching the internet about flu in your state, go here. And if you want to see what CDC sees, go here. Any day you want to discuss flu, go here.</td></tr></tbody></table>

**sharon sanders** · March 14, 2009, 06:47 PM

Re: Flu and You

<table class="mainTable"><tbody><tr><td> Flu And You - Part III

by: DemFromCT

Sun Jan 25, 2009 at 07:44:19 AM EST

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The reveres at the ScienceBlog Effect Measure are public health scientists and have been commenting about public health for as long as I have been blogging (i.e. since 2003.) I got one of them sit sit down and talk about where we have been and where we are going, in the context of seasonal flu, pandemics and public health in general. This will be a two part interview, with part III today and part IV next week. For flu background, see Flu Basics: Science And Threats from 2006 and H5N1 And The Long War Against Flu from 2008, or the Flu Wiki science section which the reveres organized and edited.

DemFromCT: We started Flu Wiki together with the late Melanie Mattson in 2005. Are we any better prepared now for a pandemic than we were then?
Let me take this in two parts: the public response and the government/public health response. As far as the public and the news media goes, there's a lot of "flu fatigue" out there and with all that's going on it's more and more difficult to get their attention except with scare headlines. But I'm going to surprise a lot of people and say I think in terms of public awareness, the short answer is "yes," we are better off. As usual, it requires a longer answer to make clear the limitations of a "yes" answer.

</td> </tr> <tr> <td>We are better off because a lot of people have been thinking about this and trying to visualize the consequences of a pandemic. When you, Melanie and I started Flu Wiki in June 2005 only a handful of people, and almost no one in the blogosphere, talked about this problem in a serious way. Since then there has been a lot of effort devoted to "pandemic planning" and there's been a significant amount of dedication and creativity in the flu world's version of the netroots. Thanks to you and other denizens of flublogia there is a network of knowledgeable citizen advocates distributed in many communities here and abroad. In the past I downplayed individual prepping for a pandemic for a political reason. I wanted to keep the pressure on government to play an appropriate and meaningful role and I thought that placing the burden on individuals to protect themselves and their families was the wrong message. I am optimistic the new administration will be more receptive to the task of rebuilding public health infrastructure, both its human capital and its material substance, and will revive the idea of fulfilling the mission of public health. If this happens and combining it with a new spirit of public service I think there is less risk of letting government off the hook by pushing individuals and communities to take up the burden. But there is still a long way to go. Preparedness advocates are still a marginalized minority in their communities and often feel extremely frustrated at their inability to convince others of the potential danger. Let me make a small digression here, because I think it's useful for Daily Kos readers and bears on what we are talking about. I've spent many decades in academia, most of it in a major School of Public Health where I am a Professor and researcher and was a longtime Department Chair. I was an anti-war activist in the sixties and remain one today and because of that I've spent a lot of time organizing on peace and other justice issues within schools of public health and schools of medicine. My personal experience has been that it is much easier to organize in a school of medicine than in a school of public health. This sounds counterintuitive because students and faculty in schools of public health are intimately occupied with access to care, environmental contamination, the plight of our society's least advantaged and much else intimately connected to social justice. Many are passionate advocates for their particular specialty areas, like substance abuse or reproductive rights. In describing them, however, I have deliberately used the word "advocate" rather than "activist," because that's what they are. They work tirelessly and effectively for their particular area but quite often have blinders and little time for any other issue. Their area is the most important. The citizen preparedness advocate is often of this stripe (there are many exceptions, of course, but I am trying to make a general point). If you couple a tendency to cleave toward advocacy rather than activism (meaning a more general progressive political stance that crosses issue boundaries) with the fact that the main employers and institutions public health students identify with are in the public sector, it becomes understandable that mobilizing them against government actions on issues outside of their area of interest is not something that comes easily. Medical students, on the other hand, often feel independent, empowered and self confident enough to question government actions. They start out poorly disposed to the government in the first place and as students they are still idealistic enough so there is a reasonable yield of activists amongst them.

Preparedness advocates are sometimes pejoratively referred to as the "flu obsessed" but they should more properly be thought of as the kind of passionate advocates like my students and colleagues in our School of Public Health. They tend to be very bright and they know a great deal about flu, often much more than their doctors. But they aren't activists and they don't organize easily. They will be a tremendous resource, if and when, and because they exist I think we are better off than four years ago when they didn't.

As far as government response, however, I am not confident we are better off. There has been a lot of planning on paper, but like a military plan that never survives the first engagement with the enemy, the pandemic plans on paper will be out the window in the first week of a catastrophic disease outbreak. This always happens, but it will be more severe today than four years ago because of the deterioration of local and state public health and its distorted priorities during the Bush years. There has been a lot of stockpiling of antivirals (Tamiflu and Relenza), but whether they will work for bird flu or whether the virus will quickly develop resistance we don't know, although the signs are that this could be a big problem. There is as yet no vaccine matched to a pandemic strain because we don't know what that strain will be, and in any event the time to produce a vaccine is long enough so that we will have to endure at least one wave of a pandemic and after even after that, if a vaccine can be produced there will not be enough to go around or adequate ability to distribute it. That's a consequence of the lousy shape our health care and public health systems are in. And they continue to get worse.

DemFromCT: So speaking of flu pandemics, what are the chances we will have a catastrophic flu pandemic in the near future?
No one can predict this. I don't take it as a given and never have. It's true that pandemics happen at intervals, although there is no rhyme or reason governing how long the interval is. We don't understand the dynamics of this virus well at all and the world has changed in many ways. Most of the ways the world has changed involve a closer interconnectedness that would make spread easier and more rapid, so I'm not heartened by the fact that the world is different than it was in 1918 or 1957 or 1968, the years of the last three pandemics. But we also don't understand what makes some years much worse than others and some pandemics much worse than others. We don't even know the major mode of contagion and for some flu virus subtypes, like H5N1, we can't be confident we know all the current or potential reservoirs in nature.

We've learned a lot since H5N1 returned in full force in 2003, but much of what we've learned is that what we thought we knew we were wrong about. This is a wily and dangerous enemy and it's a race between gaining effective knowledge to treat and control it (which we don't have at the moment) and the continual experimenting the virus is doing to find ever new ways to make copies of itself, its only meaningful activity from the virus's perspective.

I think it is quite plausible we will have another pandemic from some influenza subtype humans have no immunity to that will still be non-catastrophic, more like 1968 or 1957. Those were bad but not like 1918. On the other hand, it is also perfectly plausible we could have a truly terrible pandemic with high mortality and horrendous social disruption. It doesn't have to be H5N1. There are other flu and non-flu possibilities in a world where the most remote spot is not more than an incubation period from an international airport. Given that, it would be prudent to build our public health and social service systems like brick houses instead of the houses of straw and stick we have today.

DemFromCT: We have often talked about 'rebuilding public health infrastructure'. Last week we discussed one aspect of that (the lab capability). What else does 'rebuilding public health infrastructure' mean?
Over at Effect Measure we've been saying for years that the best way to prepare for an influenza pandemic is not with antivirals or vaccines (although both have important uses) but by strengthening the public health and social service infrastructure to make it robust and resilient. Our view is that preventing a pandemic is technically difficult or impossible so the main task is to prepare to manage the consequences. The consequences of a large proportion of our population being sick or dying extends to almost every part of our society.

It's the Three Little Pigs principle. The piggies' mommy sent them out into the world to "seek their fortune," but the world is full of danger. The first pig invests little effort in getting settled and builds a house of straw, only to get eaten when the wolf blows it down with ease. The same thing happens to pig number two, who tries to do better but doesn't make a sufficient commitment, building a house of sticks. Only pig number three escapes because she had enough foresight to build her house of bricks. Pig number three would have survived not only the wolf but a hurricane or a fire or a blizzard. The brick house symbolizes a sound public health and social service infrastructure.

Unfortunately it is a superficial if seductive analogy. One of the reasons I have not responded to your insistent and well founded requests over the years to spell out what I mean by rebuilding the public health infrastructure is that every time I sit down to do it I run into unexpected difficulties. It turns out not to be as simple as waving a nursery rhyme under the noses of policy makers.

Consider, for example, the meaning of the word "infrastructure." There is a halo effect from the use of this word for bridges and roads and electrical grids but when applied to public health it doesn't transfer easily. Infrastructure is the "structure" that is below our vision, the stuff we take for granted, don't know is there or don't understand but that nevertheless makes many other things possible by supporting them. Infrastructure doesn't produce anything but is part of society's capital. This seems straightforward, but isn't. If you try to stipulate what part of the public health or social service or any other system is infrastructure not everyone can agree. Bank of America is not infrastructure but the banking system is part of the economy's infrastructure. A state public health laboratory is not part of the public health infrastructure but most of us consider the laboratory system to be an essential element of infrastructure. Similarly for our disease surveillance system, which provides us with the "situational awareness" we need to make decisions about disease outbreaks or resource allocation. It's public health infrastructure. But being infrastructure doesn't automatically make it good. There are things that are infrastructure but have no particular public purpose or that facilitate some private one (the wave of armory building in the wake of the 1877 railroad strikes is a historical case in point but there are many others).

Then there are things of ambiguous status. What about the vaccine production system? A no-brainer you'd say? I had a long discussion about this with a like-minded colleague over the lunch table but we couldn't agree. He is an economist who doesn't consider the vaccine system to be part of infrastructure, whereas I argued it was. I'm less sure about the nation's drug manufacturing capacity.

DemFromCT: There's more about infrastructure I want to talk about, but that will need to wait until next week.
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**sharon sanders** · March 14, 2009, 06:50 PM

Re: Flu and You

<table class="mainTable"><tbody><tr><td> Flu And You - Part IV

by: DemFromCT

Sun Feb 01, 2009 at 10:35:49 AM EST

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The first three parts of this series are here, here and here. Last week, we began an interview with senior public health figures, the reveres at Effect Measure, and began a discussion about public health infrastructure. Today, we finish the interview, and with events this week (including salmonella in peanut butter and a close look at what the HHS Secretary is in charge of) focusing on public health as well as health reform, let's dive right in.

DemFromCT: Last week I asked you about public health infrastructure in relation to being prepared for a flu pandemic and instead of answering me directly, you made it into an abstract question. Surely it can't be as difficult as all this.</td> </tr> <tr> <td>LOL. You are probably right. Trying to define what infrastructure is in general is probably a fool's errand. But remember how we reveres got into the flu business. I'm a cancer epidemiologist whose research is quite theoretical, so our many posts at Effect Measure on flu and pandemic preparedness might seem out of character. But, like you, we are also activists and four years ago, in the dark days of early Bush II, preparing for a potential flu pandemic seemed like a perfect lens through which to look at public health. It had all the elements: distorted priorities, incompetent government, political interference with science, destruction of the public health system by ideologues, etc., etc. But the science is also fascinating and so we have spent a lot of time on that, too. And one of the things the science teaches us is that much of what we thought we knew about flu is wrong. Which encourages taking a hard look at everything, so it's all of a piece. Still, there's a job to be done and it can't wait for all the arguments to be settled. So we wind up doing practical things and theoretical thinking all at once, in parallel and iteratively. Sort of like when Boston built a major highway (the Big Dig) underneath the existing Central Artery while the Central Artery continued to carry the full load of rush hour traffic. It's messy and probably inefficient, but we don't know any other way to move ahead. I mean really move ahead, not just turn the same crank on a machine that never worked that well in the past. The fact that a bunch of crooks and incompetents wanted to abandon that machine altogether doesn't endow it with any greater powers, retroactively.

(Laughs) There! I did it again. I didn't answer your question but went off on a tangent about politics. But remember, public health has the word "public" in it. It is inherently political and if we don't recognize that we will wind up tinkering with something that won't ever be able to do the job we need it to. It's sort of like a hill climbing algorithm in computer programming. If the program works by taking wherever we are on the hill and always moving to higher ground-- a classical incremental approach--we will get eventually to the top of the hill, but we have foregone the possibility of going back down and choosing another nearby hill whose summit is even higher. Maybe the hill we are on is the best around, but I doubt it, so I am not satisfied to just discuss this in terms of public health as we have it now.

DemFromCT: Too abstract and handwaving for me. Can you at least start to pin it down a bit?
Well, maybe we can make it a little less abstract by asking what kinds of projects warrant significant social investment and why. Here we'd be specifically interested in public health or social service projects, because roads and the electrical grid are necessary for both public health and social services to function but including them as public health infrastructure seems a bit gratuitous (although not illogical). Unfortunately the first thing we see when we ask it this way is that it opens up a whole new set of difficult questions, like what do we mean by public health and what would warrant investment. I think these questions are answerable and I will take a preliminary stab at answering them, but I still feel compelled--and compulsion is probably the clinically apt term in my case--to give it a political preamble (we Reveres are indeed incorrigible).

We in progressive public health - the circumlocution du jour for public health's left wing -- haven't done our job in thinking all this through, instead gone on for decades mouthing slogans like "Prevention Pays" and "Health is a human right." What if prevention didn't pay? Does that mean we wouldn't do it? And where does this supposed "right" come from ? I don't feel like trekking the vale of tears that is an argument from Natural Law nor the legalistic one of Constitutional Rights. I want to have a well-founded argument about what health-related things should be guaranteed to every citizen and which ones not and why. And I can't do that at the moment because we on the Left haven't done the difficult theoretical labor of thinking it through. Just trying to answer the question about what should be considered infrastructure has become a major project because I don't think we have a clear way to think about public health.

Instead we reflexively use a tired and impoverished conceptual frame of reference. Our public health world consists of people with various features we call "risk factors." We look at different health states and ask what risk factors they are associated with. Then we think about altering the risk factor profile. This is a perfectly adequate way to frame certain practical questions but in my view it isn't very helpful for the bigger questions, even when accurate (and it isn't always accurate). It tends to slide over bigger questions like why people have the risk profiles they do (other than to blame their
genes) or what are the appropriate ways to intervene in changing which risk factors. I'll grant this is a broad brush indictment and I have many colleagues with much more nuanced and enlightened views, but it isn't too far off the mark for public health as a whole. It is a field whose habitual mindset is constricted and circumscribed.

DemFromCT: Well if you aren't going to use the dominant paradigm for public health, what are you suggesting public health is?
I don't have a fully developed answer, so instead let me give an illustration of the kind of alternative answer that hard thinking might provide. It might not be the right one but it's an illustration. Then maybe we can get back to the infrastructure questions.

A colleague once referred to a nice definition of public policy as those things we as a community have chosen to do for each other (I wish I knew a source to credit). We could also say about public health that it consists of those things that we as a community have chosen to do for each other with regard to our physical and mental well-being. This is quite different than the risk factor approach to public health. It shifts the emphasis to politics by putting what we as a community choose to do, not for ourselves, but for each other. It also allows a more nuanced answer to what physical and mental well-being is because it leaves it more open. Political leadership is obviously critical because what a community in a democracy decides it wants to do is always heavily influenced (although not determined) by where its leaders are taking it.

So what should we choose to do for each other? I have two kinds of answers. One is that we should do things that will produce the kind of world I want to live in. I don't want to live in a world full of sick and miserable people. I want to live in a world where people, by and large, are satisfied and happy. But maybe that's just me and my conception of a good world. We do this kind of thing a lot.

We take our own political positions and relabel them as things public health should do. For our own sakes, if for no other reason, we should have a better way to validate what we think. Maybe some of it needs to be rethought. Shouldn't there be a more intersubjective way to go about this? I'm not a philosopher so I have probably brutally simplified this, but I find the basic Rawlsian notion of a Veil of Ignorance is helpful. What policies would a rational individual wish for were placed in a position of total ignorance of all his or her risk factors, e.g., income, social advantages, biology. If any person had some appreciable chance of starting afresh without access to health (for any of a number of reasons) or specially vulnerable (for any of a number of reasons), what kind of world would be the best one to live in? What policies would maximize an arbitrary person's opportunities to live a decent life should it be revealed they had been dealt a bad hand when the veil was withdrawn. Does a biodefense laboratory -- which is quite plausibly a part of public health infrastructure -- produce a better world in this sense? Or should we first choose to deploy services and resources to make the most disadvantaged less disadvantaged? This gets closer to what I mean by strengthening our public health and social service infrastructure, building the brick house to withstand whatever may come.

This isn't a test that's easy to apply and there will likely be many instances where multiple paths forward are indicated. It is a way of thinking about public health and its choices. Sketching those paths and deciding which ones not to go down is what I mean by the hard labor of thinking this through. It's not an answer to your very sensible question but it is a way to start answering it.

DemFromCT: OK, so let's return to the infrastructure question. How does this apply?
I've been the habit of giving easy answers to the infrastructure question, and there are some. But as you can see by the way I've answered above, I'm not particularly happy with the depth of thought that went into what I've said. Still, I think it's pretty safe to say there are some things that qualify for "shovel ready" investment in public health infrastructure.
I'd start first by rebuilding our tattered and demoralized local public health system, meaning state and local health departments. They've been decimated by years of budget cutting. Of particular importance are the things already recognized as infrastructure within those departments, the IT and communications sectors, surveillance, vital records, outbreak investigation capabilities and some of the information gathering needed to administer a 21st century health system, like inventories of available and staffed beds and particular kinds of facilities. In many states health departments are required to collect this information but have stopped doing so. Of course the diagnostic state laboratories are included in this.
One thing to notice about this list is that it involves gathering information. Information is not only necessary to support almost all public health and social service functions, but it's what economists call a non-rivalrous resource: it isn't used up when it's accessed. It's still there for others to use. This is also true about knowledge, so investment in basic and applied public health and medical science is investment in a critically important element of infrastructure: information and knowledge. That's NIH budget. But information and knowledge are not generic kinds of social capital. It has to be the appropriate kind of information and knowledge and it has to be accessible to everyone. And while the product is non-rivalrous, producing it still takes resources. Investment in one kind of knowledge can preclude producing another kind of knowledge. I have argued that generating some kinds of knowledge and some kinds of infrastructure enterprises are harmful to public health.

Regarding accessibility, public health is a global enterprise. What happens in a rain forest or on a dairy farm in rural China can affect other people anywhere in the world. Information and knowledge that is not accessible to all is not part of the public health infrastructure. So there are some knotty issues about intellectual property and common benefits that have to be sorted out. So while some kinds of things seem easy on the surface, they often turn out to be difficult and require the more thorough kinds of analysis I already mentioned.

I have been quick to say that public health preparedness, whether for a pandemic or something else, requires a strong and robust public health system that includes all its parts: not just surveillance and disease outbreaks but maternal and child health, substance abuse programs, inspectional services, etc. My rationale here is a little different. They represent another critical kind of capital, human capital. The more people trained and experienced in public health we have the better able we will be to withstand the kind of shock a pandemic would cause. When catastrophes happen people rise to the challenge and can do amazing things. But it's much better if they also have trained reactions, knowledge and experience. We saw an object lesson with the ditching of the US Airways plane in the Hudson River.

Yes, luck was involved, but this was an experienced, prepared pilot and crew, and that likely made the difference. There is no shortage of young people in this country who want to put their shoulders to the public health wheel. We can invest in training them and providing experience by requiring two years of national service in exchange for free tuition to any School of Public Health. Who would you rather was piloting your plane? Someone who wrote the software for a Boeing 747 flight simulator or someone who has spent years flying commuter airline planes? By ramping up training and assuring staffing in state and local public health we can strengthen a critical portion of the public health infrastructure.

I am only sketching some things that are begging to be made into detailed proposals. But they are the kinds of infrastructure that will pay off handsomely, the low hanging fruit of investment. Meanwhile, there is also some hard thinking that needs to be done about the whole enterprise we are engaged in.

DemFromCT: OK. I can see that if I really want to pin you down, I'm going to have to be very specific. Recently the reveres/Reveres have been posting very specifically (here, here, here, here, here and lots more) on the salmonella in peanut butter episode (someday I want you to explain why sometimes it is reveres with a lower case r and sometimes with an upper case R, but I'll leave that for another time or maybe consider it just one of Life's Enduring Mysteries). What's your take on food safety? Specifically, is our food chain safe?

Specifically? Without the political musings? That reminds me of a joke whose punchline is, "I always think of screwing," but I'll do my best to think of something else.

First, like you, I frequently use the common phrase "the food chain," but there is nothing chain-like about it. A chain is linear. One link follows another. But our food production and distribution system is more like the blogosphere itself, a network of interconnected nodes, some with few readers (personal blogs read by no one or just a few friends, like a kitchen is), some with a modest number of readers (like Effect Measure, with its small but specialized community, more like a restaurant), and then megablogs like DailyKos that are highly connected to hundreds of thousands of readers and other connected nodes (a big manufacturer or meatpacker, distributor or ingredient maker). We may think of the food system as "centralized" because there are megadistributors but in fact a problem can be introduced at any point, and in the peanut butter episode it wasn't a distributor but the maker of a common ingredient in a lot of other products, peanut paste. The malefactor, the Peanut Corporation of America, is not even one of the industry giants, like ConAgra (who also had a problem in 2007 with their Peter Pan brand peanut butter).

If you think of the food system as the blogosphere you can see immediately what can happen. It is a system that is a set up for delivering nutritious, health giving products to a lot of people (DailyKos) or adulterated products to unsuspecting or ignorant consumers (Michelle Malkin). A contaminated highly connected node in the food network like the Peanut Corporation of America is like Drudge, providing adulterated ingredients to a gluttonous MSM, who serves it up to everyone. Here the analogy breaks down, because I don't advocate regulating the contents of the blogosphere (as much as sometimes I'd like to). The food network, however, does need to be better regulated. Consumers cannot isolate themselves from the bigger food network, which also includes water, soil, air and seed stock, so even eating locally grown food, something not feasible for most people, doesn't eliminate the problem.

For this and other reasons fixing the food system is a big task, and various proposals are in the works in Congress. One of your

representatives, Rosa DeLauro (D-CT, Third District), has introduced a bill to consolidate food safety oversight into a single agency, instead of spreading responsibility for monitoring, inspecting and labeling over the current 15 agencies. At the moment consumers don't know the distribution of recalled products, and it appears that even the FDA didn't know initially where PCA's peanut paste went because there is no requirement to notify the agency of where ingredients are distributed. The industry has maintained that access to this kind of information must remain private because it could be used by competitors. Yes, theoretically true, so that's a trade-off. But the same people who wring their hands over confidential business information seem to have no trouble with my privacy.

We know they have violated all of our privacy using doubtful (I'm being generous) arguments about national security. That's a trade-off they are only to eager to make. But information that protects children from contaminated peanut butter cracker snacks? Note that half of the500 salmonella cases from this outbreak are children.

Whatever agency we wind up with (either the discoordinated mosaic we now have or a consolidated agency), it will have to be adequately staffed and with sufficient infrastructure (see, we did get back to it!). Staffing is human infrastructure. Right now there is insufficient inspection because there aren't enough inspectors. The laws are legal infrastructure. There needs to be legal authority, authority that is used and sanctions that are enforced, to make sure the nodes in the food network operate according to best practices.

There needs to be laboratories capable of doing the high through put urgent analysis of food samples from the field in the event of an outbreak. That's physical infrastructure. There needs to be research and information on food safety, developed by supported and carefully conducted research on things that are still uncertain. That's intellectual and scientific knowledge infrastructure.

This is just for starters, but it's all infrastructure investment because the system is in urgent need of repair. Part of that infrastructure just fell down and injured over 500 people and killed 8 of them. The fact that it was salmonella and not a bridge collapse is not very relevant to the victims.

More thoughts from the reveres can be found at Effect Measure, where they have been blogging since 2005.
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**sharon sanders** · March 14, 2009, 06:52 PM

Re: Flu and You

<table class="mainTable"><tbody><tr><td> Flu And You - Part V

by: DemFromCT

Sun Feb 08, 2009 at 08:44:06 AM EST

</td> </tr> <tr> <td> Senator Susan Collins (R-ME)on pandemic flu and the stimulus (click to play video on another site):

"Everybody in the room is concerned about a pandemic flu, but does it belong in this bill? Should we have 870 million dollars in this bill? No, we should not."

Well, that's an interesting statement, when you think about it. Everyone in the room (and that would be mostly Senators) was properly concerned about the possibility of a pandemic. That part is crystal clear (and thank you, Senator Collins, for saying so.) </td> </tr> <tr> <td>As to whether it's appropriate to put the money in a safety net/stimulus bill, that's the debate that's ongoing. A case can be made that money spent on science, health and education - and that includes public health - is a great investment in jobs and infrastructure. Unfortunately, more people believe that on the House side than the Senate side, as Collins articulates, and so the 870 million was removed from the Senate bill, for now (900 million still sits in the House bill - details here.) Interestingly, at the beginning of the week I spent two days with scientists and public health officials from all over the world who are experts on the topic of pandemic and seasonal flu. And guess what? Everyone in the room, from the White House to WHO, was concerned about a pandemic flu. There was some consternation at the meeting about Tom Daschle withdrawing (both nature and scientists abhor a vacuum.) And there was a good deal of concern about the fate of public health funding in this stimulus bill. Ultimately, the meeting was about science and policy.
The science meetings were sponsored by IDSA (the Infectious Disease Society of America), who have been involved in pandemic influenza preparedness since at least 2005. Back then, Dr. Andew Pavia (the chief of the Division of Pediatric Infectious Diseases at the University of Utah Health Sciences Center and Primary Children's Hospital) was also chair of IDSA's Pandemic Task Force (after a stint on the public policy committee, he's back on the Task Force.) In testimony to Congress (.pdf) <sup>*</sup>, Dr. Pavia noted the fragility of our nation's vaccine supply, and the importance of bolstering R&D, which is where most of the pandemic dollars in the stimulus would go. In addition, a need for antiviral R&D, stockpiling and distribution plans was identified in 2005.
I caught up with Dr. Pavia at the meetings and asked his opinion of how far we've come, and where we need to go. His opinion was that there's a "mixed scorecard". While the vaccine picture has certainly improved, with high-tech solutions for mass production on the horizon, and research into adjuvants and other antigen-stretching techniques (making vaccine more efficacious, and allowing more vaccine to be made with the same hard-to-produce antigen) has come a long ways, the "under-exploited" state stockpiling of anti-virals was notable (see Trust For America's Health 2008 Ready or Not? report.) The Biomedical Advanced Research and Development Authority (BARDA), for example, still gets year-to-year funding, and many states cannot afford the purchase of anti-virals. The resistance developing in some flu viruses (see part I of this series) just complicates things even more.
Dr. Pavia reminded me that IDSA suggested in 2005 and affirmed in 2007 that health care workers really need to get their flu shots, not just to set an example but to keep their patients healthy. In 2007, "the current rate for this group is about 40%, the ISDA report says," which is disgraceful.
Dr Keiji Fukuda from the World Health Organization emphasized that the pandemic threat from H5N1 has not diminished, even as reported human cases have declined since 2006. Unfortunately, new cases continue to be reported from China, Egypt and Vietnam, where the virus is endemic in wild birds. [Establishment of zoonotic infection is less known as hard fact than we would like, particularly on the issue of poultry vs wild bird reservoirs, and where disease comes from when humans catch it in individual countries affected also remains unclear.]
Researchers from all over the world presented data on the surveillance of flu viruses, and also discussed how work done on pandemic flu and H5N1 spills over into seasonal flu and other infectious disease control.
We've been having ongoing discussions here about public health infrastructure and what that means (this meeting and others like it are part of that infrastructure). Every scientist and public official I spoke to emphasized that infrastructure can't be created overnight, or turned off and on with a switch. Public health infrastructure also means jobs.
That brings us back to Sen. Collins' remarks, and the difference between the House and Senate versions of the recovery, stimulus and safety net bill.

Jeff Levi, PhD, executive director of TFAH, said in the statement, "This is an unprecedented one-time investment in public health." In 2008, a TFAH expert panel reported that the country faces annual $20 billion shortfalls in critical public health program funding across state, local, and federal levels. The National Association of County and City Health Officials (NACCHO) said in a Jan 15 statement that federal support for effective public health programs has eroded steadily over several years. "This (House) bill would reverse that course and set the stage for an emphasis on wellness in forthcoming discussions of reform of the nation's health system," the group said.
On Jan 27 TFAH released a statement applauding the Senate Appropriations Committee for including $16 billion for public health in its version of the stimulus bill. "This funding is desperately needed to revitalize and modernize the country's ailing public health system, and we'll be putting more Americans to work in programs that will directly improve the health of communities where they live," Levi said.

I don't think anyone cares if money for health and safety (including R&D) is removed from this bill and passed in some other bill. But keeping the focus on public health infrastructure, much of which gets back to the states, is essential to keeping our citizens healthy. And accepting that these funds are essential is part of the on-going debate as to where and how we best spend our limited resources. Senator Collins didn't challenge the need, just the vehicle to get there. That, at least, is a start. But just as with education, dollars spent here not only create jobs, they keep jobs at state level while promoting the public good. It's a twofer that should be emphasized while we debate these and subsequent bills. <sup><sup>*</sup>IDSA represents nearly 8,000 infectious disease (ID) experts, many of whom administer the flu vaccine to patients, treat life-threatening complications of influenza, conduct vaccine and antiviral research, and implement influenza surveillance activities and other important influenza public health programs at the local, state, and federal levels. Let me be very clear from the onset: Although we are speaking on the same panel as our industry colleagues, our testimony is provided strictly for the good of public health and the patients whom we treat. IDSA is not here on behalf of the pharmaceutical or biotechnology industries nor is our advocacy financed in any way by industry. </sup>
<sup>From page 2, Infectious Diseases Society of America's Statement by Andrew T. Pavia, MD, Concerning Pandemic Influenza Before the Committee on Energy and Commerce Subcommittee on Health United States House of Representatives</sup>
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**sharon sanders** · March 14, 2009, 06:53 PM

Re: Flu and You

<table class="mainTable"><tbody><tr><td> Flu And You - Part VI

by: DemFromCT

Sun Feb 15, 2009 at 07:41:08 AM EST

</td> </tr> <tr> <td> By the way, flu season is heating up. You can check that by clicking the link, or going here. There's lots of the milder influenza B, and some of the nastier influenza A, but on the whole, we've had worse years (but this one is not over.) Luckily, the vaccine this year seems to be hitting the A strains fairly well (one of which is tamiflu-resistant), but the B strains not so well (see part I of this series).</td> </tr> <tr> <td> <embed src="http://www.dailykostv.com/flv/player.swf" bgcolor="black" allowfullscreen="true" flashvars="config=http://www.dailykostv.com/vxml/000710.php?448" height="252" width="448">
This week was also the week the Congress passed the President's 789 billion stimulus bill. There was money for science, and money for health, but not for pandemic influenza planning (removed in conference.) To follow up on that, and to discuss why it was there in the first place, I contacted Jeff Levi of Trust For America's Health. Jeff's been with TFAH since 2005, and its ED since May 2006; more from his bio:

Jeffrey Levi, PhD, is Executive Director of Trust for America's Health, where he leads the organization's advocacy efforts on behalf of a modernized public health system. Dr. Levi oversees TFAH's work on a range of public health policy issues, including its annual reports assessing the nation's public health preparedness, investment in public health infrastructure, and response to chronic diseases such as obesity. Dr. Levi is also an Associate Professor at The George Washington University's Department of Health Policy, where his research has focused on HIV/AIDS, Medicaid, and integrating public health with the healthcare delivery system. He has also served as an associate editor of the American Journal of Public Health, and Deputy Director of the White House Office of National AIDS Policy.

I've heard Jeff present at a number of health-related conferences over the years, where he's called upon to summarize governmental outlays and involvement, and I've linked and sourced TFAH frequently . Jeff was kind enough to answer a few questions for us.

DemFromCT: TFAH follows government spending and budget items. Can you explain to our readers why pandemic influenza or other public health preparedness and infrastructure funding belongs in a stimulus bill?
There are two levels of argument in favor of including pandemic preparedness in particular and public health programs in general as part of the stimulus bill. First, these do meet the test of stimulating the economy. Much of the nearly $900 million in pandemic money would go toward research and development - biomedical research that is very similar to the work that NIH funds. Ironically, as the pandemic money was being cut as inappropriate to a stimulus bill, the Senate was simultaneously increasing funding for the NIH. In fact, the bioscience sector is a source of high-wage jobs. The average bioscience job paid $ 71,000 in 2006, $ 29,000 more than the average private sector job. It has been estimated that each bioscience job generates an additional 5.8 jobs in the national economy.

The public health sector in general is also hurting. TFAH has conservatively estimated that the $5.8 billion in public health spending that was withdrawn from the Senate bill would have created 40,000 jobs - that's without calculating a multiplier effect in the local economy. State and local health departments are hurting. Recent surveys by the trade associations for state and local health officials have shown that 11,000 jobs have already been lost; another 10,000 have remained unfilled as they became vacant. This gets at the core capacity of health departments to respond to emergencies such as a pandemic as well as to serve a core safety net function during a recession - providing preventive services and direct care for the growing number of uninsured.

As originally proposed by the Administration, the stimulus bill was meant to accomplish two related goals: first, provide direct stimulus to the economy and second, to start building the nation's core capacities for health reform. Indeed, the funding for creating electronic health records remains in both the House and Senate bills, as well as funding for comparative effectiveness research. The prevention and wellness funds were also designed to increase the capacity of our public health programs to improve the health of communities - so that uninsured Americans (and all Americans) would enter the reformed health care system healthier. That is still a worthwhile goal of any legislation called the Economic Recovery and Reinvestment Act. But as I mentioned above, these investments can also have a stimulative effect.

DemFromCT: And where does that stand in the final bill? (The stimulus .pdf summary here.)
The final bill does not add back any of the pandemic money. So this leaves my original comments on that subject intact. We have been told that there will be an effort to include these funds in the omnibus FY 2009 bill that is expected to move soon - but we shall see.

Only other addition is that the final number for public health prevention is $1 billion - down from the $3 billion in the House number, but obviously better than being zeroed out in the Senate bill. This is a major investment ($300 million for immunizations, $650 million for community-level prevention, and $50 million for health care acquired infections) the likes of which the public health community rarely, if ever, sees. I think it is a signal that the Obama administration is committed to investing in prevention and public health - and that public health will have an important seat at the health reform table.

DemFromCT: Do you think professional societies (e.g., IDSA, AAP, APHA, etc) have been visible enough in explaining why public health needs funding?
One of the things that has been quite gratifying about the current fight to preserve the prevention and pandemic funds is the degree of unity within the public health community. We are speaking with one voice. But that said, we still lack the grassroots or even "grasstops" support that so many other issues have.

DemFromCT: You've written about the role of the states vs the role of the federal government by helping to produce readiness report cards. What's the impact of the recession on the grades you've already assigned? Do you expect states to be able to deliver on programs already underway? How else does the recession affect the feds and the states?
In releasing our 2008 version of Ready or Not: Protecting the Public's Health from Diseases, Disasters, and Bioterrorism we expressed great concern that some of the progress we have measured over the last six years will diminish as states make budget cutbacks and the impact of federal cuts in preparedness funding are felt. We know that states are cutting public health budgets; we know that states are laying off key personnel and leaving vacancies unfilled. This will inevitably have an impact on preparedness. It will take some time to be able to measure that impact, but we certainly know anecdotally that it is real. That is why the funding for state and local health departments - and state governments in general - in the stimulus package has been so important.

DemFromCT: Do you have any strong feelings about whether health czar and HHS Secretary should be one job or two? Any preferred candidates? If not, how about skill sets for each of the jobs?
I think whether these positions should remain one will be determined in part by the personality and experience of the final choice for HHS Secretary. Tom Daschle had a unique set of skills: a combination of familiarity with the breadth of health issues, in-depth (almost wonkish) understanding of health reform concerns, and tremendous political skills to shepherd policy through Congress. Running HHS is a major undertaking in itself. The policy development around health reform is another full-time job. Jeanne Lambrew, who is the deputy in the White House Office of Health Reform, has the knowledge and depth of experience to do the policy development part. As long as she and the new HHS Secretary have a strong working relationship, this might be a more balanced approach. My bottom line: being sure that whoever is involved in running HHS and/or developing a health reform proposal recognizes that public health and what happens in communities is a critical component of health reform - it's not just about providing coverage for everyone, as important as that may be.

DemFromCT: Can you touch on why single payer health reform seems to never be a seat at the table?
I have never fully understood why single payer has been so readily delegitimized as an option. I think it suffers from a combination of bad press (being so easily stigmatized as government-run medicine) and the instinctive American discomfort with major structural change. I have always been struck, of course, by the inconsistencies in this debate. We have been willing to embrace single payer for the elderly (that's what Medicare is) and a national health service for veteran (which has better health outcomes than most private plans). Both are immensely popular programs that politicians eagerly support. I can't explain why we haven't created the political will to offer comparable programs to the rest of the country.

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**sharon sanders** · March 14, 2009, 07:05 PM

Re: Flu and You

<table class="mainTable"><tbody><tr><td> Flu And You - Part VII

by: DemFromCT

Sun Feb 22, 2009 at 09:09:35 AM EST

</td> </tr> <tr> <td> This public health series uses influenza as a common illness to explore the intersection between public health, policy and politics, and today, we're going to talk a bit about children's health insurance (SCHIP) and smoking.</td> </tr> <tr> <td> For your weekly seasonal flu update go here or here. Connecticut is peaking and beginning to drop, but the occasional flu case can be deadly. From CDC:

Six influenza-associated pediatric deaths were reported to CDC during week 6 (Arkansas, Colorado, Florida, North Carolina [2], and Pennsylvania). One death occurred during week 8 of the 2006-07 season (week ending February 24, 2007), bringing the total number of reported pediatric deaths occurring during that season to 78. The remaining five deaths reported this week occurred between January 25 and February 14, 2009. Since September 28, 2008, CDC has received nine reports of influenza-associated pediatric deaths that occurred during the current season. Bacterial coinfections were confirmed in six (66.7%) of the nine children; Staphylococcus aureus was identified in four (66.7%) of the six children

Staph infections and bacterial co-infections in general are always a threat with flu... reports from 1918 suggest bacterial co-infection was a major source of mortality. However, in a pandemic, even if this is the major culprit (and it's not been in the current H5N1 outbreak from 2003 onward), the lack of resources (antibiotics and hospital beds, or as we call it, the lack of "staff, space and stuff") would be a huge problem.

In most modern healthcare systems, which increasingly emphasize just-in-time supply chains, shortages of antimicrobial drugs may occur rapidly unless more are stockpiled. These shortages would limit the treatment of secondary bacterial infections in the middle and the later stages of a pandemic.

These kind of logistical nightmares are part of the health infrastructure discussion we've been having in this series (including surveillance and lab capacity in part II), and for this week's offering (I'm planning a future post on staph aureus and it's antibiotic resistant cousin, MRSA), we had a chance to catch up to Erika Sward, Director, National Advocacy at the American Lung Association, and ask a few questions about that organization's views on the intersection of policy and politics. By the way, the ALA provides a zip code search of flu vaccine sites and is a strong supporter of flu prevention. Just click here. The first topic we discussed was the Children's Health Insurance bill (SCHIP), partially funded by a tobacco tax. The ALA regards this as a "win-win" scenario:

Funding for the program comes from a 62-cent increase in the federal cigarette tax. By increasing the cigarette tax to $1.01 per pack, the expanded CHIP adds the benefit of reducing youth smoking to the already substantial impact it will have on improving children's health nationwide.

Higher cigarette taxes are proven to prevent kids from starting to smoke. The 62-cent increase is a significant increase over the previous 39 cents and will mean tobacco use among children and adults alike can be reduced, saving lives and preventing the incidence of many chronic diseases, including Chronic Obstructive Pulmonary Disease.

Erika Sward pointed out in response to a question about reduced usage and reduced funds that in states like NY with high tobacco taxes (and reminded me that all tobacco products are problematic), a "tipping point" where revenues dry up because of high taxes has not happened, so it's more a theoretical than an actual problem, hence the "win-win" designation. This was partly behind the thinking that led Congress to fund the bill with a cig tax mechanism. And as the ALA site notes, the tobacco industry is not passive about children and smoking:

For decades the tobacco industry has developed cigarette brands and marketing campaigns aimed at young women and girls. The effect on women's health has been devastating.

Another issue we touched on is the idea that tobacco control is no longer, as Sward put it "the third rail" of American politics, and that it can now be openly discussed. In fact, for two decades, the ALA has recognized that only the Federal Government can regulate tobacco, and that if it is treated as a drug, that properly belongs under the auspices of the FDA. John McCain sponsored legislation in the Senate to do that, and in 2004 it passed the House, but never became law. This year, Henry Waxman promises to include such a provision as part of comprehensive health reform:

He [Waxman] also said he would advance legislation requiring the FDA to regulate tobacco products "in a matter of weeks" and a bill on embryonic stem cell research to move "very fast."

The ALA is among the many science and health advocacy groups supporting science and health dollars in the stimulus bill including the pandemic doillars that were removed in the final bill (as we learned last week, likely to reappear ion an omnibus spending bill later this year). "Spending dollars on wellness and prevention is spending dollars and state and local health departments, and that means jobs," Sward said. And on the health reform side, Sward would like to see prevention and wellness emphasized, as well as evidenced based outcomes research on TB, asthma and influenza to help guide policy. This means research dollars (and jobs), and therefore appropriate for stimulus discussions.

Like a fire department that's only open three times a week, health departments won't be there when you need them if they get cut when times are tough. And whether it's food and restaurant surveillance, asthma surveillance or influenza surveillance, sometimes you only realize that when they're gone.

In the meantime, look for continued rather than diminished pressure on tobacco as health reform gets into gear. Tobacco companies are far more sophisticated than most when it comes to PR, and there'll be plenty of push-back. SCHIP is one battle, but the conflict will go on, and FDA regulation of tobacco as a drug looks to be the next big battle on the horizon.

The American Lung Association can be found here.
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