Back to the Future: H1N1 and Public Health
Article Outline
Editor's Note: I wish to extend my appreciation to Drs. Vessey and Turner-Henson for this issue's editorial regarding this important public health issue impacting children and their families. Cecily L. Betz, PhD, RN, FAAN
In the fall of 1918, the influenza pandemic tore across the world. Public health nurses in cities throughout this country cared for some of the most vulnerable—sick children and families from poor communities, their fragile economies further devastated by this scourge. At that time, nurses' practices were governed by Florence Nightingale's precepts of good hygiene, nutrition, fresh air, and rest. They worked to do right by their patients, but their ability to make a difference was tempered by the lack of existing knowledge and resources needed to provide the most efficacious care possible.
Today, we are in the midst of a new global H1N1 influenza pandemic. Although H1N1 is an “equal opportunity virus” able to infect anyone in its range, children are at increased risk for infection, comorbidities, and complications. They lack residual immunity, spend more time in crowded child care and school settings, and usually shed more virus and for longer periods of time—often to peers and family members, furthering influenza spread (Stevenson et al., 2009). In addition, although there is no specific viral affinity for the poor, those from lower socio-economic backgrounds assume the greatest social burden.
Throughout inner-city schools, the following scenario continues to play out: A child is sent to school regardless of feeling fatigued, achy, and feverish. Despite the child's symptoms, the mother, a single parent, gives her child an antipyretic/analgesic and, hopes against hope, that her child's malaise and fever will go unnoticed and that he can stay at school for the entire school day. It is the contagion of absenteeism—missing a day of work due to an unanticipated child's illness—not the symptoms of influenza, that the mother also fears. An unintended consequence of the mother's decision is now her sick child becomes a vector for viral contamination across the school's student body, furthering the spread of H1N1.
Although most children who have H1N1 only are mildly sick for 5 to 7 days and experience few complications, there are still significant costs associated with caregiving. Quite simply, when a child is absent, the parent must stay home from work. The more diminished a parent's economic circumstances, the greater the chance that employee absences will be without pay and the more tenuous is job security. Families also need to cope with additional expenses associated with illness care, such as unexpected clinic visits, transportation costs, and prescription and over-the-counter medication costs. Inequitable allocation of health care resources in inner cities, including fewer primary care providers and after-hour clinics, insufficient capacities of existing providers to increase patient loads, and less access to pharmacies that routinely stock antiviral medications or offer vaccinations, further complicate the picture. Overburdened emergency departments, often with limited pediatric specialty services, remain the safety net.
Despite nearly a century of health care innovation, there still is no cure for influenza, treatment focuses primarily on symptom care, and new medicines offer only modest efficacy. Public health care policies have made modest gains through mass media campaigns, electronic disease surveillance, the ubiquitous presence of hand sanitizer, and immunization (when available). However, these requisite activities are still insufficient for successfully supporting families with limited resources. Unfortunately, this influenza pandemic highlights the inadequacy of the public health infrastructure to address the needs of low socioeconomic communities.
When the present influenza pandemic passes, we will examine the outcomes and once again identify recurring capacity disparities. Essential elements of preparedness for influenza pandemics go beyond infection control measures, early detection of cases, rapid treatment, and isolation of cases (Santibanez, Fiore, Merlin, and Redd, 2009). Evidence exists that school nurses, school-based clinics, sick child care, paid family medical leave at all levels of the workforce, and adequate primary care clinics reduce disparities. Unfortunately; widespread implementation of such strategies is all too often side railed by ideological chasms or underfunded legislative mandates. In the future, inclusive preparedness programs derived from an integrated nexus of health, educational, and social systems would help provide a comprehensive response to pandemics required by vulnerable populations.
Like public health nurses at the turn of the 20th century, pediatric nurses today continue to care for the some of the most vulnerable victims of the influenza pandemic. We care for children in our practices, volunteer in school or community immunization clinics, teach hand washing to community groups, and all too frequently, find ways of helping schools and families acquire soap, sanitizer, and other frontline tools needed for prevention. However, these efforts are insufficient. It is time for political activism to advance public health resources to children and families and advocacy at all levels of government and diverse arenas of care. The federal government is finalizing the U.S. public health objectives for the next decade in Healthy People 2020; they are asking for our critique. Please take a moment and log on to their Web site (www.healthpeople.gov/HP2020/) and make your voice heard.
References
PII: S0882-5963(09)00335-2
doi:10.1016/j.pedn.2009.11.002
© 2010 Elsevier Inc. All rights reserved.
