The Sun is committed to providing fair and accurate coverage. Readers who
have concerns or comments are encouraged to call Paul Moore, the newspaper's
public editor. He can be reached at 410-332-6364 or toll free at
1-800-829-8000, ext 6364, or by e-mail at
An article on flu shots in yesterday's edition incorrectly stated that
Maryland has yet to record any cases of influenza this season. The state
Department of Health and Mental Hygiene reported Thursday that a woman had
come down with a confirmed case of the "B" strain.
Lobbyist Struggles As Bans Multiply Through D.C. Area
By Dan Morse
Washington Post Staff Writer
Sunday, November 6, 2005;
County, Melvin Thompson could understand. It's filled with government
workers. "There's a tendency to believe that government can solve problems
for you," he said.
Similar sentiments run in Howard
County,home to Columbia, the giant planned community. It wasn't until Prince George's
County moved last month to outlaw smoking in bars and restaurants, he says,
that he fully understood how rapidly smoke-free forces can now move through
Thompson is a lobbyist for restaurant and bar owners in Maryland. He fights
proposed smoking bans. Tracking his recent efforts helps explain how an area
stretching from the District to just south of Baltimore could soon become a
no-fly zone for smoking in bars and restaurants.
County ordinance is two years old. Howard's ban was proposed Oct. 25. The
next day, a D.C. Council committee approved its measure. In Prince George's,
council members will hold a hearing Tuesday and are poised to pass it.
"Initially, I wouldn't have said Prince George's was vulnerable," Thompson
said, citing the county's desire to lure sit-down restaurants, concerns
raised by the county's chamber of commerce and a strong working-class bar
crowd near the Route 1 corridor.
But statistics indicate that fewer than one in four voters smoke. At the
same time, anti-smoking advocates have been presenting politicians with more
research concluding that the bans don't hurt the restaurant business overall
and that they protect workers from secondhand smoke. Last month, Montgomery
released a study showing that its ban hasn't hurt its hospitality industry.
"In terms of what's good for votes, it's a political no-brainer," said
Thompson, who asserts that many of the studies are flawed.
In Virginia, where tobacco interests have long held political sway, a
statewide ban on smoking in bars and restaurants seems unlikely anytime
soon. And because the state's constitution generally forbids counties from
passing laws more restrictive than the state's, local jurisdictions are
hindered in efforts to pass anti-smoking measures. Still, in Alexandria,
more than 50 restaurants have voluntarily agreed to ban smoking on their
premises, according to city officials.
"I think the entire state of Maryland
and D.C. within the next two years will be smoke-free," said Kari Appler,
executive director of the Smoke Free Maryland Coalition and Thompson's
political arch-opponent on the issue.
Thompson said there are plenty of battlegrounds left, such as Anne Arundel
and Baltimore counties. Smoke Free Maryland's polling data show that
although support is strong for statewide bans in suburban Washington,
it drops to 55 percent in suburban Baltimore.
Thompson and his supporters say the bans hit certain establishments hard,
such as those catering to sports fans and draft beer drinkers. Thompson also
takes the position that the known dangers of secondhand smoke are repeatedly
overcooked. But, he said, sighing, fewer politicians want to hear his
"I don't need a ton of bricks to fall down on my head to know they don't
want to sit down with us," he said of the Prince George's County Council's
nine members, only two of whom have returned his recent calls.
Thompson earlier worked for U.S. Rep. Wayne T. Gilchrest, a Republican from
Maryland's Eastern Shore. He then pursued a longtime dream and worked as an
assistant chef in a French restaurant. He and his wife didn't like the
hours, so he returned to politics, joining the Restaurant Association of
five years ago.
In fighting this battle, he also faces challenges from his own side. He
doesn't get much help from big chains, such as Outback Steakhouse and the
Olive Garden, that survive more on dinner volume than bar receipts,
independent restaurant owners say. Even some Maryland
restaurant and bar owners who are members of his organization tell lawmakers
they'd be willing to live with a statewide ban if the District follows
through with its own legislation, eliminating that competition.
And when Thompson tries to generate momentum among smokers, such as recently
faxing material to bars in Prince George's,
those folks tend not to show up at public hearings, where ardent smoking
foes regularly do, he said.
Local officials certainly are following trends. At least seven states,
including California, New York and Delaware, and 180 localities, insist on
smoke-free bars and restaurants. Even Ireland now forbids smoking in pubs.
In Maryland, smoke-free proponents say that Thompson is too quick to cite
politics and criticize research and that local officials simply are trying
to promote safe environments for all workers.
Debates on smoking in Maryland
bars stretch back to at least the early 1990s. In 1993, Howard and Anne
Arundel counties and the city of Baltimore proposed cutting back. Even the
restaurant association seemed to agree about the dangers.
"We see more and more scientific reports linking exposure of tobacco smoke
with illnesses," Paula Kreuzburg, the association's then-president, wrote in
a memo to the group's board of directors, according to a copy of the memo
posted under the "Secret Documents" section of the Smoke Free Maryland
Coalition's Web site.
In 1995, Maryland
enacted rules barring smoking in indoor workplaces. But state politicians
carved out exemptions for restaurants and bars. The industry's argument has
long been that restaurants, and particularly bars, aren't like airplanes or
office buildings -- that many of them need smokers to thrive. In 1996,
Howard officials enacted a law calling for establishments to seal off
Things remained relatively quiet for the next eight years. Then, in 2003,
Montgomery's ban went into effect.
As for TalbotCounty,
where smoking in nightspots was snuffed out last year, it is increasingly
filling with wealthy retirees -- who, unlike longtime residents, weren't as
apt to get a beer at a smoky bar, Thompson said.
He continues to distribute research by James E. Enstrom at the School of
Public Health at the University of California at Los Angeles. Enstrom and
others studied 35,561 nonsmokers with smoking spouses, concluding that the
data didn't support a causal relationship between secondhand smoke and
Reached in Los Angeles, Enstrom said that he is not necessarily opposed to
smoking bans -- in part because he thinks actually smoking is more dangerous
than many people believe -- but that his research into secondhand smoke
tends to be dismissed out of hand in the current environment.
"All the science gets lost in the battle to implement these bans," he said.
Other studies, of course, show secondhand smoke to be dangerous.
In Prince George's, Chairman Samuel H. Dean (D-Mitchellville) and
council member Douglas J.J. Peters (D-Bowie) say they expect the council to
pass the smoking ban Tuesday.
Regarding possible sit-downs with opponents of the bill, Peters said, "What
we're trying to say is we appreciate your input but we've weighed the pros
and cons and we think public health is going to win out."
In the District, even council member Carol Schwartz (R-At Large), an
opponent of the ban, said the measure is likely to pass. She also predicts
it will be a challenge to amend the ban for establishments that, among other
measures, install ventilation systems. "Listen," she said, "the votes are
there for smoke-free."
The debate in Howard County might turn out to be the most contentious.
Council member David A. Rakes (D-East Columbia) intends to submit
legislation that grandfathers in establishments with sealed-off smoking
"They've already spent so much money to comply with our old law that we
shouldn't now change the rules on them," he said.
Kendal Richardson, 27, tested positive for the AIDS virus in 1996, not long
after graduating from high school in Sterling. He said he continued to have
unprotected sex with men for five years before seeking treatment.
Geno Dunnington, 49, tested positive in 1985. "The first thing I did was
went out and got married," he said. His wife and two children were not
infected, he said, but he continued to have unprotected sex with men for
more than a decade.
Ronald Morgan, 43, tested positive in 1984 but continued to have unprotected
sex until last winter, when his skin broke out in boils. "My HIV had
progressed to full-blown AIDS," he said.
Yesterday, Richardson, Dunnington and Morgan joined nearly 300 other people
with HIV from across the country outside Robert F. Kennedy Memorial Stadium
to call on the president, Congress and society to make a renewed commitment
to ending the AIDS epidemic.
Then the crowd, organized by the Campaign to End AIDS, marched to Anacostia
Park to call attention to the virus's growing devastation of the black
community, particularly in the nation's capital.
Washington has a far higher incidence of AIDS -- 170.6 cases per 100,000
people, according to federal statistics -- than other major U.S. cities,
including New York and San Francisco. An estimated one in 20 District
residents is infected with HIV, the virus that causes AIDS. And that number
climbs to an estimated one in seven among black men in the District, said
Michael Pickering of RAP Inc., a drug treatment program that works with
people who have AIDS.
"That number should petrify us all," Pickering said as marchers chanting to
a single snare drum and carrying colorful state flags straggled into
Anacostia Park to listen to music and hear speeches from AIDS activists and
D.C. Council member Adrian M. Fenty (D-Ward 4). "There shouldn't be room to
stand in this park," Pickering said.
Richardson, Dunnington and Morgan are among the statistics. All three are
African Americans who contracted HIV while living in or around the District.
They are also examples of why the virus can spread so rapidly in the city's
black community: All said they initially dealt with news of their infection
not by seeking treatment, but by withdrawing into a state of denial.
"I wanted to be regular. I wanted to fit in. So I did everything everyone
else was doing so they wouldn't know," said Richardson, who lives in
Atlanta. That included going to "the sex shops, the O Street Follies, and
just doing anything and everything," he said.
Since seeking treatment and finding religion, Richardson said, he has
contacted former sex partners and was relieved to find that none had
contracted the virus. "But you don't know who else you could have done it
to," he said.
Dunnington, who lives near RFK Stadium, and Morgan, who lives at RAP's
treatment center in Northeast Washington, said they have no doubt that they
passed the AIDS virus on to others before seeking treatment for drug and
alcohol addictions -- behavior similar to that of Sundiata Basir, the former
D.C. government worker who was sentenced last week to 21 years in prison for
exposing at least seven women and girls as young as 15 to the AIDS virus.
Although Basir was unapologetic, Dunnington and Morgan said they are trying
to atone for their actions by getting involved in advocacy programs and
reaching out to young people who might be making the same mistakes they did.
"We need to stop, take a chill pill and get a new direction," Morgan said.
"If you have HIV, you need to learn to disclose."
Although the marchers voiced concern chiefly about changing individual
behavior, leaders of the Campaign to End AIDS said little will improve until
Congress fully funds education and prevention programs that teach people to
do more than practice abstinence. They also decried proposed cuts in the
Medicaid budget and the expiration of the Ryan White CARE Act, both of which
provide a crucial safety net for hundreds of thousands of people with HIV.
Over the next three days, leaders of the campaign will lobby Congress for
more attention and money for research on the disease.
They also will protest outside the White House and the offices of
But most important, they said, they will urge national leaders to fund
research into a cure for the disease that is still killing millions
No one "is articulating a vision of a world without AIDS," said Charles
King, president of Housing Works, a nonprofit organization that serves the
HIV-infected homeless in New York and Mississippi. "We really could end this
epidemic if we had the will, the compassion to do that."
CUMBERLAND - The Western Maryland Health System was recently granted
accreditation by the American Association of Blood Banks (AABB).
The accreditation follows an extensive an on-site assessment by the
specially trained assessors and establishes that the level of medical,
technical and administrative performance within the facility meets or
exceeds the standards set by AABB.
By successfully meeting these requirements, WMHS joins approximately 1,700
similar facilities across the United States and abroad that have earned
“The AABB's Accreditation procedures are voluntary,” said Dr. Jonathan
Walburn, pathologist and medical director of transfusion services at WMHS.
“Both Memorial and Sacred Heart have sought AABB accreditation because this
program assists facilities around the country in achieving excellence by
promoting a level of professional and medical expertise that contribute to
quality performance,” he said.
Walburn said the WMHS employees who work with blood services are
extraordinary and should be commended.
“Without our blood bank staff, we could not achieve the high standard of
excellence that AABB has bestowed on us,” he said.
Since 1958, AABB has been engaged in the accreditation of blood banks and
Today, its accreditation program assists blood banks, transfusion services,
cellular therapy facilities, parentage testing laboratories,
immunohematology reference laboratories and perioperative services in
determining whether methods, procedures, personnel knowledge, equipment and
the physical plant meet established requirements.
Starting Nov. 15, seniors can join in on the biggest change in Medicare
history: a program to help pay for prescription drugs.
But with 47 available plans and an avalanche of information arriving in
mailboxes, seniors have a lot to sort through before signing up for the
program, known as "Part D."
Advocates are urging seniors to take the time to research the plans so they
can sign up soon after Nov. 15. If they are hopelessly lost, there's help
"It will become easier with time," said Susan Knight, who leads the county
Department of Aging's Senior Health Insurance Program. "Although this may
not be a perfect plan, it's the one we have to work with."
The addition of Part D represents a huge change in how Medicare works.
Until now, Medicare - the federal government's health insurance program for
seniors - didn't offer a dimefor regular prescriptions. When Medicare was
started decades ago, there weren't as many drugs prescribed as there are
Seniors now find themselves on regimens that can include several
prescription drugs, and they are often expensive.
survey of 200 drugs released by the AARP last week found that the price rose
an average of 6.1 percent from July 2004 to June 2005 - twice the rate of
Ms. Knight and her team of insurance experts have been giving presentations
on Part D at senior centers since July in anticipation of the Nov. 15
opening of enrollment. They've also been fielding about 50 calls a day from
Medicare members seeking help.
About 60,000 seniors live in Anne Arundel County. A good portion of them are
retired from the government, military or private employers with so-called
"creditable" insurance plans or are covered through the Veterans
Administration, and therefore won't enroll in Medicare Part D.
But Ms. Knight estimated the county's Medicare population somewhere in the
tens of thousands. That's a lot of people looking for answers.
The reason for so many questions is that Part D is complicated. The 47 plans
are each offered by a private company and approved by Medicare.
Each plan has its own variables: participating pharmacies, costs to the
patient and lists of covered drugs. Not every plan will offer the same
coverage, drugs and co-payments.
Ms. Knight said seniors should make sure their chosen plan will work with
their pharmacy and offer savings on at least the most expensive drugs.
Discount cards can be used for drugs that aren't covered by a Part D plan.
One way to sort them all out is to log onto
www.medicare.gov and try out the
It's a good idea to list all necessary prescriptions to make it easier when
sorting through all the literature coming from the plan sponsors. Having
things organized can help when talking with counselors from the Department
of Aging or the AARP.
The plans have been roundly criticized for having major gaps in coverage
dubbed "the doughnut hole." It's a term being used to describe how in some
cases seniors have to pay varying fractions of the overall cost of drugs.
An example plan put out by Medicare shows the senior's portion going from 25
percent to 100 percent and down to 5 percent at different levels of how many
drugs are bought.
But not all plans have that same doughnut hole.
"In reality, none of these plans is set up exactly like the model plan," Ms.
Knight said. "That doughnut hole could vary."
All the choices can be bewildering for seniors like 82-year-old Helen Crane.
She's trying to choose a plan to cover her $500-per-month prescription drug
costs. Because of poor eyesight, she relies on her daughter to read the fine
print about the plans to find the one that's best for her.
"We really need help," said the Crownsville resident as she played a game of
cards last week at the Annapolis Senior Center. "It's very confusing."
All Part D plans start Jan. 1. The deadline to enroll is May 15, and
Medicare beneficiaries who don't sign up will be subject to financial
penalties when they do sign up. That penalty does not apply, however, to
seniors with more generous retiree plans, which are termed "creditable
Another element of the program is extra help for low-income seniors to pay
for their drugs.
In addition to Ms. Knight's presentation, there are other sources of help.
U.S. Rep. Wayne Gilchrest is planning eight visits to senior centers and
libraries in his district, and his staff will make seven more presentations.
Mr. Gilchrest represents the Eastern Shore, as well as some Western Shore
communities, including the Broadneck Peninsula, Arnold, Severna Park and
"The congressman's goal is to get out there and provide some experts to give
answers," said Cathy Bassett, Mr. Gilchrest's spokesman.
The congressman's offices have been getting plenty of calls about Part D,
and Mrs. Bassett expects the volume will only increase as Nov. 15
Other congressmen have been hitting the road, too, though none of Anne
Arundel's three other congressmen has local presentations planned this
Representatives from the AARP also have been out in force since summer
helping seniors understand Part D. The group also has plenty of advertising
and put out an informational brochure, "The New Medicare Prescription Drug
Coverage: What You Need to Know."
"We're going to continue through November and into May," said Kelley
Coates-Carter, a spokesman for AARP-Maryland.
While AARP sponsors one of the Part D-approved plans, Ms. Coates-Carter said
AARP is focusing on helping seniors find the right plan, no matter who the
"The word 'informed decision' is what we're focusing on," she said.
Capital News Service reporter Kim Hart contributed to this story.
Published November 06, 2005, The Capital, Annapolis, Md.
DAVIS, Calif. - Bang! Inside an improvised duck blind - her parked car -
Grace Y. Lee presses a switch, and her gun blasts a square of light
volleyball net over the dirt road she is watching.
One of the two magpies she has baited into range with cornbread,
cheese-flavored rice snacks and dog food is snagged, flopping furiously
"We mostly catch the young ones," Ms. Lee said. "These birds are too smart
to be caught again. We get them once, and they don't shop here anymore."
With the country waiting nervously for avian flu to arrive, catching wild
birds is no hobby. It has become part of a national early detection effort,
and Ms. Lee, a researcher at the University of California here, is a sentry
on the country's epidemiological ramparts.
She is one of hundreds of ornithologists, veterinarians, amateur
bird-watchers, park rangers and others being recruited by the National
Wildlife Health Center to join a surveillance effort along the major
American migratory flyways. They will test wild birds caught in nets; birds
shot by hunters on public lands, who must check in with game wardens; and
corpses from large bird die-offs in public parks or on beaches.
The plan also calls for sampling bodies of water for the influenza virus,
which is shed in bird feces. And it is designating some ducks and geese -
like those in backyard flocks or living year-round in park ponds - as
"sentinels" to be captured, tested, released and periodically retested.
Surveillance of poultry is already in place. Long-standing federal and state
laws require farmers to report deaths of birds from any flu strain. The
surveillance system was worked out this summer by the Agriculture
Department, which oversees poultry, and the wildlife health center in
Madison, Wis., part of the Interior Department, which oversees wildlife -
including migratory birds, which are thought to be the most likely entry
route for the flu virus.
Dr. Christopher J. Brand, the center's research chief, estimated the cost at
$10 million. [On Nov. 1, President Bush announced a $7.1 billion plan to
guard against a flu pandemic; Dr. Brand said he hoped money for the
surveillance system would come from that.] The sampling plan had a small
test run this fall in Alaska, which Dr. Brand said was the obvious choice
because of the flu's surprise appearance in Siberia in July. Birds from
there mingle in the summer Arctic nesting grounds with birds that migrate
down the North American coast.
Now the flu's recent crossing of Europe "has opened up more eyes," Dr. Brand
said. It is unlikely that infected birds will cross the Atlantic, because
most migrate north-south and the birds detected in Eastern Europe were from
species that migrate to Africa. Still, Dr. Brand said, there is now talk of
setting up a surveillance network for Greenland, eastern Canada and the East
The threat of avian flu has also sped a transformation that was begun by the
fear of bioterrorism and fueled by the fight against West Nile virus:
veterinarians and doctors, as well as the agencies overseeing them, are
Previously, said Dr. William B. Karesh, head of the field veterinary program
at the Wildlife Conservation Society, which runs the Bronx Zoo, the two
fields almost never worked in tandem.
"Human medicine and veterinary medicine have advanced beautifully in the
last 30 years, but they were not linked," Dr. Karesh said. That has always
frustrated him, he said, because "diseases don't care which way they flow -
there is a whole world of bacteria, viruses and fungi that move between wild
animals, domestic animals and humans."
Dr. Karesh described once trying to get a research grant for surveillance of
animal diseases that infect humans, known as zoonoses. The National
Institutes of Health told him to apply to the Department of Agriculture, he
said, and officials there sent him to the Fish and Wildlife Service, which
told him it had no mandate to study disease.
"Then we went to Homeland Security, and they understood what we were talking
about," Dr. Karesh said. "But they said: 'You're an orphan. No one does
this.' And in their rankings, we're lower than people trying to blow up the
subway in New York."
Now, instead of sharing information haphazardly and getting into
jurisdictional disputes - problems that cropped up during the 2003 monkeypox
outbreak and in surveillance for mad cow disease - health officials are
writing plans that emphasize teamwork.
The United States still does far better at animal surveillance than most
other countries because its medical and veterinary systems are each
excellent and because outbreaks cannot be hushed up - as, for example, the
SARS outbreak was in China.
But zoonoses fall into a gray area, and the 2003 monkeypox outbreak in the
Midwest is a perfect example of what can go wrong, said Peter Daszak,
director of the Consortium for Conservation Medicine at the Wildlife Trust,
a group specializing in human-animal diseases.
The disease, related to smallpox but less deadly, arrived in a shipment of
18 Gambian giant pouched rats imported for a Chicago pet store, where they
infected prairie dogs. By summer's end, there were 37 confirmed human cases
- none fatal, but some scary - mostly among prairie-dog owners.
"Millions of live animals come into the country each year, and very few have
really good surveillance," Dr. Daszak said. "Fish and Wildlife checks
cargoes to see if they have endangered species, but it's the U.S.D.A. that
does health checks, and they don't go unless it's an agricultural product,
so the pet trade tends to get a pass."
"The C.D.C. does a great job with outbreak investigation, but that's after
the fact," he said of the federal Centers for Disease Control and
Prevention. "After monkeypox, they put a blanket ban on rodents from some
West African countries. But who's looking at rodents from other places?
Nobody. And that's a gap."
Surveillance for diseases in wild animals is particularly difficult, since
they do not come to hospitals, are not watched by veterinarians and do not
like to be caught.
In the case of the magpie in Davis, it took Ms. Lee and her boss, Dr. Walter
M. Boyce, director of the university's Wildlife Health Center, more than 30
minutes to disentangle the bird, set up a lab table, zip themselves into
disposable coveralls and get a beak swab, a feces swab and a blood sample
before releasing the miffed-looking bird, which high-tailed it for the
Dr. Boyce also gets swabs from hunters' ducks, and his colleagues at the
state-run agriculture laboratory on campus get them from poultry farms and
from dead crows, jays and robins collected by city health departments on the
watch for West Nile virus, which arrived in California earlier this year.
During the test run in Alaska, Dr. Jonathan Runstadler, a biology professor
at the University of Alaska in Fairbanks, said he had collected nearly 5,000
fecal samples from ducks, geese, gulls and other shorebirds, owls and other
raptors, and even songbirds.
With limited money, Dr. Runstadler could not mount his own bird-catching
efforts, but university ornithologists and dedicated amateurs who study
migratory patterns run what he called "ring and fling" leg-banding
operations. "Our technicians and grad students go out with them, pull out a
Q-Tip and say, 'Excuse me, can I take a sample here?' " he said.
Another difficulty is deciding which species to pursue. Dr. Karesh expressed
frustration that no country with birds dead of flu, from China to Romania,
had noted which healthy species were nearby, because survivors were the more
likely carriers, he said.
Which explains why Ms. Lee was netting birds that live year-round in Davis.
It's "a bit of a maverick approach," Dr. Boyce admitted, but his theory is
that scavengers like magpies, crows and cattle egrets are the most likely
vectors for moving the virus from the millions of ducks flying down
California's Central Valley each fall to domestic chicken farms.
American industrial farms have high levels of biosecurity, penning thousands
of birds in hangar-size barns "that no self-respecting duck or goose is
looking to get into," Dr. Boyce said, "but there's a lot of free food there
for an opportunist."
Since scavengers also bathe in the ponds where ducks stop over and hang
around humans' garbage cans, he said, "we're looking for flu in species that
can make the link between wildfowl, poultry and people."
HONOLULU // Hawaii became the first state in the nation this week to monitor
airports for signs of bird flu or other flu viruses, health officials said.
Passengers and visitors at Honolulu International Airport will not be
required to submit to examinations but will be tested only voluntarily using
nose or throat specimens taken at the airport clinic. Passengers could also
be referred to the clinic by an airline or medical personnel. Making flu
testing available is expected to improve the state's ability to respond to
any threat of a pandemic flu, according to Catherine Chow, a medical
prevention officer for the U.S. Centers for Disease Control and Prevention.
PRESIDENT BUSH was greeted with blunt skepticism a month ago, when he first
mentioned the deadly H5N1 strain of avian flu at a White House news
conference and suggested he might need new authority over the military to
Cynics suggested that he was reaching for greater presidential powers, or
trying to distract attention from Iraq and Hurricane Katrina. (After all, in
2002, part of the groundwork he laid for the Iraq war was to call for the
inoculation of 10 million health care workers in case Saddam Hussein
unleashed smallpox on the world.)
But last week, when Mr. Bush issued an urgent warning about avian flu,
unveiling a $7.1 billion flu-fighting plan in a speech to the National
Institutes of Health, virtually all public health experts agreed that it was
well past time to act.
The World Health Organization and the European Union have already sounded
the warning, and in March, the Centers for Disease Control ranked the bird
flu as the world's No. 1 public health threat. But why is it time to raise
the alarm, to institute elaborate public health procedures at great expense
to protect against an illness that has still claimed only a few dozen people
in Asia (as well as 140 million birds killed or culled to stop the virus's
The short answer is that those protections must be in place before a
"Pandemic flus are like earthquakes and hurricanes," said Dr. Michael T.
Osterholm, director of the Center for Infectious Disease Research and Policy
at the University of Minnesota. "There have been 10 in the last 300 years.
They're the one area in public health you can predict.
"Now, we're like the guy going to his 25th reunion who decides the night
before that he needs to lose 50 pounds. The best he can do is get a new suit
and a shoeshine."
But there is, experts said, no way to predict exactly when or whether a
particular virus will become an imminent threat. "It's a very difficult
balancing act," said Dr. Andrew T. Pavia, chairman of the pandemic influenza
task force of the Infectious Diseases Society of America. "You want to
create an alertness without creating a panic."
Flu, at least, is familiar. Mysterious killers tend to create more panic.
AIDS terrified gays and hemophiliacs for years before its cause was found.
SARS, an unknown coronavirus, terrified Asia.
But even flu is unpredictable. No public health expert forgets the swine flu
debacle of 1976, in which 40 million people were inoculated with a vaccine
made in haste after a single recruit in Fort Dix, N.J., died of what
appeared to be a new lethal bug. The epidemic never emerged, but a rush to
vaccinate was created in part by confused news coverage of Legionnaire's
disease, an unrelated new bacterial illness that broke out that same year at
an American Legion convention, killing 29 people.
Vaccinations were halted after many who were vaccinated were struck by
paralyzing Guillain-Barré syndrome, and the director of the Centers for
Disease Control was forced out of office. "Ever since, that has made people
gun shy about declaring an epidemic," said Dr. Donald R. Hopkins, a former
deputy director of the C.D.C.
So are the experts right this time, with the call to arms on avian flu,
which is still almost exclusively a poultry disease? (Other types of bird
flu usually give poultry workers only pinkeye.)
The obvious trigger moment would be the emergence of a strain that moves
easily between humans. That might never happen. But if it does, "by then,
it's too late" said Dr. David Nabarro, the new United Nations coordinator
for pandemic flu.
"The last thing I want is to be truly alarmist," added Dr. Nabarro, whose
job is to raise the alarm. "But the world is not really ready to deal with
an avian pandemic."
It won't be, he said, until governments not only have vaccination,
quarantine and treatment plans written and stockpiles in place, but have run
repeated simulation exercises that include doctors, police officers, utility
workers and others. All these are called for in Mr. Bush's plan, but putting
them in practice is still well off in the future.
Other experts expressed dismay that the hoopla over Mr. Bush's plan turned
the focus to measures in America, like closing airports, forcing patients to
wear masks, rationing the drug Tamiflu and ventilators, and having the army
enforce quarantines or control riots. Much smarter, said Dr. William B.
Karesh, chief of field veterinarians for the Wildlife Conservation Society,
would be to focus on fighting the virus "upstream," while it is still in
chickens and ducks.
In Vietnam and China, poor farmers have told reporters that they are
reluctant to admit owning sick chickens because the government will kill
their flocks without paying for them. (In China, the official price is 60
cents per chicken, but farmers say they rarely get it.) Using taxpayer
dollars to buy those birds would be more effective and cheaper than buying
Tamiflu, some experts said. More money is also needed to test backyard
flocks and migrating birds, rather than waiting for dead birds like those
found in Chinese nature reserves last summer to give notice that the virus
is on the move.
Last week, the World Organization for Animal Health in Paris called on rich
countries to donate $150 million to help poor countries vaccinate their
poultry and train rural veterinarians to diagnose flu.
Some of the proposals are controversial. Improperly weakened vaccines are
suspected of spreading the flu in Asia, Dr. Osterholm said. But many experts
say the focus should still be overseas.
Both Dr. Karesh and Dr. Nabarro said they were pleased that Mr. Bush's
proposal envisioned tactics like compensating Asian farmers. "I'm very
encouraged," Dr. Karesh said. "These things weren't even being talked about
a month ago."
Cell-culture technology Bush advocates would require major investment by
By Frank D. Roylance
Sunday, November 6, 2005
The threat of a pandemic may persuade the makers of flu vaccine to give up
the chicken eggs they've used for decades and begin moving to a newer,
faster production system.
The question is whether they're willing to abandon the tried-and-true - or
do it soon enough to head off the next potential public health disaster.
Last week, President Bush branded current vaccine production methods
"antiquated" and asked Congress for a $2.8 billion "crash program" to help
the industry develop simpler and more flexible "cell-culture" technologies
that can better keep up with new flu strains.
For decades, drug companies have made flu vaccines by growing viruses in
millions of live, fertilized eggs. The system works well, but all agree that
it's cumbersome, time consuming and hard to ramp up quickly in a public
Cell-based production methods grow the flu virus in steel vats filled with
living cells derived from monkeys, dogs, humans or even insects. Some
vaccines produced this way have won limited approval in Europe, but none has
been cleared for use here.
"By bringing cell-culture technology from the research laboratory into the
production line, we should be able to produce enough vaccine for every
American within six months of the start of a pandemic," Bush said.
Cell-culture technology is hardly new. The industry has used it successfully
since the 1950s to produce vaccines for such viral ailments as polio,
measles, mumps and tetanus.
But vaccine experts and drug makers say the industry has stuck with eggs for
flu vaccine production because they work pretty well. And change would cost
"We've got the plants set up. We've got the whole system worked out, and
we're not going to rock the boat unless we have to," said Dr. Samuel L.
Katz, a professor of pediatrics at Duke University and co-developer of the
"Now, maybe we have to," he said.
Moving the industry to cell-based technologies will require billions - money
for continued research and development, money to win federal approval for
new cell lines in human products, money for human clinical trials.
When all that's done, drug makers will need millions more to build the
factories to produce hundreds of millions of doses of the new vaccines every
That's why the president is asking Congress to help.
Len Lavenda was understandably miffed by Bush's use of the word
"antiquated." He's a spokesman for Sanofi Pasteur of Swiftwater, Pa. The
company, based in France, is one of the world's largest flu vaccine makers,
and the last one with production in this country.
Sanofi Pasteur uses eggs.
"The fact is, it's a tried and proven technology that has worked well for
us," Lavenda said. Other drug makers have abandoned the flu market in recent
years because of low and inconsistent demand for flu vaccine and
correspondingly slim profits - not problems with the egg-based vaccine
"We believe our nation will remain dependent on egg-based technology for at
least the short to medium term," Lavenda said. "We're looking at quite a few
years before we can obtain licensure for commercial-scale, cell-culture flu
Meanwhile, Sanofi is using an infusion of $41 million in federal tax dollars
to expand and maintain its chicken flocks and enable year-round egg
Flu vaccine makers got into the egg business to start with, Katz said,
because the first flu vaccines were developed before World War II - before
the first cell-culture techniques were invented.
At that time, eggs were already being used to make yellow fever vaccines,
and the technology proved to work well for flu vaccines, too. Drug makers
who later adopted cell-culture technologies for other vaccines saw no reason
to tackle the established technology for flu vaccines, Katz said,
Besides, he said, flu is a real headache because the viruses change so
"It's something you have to fiddle with every year," he said. By contrast,
"we're making the same measles vaccine in 2005 that we made in 1963, when we
developed the vaccine."
That might be changing. Several big drug companies, from Sanofi Pasteur to
GlaxoSmithKline and Chiron, are developing cell-based flu vaccines.
No Maryland companies are known to be working on cell-based flu vaccine at
the moment. But government and business leaders see it as an opportunity.
Baltimore Mayor Martin O'Malley, with backing from state officials and the
Economic Alliance of Greater Baltimore, is pushing for a new cell culture
vaccine production center in the city or elsewhere in Maryland.
"I think we've got a great shot at it," said Nipon Das, executive vice
president of the Alliance, a nonprofit group dedicated to furthering the
region's business interests.
Das said the group hopes to complete a feasibility study by the end of
Small companies are engaged as well. In Meriden, Conn., for example, Dan
Adams, president and chief executive officer of Protein Sciences Corp.,
insists the future of cell-based flu vaccine is not that far away.
He says his tiny company - just 35 employees - has a vaccine that has done
well in clinical trials and could win federal approval as soon as 2006. "If
we focused on the pandemic [H5N1 avian] flu and not the annual vaccine, we
could produce around 400 million doses in a year," he said. He added that he
could do it by 2007.
There are plenty of differences between the egg-based and cell-culture
technologies. But they have some things in common.
Both start with a "seed virus" supplied by the federal Centers for Disease
Control and Prevention, which identifies and isolates the target flu virus
from its earliest victims.
First, CDC scientists alter the virus' genes. While preserving proteins the
virus needs to stimulate a human immune response, the scientists snip out
DNA segments that cause serious disease, or would kill off the very eggs or
cells in which they grow. Scientists add other genes that will make the
altered virus more likely to multiply well in the manufacturing process.
Samples of the altered virus, called the "seed" virus, are then shipped to
At egg-based plants such as Sanofi's, the seed virus is processed to produce
enough volume to inject into millions of eggs. Each egg is punctured by a
needle that leaves a tiny amount of virus in the fluid around the embryo.
The virus invades the embryo's cells and commandeers their metabolic
machinery to replicate itself.
After several days of incubation, the egg's fluids are teeming with the
virus. At that point, it's harvested and killed so that it can't produce
illness; then it's purified, filtered, concentrated and packaged. The whole
process can take four to five months, from preparation of the seed virus to
shipping, Lavenda said.
There are advantages to using eggs, according to Richard J. Webby, a
virologist at St. Jude Children's Research Hospital, in Memphis, Tenn. "Most
flu strains grow very well in those conditions, and you get lots of virus
out of a single egg," he said.
The downside is that the whole system relies on the availability of millions
of chicken eggs - which have to be ordered months in advance, laid and
"When you have a flu season, as we have in the past, where one of the
manufacturers goes down, or when there's a pending pandemic, you can't scale
up that production process very quickly," Webby said. In fact, an outbreak
of avian flu could destroy the egg flock.
Until drug makers can deliver the new vaccine supplies, doctors have to rely
on antiviral drugs that can prevent infection or lessen the impact of the
illness once infection occurs.
In cell-based vaccine production, the seed virus is mixed into a culture of
living cells and nutrients. It invades the living cells and begins to
reproduce, just as it does in eggs.
Some manufacturers are developing flu vaccines from virus grown in a cell
line called MDCK, derived from dog kidneys. Others use "Vero" cells
extracted from the kidneys of African green monkeys - a type used to produce
Still others rely on cells grown from human retinal cells, or the ovaries of
the fall army worm - a green caterpillar.
Unlike chicken eggs, these cell lines don't have to be harvested from live
animals for each vaccine production run. They come from cells that were
harvested from animals once and then kept growing and reproducing in
laboratories. "You can have a freezer with hundreds of vials of cells,"
Webby said. When the new seed virus arrives, "you take out a vial of cells,
put it in the medium and ... within a couple of weeks, they're ready to
infect the cells and grow up your vaccine."
"The benefit is, it's much more flexible and easier to ramp up quickly," he
Also, unlike viruses grown in egg shells, these are accessible, Katz said.
Drug makers can dip in and "observe directly what's happening, how the cells
are changed by the virus growing in them. You can quantify the amount of
virus that's growing."
When they're ready, the viruses can be extracted, purified, processed and
made into vaccine.
Even Sanofi's Lavenda acknowledges the upside of cell-line technology,
including the elimination of chicken and egg proteins that can cause
allergic reactions in some recipients. "And, from a manufacturing point of
view, it's a more desirable, controllable, predictable process," he said.
Sanofi, under a $97 million federal contract, has embarked on its own
pursuit of a cell-line vaccine, based on a human cell line. Clinical trials
could start next year, Lavenda said.
But there's also a downside. Cell lines generally aren't as productive as
chicken eggs, Webby said. "The amount of doses you get per production run is
less than what you get out of an egg. ... From a manufacturer's point of
view, the more vaccine they can get for the least amount of volume, the
better it is for them," he said.
Then there's a simple fact: No company is ready to go into production with a
cell-based flu vaccine for the U.S. market. Manufacturers face a long list
of challenges. First, drug makers who have developed cell-based flu vaccines
in small quantities for testing still face the uncertainties of scaling the
process up to commercial volume. "Making vaccine in a small flask is
relatively easy," said Dr. James Campbell, lead investigator for avian
influenza vaccine trials at the University of Maryland School of Medicine's
Center for Vaccine Development. But "making it in large flasks or
containers, you have issues of keeping the cells alive, and having the same
yield you would be able to get in small quantities."
Then there's the government, Katz said. "Up until now," he said, "the cell
systems in which it has been possible to grow these viruses have never been
approved by the FDA ... for the production of human products."
Federal regulators must be convinced that these cells don't carry other
viruses or contaminants that could cause illness in people.
Then drug makers face long and costly clinical trials to prove to the FDA
that their cell-based vaccines are safe and effective.
Ultimately, if they're convinced they can make money producing flu vaccines
from cell cultures, drug companies must find and spend the money to build
The federal dollars that President Bush is asking Congress for would help
the manufacturers address these issues.
All the big vaccine makers are expected to compete for the money. These
include Sanofi Pasteur; Chiron Corp. of Emeryville, Calif. (which also has
an egg-based flu vaccine in development); Netherlands-based Solvay
Pharmaceuticals, which has a cell-line vaccine approved in the Netherlands;
and Britain-based GlaxoSmithKline.
But even with billions in federal dollars to grease the wheels, it will be
years before the cell-based flu vaccines are ready for market.
For now, said Lavenda, it's all about chicken eggs.
"There are advantages to cell-based technology, but we don't have that
technology available to us today," he said. "And nobody can predict exactly
when it will be available. We really can't afford to wait."
Campaign to End Polio Complicated by Rise of Bird Flu
By Alan Sipress
Sunday, November 6, 2005; A19
TANGGAMUS, Indonesia -- When the first human case of bird flu was discovered
on Indonesia's Sumatra island this fall, provincial officials raced to
investigate. But local health officers were unavailable to help them because
they were busy vaccinating thousands of young children against a polio
Within the last six months, Indonesia has moved to the front lines of two
global health crises, seeking to curb the spread of both bird flu and polio
before they spill across the border.
"It has stretched resources and capacity to the limit," said Thomas Moran of
the World Health Organization's office in Jakarta, the Indonesian capital.
Faced with the fastest growth of new polio cases on Earth, Indonesia
launched a campaign this summer to immunize about 24 million young children.
Then, just as officials were preparing in July for the first of three
nationwide rounds of polio vaccination, Indonesia detected its first human
case of bird flu and since then has registered more cases of the disease
than any other country.
Since January 2004, more than 60 people have died of bird flu in Vietnam,
Thailand, Cambodia and Indonesia. The virus has also spread through parts of
Russia and to Eastern Europe.
Indonesia's two-front battle is straining the country's sorely underfunded
health system, which had sharply eroded since the 1997 Asian financial
crisis and was already unable to provide basic care across much of the
"We've become a red zone for bird flu because it's endemic in livestock and
infected humans here," said Ida Fitriati, deputy health director in Lampung
province on Sumatra's eastern tip. "We're overwhelmed by this."
Health experts said the country needs funds to monitor possible cases,
improve laboratories for testing and enhance medical facilities and supplies
to include a larger stockpile of antiviral drugs.
Health officials said they worry that efforts to contain bird flu and polio
could drain funding from other disease control programs that have begun to
make progress in recent years.
Indonesia ranks third in the world for a high burden of tuberculosis,
according to the WHO. Attempts to improve the detection of new cases
regained momentum two years ago after stalling in the wake of the financial
crisis and political upheaval after the ouster of longtime dictator Suharto
Malaria remains endemic on many Indonesian islands, worsening in the late
1990s before foreign funding for control programs helped reverse the trend.
Dengue and diarrhea-related diseases are epidemic.
"Anyone trying to manage public health, especially with an avian influenza
risk, is faced with an extremely difficult and complex decision about how to
get the maximum good out of limited resources," said Steven Bjorge, the WHO
official in Indonesia responsible for managing bird flu, malaria and several
Fitriati, who oversees communicable diseases for Lampung, a province of
seven million people, said her team of six investigators responds to
reported avian influenza cases one morning and polio the next, often
venturing to isolated hamlets in the island's mountainous interior. Local
health staff, she added, lack the expertise to verify outbreaks themselves,
and communication is so spotty that days can pass before provincial experts
Indonesia had been free of polio for a decade when a traveler from the
Middle East carried it to the main island of Java early this year. The
crippling virus quickly reached 10 provinces and infected at least 288
people. After repeated immunization drives, the disease was contained where
it first surfaced in western Java, health officials reported. But just a
short ferry ride away across the Sunda Straits, Lampung province is now
recording the most new infections with more than two-thirds of the 24 cases
centered in its district of Tanggamus.
Bird flu also first appeared in Java, infecting at least five people in and
around the capital Jakarta. When the virus spread, it likewise jumped to
Lampung, sickening a man and his young nephew, again in Tanggamus.
Although there have been only a few confirmed cases of bird flu,
international health experts predict the virus could develop into a new form
easily passed among people, potentially devastating Indonesia and the world
But at the Pagelaran public clinic in Tanggamus, health officers admitted
they had no program to monitor bird flu or prepare for a wider outbreak.
Their preparations consist of a lone poster on the entrance of their low
white building warning of the danger.
Bird flu remains a concern for agriculture officials, explained Edy Susanto,
41, a local paramedic.
Susanto, who directs the clinic's immunization program, shuffled into his
tiny, tiled office, apologizing for the rat droppings that litter the floor.
He opened the rusty clasps on the 15-year-old freezer in which he keeps the
vaccines, lifted the cover and motioned to the contents. It was almost
"For us, it's hard to answer the parents when they ask why the vaccines have
run out," he said, smiling sheepishly and raising his eyebrows. "We can't
answer it. It's not in our hands."
He complained that health workers are forced to scavenge for unused syringes
in other medical offices or scrape together money to buy their own. The
refrigerator with which they usually make ice for transporting vaccines into
the field is broken. He said there is also a shortage of doctors. The
physician who serves as the clinic's director is often absent during the
busy morning hours because he runs his own, better-paying practice, he said.
"There's been less money and support since the financial crisis," Susanto
concluded. "Money is our unending problem."
At the provincial health department, Fitriati agreed that the Indonesian
health system has slipped. "The function of local health posts has
deteriorated. And since they don't function well, some people don't use them
any more," she said. "It's not only Lampung. This is the picture in other
provinces of Indonesia."
Nyoman Kandun, Indonesia's national director for communicable disease
control, estimated that half the village health posts in the country no
longer operate. And although the central government has enough money to buy
vaccines for all Indonesian children, officials in the cash-strapped
districts are unable to pick them up from the provincial health office,
according to Kandun.
Now devoting much of his time to soliciting money from foreign governments
and agencies, Kandun said he is finalizing his "shopping list" for bird flu
programs that require financial support.
The emergency polio campaign to immunize the country's children has already
cost the central government more than $12.5 million for the first two
rounds, with foreign donors paying nearly an equal sum, he said. For the
third round, scheduled for Nov. 30, Indonesia can muster only $2.7 million,
leaving a shortfall of $10 million.
Kandun said last week his fundraising efforts have whittled that deficit to
Special correspondent Yayu Yuniar contributed to this report.
TIJUANA, Mexico -- There are world-class hospitals in San Diego, not far
from where Luis Gonzales lives. But when he or a member of his family needs
a doctor, they drive 50 miles south to a clinic in Tijuana.
The Gonzaleses are members of a Blue Shield of California HMO that provides
all of the family's nonemergency care in Mexico. They are among 20,000
California workers and their dependents in health plans that cost 40 to 50
percent less than comparable care in the United States because the doctor's
visits are outsourced south of the border.
With health care costs in the United States continuing to rise, many
employers in Southern California are turning to insurance plans that send
their workers to Mexico for routine care, plans that are growing by nearly
3,000 people a year. And Gonzales, for his part, is happy about it.
"They have everything I need," Gonzales said. "They're clean. You don't see
a difference between a doctor over here and over there."
Despite Gonzales's satisfaction with the quality of his family's care, the
new trend has some medical professionals in the United States worried that
care is being sacrificed to low prices.
"There are quality standards that we are developing and implementing in
America that are not going to be implemented there for a long time," said
Jack Lewin, chief executive of the California Medical Association. "In terms
of specialized care, it's critically important that we look beyond just cost
Five years ago, California became the only state to regulate insurance
programs that require border crossing for basic health care. Since then,
more than 700 non-agricultural businesses have offered plans requiring
treatment in Mexico. Hundreds of farms offer similar coverage for about
120,000 migrant laborers.
In Texas, legislators explored the possibility of allowing health
maintenance organizations to operate on both sides of the border. But
physicians in South Texas lobbied against the changes, arguing that local
doctors could not compete with the lower costs in Mexico.
Lower-priced labor, malpractice insurance and overhead in Mexico mean both
basic and sophisticated medical procedures can be performed at a small
fraction of the cost. A hysterectomy that averages $2,025 in the United
States costs $810 in Mexico, said Mary Eadson, director of legal compliance
for the Western Growers Association, an agricultural organization that
provides health insurance for California workers in Mexico.
The movement of U.S. health care across the border has sparked a boom in
hospital construction in Tijuana, with clinics and pharmacies opening a
short walk from the border.
Francisco Carrillo owns and operates a Mexican HMO plan for California
workers called SIMNSA, and he owns the Centro Medico clinic, where large
windows face the border bridge many of his patients cross on their way to
the waiting room.
On a recent weekday, half the cars in the parking lot bore California
license plates. On two of the clinic's six floors, a new surgical center and
a dentist's office are under construction. The clinic's other floors were
crowded with patients.
"Things are moving very fast," Carrillo said. "We're growing."
David Castillejos Rios has performed laser eye surgery on both sides of the
border. At a small hospital in Tijuana, he charges one-third as much as he
does in San Diego.
"The medicine is the same, and to me, whether I do it here or there, it's
the same," Castillejos Rios said. "Only the price changes."
The difference can translate into the kind of affordable monthly premiums
most American businesses have not seen in a decade. At Health Net, the cost
of insuring a family of four whose treatment was covered in the states is
$631 a month. Using physicians in Mexico, the same family would pay $306 a
month, company officials said.
At the Santaluz golf resort in San Diego, where Gonzales supervises golf
course maintenance, workers can sign up for a Blue Shield of California plan
called Access Baja. Their doctor visits are covered in the United States or
Mexico, while their families are covered only in Mexico. Dale Standfast, the
resort's controller, said several workers whose dependents were not covered
switched plans to cover their families.
Offering Access Baja saves the resort about $1,000 per month in premiums, he
said. This year the club used the savings to offer vision coverage to all
employees for the first time, Standfast said.
Representatives of Blue Shield of California and Health Net, both of which
offer cross-border HMO plans in California, said the quality of care is
comparable in both countries. Their doctors are credentialed in Mexico, and
the HMO operations are subject to California oversight. The insurance
companies audit Mexican clinics themselves, and then report to the
California Department of Managed Health Care.
Company officials emphasize the warmth of the Mexican medical culture.
"Mainly, the patients that come here are searching for more attention," said
Juan Carlos Helu Vazquez, a gastroenterologist in Tijuana who sees Mexican
and American patients. "They want the doctor to talk to them, be warm to
them. There are a lot of patients who like the old-time medicine. They like
the doctor asking about your family, your work."
Gonzales said he had better care in Mexico than in the San Diego region.
"I went to the doctor over here and he never cured the problem, he never
gave me a good medicine, never sent me to a specialist. He never cared about
my health," Gonzales said. "When I went over there, the first doctor I saw,
he sent me to a specialist. He wasn't just going to say, 'Take this and go
Administrators at cross-border HMOs expect their plans to grow because the
cost of health insurance in the United States is out of reach for an
increasing number of working families.
That is what worries Lewin of the California Medical Association.
"It's understandable that lower-income workers are trying to seek health
care they can afford," he said. "But these people are largely paying taxes
and contributing some of their own financial resources to this country. It's
high time we provided good care for these people through enlightened public
Smoking is banned from most workplaces in this country. Why? Because
secondhand smoke contains 50 known carcinogens and raises the risk of lung
cancer and heart disease in people who don't smoke. The Centers for Disease
Control and Prevention estimates that at least 38,000 people in the U.S. die
each year because of exposure to secondhand smoke. Unfortunately, many
states, Maryland included, don't prohibit smoking in all restaurants and
bars. It's a costly - and potentially deadly - loophole.
But that's changing. Tomorrow, Howard County Executive James N. Robey is
expected to formally introduce legislation to ban smoking in bars and
restaurants as well as at outdoor athletic and entertainment events. If
successful, Howard will join Montgomery and Talbot counties, where similar
smoking bans have proved to be effective. Two County Council members have
already promised support for the proposal, and a third, David A. Rakes,
pledged to vote for a ban when he ran for office in 2002.
It's a welcome trend. In recent years, eight states (including neighboring
Delaware) have endorsed smoke-free bars and restaurants, as have at least
190 localities. Howard County has a history with the issue, too. Under
legislation passed 12 years ago, restaurants that choose to permit smoking
must have a smoking area with separate ventilation. That was a progressive
decision for its day, but the requirement failed to address the health of
the county's restaurant and bar workers.
Protecting employee health is a prime reason why Howard County - and the
rest of Maryland - needs to ban smoking in all businesses. Customers can
choose not to patronize bars that permit smoking. Employees can't. And they
have to breathe the toxic fumes day after day. Certainly, we wouldn't allow
companies to knowingly expose workers to harmful chemicals. Tobacco
shouldn't be treated differently.
Research shows smoking bans are effective and the public supports them. A
recent study in Ireland found a similar nationwide smoking ban has
significantly improved the health of bar staff. Mr. Robey's proposal
wouldn't go into effect for two years, but we see no reason for such a
delay. Smoking bans don't hurt the restaurant industry, but secondhand smoke
does - by harming employees and driving up health care costs. Might a ban
inconvenience some customers? That could prove a secondhand benefit: The
more lives spared, the better.
Don't Close Walter Reed and Other 'Obsolete' Facilities
By Phillip Longman
Sunday, November 6, 2005; B07
Got your Tamiflu yet? How about a home respirator and a live-in nurse? If
expert predictions of a coming flu pandemic prove right, there's little
chance you'll be able to find a hospital bed in which to recover.
Here in Washington, for example, after a long series of hospital closures,
there are only 4,346 hospital beds left -- a number that will soon go lower
with the closing of Walter Reed Army Medical Center's main facilities. Yet
projections show that even a moderately severe strain of a pandemic flu
virus would require some 5,000 people to be hospitalized in the District
alone. Even if we discharged every patient in Washington's hospitals --
including all the mental patients in St. Elizabeths, all the frail elderly
in Hadley Memorial's long-term acute care facility and all the veterans in
Veterans Affairs Medical Center -- there still would not be enough hospital
beds available to care for, or even to quarantine, highly infectious flu
The same is true nationally. Since 1980 the number of hospital beds
available per U.S. resident has declined by roughly 40 percent. Today the
United States has only about 965,000 staffed hospital beds. Yet Trust for
America's Health, a nonprofit group committed to promoting public health,
estimates that the emergence of a pandemic flu virus like the one of 1918
would require hospitalization of 2.3 million people in this country.
There are many sound reasons why the number of hospital beds has been
declining. New technology allows for much greater use of outpatient
facilities. Galloping medical inflation demands more cost-effective care.
But the result is a health care system that is perpetually running at or
above 100 percent capacity, and that will be overwhelmed by a pandemic,
major terrorism attack or natural disaster.
Fortunately, there is a way to help solve this problem and many others that
plague our health care system.
Let's start with the example of Walter Reed. Located just 5 1/2 miles from
the White House, 6 1/2 miles from the Capitol and six miles from the
Washington Convention Center, its facilities, including a hospital built in
1972, are an integral component of the District's emergency preparedness
plan. In the event of a mass casualty terrorist attack or other public
health emergency, the plan calls for Walter Reed to discharge its
noncritical patients and begin treating civilian victims within as little as
three hours. Walter Reed is particularly well equipped and well situated to
treat not only victims of a flu pandemic but also those wounded by a nuclear
or biological attack in downtown Washington. But maintaining this capacity
is expensive, and right now Congress is poised to accept the recommendation
of the Base Realignment and Closure Commission that the main hospital and
most other buildings on the 113-acre campus be razed.
It may well be appropriate for the military to reorganize and rationalize
the way it delivers care in the Washington area and many other parts of the
country, just as it is for the private sector. Across the Northeast and
Midwest, for example, many VA hospitals have lost their patient base because
so many aging veterans have retired elsewhere. The Department of Veterans
Affairs has announced that it is closing hospitals in Pittsburgh and in
Brecksville, Ohio, and it is threatening to close facilities in Brooklyn and
Manhattan. But rather than abandon these and other "obsolete" hospitals --
including many shuttered public hospitals such as D.C. General -- we should
turn at least some of them into facilities that will stand ready to serve
the public in the event of disasters and that between disasters will serve
the uninsured and those on Medicaid.
Private health care providers are under such enormous pressures to contain
costs that they cannot begin to afford to keep wards open that aren't filled
nearly every day. This makes it the proper role of government to ensure we
have surge capacity that the private sector cannot deliver. Literally every
American, including those with gold-plated health insurance plans, stands to
benefit from a health care system built to handle such increasing risks as a
flu pandemic, another Katrina, a major earthquake or a terrorist attack.
Such a plan would also go a long way toward both rationalizing the U.S.
health care system and making it more equitable. Study after study has shown
that Veterans Affairs, by making extensive use of electronic medical
records, information technology and provider incentives, is providing health
care of far higher quality, and at less cost, than that received by most
insured Americans, let alone the uninsured. At the same time, hospitals in
the District of Columbia spend nearly 7 percent of their revenue on the
uninsured, and the total cost to the local health care system is much
higher. Meanwhile, nearly a quarter of all patients in Washington hospitals
are on Medicaid, and to hear the hospitals tell it, they lose money on every
Message to Congress and local decision makers: Why not turn Walter Reed and
facilities like it across the country into pilot projects that can point the
way toward true reform and improvement of our beleaguered health care
writer is a senior fellow at the New America Foundation.
Long-simmering doubts about the benefits of mammograms to screen women for
breast cancer should be dispelled by a new study conducted by seven major
research groups. Mammograms have long been recommended as an effective tool
for detecting tiny breast tumors so that they can be treated before they
become dangerous. But four years ago, an analysis published in a British
medical journal found so many flaws in studies that purported to show a
benefit from mammography that the results were deemed virtually meaningless.
Other experts agreed that the evidence was shaky, but mainstream cancer and
medical organizations remained convinced that mammograms save lives.
Now comes a study, published in The New England Journal of Medicine, that
was conducted by research teams including both skeptics about mammograms and
true believers. The study sought to estimate the relative importance of
screening mammograms and powerful new drugs in producing a 24 percent
decline in breast cancer mortality in the United States from 1990 to 2000.
Seven research teams each developed statistical models of breast-cancer
incidence and mortality and plugged in additional information to tease out
The results varied widely. One team found screening responsible for 65
percent of the decline and drug therapies a mere 35 percent. Another team
gave drugs fully 72 percent of the credit. The other estimates fell in
What seems most important is that each team found at least some benefit from
mammograms. The likelihood that they are beneficial seems a lot more solid
today than it did four years ago, although the size of the benefit remains
Women still need to make their own judgments as to whether the usefulness of
screening outweighs the risks, which include false positives and possibly
needless treatment to remove tiny tumors that might never have caused a
problem if left alone. The good news is that women can now be pretty
confident that there really are benefits from mammography.
Two years ago, when Congress was designing the new Medicare drug benefit
that takes effect in January, lawmakers feared drug plans might not be
offered in rural areas because private insurers would consider them
Those fears proved wildly off base. Ten separate drug plans are available to
Medicare beneficiaries nationwide, and thousands more regional plans have
been offered, leaving no part of the country out.
Thus, Senate budget cutters, looking to reduce the deficit without cutting
direct benefits to people, figured the $5.4 billion in incentives intended
to lure drug plans into rural markets was an obvious target.
Amazingly, the Bush administration has singled out this common-sense cut as
a reason to veto the first deficit reduction legislation enacted since 1997
- a $35 billion to $50 billion package likely to meet some of the
president's most dearly sought goals.
Our first impulse is to say of the veto threat: Go ahead, make our day.
After the House adds its contribution to this legislation, the package
appears likely to be an all-out assault on the poor, sick and disabled that
won't even save money because $70 billion more in tax cuts for the wealthy
are scheduled to soon follow.
This phony belt-tightening exercise is also the device through which oil
companies are expected to finally get the right to drill in Alaska's
pristine wildlife refuge.
But genuine deficit reduction is a worthy goal. Perhaps some queasiness
among House Republicans about such hard-hearted proposals as kicking 300,000
people off food stamps - as well as opposition to the Alaska drilling - can
lead to the crafting of a more responsible measure.
Few items more clearly qualify for chopping from the budget than the $5.4
billion earmarked over the next five years to pay incentives, if necessary,
to get private drug plans to offer the Medicare benefit.
The administration argues that the current flurry of interest by drug plans
could dissipate in later years. And Mr. Bush is particularly determined to
avoid any legislative tinkering with the prescription drug program before it
When such caution comes at the expense, though, of families losing food
stamps, single mothers denied help collecting child support and poor
children forced to make co-payments for health care, it simply can't be
defended. Judd Gregg, the Senate Budget Committee chairman whose colleagues
eliminated the incentive fund money to avoid harming individuals, called Mr.
Bush's veto threat "absurd."
While we wouldn't mind seeing the president finally wield his veto pen on
this legislation, we'd prefer a deficit-reduction measure worthy of the name
that puts the highest priority on protecting the most vulnerable Americans.
By now you should have received the booklet "Medicare & You 2006" in the
mail. It contains instructions for signing up for the Part D program and a
list of the 47 approved plans.
What follows are a list of questions answered by Katrina Eversole, an
insurance advocate who works out of the offices of the Washington County
Commission on Aging.
plan is right for me?
It depends on a number of things. Your pharmacy probably won't participate
in every plan, so a good first step would be to talk to your pharmacist and
find out which drug plans they will accept.
do all the plans have in common?
All plans must offer brand-name and generic drugs. Each plan will have a
network of pharmacies for its members. Each plan must allow its members to
obtain at least some prescriptions in an out-of-network pharmacy, if, for
example, you're on vacation and need medicine.
Each plan must include at least two drugs in a therapeutic or diseases
class, so your doctor has some choice. If a pharmacy decides to withdraw a
drug that has been on its list, it must notify the beneficiaries in writing.
much will it cost?
Every plan is different, but if you meet income guidelines, you will be
eligible for financial help, and application forms are available through the
local Social Security office. Those who qualify include individuals with
less than $14,355 in gross annual income who have less than $11,500 worth of
assets. Your home and car don't count as assets. Couples qualify if they
have a gross annual income of less than $19,245 and less than $23,000 worth
of assets. Again, your car and home don't count in the asset total.
if I don't qualify for assistance?
The Part D program is not just for low-income people. Every Medicare
recipient is eligible. There are various premiums and deductibles, depending
on the plan that you choose. But whether you have to sign up depends on
whether the prescription drug plan you have now is "creditable."
In other words, if it is as good or better than Part D program, you can
stick with what you have now.
will I know whether my present plan is "creditable"?
You may already have been notified by mail or will be notified by Nov. 14,
2005. You may want to call your former employer to see if drug coverage will
continue and whether it will be as good or better than what the federal
government is offering.
do I know whether my present plan will continue?
Again, you should have been notified by mail. Three plans we know for sure
will continue are: Federal Employee Health Benefits Program (FEHBP), the
Veterans Administration (VA) program and Tri-Care.
plans are closing for sure?
Medigap plans with H, I and J coverage are not creditable and the
prescription part of this supplemental medical coverage will not continue
after Dec. 31 - you will be offered a choice of Medigap plans (with
comparable medical coverage) without prescription coverage.
Maryland Pharmacy Assistance Program, as well as the Maryland Pharmacy
Discount Program, will end Dec. 31. CareFirst Senior Rx Plan will also end
on Dec. 31, and members will receive help transitioning to new plans; namely
a $25 per-month subsidy for the plan of the member's choosing. CareFirst
members are receiving information in the mail now about trade shows and
seminars in Washington County.
if my employer decides to discontinue the Rx coverage to retirees at a
Then you will have 63 days to enroll in a Medicare Part D plan with no
penalties (if it is after the May 15, 2006 deadline.)
the Part D program affect my medical coverage under Medicare?
if I'm on Medicare and medical assistance?
The pharmacy part of that coverage will end Jan. 1. You will automatically
be eligible for financial assistance, but if you do not choose a plan on
your own, one will be chosen for you and it may not be the best choice. You
need to pick a plan that covers all the drugs that you are using.
if I receive state assistance (QMB or SLMB programs) to help pay for my
Medicare Part B coverage?
You will also receive assistance to pay for Part D, but you must actively
choose a plan to get the benefit of that assistance.
about Medicare approved discount drug cards?
They will be phased out by May 15, 2006, or if you choose an Rx plan earlier
than that date, the card will cease to provide assistance.
my prescriptions through Medbank. Can I continue to do so?
Medbank funding will continue for those who are not eligible for Medicare.
Some pharmaceutical companies recently notified Medbank that they will not
supply free drugs to anyone who is eligible for Medicare Part D (this means
all Medicare beneficiaries).
Other companies want to see proof that you have applied for "extra help"
through Social Security and have been denied financial assistance.
if I don't take any prescription drugs now? Do I still need to sign up?
Yes, because you will face a penalty later if you don't. Choose the cheapest
plan now and you can transfer to another later if your needs change. Do the
math to see if it is worthwhile for you to do so at this time.
often can I change plans?
You are locked into a plan for one year. Open enrollment is from Nov. 15
through Dec. 31 of each year.
What if I'm in a plan and my doctor says I need a drug that isn't in the
list of approved drugs?
There's a special exception process that requires the physician to request
that the drug be added to their formulary until you are able to choose
another plan that covers all of your drugs.
Medicare Part D
Public Education Seminars Robinwood Medical Center
(blue or silver entrance)
Monday, Nov. 7 9 a.m.
Friday, Nov. 18 1 p.m.
Tuesday, Nov. 22 - 6:30 p.m.
Tuesday, Dec. 6 9 a.m.
Monday, Dec. 12 9 a.m.
Monday, Dec. 19 1 p.m.
Monday, Jan. 9 1 p.m.
Wednesday, Jan. 18 9 a.m.
Tuesday, Jan. 31 1 p.m.
Friday, Feb. 10 1 p.m.
you will learn at Medicare Part D seminars
(Note: Please bring a pencil and pad so you can take notes. A
question-and-answer period will be held at the end of each seminar.)
1) What is Medicare Part D?
2) Will the prescription drug coverage that I carry now change or expire at
the end of 2005?
3) Should I enroll in a prescription Rx plan sponsored through the federal
4) Am I eligible for extra financial assistance to help pay for the premium
of the drug plan that I choose?
5) How long do I have to make a decision before my coverage runs out or
until a penalty is imposed?
6) What kinds of Rx plans are being offered in Maryland?
7) How do the new drug plans work?
8) What do I need to know to make an informed decision?
9) What resources/contacts are available to help me make a wise decision?
What Medicare Part D seminars will NOT do (or what can YOU or a family
member can do to help yourself)
1) Check with your pharmacy to see what prescription drugs plans they have
decided to participate in.
2) Call your doctor to ask questions about current drugs.
3) Call a Rx drug plans to see if your drugs are covered under that plan.
It's hard to think of anything more important than to get enough of the
right vaccine and get it quickly enough to prevent millions of deaths in a
pandemic if bird flu virus in central Asia mutates into a form contagious
Yet we're going about it in the opposite way we should. Here we are, with
the virus practically upon us, talking about appropriating money and
immunizing (no pun intended) from civil liability the only private company
that can produce the vaccine necessary to protect us -- even then with old,
small-batch technology that will not produce nearly as much vaccine as would
be needed to immunize all of us.
Nor will it produce the right vaccine, quickly enough, to deal with the bird
flu virus as it mutates further.
While the president's speech last week was reasonably optimistic, at its
heart was the idea Draconian measures might be needed to control movement of
people and to deny access to certain areas to prevent against from a viral
catastrophe. In short, the vaccine approach to the bird flu might fail.
This is the wrong answer. We should be much more "ahead of the problem," and
we need to address it -- comprehensively.
Let's fund and build a state-of-the-art government facility and keep it
producing enough of the right vaccine to immunize us against the most
serious flu-based viral diseases that develop.
The "model" for this is the Government Ammunition Plant, an we have held
onto for 200 years to ensure our military always has enough of the proper
ammunition in any conflict involving us at any time, anywhere.
And, as we debate the flu pandemic, there is a huge government factory in
Lake City, Mo., turning out all the small-arms ammunition we need. The last
of 12 government-owned and -run ammunition plants, now run by a contractor,
the Lake City Ammunition Plant, has several associated Web sites. Look at
them and think how we might use this idea to produce enough of the flu
vaccines we will need each year.
Without getting into a political discussion, most Americans would probably
agree that protecting our people -- at home -- against a catastrophic flu
epidemic is a priority at least as high as ensuring U.S. troops have enough
And, there will always be the public-private debate: Even as the Army
worries about "shortfalls" in small-caliber ammunition, it opposes building
more government-owned plants and believes shortages can be made up through
If there were vaccine "shortfalls," we could look to the private sector too.
But should we look there for all of it? I think not.
There will always be at least one government-owned ammunition plant, albeit
run by a private contractor. Congress has always seen the great wisdom of
And the lawmakers should likewise see the same wisdom regarding production
of enough of the proper flu vaccine so every American can be immunized.
Much of the last year's vaccine supply proved bad and we simply didn't have
enough of the good kind. The government's sole contract with a foreign
vaccine producer failed to deliver: The contractor could not provide nearly
The odds of this occurring with a government-owned plant, even if operated
by a contractor, are very low. And we must plan our public-heath strategies
around this sort of confidence, especially when the potential disaster is so
This year, we simply can't afford to make a mistake. Yet we again have
limited our options: We must depend on the private sector, pay what they
ask, and suffer the results of their failure if they don't deliver -- and,
like last year, they may not.
In short, we need much better odds against the Asian bird flu pandemic than
we have given ourselves.
Daniel Gallington is a senior fellow at the Potomac Institute in Arlington,
Va. He has served in a number of senior national security policy positions.
Washington – Last week, President Bush released plans to prepare the nation
for the possibility of an outbreak of deadly influenza, calling for Congress
to appropriate $7.1 billion for research and the stockpiling of vaccines and
antiviral drugs. As a summary of goals and strategies, the president's plans
are commendable. But drafting them was the easy part. Putting them into
effect will be the challenge.
The problem with President Bush's plans is that they can't succeed in the
current bureaucratic structure. Were the federal government ever entitled to
the benefit of the doubt, it forfeited that presumption in the aftermath of
Hurricane Katrina. Unless these shortcomings are fixed, we have no grounds
to presume the administration's laudable avian flu strategies will be
translated into action.
What we need to do to prepare for and respond to a pandemic is change the
very way the government delivers services. And to do that, the following
initiatives must be integrated into the government's response:
Designate a single, accountable leader. An avian flu pandemic is among the
greatest threats to our country today. Given our vulnerability and the
amount of work to be done, the president must appoint a leader who is
singularly focused on avian flu. This leader must be fully accountable for
the government's progress. And the president must make it clear that this
leader speaks on his behalf.
Fragmented authority will cripple the administration's efforts. In the
president's plan, responsibilities are spread out among a number of United
States departmental and agency heads. This is a recipe for disaster that
could result in confusion, finger-pointing and neglect. If after the failure
of Hurricane Katrina the administration hasn't understood the need for a
single, dedicated leader, it hasn't yet faced up to the scale of disaster
that a flu pandemic presents.
Replace bureaucratic administration with entrepreneurial management. If an
avian flu pandemic sweeps the United States, it will pose a tremendous
challenge in terms of speed, lethality and complexity. Federal, state and
local governments will need to act with the speed and agility of the
Unfortunately, our government cannot operate at anything approaching this
level. Despite modest civil service reforms over the years, the government
remains caught up in a bureaucratic process-oriented approach to business.
The government's pandemic preparations must be equipped with 21st century
entrepreneurial management practices that mirror those of America's best-run
corporations. The government will need to stop focusing on process and
concentrate instead on results.
To do this, it will need a management system that allows for collaboration
between the government and communities similar to the Compstat crime system
used by the New York and Los Angeles Police Departments. Compstat links
headquarters to each precinct, allowing for accurate intelligence, rapid
deployment and relentless follow-up.
Prepare for the days of a phony war mentality. Until we receive word that a
pandemic is loose in this country, last week's announcement could well be
the high point of public attention to the threat posed by avian flu. The
pressure to prepare will decline. And as this happens, government attention
will be pulled in other directions.
Resisting this temptation will require strong leadership from the
administration and from Congress. But it will also be aided by concentrating
on efforts that have multiple uses in peacetime as well as during a
pandemic. These dual-use investments will be easier to justify if they are
presented as an essential step in preparing for a deadly flu outbreak.
leading example of such an investment is an electronic health record system,
which would allow the federal government to track the course and impact of a
pandemic in real time. Public health experts widely agree that this kind of
network would not only allow for safer and more efficient care under normal
circumstances, but would also equip federal, state and local governments
with the data needed to direct scarce therapies, medical teams and supplies
to where they are most needed as a pandemic unfolds. There's no good reason
why every American couldn't have a preliminary electronic health record by
the end of 2006.
While we can be grateful that President Bush has acknowledged the
seriousness of a possible deadly flu outbreak and outlined strategies to
prepare the nation to respond, much more needs to be done. Focusing on these
three initiatives will ensure that we are prepared. The success of the
president's plans hinges on getting this right.
Gingrich, a former speaker of the United States House of Representatives, is
the founder of the Center for Health Transformation. Robert Egge is a
project director at the center.
Department store magnate John Wanamaker once famously said that he knew that
half of the money he spent on advertising was wasted -- he just didn't know
His wry comment helps describe the serious dilemma now faced by those who
create advertising for new drugs or organize public service health
campaigns, according to researchers at Indiana University. It seems that
many drug ads and public service messages may have the unintended
consequence of dissuading people from obtaining potentially life-saving
drugs or taking preventive steps such as getting vaccinated, according to
studies conducted by Anthony and Dena Cox, professors of marketing in the
university's Kelley School of Business, and Gregory D. Zimet, a professor of
pediatrics and clinical psychology at the Indiana University School of
"People who design real campaigns may -- with the best intentions --
actually end up designing programs that are ineffective or even harmful,"
Anthony Cox said. And what's more, he added, it is exceedingly difficult to
predict whether a particular ad message will help or hurt.
In a study funded by the National Institutes of Health, the researchers
tested different print messages to see whether they affected the willingness
of people to get vaccinated against hepatitis B, a potentially lethal liver
disease transmitted by sexual contact and drug abuse. Their test subjects
were 213 randomly selected clients at three public clinics offering
treatment for sexually transmitted diseases -- precisely the group that
should get vaccinated.
One group saw messages emphasizing that the vaccine would greatly reduce the
chance of getting hepatitis B or spreadingthe disease to uninfected
partners. Advertisers call this a "gain-framed" message, because it
highlights the benefits that would be obtained from getting vaccinated.
The others read a "loss-framed" message that stressed the awful consequences
-- death or infecting a loved one -- of not getting vaccinated. (Only a few
words were changed to alter the messages. The positive message included this
statement: "People who get the hepatitis B shot are gaining a chance to
protect themselves and the ones they love," while the negative message read,
"People who don't get the hepatitis B shot are losing a chance to protect
themselves and the ones they love.")
These subtle but opposing approaches produced dramatically different
results. Test subjects who read the positive pitch were inclined toward
vaccination, and more likely to discount so-called "nuisance risks" ("the
shot will be painful"). The subjects who read the negative appeal were more
likely to say they didn't want to get vaccinated and to worry about the
nuisance risks, the researchers report in a forthcoming issue of the Journal
The solution seems simple enough to me -- design ads that emphasize the
benefits and avoid messages that attempt to scare people into action.
Not so fast, says Anthony Cox. An earlier study produced what he called "a
very different" finding.
In that study by the Coxes, published four years ago, women were shown
different print ads that encouraged them to get a mammogram. One ad
emphasized the benefits of getting the test, including a greatly reduced
risk of dying from breast cancer. (Significantly, Cox noted that similar
upbeat messages are almost universally employed in campaigns encouraging
women to get regular breast exams.)
The other ad emphasized what would happen if they didn't get a mammogram,
including the fact that they ran a much higher risk of dying from cancer. A
third group saw no ad. Then the women in the three groups were asked whether
they intended to get a mammogram and their overall views of breast cancer,
including whether they expected to develop the disease sometime in their
Those who saw the upbeat ads said they were less likely to get a mammogram
than those who saw the negatively framed ad. And if that weren't enough,
they also were more likely to believe that they would not get breast cancer
than either the group that saw the negative ad or the women who saw nothing.
So, Professor, what's your prescription for deciding whether to go positive
or negative in a health campaign?
"Pretest these campaigns to see what the real-world effects may be," Cox