Dispatch from the front lines: From Pakistani refugee to APHA chief

Mohammad Akhter, MD, MPH, executive director of the American Public Health Assn., reflects on the traditional, and new, challenges facing our public health system.

By Stephanie Stapleton, amednews staff. Dec. 17, 2001.

Public Health: Renewed Attention
A six-part series exploring the role of the public health system in the context of our nation's newfound state of alert.

Weeks ago the nation was frozen with fear as anthrax became a household word and other infectious diseases -- smallpox, plague and other scourges usually considered exotic and unlikely -- suddenly emerged as everyday concerns. As a result, the public health system was thrust into the spotlight, and its role as first-line defender against such diseases became clear.

But to public health experts such as Mohammad Akhter, MD, MPH, these events were not a surprise. They have warned for years that a bioterrorist assault was not a matter of if, but when. They repeatedly detailed the shortcomings of the infrastructure and called on the federal government to provide more resources to shore it up.

Curriculum vitae
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As executive director of the American Public Health Assn., Dr. Akhter has strong opinions about what needs to happen now to protect against future outbreaks of disease -- whether the result of attack or nature. Some of these opinions are informed by his tenure as a policy adviser at the Dept. of Health and Human Services, or his work as a public health official in Washington, D.C., Illinois and Missouri. But his thoughts are also guided by another set of influences -- early memories of being a refugee in Pakistan, of emigrating to the United States and returning to Pakistan as a medical missionary and public health educator.

He recently sat down with AMNews to share his thoughts on the challenges public health now faces.

Q: Is the public health system really underprepared, and how did it get to this point?

Dr. Akhter: We have made tremendous strides in conquering infectious diseases since the 1950s. We came up with wonderful vaccines and great antibiotics. We were doing wonderfully well. But people didn't pay attention to maintaining the same level of readiness and preparedness.

Over the years, the public health budget was cut. Its infrastructure was reduced. Our total effort became immunizing children and occasionally following up on a foodborne illness outbreak. We got to a point where we just had bare minimum capacity. We were not prepared to do battle with an outbreak like anthrax, like bioterrorism.

That's where we find ourselves today -- totally unprepared.

Q: With what we know now, what should be done to reverse the situation?

Dr. Akhter: Our priorities should be in three very distinct areas. The first is an early warning system. Communities need [infectious disease] early warning systems so that when the first case occurs, it gets immediately reported.

Only 20% of local health departments have that capacity. What is needed is to connect electronically the ambulance providers, paramedics, hospitals, labs, doctors and clinics with health departments. That way, any time an unusual case is seen it would get reported in real time, and health departments can act quickly to find the cause of the illness, take action to save the lives of the people who are exposed and prevent the spread of disease.

That kind of early warning system is a must in dealing with a bioterrorism attack, but it would be helpful in tracking natural occurrence of disease.

Also needed is re-education and education of physicians, nurses, public health community and other medical personnel about these infectious diseases. Many of us have never seen a case of smallpox, never seen a case of plague. We need to know what the case will look like, what the patient will look like, what kind of tests to do to make the right diagnosis, what kind of treatment to provide, and what kind of preventive measures to take to protect ourselves and other hospital workers from the disease. That knowledge is totally lacking.

The third piece is expanding the public health capacity at all levels of government. At the federal level, we need to have adequate supplies of vaccine, drugs and the experts who can give advice when there is an outbreak. Right now we don't have it. At the local level, we have very poorly staffed health departments. Many of them are 9-to-5 operations. They are only open Monday through Friday. So if [physicians] report a case after hours, there won't be action until Monday morning. That is unacceptable.

Q: What about the regular public health responsibilities in addition to these newer problems?

Dr. Akhter: Well, we have four challenges.

The first one is that bioterrorism has really taken attention away from the other work that we do -- the average, daily work. The lab's attention, for instance, is totally focused on analyzing all of these [bioterrorism-related] specimens. Other testing has been slowed down.

The second challenge is that new problems have emerged [since Sept. 11] for which there are no resources and no budget. And there are other needs, too, like air-quality problems from the World Trade Center disaster. Also, counseling for the people who have been impacted, who are having trouble coping. It's a big, big, big task. How do we provide services to those people?

The third thing affecting us is the issue of the war itself. Whenever a war goes on, it takes some resources away from social programs. Federal funds are going into the defense buildup. This puts pressure on the social services budget, on the public health budget.

The fourth challenge is the slowing economy. This means that the state and local governments do not have the revenues that they projected earlier in the year. And when they don't have the same revenue, they cut services. But with the slowing economy, a lot of people also become unemployed. They don't have health insurance. The public health burden increases. That is another concern. We really find ourselves quite squeezed at the moment.

Q: That seems to be an irony because though public health services are receiving more attention than ever, they seem at risk of not being given the resources necessary to meet expectations.

Dr. Akhter: That's correct. If there were ever a time to invest in the public health system, it is now. But that's not where we have seen the investment go. There has been a lot of talk, a lot of discussion. There have been plenty of hearings in Congress. But the action has not come.

Meanwhile, local people are being very vigilant. They are trying to do their very best, but they don't have the right equipment, the training, the right monitoring system. Don't expect them to be able to protect the health of the American people without the necessary resources.

Q: You've talked about these issues for a long time and also warned about bioterrorism and other threats, as well as the system's vulnerabilities. Have the worst fears been realized?

Dr. Akhter: Absolutely. I think it has come to pass, and I think that our nation has still not come out of shock. I think we still have not paid the kind of attention that we should pay to these threats. There is anthrax in the hands of the wrong people. No question about that. And they have delivered it. Nobody can say now, "We're just talking hypothetically."

And the second reality is that we are not prepared. Even the very small number of cases [associated with the recent anthrax exposure] stretched the capacity of our best health departments. We're talking about Washington, D.C., New York, Florida. We're talking about the Centers for Disease Control and Prevention. The enemy has us exhausted because we don't have really the capacity to deal with it.

Q: We're in this new world order -- the post-Sept. 11 order. How do goals such as the effort to reduce racial and ethnic health disparities fit in? It's an issue that became central to Washington, D.C.'s recent anthrax experience. Does the way we think about this now change?

Dr. Akhter: There's more urgency for the problem. I say this because African-Americans are a segment of the population that believes that even in the case of a national emergency -- even in the case of very trying times -- there are some people who get better treatment than others. The postal workers complained that two people had to die before action was taken. They compared [their experience] to the congressional [experience]. Their feelings create an instability and distrust and mistrust among the people.

We should deal with the concerns of our ethnic minorities and provide them with the same treatment and care we provide others. Also, we should make sure that in the planning for a response to a bioterrorist event, diverse groups are involved.

The response [to this kind of emergency] must be rational, not one that appears to be based on who is most powerful or who lives where. It must be based upon scientific facts and a very clear plan designed to identify the case and provide treatment.

Q: What about other ongoing initiatives, such as the partnership between medicine and public health?

Dr. Akhter: I just had a meeting with the AMA president, chair of the Board of Trustees and the AMA's president-elect to figure out a cohesive way of dealing with educational issues for physicians. We have been working together to really deal with that issue -- just as we have worked on many other issues in the past, like smoking. But this is a new day. And there has not been an issue of this magnitude that affects all of our citizens and all of our health care professionals.

Q: How does your personal background impact the way you have been living life these past couple of weeks and been seeing and processing the current events?

Dr. Akhter: I think it impacts me a great deal. There's one thing that continues to push me. I became a refugee when I was 3 years old. I know what it is like to stand in the line for half a day to get a jug full of water. Particularly when you happen to be small and you are always pushed aside. It is difficult for me to see what is happening in Afghanistan with all of these people becoming refugees. My heart goes out to them. We should try to do the best we can to provide them aid, assistance and medical care. There shouldn't be a reason why the innocent people who for no fault of their own are suffering so much.

Also, as a physician, a public health practitioner, I have concerns for the safety of our people. People need to be protected.

I took an oath when becoming a physician -- to maintain the human dignity and provide individuals the best care. And sometimes that makes me very outspoken, when I see things in our system that will hurt people if there is an outbreak. I consider it not only my personal responsibility, but an obligation to bring forward the issues I think are important to protect the health of the people.

Public Health: Renewed Attention is a six-part series exploring the role of the public health system in the context of our nation's heightened state of alert. The next of installment will examine how the system's recent history has contributed to its current capacity.

ADDITIONAL INFORMATION:

Curriculum vitae

Mohammad N. Akhter, MD, MPH
Age: 54
Background: Born in India. Raised in rural Pakistan. Became a U.S. citizen in 1984.
Education: Medical training from King Edward Medical College, Lahore, Pakistan; master's degree in public health from Johns Hopkins University, Baltimore.
Public health career highlights: Chief, Illinois Division of Emergency Medical Services and Highway Safety, 1976.
Director, Missouri State Dept. of Health, 1980.
Commissioner of Public Health, District of Columbia, 1991.
Senior policy adviser, Dept. of Health and Human Services Agency for Health Care Policy and Research, 1994.
Executive director, American Public Health Assn., 1997.
Activism: Returned to Pakistan with wife as medical missionaries, 1987; developed the Dept. of Health and Hospital Administration at the country's only school of public health; became the school's dean.
Personal: Wife, Jeanette Akhter, MD, is an obstetrician. Daughter, Sarah, is in graduate school.