By David Goldstein | McClatchy Newspapers

WASHINGTON — Overhauling health care was going to be tough enough for Kansas Gov. Kathleen Sebelius.

However, the growing scare over swine flu is likely to command her attention, if, as expected, the Senate on Tuesday confirms her as secretary Health and Human Services, the final vacancy in President Barack Obama's Cabinet.

Robert Kadlec, a top homeland security and biological defense official in the Bush administration, said that Sebelius was "walking into a firestorm, between this and health care."

As of Monday afternoon, 40 cases of swine flu had been diagnosed in the U.S., including two in Kansas. No one has died, but in Mexico, where the disease first gained attention, authorities have blamed it for 149 deaths.

Cases also have been reported in Canada, Spain and Scotland.

As head of the largest piece of the federal health care bureaucracy, Sebelius would oversee an array of agencies. Several play important roles in the effort to understand the previously unknown strain of flu and how to combat it should it develop into a full-blown public health crisis.

Among them: the Centers for Disease Control and Prevention, and the National Institutes of Health, whose focus is medical research.

She'd also coordinate her department's efforts with those of others, including Defense and Veterans Affairs, which both operate large health services, and Homeland Security. In addition, Sebelius would serve as the liaison for health officials in 50 states.

Even if Sebelius wins confirmation, however, nearly 20 other top HHS positions, including surgeon general, remain vacant.

"In a situation like this, the HHS secretary becomes the top public health official in this country," said William Pierce, who served as spokesman for former HHS Secretary Tommy Thompson during the Bush administration. "It's a big job. Getting her in there is important . . . . She is going to have to hit the ground running."

The Secretary of Homeland Security, Janet Napolitano, has been the Obama administration's lead face on swine flu since Sunday, when she and other top federal health officials held a White House news conference to bring the public up to date.

That's likely due in part to the fact that the health secretary's job is vacant. The Homeland Security chief, however, is the federal official designated to deal with a pandemic, which is an epidemic that spreads across a wide region. So far, swine flu hasn't become one, though the government is taking preparatory steps just in case.

The World Health Organization on Monday raised its alert level and said that chances of a pandemic have increased.

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