July 20, 2009 The Pump Handle 0Comment

by revere, cross-posted from Effect Measure

We’ve been talking about the possibility of a flu pandemic here for four and a half years. The cliché during much of that time was that the right way to think of a flu pandemic was not “if,” but “when.” As long as no pandemic materialized, however, there was great scope for what it would look like and hence what to plan for. The hoary adage, “Hope for the best, plan for the worst” made sense but left a great deal of scope for different approaches to planning. What, after all, was the worst we could expect? We had two models, one historical, one hypothetical but plausible. The historical one was the 1918 pandemic, a truly catastrophic public health event brought to vivid life by John Barry’s book, The Great Influenza, a surprise best seller just at the time we were contemplating the hypothetical, but plausible, prospect the next pandemic could come from H5N1 avian influenza. The relatively rare cases of human bird flu showed a virus even more virulent than the 1918 virus and there was (and is) a prodigious amount of it “out there” in the form of a panzootic in poultry and wild birds. So far, though, H5N1 has not learned to transmit easily in humans. Yet the pandemic arrived anyway, in the form of swine flu H1N1. For the moment, then, we need to be ready to manage the consequences of the pandemic that’s here, not the one that is not yet and may never be. This means the calculus of “hope for the best and prepare for the worst” has become more concrete and narrowed in scope. That means adjusting on both what hoping for the best means and what planning for the worst means. In some respects, we believe there is a danger of getting it wrong on both scores by simultaneously planning for the best and if not hoping for the worst, imagining worse than is plausible.

CDC’s teleconference on Friday (transcript here) was taken up largely with vaccine supply and plans. This is understandable, perhaps, but we think it is a bit too close to “planning for the best.” An effective and timely vaccine could well make a huge difference but it depends on many uncertainties, not just whether there is sufficient productive capacity to supply the world’s population (or your community, take your pick) but even if there were and it could be produced in time whether it would work. Assuming a good match and a sufficiently immunogenic dose — two optimistic assumptions — we still have to administer it and once administered it would need to protect people against the circulating virus. Even under the best of circumstances this is uncertain. If all our planning eggs are in the vaccine basket (note the aptness of the metaphor), we are truly “planning for the best.”

Planning is not just vaccines, of course. Public health agencies, the private sector and individual citizens are also engaged in many other activities to manage the consequences of the pandemic that has already begun (we know most people aren’t yet paying attention, but enough are that we will continue to talk about the ones who are preparing, since that’s the subject of this post). And this is where “planning for the worst” comes into the picture. Besides vaccines (and the mirage that we will be saved by antivirals), what we do in addition depends on what we are planning for and at what level. Public health concerns groups or populations, and that’s one level. Clinical medicine concerns treating individuals and that’s another. Both have lay counterparts, in public health all the institutions and structures that enable communities to function as communities instead of separate individuals. The counterpart to the “one at a time” perspective of clinical medicine are all those things involving individual responsibility and self-help that everyone should practice to the best of their abilities and resources. If you can help yourself and your family you should. You shouldn’t depend on others to do for you what you should and could do for yourself.

Having said that, for more than four years our position on prepping for a pandemic has stressed community preparation rather than individual preparation. We live in a a tightly interconnected world. Being self-sufficient in any meaningful sense is not an option for any but a tiny fraction of people. And planning for personal self-sufficiency is neither possible nor, if everyone did it, desirable. As a community we will get through this better together than we could possibly do separately.

More importantly we don’t think planning for self-sufficiency is necessary or wise. We’ve thought about it carefully and been engaged in planning at a concrete level, and in our view a total collapse of critical infrastructure is not likely or even plausible. It didn’t happen to any extent in 1918. In most places life went on without interruption and relatively normally. The eventual toll was frightful and personal tragedies many, but day to day life continued. The spatial epidemiology of influenza is notoriously patchy (we don’t know the dynamics that produce this but it is been true in all the pandemics and seasonally), which means that two cities 100 miles apart can differ greatly in their flu experiences, with one hard hit and another almost normal. We also don’t have to imagine what this pandemic could be like. The plausible scenarios have been narrowed. It’s here and we can see it. So far this pandemic is showing signs of being more like 1957 (which I lived through and was barely conscious of), not like 1918. Could things change? Of course. Am I saying that preparation isn’t urgent? On the contrary. It is of the highest urgency. But time is very short and our efforts and resources have to be used as efficiently as possible. That means preparing for consequences most likely to happen. We should target them for what is eminently foreseeable.

With the usual disclaimer that flu is unpredictable and no one knows for sure how this will unfold, here is our version of planning for the worst. You can do your own version of hoping for the best. We think the most obvious pressure points will be in hospital emergency rooms and intensive care units. We should be planning now for triage, diversion to special flu units to segregate the infectious from other emergent cases, use of people usually engaged in non-emergency care and retired volunteers as back up and the provision of necessary supplies like intravenous kits, antibiotics, oxygen and ventilators, especially pediatric vents. We should also be prepared to expand critical care capacity by a planned and flexible conversion of acute care beds to the purpose. Some of this will require additional stockpiling and some planning for alternate sources of supply. All of this can be thought through in the time between now and September. It’s not rocket science. In our view the most obvious and visible sources of public anxiety will be media scenes of overwhelmed emergency rooms and hospitals. We can get ready for that. We know it’s coming.

Perceived shortages of staples or necessities are a second likely source of major public anxiety. When the swine flu outbreak became a media headline in May some locations reported shortages of face masks and hand sanitizers. In reality there wasn’t a true shortage but a temporary and local one induced by a just-in-time inventory system. We can’t change that system in general, but we can alter it on relatively short notice for readily predictable items, including certain kinds of essential pharmaceuticals (insulin, blood pressure meds, etc.), infant formula and baby supplies and a few other things. We don’t need to change just-in-time inventorying for DVD players or botox. Now is the time to make up the list and identify the inventories and supply chains for a very restricted list of critical supplies. Retail outlets should also be prepared to explain that temporary shortages are temporary and give estimates for when new supplies will arrive. We can have FAQs and fact sheets prepared ahead of time for particular kinds of staples and supplies.

It is these two items — the pressure on the health care delivery system and the psychological effect of temporary shortages of staples and necessities — that are at the top of the list for planning. This is what “preparing for the worst” means at this moment in time. We can think it through now, or when the problem is upon us we can try to muddle through. If we want to minimize harm to our communities it’s clear which path to take. There will be many other problems but they won’t bring us to our knees. School closures have received a lot of publicity and they are a vexing and difficult problem. But we can survive schools being shut down. It happens every summer and during holiday vacations. It creates difficulties and it costs money. But the world doesn’t end. Water systems? Many small community systems depend on a few or even one person to keep them running optimally. But there are over 50,000 community systems, all separate. And it’s extremely unusual for water systems to fail, even in natural disasters. The electrical grid is arguably more of a problem. The two issues we see are damage to the distribution system from something like an ice storm that could take longer than usual to repair; or a cascading failure as has happened in several catastrophic and huge blackouts. But in each instance the problem has been fixable with reasonable time and effort. The grid doesn’t stay down for weeks except in very localized areas, certainly not regionally or nationally and not for a month. The utilities are allegedly engaged in continuity of operations plans in the event of substantial absenteeism. It’s something they can do, now, to minimize interruption of service. If you are stockpiling a month or more worth of food and water in your basement, you are among a tiny minority of people in this world who can do it. And in our view it won’t be needed. It’s possible to imagine the apocalypse. But with time short and resources and attention limited, it’s not a reasonable basis for planning for individuals, communities or nations.

A nasty flu season will be a trial. There’s no doubt about that. But 1918 taught us that communities where there was free flow of information (and the trust and confidence in authorities that goes with it); where neighbors helped neighbors because there were structures in place to make that possible or easier; and where there was a strong and resilient public health and social service infrastructure — communities where these things were present — did much better. That’s the kind of prepping we advocate, along with preparing for the health services pressure points and the supply chain or local stockpiling of a very small list of community staples.

So along with the adage, “Hope for the Best, Plan for the Worst,” we should put next to it: “When the going gets Tough, the Tough get going.” It’s time to get going and in the right direction, in a clear-eyed, calm and systematic way.

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