A Shot in the Dark

It won't be like Hurricane Katrina: a cataclysmic event that kills, injures or traumatizes everyone within its force and destroys homes, highways and businesses within...
by | September 30, 2007

It won't be like Hurricane Katrina: a cataclysmic event that kills, injures or traumatizes everyone within its force and destroys homes, highways and businesses within seconds.

A pandemic flu outbreak -- something scientists consider long overdue -- would unfold over an extended period of time. The onset might be slow, but it would eventually spread everywhere -- which means that no state or locality would be able to help another jurisdiction. There'd be no spare medical teams or special equipment to alleviate a neighbor's suffering.

No populations or sectors of the economy would be spared -- from school systems whose young charges would be hit hard by illness to businesses and governments whose workers would stay home to recover or care for others. Meanwhile, protection against the illness would be a long time in coming. The virus strain causing the deadly disease would have to be precisely identified in order to develop and distribute a vaccine. That would take months. In the interim, the only primary medical response any state or locality would be able to deliver is a shot of Tamiflu or another antiviral medication to treat symptoms.

The impact could be staggering: The last major worldwide pandemic in 1918-19 killed half a million people in the United States and millions more across the globe. Next time around, the numbers of people who could be affected and the needs of those who become desperately ill with the disease would be as great, if not greater. It's unlikely that there will be enough hospital beds, ventilators and medical personnel to treat everyone. It will be up to individual states and localities to figure out how they will respond to such a crisis -- how they will gather resources, who will be treated by those scarce resources and how they will keep the public informed about safety and treatment.

The federal government will not play a central role in planning or managing the crisis. Its agencies have been putting out a consistent message: States and localities will have to make nearly all of the critical decisions. "Communities that fail to prepare, expecting the federal government to come to the rescue, will be tragically mistaken," Michael Leavitt, the Health and Human Services secretary, told a June leadership forum on pandemic flu. That message leads many local officials to say with a combination of derision and resignation that the federal government has engaged in "YO-YO" planning, as in, "You're On Your Own."

This is particularly troubling to state and local officials, who are concerned that, at a time when the effects of a health crisis will have national repercussions, one state's citizens could be significantly less prepared than those in neighboring states. That alone could have important national implications. "If you haven't controlled this everywhere," warns Jeffrey Levi, executive director of the Trust for America's Health, "you haven't controlled it anywhere."

What the feds will do is oversee scientific research, vaccine development and funding for the purchase of antivirals. The states and localities are in charge of making plans related to such dicey matters as quarantining citizens, closing schools and other operations, allocating medical supplies, educating and informing families and businesses, and otherwise managing the disease and the afflicted population -- and still keeping the government and local economy in working order. It's a tall order, one that leads Jill M. DeBoer, associate director of the Center for Infectious Disease Research & Policy at the University of Minnesota, to call planning for a pandemic "the biggest challenge right now facing public health."


Although no one knows for certain when the next pandemic will hit or what disease will be involved, the pace of governmental activity has quickened as a result of attention to H5N1, a bird-flu strain that has killed or sickened millions of birds but only about 200 people. Authorities are concerned that a strain such as H5N1 could mutate so that bird flu would be transmitted not just from bird to person but from person to person.

With no effective vaccine available to prevent the disease from spreading, state and local governments need to have their treatment resources, such as hospital beds and ventilators, and policies, such as social-distancing plans, lined up. Multiple agencies are involved in such efforts, but much of it is the domain of public health departments.

While any public health planning effort has many aspects, the California Department of Public Health has received attention in particular for its hands-on approach to dealing with hospital "surge capacity" in the event of a crisis -- be it pandemic flu, a terrorist attack, earthquake or other threat. State public health officials have surveyed every hospital in the state on bed capacity and staffing issues. Comparing those numbers to anticipated need for services using a Centers for Disease Control and Prevention model, they have concluded that California might need an additional 40,000 hospital beds even after facilities take measures to increase capacity by placing patients in all available spaces and postponing non-urgent procedures.

The state is working on several purchases to help improve hospitals' response capacity. These include the acquisition of 21,000 beds to be used in alternate-care sites such as school gymnasiums and armories -- 600 of those beds will be situated in mobile field hospitals that are equipped with operating rooms and intensive care units. The state also is purchasing 2,400 ventilators, doubling its overall supply.

State officials also are planning to secure access to enough doses of antivirals to assist one of every four Californians. And the state will have a supply of 50 million N95 masks for workers who must come into contact with infected individuals. Since most workers would have to use three or more masks per day to protect themselves, the number of masks being secured is actually not as excessive as it sounds, says Mark Horton, director of the Department of Public Health. The state's purchases are being funded through $214 million in fiscal 2007 general fund dollars that was set aside to enhance the health community's response to a pandemic.

Another health care-related question revolves around the extent to which regulations on health care facilities would be relaxed during a pandemic outbreak. California has hired a consultant for a project in which manuals for delivering care will be issued. The kinds of questions that will be answered in this process include whether mandated nurse-to-patient ratios can be waived in a pandemic, and whether paramedics and other workers can be allowed to perform needed duties that are outside the scope of their professional license.

In addition, the state is building capacity for health professionals to register in advance as volunteers, well aware that during Hurricane Katrina some professionals were stalled in the effort to offer help because their credentials had not been verified.

There is also the question of social distancing -- which could include quarantining residents. The success of any response to a pandemic may depend on quarantines in which individuals exposed to the virus but not yet showing signs of illness are isolated from those who have not been exposed. In Des Moines, Iowa, health officials have suggested a number of potential sites of alternative housing for exposed individuals who could not stay home. While it is hoped that quarantines would occur on a voluntary basis, several Iowa counties have adopted an ordinance that would give officials the authority to order people into quarantine under appropriate circumstances.


Acquisition of needed equipment addresses only half of the equation. There will not be enough resources to treat everyone. Ventilators in particular will be in short supply in a pandemic. Decisions on triaging patients who need medical attention in an emergency are generally left to hospital personnel. But a pandemic is such an uncommon and pervasive threat that the health care community is looking to government officials to outline policies -- to give health workers guidance to decide who will receive treatment and who will not.

That is an issue that a New York State task force has been grappling with. Medical professionals, attorneys, bioethicists and religious leaders can come up with a dozen different answers on the fairest way to do this, says Tia Powell, executive director of the New York State Task Force on Life and the Law, and each one would be plausible.

Last March, a task force panel drafted for public comment a planning document for allocation of ventilators in a pandemic. The recommendations were not easy to come by; Powell says a finalized document is months away as the group seeks more feedback from people not tied to the medical community.

So far, the draft guidelines reject using a patient's age as a criterion to exclude him or her from being placed on a ventilator. Health facilities instead are asked to take a broader look at a patient's prognosis, meaning that a healthier-than-average elderly person could receive a ventilator over a younger person with a poor health profile.

In addition, the panel's guidelines do not give special priority to health care workers and first responders who become ill and need a ventilator. In a pandemic event, an individual's recovery will take such a long time -- if it occurs at all -- that it may be unrealistic to implement a policy based on getting health care workers back on the front lines of emergency response. "There can be no perfect solution," Powell says of an allocation guideline. "The perfect solution is not to have a pandemic. But we may not have that choice."

Finally, the guidelines are likely to suggest that allocation policies be voluntary, which Powell acknowledges has troubled some observers. The rationale is that if the guidelines were turned into a regulation or a law, that would lock a jurisdiction into them and that, Powell points out, is "problematic for anything involving medical care. If a pandemic happens any later than tomorrow, we'll have more medical knowledge than we have today." It is possible that state legislators could create an incentive for use of the guidelines by enacting liability protection for facilities that employ this standard of care.


Any plan that outlines what the government plans to do and how the public should respond in case of a pandemic needs to be communicated to residents -- which is easier said than done. There is a tendency for people to tune out warnings until a crisis is at their doorstep or, in the case of avian flu, to minimize a threat when news reports about its occurrence are not followed by accounts of widespread deaths. "I've heard pandemic flu labeled the new Y2K," says the University of Minnesota's DeBoer, and such dismissals are apparent, she points out, not only among a skeptical public but even among some public officials.

Many units of government are addressing this problem by integrating their public education efforts on pandemic flu with other emergency preparedness information, particularly emergencies that sound more pressing to residents. In California, that means earthquakes, and some communities are using that concern to keep residents up to date on the pandemic possibility.

"Generally there's an appreciation here to be prepared," says Joy Alexiou, public information officer for the Health and Hospital System in Santa Clara County. The California county's board of supervisors has, accordingly, authorized $750,000 for public awareness efforts on pandemic flu, and many of those efforts are taking their cue from earthquake-preparedness experience.

In 2003, for instance, Santa Clara County used local radio and newspaper advertising to announce the availability of English, Spanish and Vietnamese versions of a pocket guide on earthquakes. It distributed 250,000 guides within two weeks. Two years later, with bird flu in the news, the county printed guides on preparing for a flu pandemic, including information about social distancing and caring for sick loved ones at home. An initial run of 350,000 guides was depleted even before the campaign officially started. Even so, according to data the county has seen, only 10 to 20 percent of households have the supplies of food, water, over-the-counter medications and other items the guide recommends having to isolate at home for a prolonged period.

An influenza event, Alexiou suggests, poses several challenges in proper messaging by government agencies. The fact sheets discuss basic information -- precautions such as washing your hands -- but there is, she says, a disconnect. "People will tend to say, 'You talk about a big, bad thing that's going to happen, and then you tell me to wash my hands.'"

When working in ethnically diverse communities, public health officials often learn that they may not be considered the most trusted source of information. To counteract that problem, the St. Paul-Ramsey County Public Health agency began teaming up with other Minnesota entities involved with emergency preparedness to establish a collaborative designed to share important information with limited-English-speaking residents. Today, ECHO -- Emergency and Community Health Outreach -- is three years old and has worked closely with ethnic communities and nonprofit agencies to establish public health and emergency information broadcasts in 10 languages (including Somali, Vietnamese and Hmong), over a combination of public television, the Internet and telephone lines.

Lillian McDonald, executive director of ECHO and the former public information officer for the St. Paul-Ramsey County agency, says many of the monthly television broadcasts are hosted by personalities who were selected by members of their ethnic community. "Some of the individuals we're trying to reach are probably not going to listen to the government in the time of a crisis," McDonald says. "But they are going to listen to a clan leader, or an elder, or maybe a clinic, especially if there is someone there who speaks their language."

By presenting a variety of topics ranging from diabetes to child safety seats to pandemic flu, ECHO wants viewers to get accustomed to using the airwaves to gather important information. "We're totally trying to brand ECHO as the go-to resource," says McDonald.

Currently about 9,000 viewers a month are tuning in. Emergency preparedness dollars cover half of the programs' costs, with corporate and foundation sponsorships making up the difference. ECHO has already aired one program on pandemic influenza and two on avian flu.

There are not that many ECHOs out there, and there is concern among health experts that if governments know the public is likely to be apathetic about a health threat it cannot fully comprehend, agencies must bring the issue to the forefront. "Cross-discussion among relevant agencies in the states is not happening," says Levi of the Trust for America's Health. "Some states are in a state of shock."