Effect Measure

The headline said, “Vaccination plan puts health care workers first,” but you had to read the article to find out who goes next: the military. This according to the Guidance on allocating and targeting pandemic influenza vaccine released yesterday by the US Department of Health and Human Services (DHHS). The guidance is premised on the assumption that in the early phases of a pandemic, any vaccine will be in short supply and will need to be rationed. The document gives “strong advice” on how DHHS thinks this rationing should take place, although much is left unexplained. Since the allocation to states will come from a national stockpile, the strong advice will have some weight. Moreover, some of the vaccine will be taken “off the top” for federal government use and this will not be subject to any decisions downstream. And some of the federal allocations appear to us to be highly questionable:

The plan puts a million health care workers, such as emergency room staff and nurses, at the top. Next are military and “mission critical” personnel, public health workers and hospital and nursing home staff.

All of these play a “critical role in providing care for the sickest persons; highest risk of exposure and occupational infection,” the plan reads.

“This guidance is the result of a deliberative democratic process,” HHS Secretary Mike Leavitt said in a statement. “This document represents the best of shared responsibility and decision-making.” (Maggie Fox, Reuters)

Putting frontline health care workers at the top makes sense (NB: I am a health care worker but as a researcher-physician would not be considered “front line,” so this isn’t special pleading). But why is the military at the top along with them, ahead of many other “mission critical” workers like police, fire and communications? Reading the document provides no obvious answers. The document is replete with claims that the guidance was developed by an open and transparent process with ample opportunity for the public and other stakeholders to comment to the Working Group that drafted the document:

“This guidance is the result of a deliberative democratic process,” HHS Secretary Mike Leavitt said in a statement. “This document represents the best of shared responsibility and decision-making.” (Reuters)

But we also read that in meeting after meeting the same objectives were identified:

• Protect persons critical to the pandemic response and who provide care for persons with pandemic illness
• Protect persons who provide essential community services
• Protect persons who are at high risk of infection because of their occupation, and
• Protect children. (Guidance document, Appendix A)

There is no mention of putting the military up at the top. In fact there is no mention of the military at all. In the “rigorous” decision process they apparently didn’t score very high:

Groups with the highest overall scores, regardless of pandemic severity, included front-line public health responders, essential health care workers, emergency medical service providers, and law enforcement personnel. Among the general population groups, infants and toddlers ranked highest. (Guidance document, Appendix A)

So how did they get up to the highest Tier and within the highest Tier the second highest priority after front line health care workers? The document doesn’t tell us, but the game seems to have been rigged at the outset by its structure. The entire population was divided into four categories: homeland and national security, health care and community support services, critical infrastructures, and the general population (Guidance Document, p. 5). Each category was then divided into five Tiers or priority levels, with everyone in a Tier initially receiving equal priority regardless of category. Thus by including homeland and national security as a category, the military was guaranteed a top Tier (since each category had a top Tier). Moreover each Tier has its own priorities in the event there isn’t enough vaccine to cover the Tier. At the top of Tier 1 are frontline inpatient and hospital-based health care workers (estimated to be about 1,000,000) and right after them comes the military (700,000), before five other Tier 1 categories, i.e., ahead of:

Front-line Emergency Medical Service personnel (those providing patient assessment, triage, and transport)
Front-line outpatient health care providers (physicians, nurses, respiratory therapy; includes public health personnel who provide outpatient care for underserved groups)
Front-line fire and law enforcement personnel
Pregnant women and infants 6-11 months old
Others in Tier 1 (includes Tier 1 health care workers not vaccinated previously in hospitals, outpatient settings, home health, long-term care facilities, and public health; emergency service providers; manufacturers of pandemic vaccine, antiviral drugs, and other key pandemic response materials; and children 12-35 months old) [p.10]

I don’t know how the military got a category of their own and then a spot almost at the top despite the fact they never scored high in the “open and transparent” process touted by DHHS, but there you have it. The reasoning doesn’t make much sense. Do we need the military to be ready to fight a war in the midst of a pandemic? If the whole world is sick (and much of it sicker than the rich nations), do we think we are going to be attacked? If the problem is the living conditions of the military, then change their living conditions. That’s called a non-pharmaceutical intervention and it will be urged on the rest of us.

And not everyone with expertise thinks they have the rest of it right, either:

Mike Osterholm, an infectious disease expert at the University of Minnesota’s Centers for Infectious Disease Research and Policy, said the plan did not do enough to protect critical workers.

While it designates people involved in making vaccines and drugs for flu, it does not account for other drugs such as insulin and antibiotics, he said.

“It does nothing to help support the manufacturing and transportation system for moving these drugs from offshore to the United States,” Osterholm, who advised the government on the guidelines, said in a telephone interview. (Reuters)

DHHS has it right that it is critically important to discuss this with the public in an open and transparent manner. It sounds, though, that someone shot an arrow and the Working Group complied by painting the target around it.

Comments

#1 SaddleTramp
July 24, 2008

This makes perfect sense if you are assuming (1) that there wont be enough vaccine to go around, and (2) that you need the military to control the mobs and maintain order and fill critical vacancies once the sheeple finally realize that they have been lied to about the severity of the pandemic and that they and their near and dear are NOT going to get vaccinated.

It has absolutely nothing to do with war-fighting.
#2 Andrea M
July 24, 2008

Here in Italy, in case of natural disaster, the military is generally expected to step in and provide some essential services in the disaster area – e.g. assist the victims with housing, food, and disesase control, provide essential communications, etc. Indeed the military is the only branch of the state that is able to fully operate in emergency situations because of its autonomous and well organized logistics. Even in milder emergencies, the contincency plans rely at least in part on military – civilian cooperation. In Italy, it would make sense to vaccinate the soldiers, because they would be needed to patch the holes that would inevitably pop up in the system.
Whether it would make sense in the US, where the military is more strictly separated from the civilian authorities I cannot tell.
#3 Andrea M
July 24, 2008

Oh, yeah, and if the doses are not enough for everyone and the pandemic is deadly enough, the military is also expected to provide crowd control, as SaddleTramp pointed out. Also in Italy / Europe.
#4 revere
July 24, 2008

ST, andrea: The military referred to here are deployed forces, i.e., active duty soldiers. The kind of civilian duty you refer to is usually assumed by the National Guard who are mobilized for the purpose (the ones not tied up in Iraq or Afghanistan, that is). When Bush broached the idea of using the military for quarantine purposes it received a lot of bad publicity and significant pushback, so if this is signaling a similar role for active duty military then it is something to take notice of. One would still have a hard time giving them the priority over police, fire and civil emergency workers envisioned here. They would be used in preference to civilians and that is a hidden policy decision. More importantly, it is hard to see how this comes out of an “open transparent process” if the intention is, as you say, not explicit. Since the decision making process for this is not evident I think it remains problematic. If the intention is to use the military to keep civil order then they should say this and say that’s why they are allocating vaccine to them. Then they should justify this allocation over police, fire and health care workers.
#5 Backcreek
July 24, 2008

They also provide mortuary services.
#6 FirstAidKit
July 24, 2008

The only reason I can see to put the military anywhere near the top of that list is the provision for likelihood of infection due to employment. The military is one of the few organizations that bunks large numbers of people together in one place for extended periods of time, leaving them at much greater risk of infection. In that situation it is difficult to implement other front line prevention methods (like quarantine), so they probably hopped up a few notches in the list for vaccinations.
#7 Paul
July 24, 2008

Some things are so obvious to most folks, they needn’t be discussed “openly,” or receive that much attention at all in any forum discussing national emergencies – such as whether the sun will shine, the possibility of market disruptions, or the indispensibilty of our military. Your reasoning is rife with inconsistencies. You acknowledge the need for protection at every tier (polic, firemen, etc.) The military are our protection of last resort. You’re concerns about our mission in Iraq and Afganistan, may be blinding you to the fact that there are real enemies waiting to attack us (HERE) at any opportunity. You may have missed 9/11 and the anthrax attacks, and may (inexplicably) be incredulous of sleeper cells of radical Islamists already situated within our borders, waiting for the first opportunity of our vulnerabilty (a pandemic being the mother of all conceivable vulnerabilities) to happily contribute to our mortality figures. As you know, the contagion will not effect 100% of our or our enemy’s population – far from it. And our enemies happen to be the first we’ve ever faced whose weapon of choice (and most effective it is) is sucide. If I remember correctly, the military units that finally brought order to New Orleans after the very localized disaster of Katrina were not their National Guard, but regular Army units. And to quote that most effective General who got things back in hand, “Let’s not get stuck on stupid!”
#8 revere
July 24, 2008

Paul: Let’s take your response apart. I was questioning the order of priority (why is the military number two, ahead of all the others, including fire and police), how was it arrived at in an “open and transparent” manner when it never scored high, etc. Now if there is a suicide bomber or other terrorist (e.g., Tim McVeigh?) how are we going to attack him/her/it/them with the military? Contrive an attack on another country like Iran? That would follow the pattern that got us into the Iraq debacle. If there are real enemies out there (besides the ones we have created with our military interventions) why aren’t we attacking them now with our military? The idea that if there is a pandemic this country would be laid open to being attacked or conquered by enemies because our soldiers are sick is really quite silly. Who are they and how are we going to attack them with our military now? This is extremely poorly thought out and is the usual reflex of the right wing whackos claiming the military keeps us safe and will solve all problems instead of the reality that it is the use of our military power that has created our problems and made us less safe. Yes, there are real, deadly problems out there. Problems that could be solved with the $12 billion a month going down the Iraq rat hole.
#9 Paul
July 24, 2008

Dr. Revere, Having read over your recent posting(but not recent enough for a timely comment) about your honesty in dealing with the “other side” (politicallly); and, perhaps in retrospect, having left my last comment on a note that could be inferred as an ad hominem (yet it really offends me when those fellow citizens who volunteer to put their very lives at risk, are skewered by fellow citizens, whose very lives and freedoms are thereby protected), I would like to add this one conciliatory comment about how you run your blog. There can be little doubt about the size and respect of your audience for your scientific expertise, and grateful reassurance we feel at having you out there keeping post against this potential disaster. Whether you’re using the same platform to so frequently express your political views is totally your option – it’s your blog; whether it dilutes your readership’s respect for your intellectual development outside the scientific field, is something for your consideration exclusively. I’m constantly astounded by folks who are so accomplished in their fields (actors, scientists, etc.) who hold forth on other fields of knowledge in which they have no credentials beyond that of other citizens, with the same assurance in the views they proffer, but fields which are totally unrelated to their more specialized knowledge. I think it behooves us all to do a lot of reading and research commensurate with the assumed authority with which we proffer opinions in any field of knowledge – including politics, history, etc. However, to the point of this comment, I wish to compliment you on your honesty in allowing comments, which indicate strong opposition to your views, to even appear as comments. Considering the recent refusal of the New York Times to publish Senator McCain’s recently submitted op-ed, when they have published so many of his over the years, and their publication of Obama’s (one of their many disappointing displays of bias), your editorial integrity far exceeds that of some of the former paradigms of editorial discretion.
#10 Paul
July 24, 2008

And what is your response to the example of the intervention of regular Army units in the Katrina disaster. If their ranks were decimated by the AI, who would be the saviors (forget protectors) of last resort? Who has the already existing organiational infrastructure, logistics experience, training, and proven bravery to just plain help their stricken and fallen citizens?
#11 revere
July 24, 2008

Paul: That was required because of a totally botched response produced by a corrupt and incompetent city, state and federal effort (plenty of blame for incompetence to go around) and the loss of personnel in Iraq. The loss of soldiers to Iraq was greater than that estimated to be caused by a pandemic. So Iraq is worse than a pandemic in its effect on military capabilities — and has shown the world the limits of US military power. We are no longer a credible force anywhere except as a short term killing machine. The military cannot do as well what trained health and emergency personnel can do but they are lower on the list. I also challenge you to point out any place in my post where I blame the military for anything. That’s like saying you are blaming police because they are lower on the priority list. Police, fire and health care personnel put their lives on the line for us daily. I am not accusing you of dissing them because you approve of having them lower on the list.
#12 Chirp
July 24, 2008

Revere,

First, thanks for giving us all a quick summary on this fresh document.

At the risk of repeating others, I’ll hazard three reasons why the military rose to the top in seeming contradiction to the planning process:

1) As SaddleTramp said, for crowd control. If H5N1 spawns our next pandemic and maintains any degree of its extreme nastiness as a bird disease, we’re in for extraordinary times. Perhaps TPTB in Washington/Atlanta looked at H5N1, looked at the list of risks we absolutely can’t afford NOT to be prepared for, and decided we’d be foolhardy not to protect the military as a top priority. I agree with Paul that this is self-evident enough that it’s left unspoken (and I generally agree with his fuller comments in his first Comment).

Should it be left unspoken? I agree that it would be good for Washington to explain why the military is being given preference when that preference doesn’t fit the logic/system of how the priorities were set. However, that may have been a risk communications decision – “We didn’t want to discuss this because we didn’t want to scare people.” Which I’d say is not a good reason, on the theories of “transparency in risk communications” and “people can bear it if they understand it.” If the government truly is so concerned about the risk level of an event that triggers civil unrest or international sword-rattling, they should be telling the public so. Such messages help get this taken seriously (by those who aren’t wearing tin foil hats). This would be a good question for Peter Sandman and Jody Lanard to comment on, if they happen to be reading.

I don’t worry about using the military for quarantine enforcement. It’s undoable, like herding cats. A misstep by Mr. Bush.

2) As Andrea M said, for response assistance. For the reasons she states. In the U.S., they’d supplement the National Guard’s frequent role in emergency assistance – since we can easily imagine the needs will exceed the Guard’s “surge capacity.” (And, yes, many Guardsmen are overseas.)

3) In my third reason, I disagree with SaddleTramp. They may indeed be needed for their primary job: war-fighting.

In a January 2006 post – “Relationships: What happens between us if a bird flu pandemic occurs?” – I discussed how bird flu events in Turkey had brought out political and ethnic frictions and how citizens and the media were criticizing the government for not being responsive enough.

And this from Mexico:

Now consider what Mexico’s Health Minister Julio Frenk thinks with respect to a bird flu pandemic:

“I think the ethical, the political, the future security implications of the situation where only the wealthy countries have access to vaccines and drugs would be unimaginable.”

And I asked:

What if the leaderships of some countries (OK, make it just ONE country) become angry that other countries aren’t sharing critical resources which are in short supply (whether such a perception is accurate or not)?

I don’t have to strain too hard to imagine countries either (a) verbally or physically assailing others “for not being fair” or (b) taking the opportunity to invade other countries while the world is very preoccupied with a pandemic (something they would do today, if they could; the pandemic just gives them “cover.”) I know I sound like MRK on that last one; but I don’t think such a scenario is out of the question at all. (I’d be stunned if Washington isn’t factoring such into its pandemic tabletop exercises.) And in our case (the U.S.), it doesn’t necessarily mean other countries are attacking us in North America (although I acknowledge Paul’s reference to sleeper cells). But if they thought our soldiers were sick, they might take advantage of the situation and attack our forces stationed elsewhere, or our allies, or our strategic interests. (No, I’m not thinking oil fields. But there are things like key raw materials, navigable waterways, even elements of modern supply chains, etc. Hey, even medicine sources; Dr. Osterholm and others have noted that 80% of the pharmaceutical ingredients used in the U.S. are imported – which relates to his quote by you above.)

I wonder what priority is given to vaccinating the military in other countries’ national pandemic plans?

Chirp
#13 Lea
July 24, 2008

Paul: You may want to put a few paragraphs breaks in your writing, it makes for difficult reading.
You also said: “I think it behooves us all to do a lot of reading and research commensurate with the assumed authority with which we proffer opinions in any field of knowledge – including politics, history, etc.”
Go right ahead and get back to us would you. Or haven’t you noticed that people are so overworked and stretched to the limit that to do this is practically impossible?
What we learn here, either coming from someone educated or not, is invaluable and beneficial.

revere: In only reading your excerpt it was noticed that the words Front Line were used. This certainly wouldn’t cover the entire military. The husband is in DoD service right now and he’s considered law enforcement personnel but, my guess is he won’t be the first to get a vaccine. The scope is too broad to pin down exactly what military will get the shot (that may not work).

And my two cents, don’t forget truck drivers. Those people are the backbone of our delivery systems.
#14 Andrew Hill
July 24, 2008

I can see Chirp’s point in 1,2,3 and in each of the original arguments they reference. However, I just don’t see how this makes more sense than Revere’s statements. It seems the counter to Revere hinges on two assumptions; first, people are going to get out of hand within the United States. Second, war will emerge or necessarily continue.
The first assumption seems to be illogical grounds for the military to be put ahead of ‘Front-line fire and law enforcement’. It seems that if those personnel were compromised, the problem would arise much more quickly. There are many other reasons why this seems flawed, but need further discussion (better knowledge of home jurisdiction, existing and present equipment, no need to move large numbers of people during a pandemic situation, etc).
The second is a much more difficult argument. But, as Revere already said, the military has the amazing ability to quarantine and atomize units of its forces in far more efficient way than in common populations. “That’s called a non-pharmaceutical intervention”. Such measures would keep them, at least, par against any enemy facing similar pandemic conditions.
#15 Lolo
July 24, 2008

Simply an observation:

I have worked on domestic Federal pandemic planning. I helped to craft the pandemic response plan for our agency. I have coordinated and participated in several tabeletop exercises testing that plan. These exercises involved high-level representatives from most critical agencies, including DHS, HHS and DOD. DOD attended reluctantly. Not because they don’t care, but because, as it was put to me during a break by one of the attendees, they have no reliable resources to offer. They’re stretched too thin and deployed elsewhere, and more than a little nervous about the level of reliance on DOD resources many of the state and local plans appear to demonstrate. It was frustrating for the reps to sit and listen to how the “military could do this” and the “military would deploy that”. As all of us are aware, a pandemic is not a regional phenomenon for long. You can’t funnel in a pandemic. Not on the scale that would be required: too few resources and too many needs. As the gentlemen I spoke to put it – they want to help, they’ll do what they can when asked, but if states and governments were depending on the military to jump in and save the day, then we’re all screwed.

So, worst case or best case, depending on your point of view, there may be trucks rolling through some streets, but it sure ain’t going to be everywhere.

Though it doesn’t directly answer your question Revere – it kind of does, doesn’t it?
#16 M. Randolph Kruger
July 24, 2008

250,000 NG troops and AF members are not going to be able to meet the needs of 300,000,000. They’ll keep the infrastructure together as long as they can and then when it pops, the whole thing will come apart. Pandemic flu is the epitome of chaos theory. It will keep right on going until the chain breaks and in this case but good.

Once its down and dependent on how many make it, it may take as much as five years to get it all back together and functional. Actually the fewer the better is the reality because those pre-made resources that we are all so accustomed to will be gone. Fewer drains from fewer people.

I guess it will come down to what your definition of doomsday is.
#17 Chirp
July 24, 2008

@Andrew Hill: I don’t know that any of us disagree with Revere’s questioning why the military is being given such priority; we were just venturing explanations.

In my case, I also was explaining why I don’t necessarily agree with Revere’s statement, “Do we need the military to be ready to fight a war in the midst of a pandemic?” Maybe not a war, but defensive actions. That’s because I can easily imagine situations where we need as many healthy, vaccinated soldiers/sailors/airmen/Guardsmen as possible because there may be government leaders in the world who would take advantage of the distraction of a pandemic to expand their territory or seize vital resources in a power play.

Or such leaders may live in a region where they fear such opportunism from neighboring countries. In either case, they want military vigor. It may be that those governments would give their militaries priority medical interventions themselves – purely to preserve their opportunistic (or defensive) options. If they smell an opportunity – like a good percentage of our soldiers sick – they might be emboldened. Vaccinating our soldiers early on might be good preventive insurance, in that sense. Also, our military are stationed all around the world – and many might be more exposed to the virus than we are stateside. Maybe.

Of course, the whole discussion, reinforced by Lolo’s comment, points to the need for local preparation by individual households and businesses and communities (and strengthened public health departments, as Revere has often noted) … instead of relying on federal intervention (be it HHS or active/reserve military). THAT’S where the action needs to be. Yes, Andrew, that certainly includes front line fire and law enforcement. But remember: if some expansionist or desperate dictator somewhere decides to take unfriendly action, we can’t send all of our Sheriffs and Fire Chiefs over there. That’s not what they’re for and not what they’re trained and equipped for. For those balance-of-power or resource-seizing problems, we’d need the military.

Anyhow, the question of the day dealt with the military’s priority vaccination, so that’s where the focus of our comments have been.

(Also, Osterholm’s concerns are absolutely correct. And what about vaccinating those who manufacture disposable contact lenses and ostomy supplies and diapers and on and on? More reasons why you can’t compare the next pandemic even to 1968, much less 1918.)

Lots to think about. I’m glad all of you are thinking about it. And thanks again to the Reveres for their thoughts and this forum.

Chirp
#18 Library Lady
July 24, 2008

Dear Revere,
May I add another log to the fire? Around the week of May 20 you posted “Pandemic Doctor’s Dilemma” which outlined Canada’s triage criteria for allocating ventilators during a pandemic. I complained at the time that the Canadian plan smacks of utilitarianism.

I objected strongly to the triage criteria and the way many states were using the Canadian tool as a model. I objected on the basis of ethical concerns. I also stated that a patient’s informed consent is a necessary component for implementation of any pandemic plan.

Perhaps I am wrong, but I sense from this post that you may have a little more empathy for my objections, if we re-visit them. We both want transparency and fairness. We both want guidelines that help health care providers to be able to live with their consciences when the pandemic is over. We both want to avoid unnecessary deaths and disruption to the functioning of society.

Perhaps it would be instructive if the guests here would go back and google “pandemic doctor’s dilemma” and read that discussion, as the post has dropped away from your archives. Or, you could bring it forward. This current thread has not yet addressed ethical considerations in rationing vaccines.

To me, the arguments for rationing vaccines must be based on the same ethical considerations on which the rationing of ventilators would be based. I am fearful that the “ways of thinking” you outlined in that previous post have already ossified at the federal level.

Love,
Library Lady
#19 revere
July 24, 2008

LL: I am strongly in favor of openness and transparency in deciding how to apportion scarce resources. That was the point of our earlier post, that you reference. I felt strongly then, as now, that this required open discussion. You objected to how the discussion was going, something I don’t think I expressed an opinion on. I was setting out the problem. In this case I think the openness of the process is not matched by the outcome. So while the comments here are related to whether this was a good idea or not, I was focussed on where the idea came from and its rationale.
#20 Grace RN
July 24, 2008

Let’s not forget after Katrina who got to the Superdome first-not the military, not police, fire, rescue personnel.

It was Walmart truck drivers, who despite being turned back by the police found a way into town to deliver bottled water.

I’ll be a front line health care provider during a pandemic and don’t expect a vaccine for me. Congreepeople and their families will be the first to get a shot, I’m sure of that.

I can cope better by assuming no one can be there for me but me, so I prep for that.
#21 ExtremeIII
July 24, 2008

revere,

I get your point: “What happened to the transparency?” It obviously went out the window with a raft of other civil liberties.

The dirty little secret is that many in the military are breathing a sigh of relief at this. While the military has a pretty good pandemic influenza blueprint in place, in reality they are woefully underprepared for a pandemic and see vaccine as their only implementable solution.

Was the fact that the military is underprepared factored into the head-of-the line vaccine privileges this process gave the military (probably not). It was more likely a knee jerk response by an administration that sees the military as the answer to all problems of an emergency nature.

The question that ought to get answered immediately after your transparency question is “how does the military plan to be good stewards of this gift of vaccine, given by the American people?”

I am certain that the military has not thought about incorporating vaccine sparing strategies into its pandemic planning.

EIII
#22 Daniel C. Harper
July 24, 2008

There are several harsh facts about a killer flu epidemic. The first is that right now, if we were to have the “actual” pandemic flu virus in its Human to Human form, in six months the US could make 30 million vaccinations. Or 1 for every 10 Americans.

The second is that, in a typical flu season, the priority is for the old and infirm, and young children. This will not apply in a lethal pandemic, as there is already agreement that vaccinations will go to essential people and outbreak areas, then to school aged children, the worst human vectors. This is actually the old way of doing things, and is a better way for lethal pulmonary diseases.

The third harsh fact is that the current shortage of ventilators in the US, just slightly more than are needed for a normal flu season, may condemn many Americans to death, who would have lived had they had a ventilator. The only possible alternative would be injections of oxygen therapy blood substitute, that can carry far more oxygen than hemoglobin. The lack of ventilators could boost mortality from about 60% to as high as 80%.

The fourth harsh fact is that medical personnel will be able to tell from a chest X-Ray if an infected person is going to live or die. Otherwise, their support will be limited to sanitation. It is unlikely that there will be any effective anti-viral agents in quantity, as ordinary strains have quickly become tolerant of them.

The fifth fact is that epidemics are unfair in how they proceed. Some cities may be devastated, and some may be touched only lightly. Young adults will be hardest hit, because of the proven cytokine storm effect. The epidemic will come in two or more “waves”, and could last from four months to a year and a half.

The sixth fact is that farm and domestic animals and wild birds could be severely diminished in number. In much of the world this could cause severe famine. Domestic animals might also be vectors to spread the disease to humans.

On the plus side, typical Americans have a good understanding of hygiene and sanitation, and an excellent communications system to disseminate information. People will also experiment a lot with alternative therapies, one or more of which may be helpful.

In practice, people will learn how to protect themselves in a layered defense against the disease.

1) Avoidance and sanitation. Frequently use alcohol hand sanitizer when out in public, and encourage public places to offer complimentary sanitizer and common dust masks at entrances.

2) Use of nasal sprays containing zinc, silver or calcium that can inhibit virus reproduction in the URT. Consumption of other chemicals to prevent virus adhesion to cells.

3) Inhibition of virus Hemagglutinin, to prevent cell infiltration. Inhibition of virus Neuraminidase, to prevent viruses leaving infected cells.

4) Use of immunosuppressant therapies to reduce the cytokine storm effect. These are singularly toxic, so are used as a last resort.
#23 M. Randolph Kruger
July 25, 2008

I wonder if it occurs to anyone that one of the reasons they want the military vaccinated is because the ones that dont get it might want to be so at the end of a weapon?

All of the other things they do will be needed. But Pezz and I discuss often in the sideline how long the system will take to fold up. We both put it between 3-7 days depending on areas (rural doing the best), and cities to the low side at 3. The distribution of the pandemic vax will be nervous and jerky at best and it will be like riding shotgun on a gold wagon. The power in the NE goes at 3 weeks. Thats it. Chaos reigns the second the power goes out. Besides, dont worry about gasoline… there wont be any because the Arabs wont tanker it for worthless US paper.

LL-You know I have all the empathy in the world for your position, but its based in the religion and not the rebuilding afterwards. I am assuming that its not going to be a 5% event which would be horrendous. I am assuming based on todays info about a 30% event. I am Episcopal and my priest now Bishop and I are diametrically at both ends of the spectrum. He has your position, I told him its unworkable.

They had to come up with something LL simply because we are not created equal in the eyes of the Constitution during a national emergency. Why? Because the only way to pass out this stuff unequally and depriving you of life, liberty and pursuit of happiness has to be done IAW the law. That law or regulation is promulgated in recent legislation via the NPFP. You have a problem with it and I guarantee to keep my damned conscience clear even though I qualify under the state pandemic plan, I wont take it. They can give mine to a kid or a single mom. In fact I’ll insist on it. My kids are grown, in the military and I plan to be around for the next 50 years. If I go, I go.

The establishment of the law states who will get it because we have to have infrastructure people during and post pandemic. Me, I think the damned politicians shouldnt get it. The federal ones are going to the bunker in VA and wait it out. When those bastards arise out of their holes it will be a brave new world. Money will be worthless or nearly so, food will become the method of exchange. Gasoline? How much do I get for my wife and daughter? The only thing that they will have at their disposal is the law and the military….. How do you think it works out? Can it get that bad?

I can assure you that it can if this goes beyond 8% and we would for sure get more than 8% in certain areas.

Wars? Maybe short localized ones unless it goes nuke. No one will have food, fuel or ammo to fight it ‘cept maybe the Ruskies. They never throw anything away. They have bombs that are unstable, arty shells, ammo that might work. If 6 out of 10 work each time, they’ll win by default.

The ONLY agreed upon way to maintain order is via the military. Every state will play their cards like Texas Hold ‘Em. Eventually they will all have to all in and the Federal Government will take over. Once we give up with that declaration, (you know the one Blanco didnt sign) the Feds are in charge. Thats an ominous thing and its never been done.

Personal preparedness and Lincoln. Lincoln said that if a government, whatever government and that included this one ever became so pervasive, onerous and ill responsive to the people, that you should take it out . That p. preparedness also includes being able to get your country back. If 5000 men in each state armed themselves and became militia then they could keep our government honest. Its sedition of course if it got to it but this has come up in more than one meeting that I went to. This was being discussed by the people that are going to be helping you out so dont think that we are not worried either. Of all of these things I fear the possibility of the emergence of a dictator here, or perhaps in the EU. One world government and a socialist/communist one at that.

Lets hope it doesnt get to that. I wont throw Obama under the bus for his positions on Iraq/Iran/Israel. But if that guy is in charge and this rolls in then he would make GWB look like a FEMA saint and I will for that alone. In fact I would insist that the bus back up to make sure that the business was taken care of. People want change? Let this come in and I can guarantee that they’ll get it.
#24 Douglas
July 25, 2008

I hope whoever decided the priority for the military does not suddenly decide that folks like Blackwater, the largest mercenary army in the world, also get apportioned ahead of our first responders.
Blackwater seems to be everywhere these days, a lot of good they did during Katrina’s aftermath. Seems a ton more money was spent for security (keep our monied-class safe) than was ever spent on helping feed, clothe and rebuild.
#25 Library Lady
July 25, 2008

Dear Revere and MRK,

I am upset because the Canadian triage criteria targets old people and the physically and mentally disabled, without informed consent. I am upset because some state planning includes nursing homes and prisons in their pool of facilities and staffs to commandeer in a pandemic, again, without informed consent. It is not right and it is not (I will use the word you love to hate) ETHICAL.

I know you are trying to help us all by giving us information we need, but the more I read about the pandemic planning the more wary I get. My big problem is WHAT DO I DO about the old people I am responsible for?

Will I be able to drive across the bridge into another state and get my Mom, and will the authorities let me cross back across the bridge and bring her home? Or will the National Guard stop all traffic on the bridges at some point? I have talked to Mom about bird flu and wanting to bring her here and she said, “No, I’ve had a good, long life. I’m going to stay home and die here.” I told her she may die, but she’s not dying alone in that house with no one to take care of her.

Revere, what are we going to do with our old people–that “greatest generation” that Tom Brokaw wrote about? Do you realize the resevoir of knowledge in those old brains? My Mom knows how to garden, can or freeze vegetables, sew, scavenge and re-use items, jerry-rig anything. She walks two miles a day and may be more fit than I am. Her brain is sharp. There are thousands of women just like her all over this country. She is a survivor. She is 79 years old. She doesn’t get vaccine OR or a ventilator?

MRK, Grandpa knows how to maintain machinery as he’s worked in factories all his life. He is unflappable in times of trouble and steady with his advice. Both are deeply religious. They both grew up in hard times, they know how to adapt. That generation has more survival skills than anything the baby boomers could ever cook up.

What are you THINKING when you decide these people are expendable?

Love,
Library Lady
#26 M. Randolph Kruger
July 25, 2008

LL-You need to be on my list for info that I send out each day. Listen, no one knows what to do because the enormity of what will happen in even a 5% situation. Remember the think locally, act globally thing? Most of it is just that….

Information about what will usher in a new phase of human evolution isnt being put out except here and a few other places. You took the time to get here, most just laugh it off and say I got my flu shot, I’ll be okay. You should see the look on their faces when I flip up the acetate overlay that I copy from the WHO Pac regions graphics into the sunlight. Then you have Revere who wont prepare because he is “old”. Uh, so was Moses….But we need guys like Grandpa and Revere around to impart the knowledge to the younger ones that they have accumulated across the years…. Fahrenheit 451 type of thing, and it might just get down to that. Imagine the shock on this planet if it came in at even 33% even though its at 83% now for the people who get it.

If you want me to tag you up on the info list, hit me at

memphisservices@bellsouth.net

Hang in there kid, this country has always rolled up its sleeves when the pooh pooh hit the rotary grinder… this will be no different. There will be some that dont make it but preparing will limit that down.
#27 bigdudeisme
July 25, 2008

First, let me say that I was consulted on the Vaccination Priority Plan and went back and forth with comments for about a year. I met with various doctors, government Agencies, Departments, and the military on this priority plan. I gave them my two cents and I know the military’s mission and their reason for getting the vaccination ahead of everyone else.

My hats off the “Chirp” for guessing correctly for the reason. We do indeed have to have a military that is ready to protect our nation, at any moment, in times of war and in times of peace. If there is a time of national emergency that includes an epidemic/pandemic, then the military must be a top priority for being vaccinated, and that is the bottom line.

Consider the fact that we vaccinate the troops for anthrax as that is currently a threat because of terrorism. If there were no threat, they would not receive this vaccination. Not all troops get this vaccination, just those that are likely to be exposed to the bacterial spores. This same logic will be used for an epidemic or pandemic. Vaccinate and have your troops healthy and ready at all times.

Additionally, the military has taken on numerous roles during a pandemic and many of those roles have been spelled out in posts above. CIKR is the most critical role. CI=Critical Infastruture, the military will protect our nations infastrure. KR=Key Resources, the military will protect our nations key resources. They are not going to be the police or the enforcers of quarantine. They will assist the NG with transportation, communication, logistics. One of their main tasks will be to distribute vaccine and anti-virals. They will make sure that the medicines flow around the nation.

Any dengration of their role is a slap in the face of these great men and women who are protecting our nation and intend only to continue their role of being ready to always defend our nation. Their plans to be their for our nation during a time of national crises of a pandemic are well thought out, creative, and will be critical to the survival of many of our citizens.

I have much respect and admiration for the military and the work that they have put into their pandemic planning efforts and the continued role they play in the protection of our nation.
#28 revere
July 25, 2008

bigdude: If asking why some group is higher on the list than another is “denigrating” the questioned group, then you are denigrating police, fire and health care workers, among others. Total bullshit. That is just wrapping yourself in the flag and the last refuge of . . . etc. You finish it. Being in the military is a job, for many a job of last resort. Glorifying them seems to come naturally for too many people. I respect them the way I respect others. If they earn respect by specific actions I respect them more. If they lose my respect by specific actions, I respect them less. Mostly they are just people like you and me, trying to get along in life and feed their families. Police and fire die in the line of duty, too, protecting you. But you resent paying taxes for them or for the military’s “socialized” health care system, the VA. If the aim is to protect transport, logistics, communication, etc., then let’s let the plan reflect that. But these folks are not the truck drivers. They are combat troops.
#29 john snow
July 25, 2008

Why don’t the military just show up in their biological warfare outfits and start taking names?
#30 Lea
July 25, 2008

Blackwater exists because there is no draft Douglas.

LibraryLady: Your mother has stated to you her desires, “No, I’ve had a good, long life. I’m going to stay home and die here.”

It’s difficult to understand yet you really should think about her words, respect her wishes and allow her to make her own decision. (not your emotional decision). There will be many undiscovered emotions cropping up before, during and after the pandemic. Each person will have to rationally work through them and accept the end result (whether we like it or not).
Completely understand your concerns Library Lady however … .
#31 M. Randolph Kruger
July 26, 2008

And if the bug comes in, the only law will be at the end of your weapon. Tennessee is about to pass a law that is specifically aimed at ensuring the sanctity of your premises. That is to say that if someone comes onto your property under the new law and they are packing in a threatening way, you no longer have to wait for them to get to the door. You can cap them anyplace inside the sidewalk, if you have them here. Elsewhere its inside your property lines and if its posted and they are operating a weapon in a threatening manner.

BigD-Revere is right. These are combat troops and each one has a mission in his unit. Support or actual combat, that would include the MP’s. Tolerance for screwing up in this stuff would be like putting yourself into a body bag and then shooting at them. All nice and neat, they would put one into you just as fast as they could bring it up and bear.

They are getting it first because we will pass thru the first line of defense which is the police/doctors/HCW’s like a breeze in Katrina. After that, its the military be it NG, ANG or Reservists. Fortunately for me the lowest ASVAB score that the AF will take is 45, you got people out there in the Army Guard that have 20′s. Aint the brightest bunch when you get to that level. They’ll solve conflicts with their weapons, simple as that.

You can stop this from happening though. Keep enough stuff on your shelves to weather it, and protect your own turf with your own legally obtained weapon. Finally, urge others to do so. They’ll look at you stupid but you have to try. I did and now I am off in Sept. to show some neighborhood watch groups some really ugly stuff on a projector. Dying chickens, a person or two with it…. Gets them everytime. Once they see how bad off both were they collect the various lists for stuff and head for the store. One block at a time BigD.

Screw the vaccine.. It aint gonna happen even if we threw a billion or two at it. It aint gonna happen from a production standpoint either so the bio zuits will be on anyway to prevent contamination of the troops. That will limit their ability to work down to about 30% and then only for four to six hours a day. C’mon… I have said it before, embrace the horror and get on out there and DO SOMETHING ABOUT IT.
#32 paiwan
July 26, 2008

D C Harper “In practice, people will learn how to protect themselves in a layered defense against the disease.

1) Avoidance and sanitation. Frequently use alcohol hand sanitizer when out in public, and encourage public places to offer complimentary sanitizer and common dust masks at entrances.

2) Use of nasal sprays containing zinc, silver or calcium that can inhibit virus reproduction in the URT. Consumption of other chemicals to prevent virus adhesion to cells.

3) Inhibition of virus Hemagglutinin, to prevent cell infiltration. Inhibition of virus Neuraminidase, to prevent viruses leaving infected cells.

4) Use of immunosuppressant therapies to reduce the cytokine storm effect. These are singularly toxic, so are used as a last resort.”

————————————————————

I recorded the above in my notebook and will share with friends. Thanks, Daniel.
#33 revere
July 26, 2008

palwan: (1) is unobjectionable. (2) is unproven and likely ineffective; (3) doesn’t make sense except for inhibition of virus neuraminidase which means using Tamiflu or Relenza; (4) has been shown to be harmful. I wouldn’t share these things as they are unreliable and/or not understandable in this form.
#34 paiwan
July 26, 2008

Thank you very much, Revere.

If I consider the case that LL presented; her mom will not come over with her and say for instance the vaccine were not available immediately. I wish that LL will educate her mom in advance about personal hygiene and when in true case, she could from time to time by telephone to monitor. That will make people like LL not so in despair. I know that she is concerned about bigger topic about ethical decision. But more prepared will have more arsenals.

My work in last 10 years have been dealing with water borne viruses, and the most effective way is from selective breeding. But it can not apply to human beings. Moreover, the air borne viruses perhaps are somehow different.

My personal experience for reasoning as follows:

1. My family background genetically has vulnerability in respiratory tract symptom, like asthma; my grandma, my son. When I was teaching in Taiwan around my thirty, every year I would contract with cough, and every time it took 3 months to recover, finally I gave up teaching job. Now I stay in tropical country and have pretty regular physical exercise due to farming job. I have about 20 years exempted from cough. My son in Taiwan now suffers with asthma sometimes.

2. My concern for H2H epidemic in cold area is much more than B2H.

3. My question here is: apart from vaccine and anti-viral medicines, is/are there practical protocols in prevention or enhance personal immunity. For instance, regular walking helps me a lot. I think that LL’s mother perhaps also has good physical exercise. (A little side tract, even I have no problem in preventing cough, but I can not exempt from back pain, my doctor now recommends to inject some oil to my left shoulder’s joint.:-( )

4. H2H prevention, for aged people perhaps are staying in hot/warm place is the best. So, the heating system is very critical.
#35 Library Lady
July 26, 2008

Dear Lea,
I really do listen to Mom, but that doesn’t mean I can sit by and let her die and rot in her house. I know you wouldn’t do it either.

I used Mom and Grandpa as examples of why the elderly should be seen as a value to the rebuilding of our society.

Can you see a society that has no one over the age of 65 in it? Do you understand the knowledge that would be lost? It would be akin to burning every book in a library that is over 65 years old.

If the Canadian triage model prevails, this country is in for a very dark time–whether the catalyst is bird flu, terrorist attack, or natural disaster. I hope all intellectually curious minds here will study the New York model for the ethical considerations it espouses.

It doesn’t hurt to consider a different way of thinking about this.

Love,
Library Lady
#36 Lea
July 26, 2008

We differ LibraryLady.
Over-the-top emotional decisions will never get you through the coming pandemic.
Detachment is key.
#37 Library Lady
July 28, 2008

Dear Lea,
I try neither to be over-the-top, nor emotional, but maybe sometimes I fail. I am an information-seeker. I am trying to discern what the people in the public health field will do about the Canadian triage guidelines for a pandemic, how our governments at the federal and state levels will utilize them, or not. This concern also applies to Revere’s current post.

I see signs that the states are all drawing up their own plans. I like New York’s. I hate Utah’s. Have you seen either, and what do you think of them?

I think detachment is good to a point. I guess a human has to detach to be able to give a little baby an
immunization, or during surgery when you’re going to open someone up, or when you have to pull a dead body out of a fire scene.

But, please don’t confuse a lack of empathy with detachment.

I have had the experience of working under a supervisor who when she asked why on earth I wanted to do children’s programming for disabled children, she told me that if her son had been born handicapped she’d as soon as “bash his head against the wall” in the hospital. I kept working for her. Then after my cancer surgery and several months of healing and therapy and finally got back to work, she told me, “Maybe you should consult a cosmetologist to get some makeup to hide that scar” and suggested I wear opague hosiery to cover the scar on my leg (where the doctors borrowed tissue). I found a reason to take a transfer. So I am a little sensitive to people who look down on others with disabilities, young or old.

Or make them dispensable, as the Canadian triage does.

I state that I believe “Physical disability or infirmity or age is not the measure of the value of a human being, no matter what.”
If you agree with that statement during normal conditions, but differ for pandemic planning, then you are saying that “During a pandemic, physical disability, infirmity, and age can be used as a measure of the value of that human being for allocation of scarce resources.” That is called “situational ethics”.
I don’t want to put words in your mouth. Just say what you mean, and I can then decide if you, as a health professional, will recognize my need for transparency in decision making, will utilize an ethics-based plan, will give citizens an opportunity for informed consent during a pandemic. Or not.

Love,
Library Lady
#38 T Reesor, RRT
July 28, 2008

In Ontario, Canada, one routine practice for the protection of first responders was recently revised to include the use of filtered oxygen masks on patients suspected of carrying an infectious respiratory based illness. Because conventional oxygen masks are not designed to filter exhaled particles, patients are left to spread their illness during the initial stages of care. Most services place surgical masks over oxygen masks, however this has never been tested for efficacy and therefore can be a potentially dangerous practice.

These new masks (there are several makes and brands available) allow the delivery of oxygen to those who need it while filtering exhaled, potentially contagious particles. The first brands evolved during the SARS outbreak of 2003 and several more became available in the following years. It is expected that these masks will become standard practice in the future, especially in the pre-diagnosis stages of care.
#39 Walrus
August 22, 2008

It’s perfectly obvious why the military are getting vaccinated first – “Continuity of Government” is the first and foremost priority of ANY Government anywhere in the world, or, to put it another way, it’s about power.

Continuity of Government means preservation of public order, the rule of law, and of course leaders, the legislature and public servants to lead, decide and implement things during a pandemic.

Ultimately this power derives from the military, because they are the ultimate implement of power if everything else fails – the last link in the chain. This is the same all over the world. I learned about it myself in the Army, over here (Australia) it is called “Aid to the Civil Power” and the state governments can request the Army to act on its behalf, killing people if necessary (for example in suppressing a riot or looting).