Effect Measure

Swine flu: prepping for tough times

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.

Comments

  1. #1 Monotreme
    July 19, 2009

    revere, some of your suggestions on what should be done now are perfectly reasonable, and some would argue, pretty obvious. The fact that you need to state them several months into a pandemic is troubling. Shouldn’t the CDC had planned for this before the pandemic? Shouldn’t a well-though out response to the ongoing pandemic have already been initiated? Shouldn’t the public be warned about the disruptions to come, right now?

    Secretary Sebelius was apparently on one on the Sunday morning chat shows today. I didn’t watch it, but those who did said she spent about 1 minute on the pandemic. Shouldn’t she have used her time to urge the measures you are suggesting?

    As regards self-sufficiency, I will disagree with you on this again as I have over the years. To recap, the more people who are prepared to stay home, the fewer infections we will have and the fewer deaths. Obviously, essential workers will still need to perform their functions. However, the fewer people they make contact with, the less likely they will become ill. Also, PPE, Tamiflu and medical care can be more readily be provided to this group if the is demand from the general public is lower.

    As you said, this is not rocket science.

  2. #2 anonymous
    July 19, 2009

    A great post. Thankyou. ‘In a clear eyed, calm and systematic way.’

  3. #3 Cornelius Robertson
    July 19, 2009

    Obviously you spout the mantra coming from those who are first in line to get the vax.

    Individuals build strong communities not visa versa.

    I had hopes your prep message whould had been stronger for the only historically proven method of flu avoidance SIP.

  4. #4 D. C. Sessions
    July 19, 2009

    School closures also free up school nurses (what few remain) to work as temporary staff elsewhere. It’s not many (and fewer lately) but looking around for nurses, EMTs, etc. outside of the usual channels for those who can pitch in is important.

  5. #5 raven
    July 19, 2009

    Revere, what about wearing N95 masks for venturing out in public?

    I’ve read that in the 1918 flu epidemic, people and cities where wearing masks was common had lower transmission rates. They used layers of guaze in those days IIRC.

    Also read the exact opposite. That wearing masks is useless at the community level.

    They are selling a lot of N95 masks these days to the paranoid.

    Given the voluminous and contradictory information available, I reallly don’t know what to conclude.

  6. #6 revere
    July 19, 2009

    raven: The mask issue is very cloudy. Places where masked are common are also places that use a variety of mitigation techniques. Arguably they don’t do any harm and might do good by preventing people from touching their nose and mouth and being a visible reminder to use good hygiene and prevent the wearer from infecting others. I’m more or less agnostic on the subject because I don’t think there’s much datal. I wouldn’t discourage it but don’t think it’s a major tactic, either. Remember, tho, to take advantage of what an N95 has over a ceap-o curgical mask ithas to be properly fitted. Not likely for most people.

  7. #7 mominohio
    July 19, 2009

    Any suggestions on questions we should be asking our pediatricians and GPs now? I’m thinking not so much about what recommendations they might have for us, but how to tell if they are preparing (because if they’re not, we might want to look around now for another provider).

  8. #8 revere
    July 19, 2009

    mominohio: Good question. I’ll let others weigh in. Maybe ask what plans for the practice they have made – if any — and what the hospital is doing — if anything. The questions might stimulate them to do something if they aren’t thinking about it already.

  9. #9 SoCal
    July 19, 2009

    Revere: You rightly emphasize the importance of community resilience, and you note that the faith of a community in the competence of its leadership is critical to that resilience. That competence will be on display as local leaders decide if, when, and how to implement a wide range of socially disruptive and economically costly community mitigation strategies, including school closures. Given the variability in morbidity and mortality that can occur from city to city in a pandemic, these implementation decisions must be made locally. But there should be some uniform set of guidelines or standards to help local officials decide these issues, and it’s up to CDC to set those standards. Without those standards, we may well see one district shut its schools, and an adjacent district keep them open. In large metropolitan areas, e.g., Washington, DC, people may well live in one county, go to school in a second, and work in a third. Lack of uniformity in these costly and disruptive decisions will not breed “trust and confidence in authorities,” and will not strengthen resilience.

  10. #10 Paul
    July 19, 2009

    I don’t at all disagree in theory, with your proposals. However, just as you’re now more clearly focusing your assessment of what we may be facing, based upon what we’re presently seeing, I have serious doubts that your suggestions (even if widely circulated and agreed upon) would be implemented, also based on what we’re already seeing.

    The basic problem, as always, is that only *certain* segments of the healthcare and (especially) merchant members of our society are implicitly being urged to sacrifice (via a gamble) their money for the possible development of a need that remains uncertain, in its gravity and scope, until the time when the realized certainty renders those sacrifices appropriate, but too late to make.

    We’ve already seen instances (e.g., in Canada) where hospitals have failed to acquire sufficient supplies of PPE, and healthcare workers protesting being put in the terrible position of either professional dereliction, or exposing themselves to their own and their families’ contagion. Thus, an example of a healthcare institution being loathe to put out funds that might prove totally (or to some degree) unnecessary (and some management decision maker being culpable for needlessly “over-reacting” and “wasting” money that could have otherwise been useful in a tight budgetary period). Stockpiling PPEs is hardly the greatest part of this gamble – throw in some extra $10,000 ventilators (that would otherwise not have been needed, nor ever will be if the pandemic proves not so severe), and you’re talking real money. Which manager should be heroic (or foolish) enough, depending on an outcome that leaves him facing his board and his own termination?

    You correctly cited the *universal* just-in-time process of inventory control extant today, but don’t sufficiently consider the full vulnerability of that problem. Actually, 1918 America was in a *better* position in terms of availability of supplies, since there was much more personal and community self-sufficiency (sans the computer technology and just-in-time management methods that have evolved since then). And why did they evolve? Because they free up capital for more efficient and profitable use. So now you’re asking certain segments of our economy (companies) to take the same gamble you’re expecting of the healthcare industry discussed above. Going back to a less efficient, less profitable model to stockpile certain goods that *might* be necessary, *should* such items be needed as a result of their uncertain future need, could leave some manager (or owner) “holding the bag” if those stockpiled goods aren’t acutely needed, placing himself and company at a disadvantage with his competitors, and other sectors of the economy whose products are not relevant to the pandemic. He’s cost that company real money (money tied up in unused inventory is *not* capital that would otherwise be available for growth or future just-in-time goods that must be purchased for sale.

    As I lamented in an earlier post here, if I can’t even get my kids to stockpile two weeks of necessities (that in any event would not represent a loss, since they’d eventually be consumed), I wish us all luck convincing individuals to gamble their jobs and/or companies, with a real and significant loss.

    People will make sacrifices when facing a clear and present danger; they will not do so for a possible future danger that is neither clear nor present. Even our volunteer soldiers get paid, whether or not they’re engaged in a war; i.e., (aside from their patriotism) their potential future sacrifice is reimbursed ahead of time.

  11. #11 revere
    July 19, 2009

    SoCal: I feel fairly sure CDC will set up guidelines, but not being a regulatory agency they will remain guidelines. They will also be very general and need to be adapted to local situations. Since politicians are not known for wanting to take responsibility for hard decisions, CDC will probably be invoked as the reason things are being done in some particular way. Could be worse. But could be better, too. In some places we can hope it will be.

  12. #12 kathy
    July 19, 2009

    I teach a pandemic influenza CERT class and in virtually every session there is someone who shares a personal story about someone in their family dying or being impacted by the 1918 flu. In my last class a 60 year old shared that he was in the army training camp in 1957 and that his unit was hit very hard by the flu and that he personally took months to recover. This seems to go along with pockets of flu effects which can vary place to place (CDC’s Dr Suchat this week called this a “popcorn spread” of the flu). I am trying to teach more classes this summer and to keep the discussions going out to neighborhood groups (that is how CERT works). I am the one in our health dept pushing “prepare for the worst”, even though I know that is scary to people (plus, while federal pandemic resources for local health depts are “on their way”, right now we have very few resources to step up preparedness and community education.

    thanks for your continuing efforts here! – from the local PH dept trenches

  13. #13 BostonERdoc
    July 19, 2009

    Great synopsis of what we need to focus the lens on for the fall. As a clinician, I am concerned about the Just in time inventory system hospitals in the US operate under–it has the potential (albeit rare) chance of causing health care workers not to show up for work. My hospital routinely runs out of supplies and I am used to doing without (yes even in a tertiary care hospital) but I aint showing up when the sh-t hits the fan unless they have the supplies period. This sentiment is extensively expressed by most health care professionals who actually treat patients for a living. Secondly, Jack squat has been done regarding ED surge capacity by the govt -frankly because they know they cant fix it. Finally, as I say time in and time out, the govt better get busy with setting up degradation of care protocols because they may need to be used in the late fall and early winter this year.

  14. #14 maryinhawaii
    July 19, 2009

    Wouldn’t it be prudent for all physicians to make some kind of plan for the continued maintenance and/or emergency care of their patients – those who suffer from any kind of chronic illness or condition – during periods of the pandemic when services are likely to be overwhelmed? Each such patient has a primary care physician, so these are not great unknowns but a finite set of managable numbers for each doctor to make a proactive plan for.

    They should inform their patients well in advance of the next wave regarding who will be on call to care for them if the primary physician is unable. They should also give their patients advice, preferably written, on how to care for any problems in their own condition or maintenance should Doctor’s care become completely unavailable for a time, as much as such home care is possible, and anything else they need to know about their condition, especially in terms of the flu if they are among those in the high risk group.

    Another thing that would help cut down the load on hospitals and emergency rooms and clinics would be to set up live help lines manned by retired doctors, PAs or experienced RNs, not just for flu patients’ calls but for all kinds of medical conditions and emergencies. This should run 24/7, where a person can call in, report symptoms and get advice as to whether this is something that can be handled with home treatment or whether it is a true emergency requiring immediate medical attention. This telephone triage center could be computerized and organized so it had lines in to all emergency rooms and clinics in the area, so that the patients that need immediate care could be directed to the one nearest them that is the least overcrowded. Those that don’t need immediate care could be told what to do to help their situation and how to monitor it for any changes that indicate the problem has worsened to the point of requiring medical intervention.

    Actually, I wish all big cities had the latter right now: it would probably cut down on a lot of unnecessary ER room visits.

  15. #15 BostonERdoc
    July 20, 2009

    Mary,

    It cant be the docs responsibility to make sure multiple medical problem pts are covered. In this day and age, you have 5 to 10 minutes top to see and address problems during ofice visits. I dont get reimbursed for any telephone or email time so why make docs work that time for free? Gone are the I am doing it because it is my moral duty. The public has spoken loud and clear they dont want docs paid for non patient face time. I dont blame them because it would add an extra $100 or 200 dollars to their health plan costs per yr. Retired docs manning the lines? You are kidding right? You would have to have total tort reform and get lawyers out of health care then the system would run cheaper and smoother. Obama announced during his meeting with the AMA last month that he did not believe law suits should not be limited since it would hurt patients.

  16. #16 M. Randolph Kruger
    July 20, 2009

    Plan as a community was a good idea, but there was nothing behind the NPFP. Frist tried to get some hard money into position when he was Majority Leader but it wasnt breathing into the Congressional nostrils at the time. Now Obama turns 1.5 billion up in about a day…Great.

    I take everything you said Revere and its the difference between minimization and maximization. IMO it needs to maxed out simply because of the people that will do nothing because its always been government that bailed them out. For everything. Yes that does mean poor and generally speaking ethnic. This time around though its the middle class AND the poor. The reason for this is that financially they are unable to. Like it or not, even the rich are getting this one. Its cutting across all social, ethnic and geographic boundaries. It is truly an equal opportunity bug.

    So, whats the answer? If you arent sitting on food and water and meds that you need by 15 September then its likely going to be a tad late. By then the temps will drop, we will very likely see more cases and in high numbers. But,forgive me but our own CDC and the vaunted WHO have now stopped counting at all.

    So someone tell me when the decisions are going to be made about using non essential personnel, and when to put school out, and when to put it back in will be made? Voodoo? Community planning? Smoke signals or the bones in the benji box?

    Seems to me that there has been a concerted effort to screw the pooch here and not follow protocols that were established under Democrat regimes. The facts are that if this vax doesnt work or it does minimally then we could see the end of the US as a world power. We can afford to lose old people, not the young ones. Sorry, but all Medicare has done is prolong the lives of people that are not productive any longer. That has done a job on the finances of the country. Nice idea, but bad follow through thinking.

    Fidelity and other groups have said that there will be a 24% hit even if we dont have high CFR’s. Only worse if it kills young people. Facts are facts and rather than warning everyone, its like a Mr. Rogers in the Neighborhood commerical. Teletubbies.

    I agree Revere that we might not see a mutation that starts whacking them in high numbers, but what do we do if it does? We wont know it until there is a huge body count after three or four days and then the superbug mutation of H1N1 2009 is out, running and will kill millions. WTF is up with this count stuff? Not counting at least as a sampling ensures that if it does break, it will be hard, across the country in five days and then spread like wildfire, truly unstoppable. This is incontrovertible fact. So why isnt the national pandemic plan being used.

    My neighbors have all but one approached me about this and I think she got the word from someone else. The protocols havent been followed for this, they arent going to and they are going to stick with its “mild” until it hits the fan and then its too late. The vax could be worthless and no one acknowledges it except maybe for you.

    H5N1 lies in wait over in Asia and the Far East. If H1N1 reassorts/recombines with the part that is still killing at 63% then we could see most of the planet go. Its already triassorted in under 5 months and its now into the pigs in Buenos Aires area. Confirmed and declared as a state of emergency in that respect. If it jumps out again I dont think its going to be pretty…

    But none of this fits the administration agenda. Goes against Katie and Brians infomercial.

    Protect those babies Revere, they may need grandpa and grannie faster than any of us think.

  17. #17 Chirp
    July 20, 2009

    Revere,

    I appreciate your analysis of the panflu prep conundrum. But I think your view of it is too focused on the perspective of healthcare and public health infrastructure (quite naturally). Your observations are in terms of the bug, its mutation potential, its clinical presentations, etc. These all come under what I’d term the “direct” impacts – the virus and the sickness/death it causes.

    For example, your comment: “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.”

    And: “We think the most obvious pressure points will be in hospital emergency rooms and intensive care units.”

    What this post doesn’t address are the “indirect” impacts – which may prove as harmful (or worse) than the direct impacts of the disease itself. Here, the plausible scenarios are innumerable. Our world isn’t 1918 or even 1957 or 1968.

    Add to that the general failure in (read that, “general absence of”) pandemic risk communications and the related issues of the “human dynamic” – how people perceive events, potentialities, how they perceive it may impact them, and their response (in attitude and action).

    As we get deeper into this pandemic, it will reach more trigger points, more reality checks, more “Hey, this is real” moments. For example, no U.S. city has been basically shut down like Mexico City was for a few days in April. I haven’t seen one person, much less masses, wearing facemasks or respirators. No people lined up for facemasks or food & diapers. There’s been no need for any of that in the U.S. thus far. But what happens if we reach that point in coming weeks/months? How will people respond?

    These factors go beyond what the virus is doing or how many PPE’s the hospital has.

    If the expected reacceleration of H1N1 occurs this Fall-Winter (1) systems will begin to be stressed (we’ll see how well organizations – governments, hospitals, businesses, NGOs, etc. – have planned & prepped) and (2) the risk will become more real and personal (dealing with sickness and/or facing the prospect of your kids getting vaccinated en masse at school [I'm really curious to see how people react to that]).

    For the most part, people haven’t been educated, therefore they’re not prepared mentally or physically. Community leaders have not been leading – they have not built the trust they need relative to this very out-of-the-ordinary circumstance.

    What if a large number of businesses – especially small businesses, who employ most people but who probably have no pandemic plan – suffer business losses due to the pandemic and have to lay off people – on top of the already 10% unemployed in the U.S. already?? As many as 2,000 restaurants in Mexico City closed after that region’s H1N1 April outbreak. I fear that travel & tourism – a mega economic engine – will suffer big time. Same for some retailing segments and other businesses fueled by discretionary spending.

    To reiterate, these “indirect” impacts go beyond what the virus and the hospitals are doing.

    If anyone should be aware of the risk and fully prepared for a surge in cases it’s hospitals (ERs and ICUs). They know about and should be planning for the whole spectrum of triage, segregating infectious cases, reallocating personnel, converting acute care beds to critical care, stockpiling pertinent supplies, etc. “All of this can be thought through in the time between now and September.” All of this should have been completely planned for and tabletop exercised two years ago! I sure hope that hospitals aren’t just now getting into planning and prepping for this! Wherever that’s the case, it’s a gross dereliction, IMHO.

    @Paul: #1 – It could be argued that managers will lose their jobs if the pandemic hits hard and they HAVEN’T stockpiled/boosted inventories to keep their businesses operating. #2 – Just as your kids or anyone should realize that most of their stockpiles will, in fact, be used and not wasted (“first in, first out” rotation), business managers should realize the same thing. At this point in the game, I’d think inventory build-up is an excellent use of capital. I think it may well put a company at a competitive advantage. Or, at least, keep it in business.

    Chirp

  18. #18 K
    July 20, 2009

    Revere, I am glad you addressed the grid. However when the grid has gone down regionally it has not gone down in other areas of the country. Workers are able to be brought in from outside the area, which is of course more difficult the larger the area. When the grid goes down, generators are used for backup. But when the grid goes down no gasoline can be pumped from service stations. Thus repair vehicles need to eventually go outside the area that is down to get fuel and tankers will need to bring diesel in from outside the area to keep generators running. When the North East grid went down all the rest of the country was up. If more than one contiguous section goes down it becomes much harder to keep the grid working.

    Until we cut an artery we pay little attention to our blood supply, always there, little cuts heal themselves etc. But cut a major blood vessel and you have a major emergency that you have very little time to deal with. Suddenly, what seems highly unlikely (death by bleeding) becomes the total focus of our awareness and all else stops mattering.

    Electricity is the lifeblood of our industrial civilization. To just trust that it will always be there for us is like trusting that our blood can never all drain out because it never has before. When arguing about global warming I have often told others that even if AGW proponents are wrong we should do something because the possible scenarios if we don’t are so major and catastrophic. When posed with such a threat we have to discount any percent chance it won’t happen and address the possibility it will because the consequences are so major.

    If all the grids in the US were down for 5 days I believe they would never come alive with our lifeblood again as we would have no way to get the gasoline and diesel to run repair trucks and the population would be rioting in the streets for food and water. The liklihood that all would go down from flu is smaller than other reasons they might all go down but the consequences are so major that it should not be ignore.

    How something so integral for our way of life became deregulated is a burning question – what were they thinking. We know what Enron did with deregulation. What most don’t know is that after deregulation electricity became a commodity to sell to gain money for stockholders and thus more and more and more cost cutting measures have been put in effect, such as not maintaining equipment, not upgrading, and cutting staff to the bone.

    http://www.theoildrum.com/node/3934
    http://www.theoildrum.com/node/4918

    I was pleased to see on Crof’s blog that at least Scotland is making some plans for their grid
    “Scottish Power said last night that government officials had been “receptive” to plans to suspend the current working time rules which state that no power workers should work more than 48 hours a week.” Well at least plans to allow them to work any well workers longer hours.

    http://crofsblogs.typepad.com/h5n1/2009/07/scotland-planning-for-the-worst.html

  19. #19 Paul
    July 20, 2009

    Chirp,

    I agree with every one of your counter-points. However, realize you are citing the “Black Jack,” “Royal Flush” outcome of the gamble. If that which most on this blog fear develops as predicted, we have managers getting mucho kudos (which will be shared by all those who followed their lead). But that benefit for each of these brave gamblers is outweighed by the risk of being terminated for being false Cassandra’s who far over-reacted. All the “practical” bean counters will want their heads.

    Your point about commercial stockpiled (i.e. poorly planned and overloaded) inventories is only correct if the pandemic is bad, and they’ve ended up “cornering the market” with their unusual stockpiles. But I don’t agree with your first-in, first-out model for them. The just-in-time inventory model (which has its own inherent minor risks of not immediately having what the customer wants exactly when he wants it), has nevertheless, universally replaced the former model of inventory control for very sound economic reasons (in normal times – normal meaning probable and expected – that on which successful business models are based).

    If you’re familiar with any kind of bureaucracy, it’s a tacit but early-learned rule that if you don’t stick up your head with novel ideas (in this case, novel with a very possible downside), you loose nothing. Those who want to make improvements in business-as-usual processes, run much greater risks of incurring the resentment of upper management for proposing a gamble that, by its mere mention, passes the responsibility (and risk) onto them for either accepting or rejecting the novel model-breaker, and that of co-workers who get co-opted into messing up their days with new requirements and late nights to implement this “jerk’s” crazy idea, that may or may not improve business, the bottom line for which, even if improved, they’ll get no individual credit or bonuses.

    Same for politicians spending (“wasting”)public funds.

    Thus, the saying, “success has many fathers, but failure is an orphan.” It’s just human nature: it’s easier to pass the buck (and the blame), than to gamble on the future, whose downside has a prominent scapegoat. Think about it; it’s not really irrational. You’re asking decision makers to gamble their and their family’s security (keeping their jobs or positions intact) on something that may not happen, and if it does (and no individual stuck up their heads and took the risk of wasting resources for an “improbable” event – in most laymen’s minds), there was “nobody here, but us chickens” (double entendre intended).

  20. #20 Kathy
    July 20, 2009

    Great post. Being a type 1 diabetic I stockpile my insulin and other diabetes supplies already, and I plan to keep doing so throughout the fall. I’m also getting extra OTC meds for flu in general as well as soups, protein shakes, etc. in case I do get sick. I always get my flu shot, I’ve gotten the pneumonia shot and I’m healthy except for the broken pancreas part. Being diabetic you kind of have to always be prepared anyway, so this level of prep is fairly common for me even in regular flu season.

    At work I helped set up remote access for our staff of 10 so we could all work from home if necessary, eliminating public transportation and its contamination threat for most of us. We chronic illness patients do think about it and do our best to be ready for the worst on a regular basis; I just hope everyone else realizes they should take this flu as seriously as we do and start thinking ahead. What I worry about is being able to survive an ER visit given all the other stuff floating around a hospital, being able to get Tamiflu or not getting in to see my doctor for diabetes-related reasons. Believe me, I’m doing my best *not* to be one of the people in ICU burdening your system! ;-)

  21. #21 Chirp
    July 20, 2009

    Paul,

    (1) I understand that Just-In-Time inventory control is more cost-effective (and flexible) than First-In, First-Out. The benefits are why hospitals have followed manufacturers in adopting the approach. (Ugh.) My point was that for the unusual challenges of a pandemic, having a larger inventory cushion is prudent … and the FIFO movement of inventory will minimize/eliminate waste. I wasn’t saying FIFO is better than JIT, but that it’s needed for the duration of a pandemic.

    I’ve used the following supply chain-like explanation for household stockpiling: it’s like moving some of the inventory of an item from your grocer’s shelf to your pantry shelf. As long as you eat the food within its shelf-life, all you’ve done is pre-loaded several weeks’ amount of inventory to your pantry – with no overall added cost or waste. The same principle holds true for manufacturers and hospitals. Obviously, this won’t work as well (or at all) for perishables. But, I can get by on canned peaches instead of fresh peaches, I can replace fresh loaves of bread with crackers or other forms of grains, etc. Similarly, businesses can do whatever they can to stockpile “non-perishables” and then second-source or otherwise make contingency plans to acquire any must-have “perishables.”

    (2) Businesses that fail to adequately plan for continuity of operations (including inventory stockpiling, where appropriate) are setting themselves up to be weak links in supply chains. Their decisions may have major impacts downstream (and maybe upstream). Which could result in soured customer relationships, loss of investor confidence, and even litigation, to mention some of the attendant risks.

    (3) We all understand the human nature behind the business attitude you describe. “Protect my spot in the org chart by keeping out of sight. Don’t rock the boat. Don’t take risks; Don’t get tagged with responsibility for risky decisions.”

    Aside from the sad selfishness of such an approach, I’d argue that these people have no appreciation for the “low probability, high impact” nature of the pandemic threat. A pandemic is unlikely. But if it happens, it’s awful.

    The approach of “lay low and don’t make any changes” loses its appeal as you consider higher and higher potential impacts. At some level of impact, the price for being unprepared – the loss – becomes unacceptably high. At that point, we’re not only justified but prudent to take protective steps … even if it turns out the event DOES NOT occur. The potential loss is just too great to leave unaddressed.

    There’s nothing radical about protecting yourself from a loss which never occurs, of course. We routinely buy fire insurance on our houses – then never experience a fire. Was there a real but low-probability risk? Yes. Was it prudent to have the insurance? Yes. Are we thankful a fire never occurred? Yes.

    For businesses, does a Board of Directors want you to have fire insurance? Yes. Do they fire management if the business doesn’t burn down?

    I’m hoping the world’s Boards of Directors have a similar attitude toward reasonable pandemic preparation – including the unusual allocation of capital to extra inventory.

    Related thought/concern: We want healthcare workers to remain on the front lines of the pandemic battle, but we as businesses aren’t willing to stick our necks out for the public good (and perhaps for the future of our businesses)? Doesn’t make sense to me. That failure to act “for the common good” is not what we need when facing a potentially large crisis like this.

    Further, businesses and governments can’t wait until the last minute to “see how bad it really is” before acting. It requires acting as far in advance as practical, for obvious reasons. It requires vision and leadership.

    Thanks for your thoughts, Paul. I hope mine are useful.

    Chirp

  22. #22 Columbkille, MM
    July 20, 2009

    Kudos on the post, Revere; this is what I log in for!

    Many of the concerns voiced in the comments are ones I resonate to. ‘My’ hospital couldn’t handle a big upsurge altho’ we do have a disaster plan, and with the economy what it is there are pressures already on the budget. So, like Kathy, I worry about those who will need emergent care for chronic or sudden illness. Those who prep, can stay home/plan to stay home and can take care of their families and neighbors (within reason) in the case of illness will be doing more than being OK themselves. They’ll be making seats on the bus for people who are sicker and lightening the load for health care folks. Big question: are Americans prepared to do this?

    One of my observations is that it is a long time since Americans have had to deal with a few big things, like war on our soil or a deadly pandemic. Wrapping your mind around this takes doing, and even then, thinking isn’t the same as living through it. Unlike the Poles for example, we haven’t the racial memory of similar times in the past.

    Question for those who might know: Is Sambucol equivalent to Tamiflu?

  23. #23 Paul
    July 20, 2009

    Chirp, You’re preaching to the choir. I’m in your choir. However, the “shoulds” you advocate (concerning business modeling, and real life business decisions and repercussions therefrom) are what they are. The evidence is already on my side of the discussion. We are seeing just how unprepared businesses are (especially those businesses [healthcare] that should be in the business of knowledgably anticipating your concerns). I am not advocating, but rather explaining (only my opinion) the very processes of inadequate prep. we are witnessing.

    Obviously, most in the business and political world are not as exercised as are your about preparing. They don’t want to know about “low probability – high impact” situations, let alone face them. Their entire personal and professional perspective is concerned only with the next quarter’s earnings, or the next election. When the stuff hits the fan, they’ve either already moved on to another company, been elevated to a higher position within the same company (where what once may have been their responsibility, was very transitory and now history) or, gone from elective office.

    Even where FIFO stocking makes perfect sense, and represents *no* potential financial or stature loss (i.e., preparation by individual families), most are failing to make preparations. Why?

    I think it’s because we’ve become a softer people, unlike those who faced the 1918 pandemic and were raised in a different era or those who fought in WWII. We don’t to know or want to hear about death; it’s become so isolated – quarantined from out daily lives (ironically much due to medicine’s/science’s advances). And we certainly don’t want to think about apocalyptic uglies that may bring on mass death – it’s so “foreign” to our society.

    We’re certainly, and anxiously, in agreement about what should be; I’m just trying to explain what we’re seeing.

  24. #24 revere
    July 20, 2009

    Paul: I’m not suggesting the responsibility is one for the private sector. I think it is a job for regional planners to identify inventories and warehouses are for a restricted set of critical staples and insuring a distribution system should it be needed.

  25. #25 maryinhawaii
    July 20, 2009

    Chirp: You say “For the most part, people haven’t been educated, therefore they’re not prepared mentally or physically.” This to me is the key point, as well as the prime indicator of just how screwed we are likely to be. It was bad enough – when the potential pandemic (with H5N1) was still a future concern – that the tptb backed off from releasing to THE BROAD PUBLIC any real information, education or advice on what could occur and how to prepare. But here we are in the middle of wave one and looking into the maw of wave 2, and 99.9% of Joe Public in the US think it is either all over or no concern anyway. A joke. Not only are tptb not letting the public know what the second wave could be like so they know what to expect and how to prepare, they are withholding information, including , as MRK points out, the counting or publishing of flu stats. How the heck are we going to know if the pandemic bug has changed in virulence and/or infectivity if we have no baseline for comparison and no ongoing counts. Incredible how we are being manipulated!!!

    MRK…I agree. Sometimes (imo)you are a bit over the top, but the point you make, which is if you don’t prepare for the worst and it comes kyag, is true. What’s your life worth, the life of your family? The fact that most people can’t afford to stock up, as someone else has pointed out, is no excuse for not telling them they should. And I’ve already made suggestions over the past 3 years of how pandemic supply cards could be given to the poor and working poor (much like food stamp cards) so that they COULD afford to put away at least a month’s basics. And you are so right, that what Americans have come to expect is that no matter what happens the government will somehow to come to the rescue. So couple that mindset with the campaign of disinformation and restricted information we are getting, and no one is going to prepare.

    Now it may seem very humane and noble for some to believe that it is actually possible for us to get together in big loving communities that care for each other, that the fish and loaves deal happens, everyone shares, there is no violence, no one steals. Right! I lived in LA during the Watts riots; we all watched on tv as masses of people night after night happily rampaged through stores in their neighborhoods stealing shopping carts full of goods, from TV’s to sofas to $100 running shoes. And they weren’t even mad, scared or hungry: they were just opportunistic. And What about all the looting after Katrina? What happened to community caring then?

    I’m sorry, but in this brave new world (make that “cowardly”) people do not take care of each other. Maybe in smaller communities, but in the megacities fear and hate rule the day, and people expect food, housing, medical care and other support from the government anytime they are unable or unwilling to supply it for themselves.

    Paul, what you said about the “pass the buck” mentality is also a key issue that cannot be ignored: Local decisions from local officials for various mitigations such as school closures aren’t going to happen because they don’t want to face the political repercussions if they call heads and it comes up tails.

    No one likes too much governing from the federal level, but in a case like this, where there is the potential – worst case – for a whole nation to be in a Katrina situation, that’s when federal government should step in. And the protocols for that need to be set up now, not after it happens.

    Everyone seems to be hoping for the best and not preparing for much of anything, just exercising thought machines, twiddling figures and contemplating business as usual, as much as possible. I sure those with this mindset are right, cuz there’s gonna be hell to pay if they aren’t

  26. #26 olywa
    July 20, 2009

    Any insights/planning yet for pts with autoimmune diseases or immunosuppressed? Thinking of RA, HIV/AIDS and such, for example would those w/ RA be more or less vulnerable given their unique immune systems, would DMARD/biologic tx impact vulnerability either way? Would the manufacture/delivery of relevant meds such as HIV or RA drugs be impacted?

    Any thought that you know of in planning for impacts on ongoing clinical trials (unrelated to flu)? I know, too many questions but you do get me thinking, which is one of your goals I believe…

  27. #27 M. Randolph Kruger
    July 21, 2009

    Olywa-The direct words from Sebillius’s mouth and Flu.gov as of Friday…

    “Transportation disruptions could be expected.”

    People with diseases that are underlying and dangerous already will need to notify and tag up with their doctors and med providers. If you need insulin I would get one of those car charged tote bag coolers to keep things cold. Not every battery in the US would be out of commission and all you need is the med/insulin to get you through that.

    Dialysis? Check with your providers because it aint happening without electricity. Make sure they have backup power. I have no idea how long it takes for that to happen but I would assume those things run non stop for the better part. Then…Who runs them?

    This is the type of stuff already happening in Buenos Aires. Totally overwhelmed.

    I suggest you assume zero assumptions. You have to ensure that YOU do what is necessary as one of the people responsible for immune compromised or as an already sick but functional person.

    Sources for real electricity are construction sites, portable pole light kits like they use on the freeway at night, generator obviously, military bases (all are wired with backup in the event of an emergency), fire stations, EMA offices, cell phone tower sites.

    Dont try to take one off the premises as you will never know whether there is commercial power or not on the line. If its running then you can assume no commercial power and by taking it, you cold be charged with manslaughter if anyone died because say they couldnt use their cell phone or EMA needed to contact someone. Survive only to be put into jail?

    Hmmmmm…..

  28. #28 phytosleuth
    July 21, 2009

    Columkille, I suspect Sambucol is binding to a specific site and it may not work at all for H1N1. Or it might. Only research can tell and I don’t know if anyone is doing that (I doubt it). I’m drying my elder flowers and will make berry juice extract later this summer.

  29. #29 Columbkille, MM
    July 22, 2009

    Phytosleuth: Thanks for the info. Are you cooking your Sambucus Niger juice? Done a lot of research on Niger since it grows here, but some seem to think the uncooked juice causes gastrointestinal upset. Others say cooking will destroy important components. Made tincture – can always cook it later but can’t un-cook it. Thanks again, Columbkille