The reaction to our post on Sunday about preparing for the ongoing flu pandemic was mixed. Some thought it was right on target while others expressed dismay over what was perceived as minimizing the possible effects, especially as we have been talking for well over four years about the potentially pervasive nature of widespread absenteeism. Still others thought we had retreated to a narrow view focused on the pressure on the health care system while neglecting what might happen in the wider world. There is some truth to all these perceptions, but we didn’t take this tack because we changed our mind. We took it for pragmatic reasons relating to the urgency of the problem. We’d like to explain because we wish to make a few points (again).
1. We are out of time. Yesterday’s post about prioritizing vaccine efficacy and safety studies applies also to pandemic preparation. For years we have been advocating a broad approach to pandemic preparedness through strengthening the public health and social service infrastructures. Since the Reagan era, both Republicans and Democratic Presidents and Congresses have systematically dismantled and in other ways crippled public health and social services in the US. Both are a shadow of what they were before Reagan. It was our belief, based on four decades in medicine and public health, that service infrastructure investment was the best way to protect us against an influenza pandemic and many other hazards as well. If a pandemic didn’t happen, there would still be manifold benefits.
But we didn’t do it and now it’s too late. Fortunately the pandemic that is evolving is not the one we feared most. It may change character, but in terms of preparing as a community we’ve only got a 10 foot dike, so it won’t matter if the flood crests at 15 feet or 20 feet. We should be getting ready to be inundated, but we’re not even doing that. The focus on vaccine availability we cited on Sunday and again yesterday is “planning for the best” (the availability of a vaccine that works). When it comes to planning for the (more likely) worst, we have to be realistic and pragmatic about how bad an event we can prepare for. We still have time to get ready for the kind of pandemic they are seeing in the southern hemisphere and which we have had twice in the last century (1957 and 1968), but not much more. The planning corollary to the perfect being the enemy of the good, is the horrible is the enemy of the bad. There is too little emotional energy, money and people to do what we should have done over the years. The has clock ran out. So now we find ourselves talking about a much more restricted response than we wanted.
2. In this context, a calm, steady and rational approach will serve best. It is easy to anticipate the media images that will produce the opposite. Images of overwhelmed health services and out of stock necessities will make communication very difficult. Other effects will have less impact. School closings are a hardship but not a cause of panic. It is unlikely water will be unavailable, for reasons we outlined on Sunday (and we have professional experience regarding water system security). If there is interruption of electricity it is unlikely to come at the outset, very unlikely to be national or regional in scope and in any event can be fixed. If you live in an area prone to outages, take that into account, as you would normally. Remember that flu pandemics are irregular in time and space. They don’t happen everywhere at once and some places are virtually untouched. The key issue is to instill a sense of empowerment and control by having objectives that are attainable, visible and rational. That was the subtext of our Sunday post.
3. The issue that seemed to provoke the most consternation was our implicit rejection of personal prepping as a solution. We plead guilty to this, so we feel obligated to explain why we have taken this position. The most obvious, and in some ways the most understandable explanation, is that this is a public health blog. Our professional object of interest and our point of application is a population or a community, not an individual. Individuals are the subject of clinical medicine, and while we are physicians, we are firmly fixed in the public health realm. Our intended audience is state, local, and national public health professionals and we know from our referrer logs we they are reading us regularly. Many others are drawn here by reason of personal interest and we welcome and often try to involve them in a public health approach. But we don’t do personal prepping here mainly because it’s not our subject matter.
But it’s not just a subject matter issue. We have a philosophical bias. We think it’s great if people take personal responsibility to prepare for whatever hazards might come, whether it’s buying home owner’s insurance or stashing away a couple of weeks of staples (contrary to what I have said, Mrs. R. informs me we have more than enough in the pantry to last a few weeks; shows you what I know). We are lucky. Most of the world cannot provide for daily needs, much less stock up a couple of days, weeks or months worth. Most of the world means most people, so we are not in favor of making self-reliance the centerpiece of preparation. It’s irrelevant to most people in the world and therefore to us as public health professionals. I realize many preppers are also generous people who will share and help others. If people talked about neighborhood food pantries, we’d consider that very appropriate. Self-reliance, though, is not a topic here nor does it advance what we stand for. Our definition of public health is what we, as a community, choose to do for each other. As I said, it’s a philosophical bias. If you are focused on individualism as a principle, you won’t like our approach.
4. Our interest in flu at the outset was as a lens through which to look at public health from a progressive perspective. This is a political blog as well as a science blog. As we’ve said many times, public health has the word “public” in it and is inherently political, in the non-partisan sense. Public health as a profession and our progressive politics are joined by a desire to make a better world. That’s a lifelong commitment for us that we’ve pursued at one time or other in dingy storefront offices, in the streets, in free clinics, in the classroom, in union halls and churches and auditoriums, with stethoscopes, petitions, typewriters, mimeomachines, xeroxes and computers. And now on the internet. Four and a half years ago, when we started this blog, one of our objectives was just to keep the lights on in a dark age. That moment has now passed and we aren’t sure we are adding much to the conversation. We’re weighing our options, looking to see if there is a better way we can be effective. But at the moment we are here.
The bottom line regarding the pandemic is that it is too late for the kind of overarching approaches we have been advocating. The train has already left the station. What remains is how to use the little time left to make things less bad. We’ll muddle through. It’s not the end of the world.
But we could have done so much better had we invested in public health as a common good, not just a technical fix for a pandemic. Maybe when this storm passes, we can again put our shoulders to the wheel to make that happen.