Effect Measure

The swine flu prepping controversy

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.

Comments

  1. #1 Snowy Owl
    July 21, 2009

    Thank you Revere, this post IMO is the best I have read concerning your Mission, your Differences and Uniqueness.

    I can tell you fist hand that the reach of some of your posts are crossing oceans and yes you have made a Difference.

    We might have arguments in the Past but you have never dropped the Lantern of Revere or of the Hermit.

    Snowy Owl

  2. #2 Ernest Lee
    July 21, 2009

    Thanks Revere for your inspirational idea and thoughts. Your frank and boldness message really brings difference to the other side of the world. I learn and see with a more broad vision from your inspiration.
    ( being an intensivist now caring critical ill swine flu patient )

  3. #3 River
    July 21, 2009

    Excellent post!

    Not sure you’re adding much to the conversation? Try finding anything you just wrote in the MSM or in areas generally available and visited by the public.

    If you decide to bag it, you’ll be turning off on hell of a bright, shining light!

  4. #4 miso
    July 21, 2009

    Revere,
    About six months ago I decided the swine flu was the last straw and I’ve “spat the dummy” in disgust at the vacuum of non-Tamiflu
    antiviral discovery, research, and manufacturing limits.

    It is no consolation that Tamiflu never left a vacuum, using every sales gimmick, after getting FDA approval with inadequate H274Y research.

    Thanks Effect Measure, and the herds of reveres, for letting me post about five years of amateur research( no funding sponsor or indentured servitude here).
    I’m sure if life can emerge from a pool of pond slime, a viable influenza vaccine can emerge from a GSK-like slime,…. and there will be a happier tomorrow.

  5. #5 Heron
    July 21, 2009

    Granted: your mission and intended readership are public health professionals, and your welcome of individual readers is gracious and a real service.

    The only logic burp I can’t quite get around in your apologia is that a focus on community preparedness is philosophically and practically at odds with the individualistic work of personal preparedness. Instead, I think they’re two sides of the same coin when approached effectively.

    Picturing both individuals and communities planning to face a hurricane, earthquake, civil threat, etc., I can’t imagine that public officials and planners would discourage personal preparedness out of concern that it ineffectively uses time and resources that would be better spent pitching in on community preparedness.

    I lived through Katrina and other disasters, and I have to keep prepared for those in the future. If the public planners stopped exhorting individuals to get their supplies now, to be prepared to take care of themselves and their families for days or weeks, and after having secured themselves to look in on friends and neighbors to also care for themselves, the post-disaster work in the community, as well of the loss of life, would be horribly worse than it is already.

    A strong family, household, individual, is the basis for a strong community and society. Planning to help everyone from a central community position, while failing to emphasize the central concept of individuals helping themselves, is begging for the frank and rapid failure of overburdened systems. Preparedness simply must start from the core of the household unit and work out, just as our expectations for individual livelihood fall on the household unit and are only backstopped at the community level.

    I strain to find the logic in a community-only preparedness position. You guys are normally so logical, I keep thinking the logic must be there somewhere.

    Further, the argument that preparedness is an impossible burden on the individual is incorrect and, from the preparedness perspective, harmful. It’s more of a planning burden than an actual burden for most people, at just about any social level, within industrialized nations and to a large extent within others.

    Emergency planners outside the public health system don’t shrink back from telling people to prepare because it costs some money and people are struggling. They tell people in advance how to prepare precisely because they aim to reduce the struggling and suffering at both the individual and public level.

    Storing water (free in used 2 liter soda or juice bottles), rice, beans, the sugar and salt for ORS solution, and a few other staples is not expensive, though it might mean cutting out some frills in the regular food budget for a while as some stocks are built.

    Buying a box of masks and a bottle of sanitizer, or a box of Mucinex or Tylenol, every payday, is within the real of possibility for most people who have a paycheck if they cut out some other small expense. It may be a sacrifice, but it might make a huge difference come flu season.

    Even those who are unemployed but still able to acquire weekly food through government or other means may be able to set aside some rice and oatmeal from their regular food purchases along with the free water they are storing (yes, water systems may not shut down due to a pandemic, but if the power goes out for whatever reason, the water is likely to be contaminated or low in pressure), and to scrape up some change for a bottle of bleach or sanitizer or a box of regular masks or gloves, any of which costs around the price of a gallon of gas, which most people manage one way or the other.

    And it costs almost nothing to download a free booklet on pandemic home care, which most of the individuals that make up your public will be facing, since public care will be overburdened.

    Tell people where to download a booklet on home care, including instructions on ORS solution, and instructions on fitting an using a mask or respirator, a list of the things to look for when a flu patient is going sour, as you say, remind them to stay informed and attentive and extra-cautious in their communities during flu season, and you have a public more educated, one individual at a time, and thus better able to defend themselves and save their own lives where possible when it can’t be done at a community level.

    I don’t want to make light of the financial difficulties of anyone in any land, especially in these times, but it seems to me that those who set themselves up to serve the public would also be concerned that the individuals who make up that very public be encouraged, educated and supported in the ways they might first help themselves, thus reducing the burden on the whole system and saving lives.

    Strengthen the individual unit and you strengthen the whole. Why is this a core principle in public safety and security and not in public health? I would genuinely like to know.

  6. #6 Comment
    July 21, 2009

    Since it is not Revere’s area of interest, can someone post a good link to a reasonable site that advocates thoughtful self-planning (i.e. not an alarmist site that exists to make money off of nervous consumers).

  7. #7 Mathematician
    July 21, 2009
  8. #8 karen
    July 21, 2009

    It is my fervent hope that you do carry on blogging. Although this site is aimed at health pros,you have,whether by accident or design, found another way to reach out to the community.I am an ordinary Jane Doe,no professional job,no real contacts with anyone who does anything,but being a regular reader, I have been able to pass on a lot of very useful information to others, via my own little attempts at blogging.I always come here, to check new information that becomes available, because of your common sense approach,you aren’t making a buck,you seem to have no agenda save that you would see people best served.You have become a source of useful information to a whole group of over forties bloggers,more than that thanks to you I am now asked all flu questions on three different websites/groups.
    Where on earth will I get such sensible info if you vanish into the ether?
    I think you are correct in your approach,only those who would ignore the hardships of others and do not understand the potential of a pandemic want to do no more than stock up.Nobody can store enough fuel,food,water and medicine for what might be a two year pandemic.The only real option is a community based one.
    ps.I always leave a link to your site as a reliable source of info,I don’t pretend to be smart.

  9. #9 phytosleuth
    July 21, 2009

    Michael Coston at A Flu Diary constantly offers suggestions of flu treatment manuals and preparation guides. Here’s a recent posting with some at the end of the post:

    http://afludiary.blogspot.com/2009/07/cautionary-tale-from-uk.html

  10. #11 Monotreme
    July 21, 2009

    revere, once again I will have to disagree with some of your points.

    First, although I’m sure you are an expert in your field and know a lot about public health, I do not find your reassurances regarding infrastructure compelling. I am also not an expert on infrastructure issues, but have communicated with those who are for several years. They are far less optimistic than you are, to put it mildly.

    Second, you state that you are primarily targeting public health professionals, not the lay public. But don’t these people have some responsibility to communicate to the public? Many people in the US think that the pandemic is over. Those who think it might come back in the fall believe there will be a vaccine ready for them. As you point out, this is unlikely. Shouldn’t the CDC and Secretary Sibelius take responsibility for telling people the truth, now?

    Third, you say you are philosophically opposed to individual approaches to preparedness. That’s fine for you. But do you or public health professionals feel that you have the right to take that decision for others? No-one can force someone else to prepare. What the CDC could be doing is telling people about the disruptions to come and let them know that the only to avoid the flu is to stay home (or use PPE) – for months. Also, they should be told that shortages of many items, including food, may occur. If some choose not to stockpile, that’s their decision. What I object to is the deliberate decision to withhold this information from the general public.

    As regards people in other countries preparing: I have strongly argued in favor of national self-sufficiency in food and other essential goods for years. Although the hour is late, every country should try to stockpile as much food, medicines and other goods as it can while it is still possible. There has been no leadership from the WHO on this issue.

    When this storm passes, as you put it, I hope the importance of personal, community and national self-reliance will be crystal clear. I suspect it will

  11. #12 revere
    July 21, 2009

    Mono: There is no way to reply to you on the infrastructure issue. I don’t know whom you have communicated with “over the last few years” about what infrastructure and giving them what frame, but if you haven’t asked them about this pandemic then it’s not very relevant. Are you storing a month’s worth of water?

    Your second point boils down to this isn’t the blog you would have. But you have your own blog. Tell the Secretary what you think. It doesn’t have to be what I think. In fact it isn’t.

    Third. I’m not making decisions for anyone, any more than you are. It’s a ridiculous point. As for what CDC should tell people about what’s to come, maybe you should lend them your crystal ball. I have some disagreements with CDC’s messaging, but pretty much I think it’s been on target. I don’t think your messaging is on target nor is it aimed at most people. Just people like you and with your means.

    National self-sufficiency? You must be joking. At any rate, I couldn’t disagree more. We all live on a single planet. I don’t owe more to you becasue of your passport than I do to anyone else, nor any less. I’m not going to hide under my national bedcovers with cans of tunafish and let the rest of the world fend for themselves. That’s me. It isn’t you. We can agree on that.

  12. #13 Monotreme
    July 21, 2009

    revere, I’ve communicated with nurses, people who work at power plants, cops, paramedics and others through the flu forums. Most importantly, I’ve listened to them. To me, this is the point of such forums. You can learn from people with different expertise, but you have to listen. This is something I’ve heard many in public health are not good at. They don’t actually listen to the public. The most notable exception is Roz Lasker.

    My second point wasn’t about telling people what to do, it was about giving them information. CDC isn’t doing this. There are materials on the panflu.gov sites that would be quite useful. But they make no attempts to share this with the public. Are you saying you are OK with that? I certainly have expressed my opinion on this lack of communication on my blog and elsewhere.

    I don’t need a crystal ball to tell the CDC what is to come. Anyone with a brain can see what is happening right now in Argentina, Australia and New Zealand and figure out what is likely to occur in the fall in the Northern Hemisphere. Health care is going to under severe stress. If medical care is available at all, it will be severely rationed. The only way to lessen stress on hospitals and other critical infrastructure will be to lessen the spread of the virus via school closures and other NPI. If people are warned ahead of time, I have confidence that many will respond appropriately. If we follow the current policy of waiting for catastrophic failure before communicating with the public, expect chaos and social disorder.

    No, I am not joking about national self-sufficiency. I don’t think mass starvation is funny. You don’t owe me anything. I grow some of my own food in my back yard and plan to grow more. In the meantime, I’ve been stockpiling while we have a functional agricultural and transportation system. It’s you who think someone else should produce your food and deliver it to you in the middle of pandemic, not me.

  13. #14 revere
    July 21, 2009

    Mono: You didn’t answer me. All you said is you read it on a flu forum. You believe what y ou want to believe.

    You think you know what people ought to know. Good for you. Maybe you’re right. Maybe you’re not.

    You think anyone can do public health. It’s just counting, right? But then you think anyone can do PCR, too. Just push the button, right?

    You’ve got a back yard. Again, good for you. I don’t. Tens o millions of others don’t. But they aren’t your concern. Look after yourself. No one owes you anything, it’s true. LIke your internet connection or your electricity or your gas or your water. Dig your own well. Connect your bike to a generator or put up solar panels. Make your own meds. Don’t expect anyone to make them for you. Lots of elderberry around and lots of bikes and the River or Lake is nearby. Communicate in person. Have fun.

    But if anyone wants to know why I think espousing self-sufficiency can have undesirable effects, I’d point to your comment.

  14. #15 stillarebel
    July 21, 2009

    Thanks for this thoughtful post.

    The simple, brutal truth is that some of us will die during this pandemic. Some already have. That is now an unavoidable consequence of previous political decisions.

    But if some people die while we are working together, as a society, helping each other, then at least maybe there is meaning to the suffering this pandemic will cause. They died helping each other. We can enhance that meaning if we are politically active afterwards, driving home the lessons learned about how unprepared the world was, in terms of public health infrastructure, how global health inequalities put us all at risk and how all talk of ending health inequalities has to be coupled with consistent action.

    I have no objection to anyone preparing personally for this pandemic. It’s great if you have the money to do it and the space to store stuff. As Revere says, on a global scale, most people can’t.

    We all prepare for things in life as far as we can, doing our own assessment of the risk. So one person might be extremely cautious about personal safety on a night out; another might eat an impeccably healthy diet to try to avoid cancer. That’s fine. But these individual actions are less important from a public health standpoint, than the collective efforts of society.

    The one thing I do object to, is the idea that some people will see out this pandemic hiding under their beds with their can-openers. If that is going to be their contribution, why should I, as a nurse with asthma, bother going to work? Hiding under the bed with the can-opener will be counter-productive if they have a heart attack, but the nurses and paramedics are also hiding under their beds.

    (Don’t worry, I will be at my work and I will also volunteer to do extra work, because I believe passionately in improving outcomes through the organised efforts of society.)

    But we ALL need to do our bit. I have no problems at all with criticising the powerful for the mess we are currently in. But do your best, not just for your nearest and dearest, but for everyone you can reasonably reach out to. And if we all do that, the vast majority of us who are going to survive this pandemic might just be a little bit more emotionally healthy at the end of it.

    Thanks again for the post, Revere. Please do not stop blogging. There are NOT lots of progressive sites out there like this one. You make a unique contribution to the blogosphere and we need you.

  15. #16 SoCal
    July 21, 2009

    Revere: Have you offered your local newspaper’s “flu reporter” an opportunity to meet with you, on background, and learn some of the fundamentals and complexities of this pandemic so that the reporter will be better prepared, when the Fall arrives, to know what questions to ask local officials, and what answers to question–or, at least, to be able to frame a useful question? If you have, would you care to share your experiences, especially about the minefields in such an activity. There aren’t many McNeils, Altmans, or Branswells at the local level, yet, obviously, local media coverage will be instrumental in shaping public perceptions and behaviors as this pandemic unfolds (whatever its severity level). Perhaps as part of community preparation, those in the community who have some knowledge of flu viruses and pandemic preparedness should try to look upon the local reporter as we would a grad student. Trying to do this when the reporter is writing a piece on deadline is useless.

  16. #17 revere
    July 21, 2009

    SoCal: yes, I get regular flu calls from the health editor of the “local” newspaper (actually it’s pretty big) and he quotes me (the real me) a lot. He knows me as an academic whom he has used as a source for many years on a variety of things. He doesn’t know who the Reveres are. Sometimes I’m not so sure, either.

  17. #18 Monotreme
    July 21, 2009

    revere, I did answer your question. I didn’t “read it on a flu forum” (a curiously dismissive position for you to take), I communicated with people on flu forum. That’s a bit different. I’ve also done my own reading, including history. I understand that I’m not going to convince. Sadly, we’ll soon see who is right about this.

    Again, I don’t think I know what is best for everyone. That is precisely the opposite of what I’ve been saying. I think everyone should be given accurate information so that they can make their own decisions. It is public health officials who think they have the right to make life or death decisions regarding the public without informed consent from said public. If they were physicians, they would be guilty of malpractice.

    I understand that not everyone has a backyard. I lived in a studio apartment in Manhattan for 5 years. I know exactly what it is like to live in a small space with no excess funds. This is why I have been advocating that the federal government stockpile food and other essential supplies for NYC and other megacities.

    In the long term, I think at least some people need to move out of the megacities. They are death traps, as we will soon see. Those who remain need to think about how to raise more food within the cities. I discussed this in detail here.

  18. #19 Lea
    July 21, 2009

    “Mrs. R. informs me we have more than enough in the pantry to last a few weeks”

    Way to go Mrs. R!

  19. #20 Teal
    July 21, 2009

    I comment little on flu blogs and forums, but something struck me in reveres’ post:

    [quote]There is too little emotional energy (snip)to do what we should have done over the years[/quote]

    Damn! THAT is what’s going on. I haven’t been able to put into words the curious disinterest in this flu. I’ve thought it a matter of CFR, or false hope for a vaccine, but it’s not. It’s that the people with an affinity for prep were emotionally burned out by prepping for H5N1.

    I can guarantee (as a person with a 5 year old pandemic flu site that is directed toward, and “scares” :), the newbies) that folks are not doing much prepping. It’s a shadow of 2005-2006, and even 2007. If there’s anything you need from the Internet, or any low-volume items, like camping gear or gas cans, you’d best get it now. As far as food, even a moderate head start will get you your Costco run. The natives aren’t restless. At all.

    http://www.planforflu.com

  20. #21 revere
    July 21, 2009

    Mono: You “communicated” with people on a flu forum? Since by your own admission you have no expertise in infrastructure operations, what exactly did your end of the “communication” consist of? I am not in the least dismissive of flu forums. I participated in them and helped start more than one. But it’s not an answer to say you got the information on a flu forum. Exactly what was it about my post — exactly — that you think others with expertise in infrastructure would disagree with as you communicated with them? I commented on the likelihood of there being no water available for extended periods. Was that it? Or that I didn’t think the grid would go out for extended periods on a regional or national scale? Or that it was fixable, even during a pandemic? Exactly what is your scenario that makes you think you should stockpile weeks or months worth of water in your capacious house or back yard?

    As you have done repeatedly over the years (which is why I am so short with you), you put words in my mouth. I never said you knew what was best for people. I said you claimed to know what people ought to know. You just said it again: that people deserve accurate information. Yes. I agree. But that’s a platitude. You also presume to know what information is accurate and that CDC does, too, and is intentionally withholding it. Public health officials do make life or death decisions (unlike bloggers) so they have to be more careful than you or I.

    Your comment about NYC stockpiling food is what I would say — and did say — about staples. What you have said previously is that no one should expect NYC to feed them. Welcome to the human race.

  21. #22 Monotreme
    July 21, 2009

    revere, if you had actually participated at flu forums, you would know about the extensive discussions regarding infrastructure which included many different content experts. The bottom line was that no sector was prepared for a 40% absentee rate – not health care, not energy, not water, not transportation, not police – no sector. You would also know that “fixing” the Grid after it has gone down is not easy. And you would know about cascading failures.
    You would also know that the CDC has provided no useful direction to any of these sectors, including health care.

    The CDC made a television advert urging stockpiling as a preparation for pandemic flu. It was pulled after a few late night runs. The pandemicflu.gov site has a detailed list of what may go wrong during a pandemic and how to prepare, but no-one knows about it. The CDC knows what to say. They just refuse to say it.

    You’re right about life or death decisions. The Director of the CDC made a life or death decision when he chose to keep the schools open in NYC despite clear evidence of transmission of pandemic flu within the schools. A lot of people died as result of that decision.

    You reserve the right to criticise politicians when they make decsions that kill people. I reserve the right to criticise public health officials when they make decisions that kill people, especially when I think they are being made for political/economic reasons.

  22. #23 revere
    July 21, 2009

    Mono: Once again, spell it out for me. I don’t know what extensive discussions you were in with content experts but I spent 30 plus months discussing this on a National Research Council committee with real content experts who maintain critical infrastructure for a living, so I have more than a passing acquaintance with the subject, even if neither I nor anyone else I know has all the answers. But I’ve thought about it quite a lot and I also know something about flu, so I ask you again, spell it out. Why do you need weeks or months worth of water and for what? As for the grid, yes, it’s not easy to fix but it is fixable and can be fixed if people are diverted to fix it, even with 40% absenteeism. Because the problem isn’t distributed, only the effects are. So you can collect people from one place and move them to where the problem is because the grid problem isn’t everywhere at once.

    When you say no sector is prepared for a 40% absenteeism rate, I don’t know what that means. Does it mean they will stop? Or just fall behind? Or disintegrate, fall apart? It’s quite true that with a 40% absenteeism rate no sector will operate normally. No one expects that. That’s not the same as being unavailable or not working at all or being out for weeks or months at a time. Exactly how do you think this virus is going to do that?

    This is a pandemic like 1957 and I remember 1957. Most people didn’t even know it was happening. It killed a lot of people and I consider it a public health catastrophe. But even if it gets much worse than 1957, critical infrastructure won’t go out for any extended period under any scenario I can imagine. I am asking you to help me imagine it. How would that work? Don’t tell me you heard it on the internet. Tell me what you heard on the internet and if you contributed to the discussion (by “communicating”) then by all means communicate it here. Or tell us how content experts, discussing H5N1, also think that H1N1 absenteeism will knock out water supplies so most people won’t have water for extended periods and therefore need to stockpile it.

    I don’t care if you criticize public health officials. I do expect you to have a basis for it and to do it as fairly as you can if you are going to do it here. CDC makes mistakes and they should be criticized for it (I’ve done it plenty) but they should be given credit where it’s due. You’ve never been in their shoes. It’s not an easy job. But they are accepting applications for Epidemic Intelligence Service officers and I’m sure you’d have a chance to get in there and do it better if you think you can. My prediction is that the real world of public health would eat you alive.

  23. #24 Monotreme
    July 21, 2009

    revere, there were several well-known threads at the old Flu Wiki on this subject. One of them was called Keeping the Grid up. Ask Dem if you are interested in seeing what formed my opinions on this subject.

    As regards your committee meetings, I hope you and your fellow committee members are right. Because the people who posted on the threads I’ve read said that their organisations had done little to prepare them. Apparently, you were told differently. I guess we’ll see what soon enough.

    As regards water, that is primarily a local matter, as you pointed out previously. However, my understanding is that many water purification facilities require chlorine to function. That chlorine must come on trucks. Are you aware that several truck drivers in Argentina were among the first to die in that country? What if truck drivers decide it is too dangerous to deliver chlorine to water purification facilities? What is the contingency plan?

    A 40% absentee rate will cause some facilities to stop. For example, surgeries that are considered non-essential, including cardiovascular procedures, are being stopped right now in countries in the Southern Hemisphere because too many health care workers are ill and there are too many patients to treat. In at least one hospital in Australia, they are already calling nurses from educational institutions because they do not have enough to staff the ICUs. And the flu season is just beginning.

    As regards the Grid, I would hope that the experts on the committee which you participated on explained the consequences of cascading failures. One failure can, and already has, cause widespread blackouts. Right now, outside aid can help repair the damage. But with pandemic flu, there will be no outside aid.

    I don’t think we know what grade of pandemic we have yet. Dr. Poland at Mayo said yesterday that the pattern thus far reminded him of 1918. Others have said similar things. I think Tamiflu is keeping the CFR down in rich countries, but is unavailable in poor ones. That’s why we see such a wide variety of CFRs. If the Tamiflu-resistant strains start to predominant or we run out, the CFR in the US will increase to at least 1918 levels, imo.

    I’ve given you my basis for criticising the public health establishment. They have failed to lead. They have failed to inform. Frieden made a decision to keep the schools open in NYC. Hundreds of people died as a result.

    I’m pretty sure I wouldn’t go far at the CDC. I’m a lousy politician. And I’m not good at keeping my mouth shut when I see eminent danger.

  24. #25 downeast
    July 21, 2009

    Revere: We, the local media, need you, rational scientists, to help us decipher and communicate. There was nothing I needed more back in April than a rational breakdown of H1H1.

    “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.”

    You seem anticipate a sensationalizing media bent on shock and awe. That doesn’t materialize too much on the local level (it’s hard to sensationalize when everyone knows everyone else), and it is the local/regional media (radio, internet) that people will turn to in an emergency. It happens again and again on a small scale — storms, mini-disasters — so we do have some sense of how to proceed. And, we are ever training new reporters how to hold a community together in these instances.

    What we, in our corner of the world, were lucky enough this past April to have was immediate and open communication with our state’s public health leader on a daily basis via conference calls. We got the info right off the bat about how the state was beefing up its manpower, how much tamiflu was heading here, etc., and we were able, for the most part, to disseminate important information to the public.

    What we did not have were responsive local health care practitioners and hospital communicators, which left a gaping hole in public confidence, and a sense of how to proceed (should those with symptoms go to the ER, how was the hospital equipped, etc. In fact, the local hospital pulled down its pandemic plan written five years ago after I asked about it. What the heck? it had sat on the site for 4 years until H1N1 showed up). In our case, the state CDC was organized and forthcoming in every necessary instance while local health care attempted to minimize everything about this virus.

    My point is, there is responsible local media waiting to inform the public when needed with information, not drama. That is our job and we take it seriously.

    SoCal: I know it’s hard to imagine, but there really are plenty of capable reporters in rural locales. In fact, many McNeils, Altmans, Groopmans, Gladwells exist there, preferring to live quietly. And deadlines are ever-rolling, so get in touch with your local reporter whenever.

  25. #26 revere
    July 21, 2009

    downeast: It wasn’t my view that the media would be sensationaizing events but reporting the accurately. In other words, if there are actual lines and overcrowded overwhelmed health care facilities, well and accurately reported, it will have a very bad effecdt. So we should concentrate on seeing that doesn’t happen. Same with shortages of essential staples. I was assuming the media would do its job and people would reacdt predictably.

  26. #27 M. Randolph Kruger
    July 21, 2009

    “Jul 21, 2009 (The Monterey County Herald – McClatchy-Tribune Information Services via COMTEX) — Homeland Security Secretary Janet Napolitano warned federal judges and court officials Monday of the urgency of national immigration reform, “an increasing cascade” of cyber-terrorism attacks and a renewed flu pandemic that could severely strain government institutions this fall.”

    “Finally, a possible return of new forms of the flu virus to the U.S. this fall could mean widespread absenteeism that affects government, businesses and schools.

    “We all need to be thinking through, how do we keep things going, how do we keep business happening with absentee rates that could be 10, 20 or 30 percent — maybe even 40 percent — at the height of the return of a flu pandemic? How will you operate the courts?” While the next outbreaks are unlikely to reach levels of the devastating 1918 flu pandemic, she said, the H1N1 virus could force school and business closures across the country. The virus is circulating through the Southern Hemisphere, she said, and is expected to make a strong comeback in the U.S. by early fall.

    “We don’t have a lot of time,” she said. “I would urge you to lean forward and navigate this issue ahead of time so that decisions are not being made in the height of a pandemic.” Napolitano told the judges she is “squeezing out” wasteful spending from her department’s $50 billion budget, all the way down to the cost of redesigning logos. That task alone cost some taxpayers $3 million, she said, as the department consolidated 22 separate federal agencies when it formed in the wake of the Sept. 11 attacks.”

    I dont think that there is much to be interpreted even in what I consider to be a very inept DHS system. I have people in DHS calling me to see what I know, or have heard. These are the guys that are supposed to be bailing the US out of a really big jam.

    Napolitano is not the brightest bulb in the socket, not the dimmest either. If everyone federalizes flu all at the same time it will bring the effective force of a huge 305 million down on just 35,000 employees of various sorts and most of which are not your G.I. Joe action figures. The number of field personnel is only about 10,000. So prep or not this is not a big question really because the lovely Janet is expressing her concerns for a 40% event without even slightly addressing the numbers of dead. Small for now, but its rising rapidly.

    Everyone gets to make a big decision right now as we have about a month. Failure to get it right could have huge consequences for you and family. Gamble that it doesnt have a high CFR? Not me…

    History always repeats itself.

  27. #28 revere
    July 21, 2009

    Randy: Outside of the fact that I have no idea what you are saying, I will observe one thing: if history always repeats itself, how do you know the thing that will repeat isn’t 1957, 1968 or 1977? But let’s get down to brass tacks. Suppose the courts only functioned at 10%. So what/ Most cases in court are business cases. A pandemic of any size will hurt the economy. Not as much as the Republicans hurt it with their sub prime and hedge fund and Goldman Sachs, but it will hurt it. We are being hurt really bad right now. But I still have drinking water and electricity. Will a lot of people get sick and die? Yes. It happens. Since we don’t invest in public health, I guess people don’t care that much. If they do, they only have themselves to blame. Too bad they might kill me. But that’s democracy.

  28. #29 Dottie
    July 22, 2009

    The reason for giving laypeople a heads-up isn’t so that every single person can stockpile huge amounts of food, it’s that some people have pre-existing health conditions or special needs and can’t “wing it.”

    I have two family members in frail health. The last time I was ill, they stayed together while I stayed elsewhere. When I came back a couple days later, I found they had lived on breakfast bars, chips and cereal (until the fresh milk ran out), ignoring a pantry full of food that needed heating or preparing. One is a picky eater, the other physically can’t stand long enough to put a sandwich together, and has tunnel vision (can’t see foods on a bottom shelf). I try to keep the house full of nutritious foods, but I discovered they can/will only open cans of chili or eat cereal or snack foods if unattended. Nothing that needs chopping or mixing will be eaten if I am gone.

    After that I kept canned chili and pasta (at eye level)around because I knew they could put it in a bowl and heat it in the microwave, junk food or not. At least they would have something to eat that they could prepare and that would fill them up. Other people have small children who can’t cook or prepare a balanced meal if parents are too sick to cook. People like us need extra time and thought to prepare.

    These two people are going to SIP. They are not “leaving anybody in the lurch” or anti-social. They are retired and dependent on others for care. These are exactly the type of people who die from the flu. You’d be surprised how many people in this situation don’t even think about keeping extra food around – because nobody explains it to them, and they don’t know themselves. People deserve to be armed with information so they can do what’s best for their particular family. It takes time.

  29. #30 M. Randolph Kruger
    July 22, 2009

    Revere, for the record the idea is that the courts are going to close and operate only on phone calls for the criminal cases. All civil cases will be put on hold. As for the other pandemics it would also be reasonable to assume that the longer we dont have one with high CFR’s the closer we get to having one that does. Pure probabilities are that we have to live in the mire of the possibilities. You could be absolutely right. But get it wrong and it goes high path and we could see the total unwinding of the US political and governmental systems. 5% is manageable, 8% simply isnt for CFR’s. If money is worth zero it will buy what? Cant print more paper to replace old paper and none of this Amero bullshit either.

    Prepping is a personal decision. Reasonable people make reasonable decisions. How about the Administration giving it to them long, loud and dirty? People always ask me where I get all of this news about flu that they have never heard or seen. I simply direct them to four or five disaggregators and they get immediately upset. WHY havent we heard this here is their big question. My answer is that Stalin controlled state run media too. Maybe not direct control here but I can say three networks are pretty much up Obama’s tail with their microphones…garbage in, bullshit out.

    Republicans hurt us with sub-prime and hedge funds? Please Revere, examine the record a bit more. Sub-prime was a Carter era project that got out of control and it was the Republicans who repeatedly warned of what was going to happen 3,2,1 years in advance. Thats what started the first stimulus two years ago..They saw it coming. Meantime the Dems were calling the federal regulators racists for suggesting that there were problems with Freddy and Fannie. Even Clinton said it on his departure that this was getting out of control. Sister Barney Franks girlfriend was number 2 under Frank Rains who got all of his Democrat numbers exactly right after cooking the books. No federal investigations on that at all. Why?

    Unless I am mistaken Revere, hedge funds are still currently a legal tool to make money and that might irk you a bit. But I would say you are more interested in spreading misery to everyone by taking from the better off to pay for the poor who do no work, have everything government subsidized and want to have healthcare paid for by someone else. There is nothing racist about who those people are. They have been poor and will remain so because they know nothing except how to remain that way. Its all they are taught for the better part. There are some exceptions but not many by comparison.

    Those people will never, ever contribute one thing to society and that simply has to be recognized, or cut out welfare entirely and see how fast they join the job markets.

    Your reference to healthcare is heard but it doesnt change a thing. UHC is just going to be used as another control tool. You had to have known that the governors will and would use their sovereignty clauses to prevent implementation in their states. It will bankrupt the US government, then the state coffers and then NO ONE will have care.

    Your statement that pandemic will hurt the economy is true. Thats a given. Your statement that the Republicans hurt it with sub prime and hedge funds is an opinion only. I would say truly it was the expansion of the program even further in 2005 by the Dems that did us all. But my opinion would be based in live video feeds from the committee rooms and that would generate my bias and my opinions of it.

    Do you have anything that says the Republicans did it? All of the laws giving the leeway on sub prime were done during the Dem takeover three years ago. I would be interested to compare Barney Frank rants or Maxine Waters before during and after. Blame Bush, Blame Republicans. Seems that dog aint gonna hunt any longer old friend. The country is broke and UHC is the only way to establish a cash flow.. Not that any of it would go for healthcare.

  30. #31 Angela
    July 22, 2009

    Revere, I’d just like to add my two cents. I really enjoy reading all of the many reveres insights I would miss not having this site to come to, I’m a stay at home mom in rural Alabama. The flu forums can be a little clannish sometimes so I really like the openess here and the patience with questions. Thank you for a great site and wonderful service for regular people.

  31. #32 downeast
    July 22, 2009

    ditto!

  32. #33 Aniket
    July 23, 2009

    I afraid my question is totally out of contest here !!

    Still I would like to know that if a person received antiviral treatment recommended for A(H1N1), does the person’s body raises antibodies against the virus?

    What are the chances that a person can be reinfected with the virus? And can the reinfection be more severe?

    I am sorry to divert the flow of discussion !! :(

  33. #34 river
    July 23, 2009

    Revere, you wrote: Since we don’t invest in public health, I guess people don’t care that much. If they do, they only have themselves to blame. Too bad they might kill me. But that’s democracy.

    Although you are comfortable blaming the Republican party for the country’s economic demise (and I agree with you there), you don’t seem to hold the common investor — the Little Guy — responsible for the complete erasure of her/his 401K. So, why are you so quick to hold their feet to the fire on healthcare? Seems Reagan et al didn’t say, “Americans, let’s all vote to rape and pillage the healthcare system to save a few bucks and hope it’s your neighbor and not you who dies as a result.” Instead, hasn’t the argument (bogus though it’s been) to vote to streamline healthcare, make it more accessible and efficient for the betterment of all?

    I think people care a great deal about healthcare. I think they’re terrified of swine flu, appendicitis, diabetes, anything that’s going to force them, their families, friends, neighbors, acquaintances into the heart and soul of the broken healthcare system. I also think they’re financially broke, overworked, super stressed, unable to achieve the constantly changing expectations of today’s society, and like 25 years ago, they are looking at their elected officials to sort out some of the larger issues, present reasonable arguments for and against, cast their vote, and cross their fingers and hope they made the right decision.

    That’s democracy.

    Be well.

  34. #35 revere
    July 23, 2009

    river: Well, it’s an interesting and pertinent question you ask me. If people vote for lower taxes, who is to blame? I suppose the answer depends on why they voted for it. Some are philosophically opposed to paying taxes. I blame them. Some voted for lower taxes for other reasons, and it depends on what those reasons are. I was generalizing and you point out I shouldn’t do that and you are right.

  35. #36 River
    July 23, 2009

    As always, Revere, I appreciate your thoughtfulness!

    Truly, be well.

  36. #37 Grace RN
    July 23, 2009

    Excellent comments. I plan/prep water simply because our water supply is contingent on electricity; we are used to summer storms knocking out the lights and have prepped for years.

    Please blog on, follow the 2009-10 panflu in real time. Best practices may pop out among the readers.

    NZ at the moment:

    http://www.moh.govt.nz/moh.nsf/indexmh/influenza-a-h1n1-update-112-210709?Open