The Federal government's flu plan is in it final stages of recapitulation -- sorry, I mean, the final stages of preparation. The headline of the AP news story says it all: U.S. Pandemic Flu Plan: Hole up at Home. Jeez.
The federal Centers for Disease Control and Prevention is pitching the plan at medical meetings and aims to send it out for review by the end of the year. State and local governments have asked for unusually detailed and specific advice on such matters as closing schools and canceling public events, one CDC official said.This week, CDC awarded $5.2 million in grants related to the plan, including research on whether to recommend face masks to the public. CDC also asked the Institute of Medicine, a group of scientific advisers, to meet on these measures later this month.
"We can't afford to neglect some of the traditional approaches to contagion control because we very well may find ourselves in a situation where that's all we've got for a period of time," said CDC's quarantine chief, Dr. Marty Cetron.
The logic here seems to be that "traditional measures" have to be used because that's all we've got. Does that mean bleeding? Leeches? The trouble with some of these measures is that we have no ore idea they work than that we do about leeches. The Director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota says what needs to be said: are we sure this emperor isn't naked?
"A lot of these things sound good but they lack practical application," said Michael Osterholm, a University of Minnesota health expert involved in the planning.
Advising people in big office buildings to avoid elevators and stay 6 feet away from each other is impractical, and people can't stay in their homes for weeks or months without needing insulin and other medications, he noted.
[snip]
As for hygiene tips like sneezing into your sleeve, "we have no data that that makes any difference" in controlling a pandemic, Osterholm said.
We are flying blind. We dodged a bullet with SARS, but no one is quite sure how or why. To say it was the result of classic public health measures (which ones?) is a stretch. All the thermal scanning at airports for feverish passengers picked up not one single case. Maybe we should have everyone keep their shoes on, too, when they pass through security so they don't catch cold. The idea that "social distancing" is going to slow a pandemic, much less stop it, is unproven and chancy. Again, Mike Osterholm says what has to be said (although few want to hear it):
However, Osterholm said there's not enough science to recommend some measures, like "keep your distance" campaigns. Scientists know flu spreads through hand contact and big droplets when people cough or sneeze, but they don't know how far tiny particles remain in the air, or how important that is for spreading the germ.
In fact, experts know surprisingly little about what enables a flu germ to spread.
Health officials need to give advice but should be honest about the limits of what is known "and not oversell it, which there is a tendency to do in times of crisis," Osterholm said.
If that happens, "we will lose credibility quickly," he said.
But some people still don't get it.
The CDC plan will list multiple scenarios for pandemics that range in severity or attack certain age groups like children or college students, and recommend corresponding control measures.
These will include voluntary isolation of sick people, voluntary quarantine for those exposed to the germ but are not ill, and protective sequestration to separate healthy people or communities from a source of infection.
"Quarantine has gotten a very bad name and for very good reason. It has been abused in the past. It works best when we obtain and maintain the public trust," [CDC's Dr. David] Bell said.
If those are the conditions under which quarantine works best (or at all), forget it. That they are even still thinking about quarantine shows that they have nothing left to do except their usual response of exercising police power. The virus won't care.
So what to do? In our view, it is not a matter of stopping or slowing the progression of a pandemic. Forget it. Any scheme to do so is like the ones people come up with to stop a hurricane by detonating nuclear devices in the eye. Some Forces of Nature are more powerful than what we have to stop them. Instead, you do the same thing you do to prepare for a hurricane (unless you are the Bush administration). You get ready for managing the consequences. So far, our government (and many others) is in a State of Denial.
Managing the conseuqences means you get together with others in your community to solve the problem of how you are going to get through 8 weeks of significant morbidity, mortality and absenteeism. You ask if you have enough supplies and equipment (like respirators) for the critically ill. You arrange for overflow capacity, which you may have to pay for by making the health care system less efficient and more redundant by having excess resources. You examine those areas where "just in time inventory" is disastrous if supply lines are interrupted, e.g., fuel and energy supplies, a short list of pharmaceuticals like insulin, a few antibiotics, blood pressure medications, etc. Not everything. Just a smartly chosen list that you had the foresight to prepare for ahead of time. You figure out how to make sure food staples will be available. You make sure you have continuity of operations plans in your business or agency. You encourage people to work with their neighbors and volunteer in case they are needed because others are out sick. You prepare for people working from home because they may not be able to get to work, not because they are "holing up."
Of course some things will be done "just because" they seem plausible, like canceling unnecessary events or schools. They might or might not do any good, but the pressure to do them will be strong. But that isn't a plan. Mostly schools would close anyway because students and teachers will be out sick and there won't be enough people to run them. In my university, if a professor falls ill for three weeks halfway through the term, there isn't much that can be done about getting the course taught, especially if others are also out sick and so are students. Airline schedules will be drastically curtailed because there won't be sufficient crews to fly them. These aren't preventive measures. They are effects. The question is not whether to do them or not. The question is what to do when they happen.
Here's a plan. Start beefing up the public health and social service infrastructures of our local communities with block grants for the major areas. Some money will be used inefficiently, but I can't believe as inefficiently as the "bioterrorism" money has been used. People in health departments have been running them for a long time and know what needs to be done. Give them enough dough to let them do it. That's why block grants make sense. Start developing programs to mobilize our communities to fight for each other in our own neighborhoods, not fight others in far away countries.
And do it like you believe in it, not because you don't have anything else to offer. Experience in the 1918 pandemic showed that those communities who understood what they were facing and were honest with their citizens fared best. Honest with their citizens.
Honest with their citizens.
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Revere: [Bit off topic]. Have you come across the preprint by Chowell et al in Vaccine? Provides some interesting insight about R during waves 1 & 2 in the 1918 pandemic. In Switzerland, R2 was about 2 x R1. In England, they were similar and reversed.
Causality is dreadfully annoying, isn't it?
/chuckle
"Maybe we should have everyone keep their shoes on, too, when they pass through security so they don't catch cold."
Thanks, didn't get enough sleep and kid is up at 5:30 am, this was a good bad icebreaker. =)
good bad day^ icebreaker.
Marissa: Thanks. Hadn't seen it. Will read with interest.
Not sure I understand why distancing or holing up won't work...is it because the virus *has* to cut a swath through us before it will downsize? So we have to put ourselves out there and die if we do, don't if we don't? I've been following flu news for a year trying to understand how best to protect my family. Is the answer that I can't?
Isn't it easier on hospitals and HCW's if we don't all fling ourselves at the virus at once? Isn't it better for children to stay home until there's a vaccine? My daughter's an Education student and has worked a lot with kids. Trying to get them all to wash properly, cover their mouths, not rub snotty hands on desks, is a job in itself. Isn't keeping schools open during a pandemic like a mass sacrifice?
We don't know how deadly H5N1 will be if it becomes easily transmissable. What is it now, 58% death rate over all, 70-something % in Indonesia? Can it really come down as low as 2%, which I believe was the death rate in 1918? Isn't it likely to be higher? And the 58% includes people who've had access to ventilators and dialysis machines. We've been told we can't expect anything like that level of care, that essentially we'll be on our own. Under those circumstances the idea of everyone just soldiering on reminds me of the movie Gallipoli, where the soldiers were told to take the bullets out of their guns and just run at the enemy.
Admittedly an emotional response.
Karen: Good questions, all. Lots of people will choose to stay home or have to stay home. Lots of businesses and schools will close their doors on the plausible grounds that congregating only increases one's chances of contracting the flu. But that's not a plan, nor is there evidence it will work for the community as a whole. It may be a personal plan, but it won't be possible to avoid all contact with other people, nor, do I think that if we could, that would be a good thing. People will be falling ill, some mildly, some moderately, some seriously. It may or may not be you, but whoever it is will need the help and support of the community. We don't know ahead of time if we will be the ones needing help, but wouldn't it be better if we were that others would be encouraged to give it rather flee from us? Past experience tells us that communities that fostered that cooperation did better.
Lots of people will help. That's always been the pattern, even in the worst of situations. We should make it as easy as possible for them to be effective, not abandon cooperation. We can plan to make this possible and easier. A lot better than planning for everyone to hunker down and only look after themselves, a technique which is not completely feasible in an interconnected society and therefore may be totally ineffecive anyway. There is no evidence it works, although I admit such evidence wouldn't be easy to gather, so I wouldn't say it won't work for some people at some times. But as public policy it involves a trade-off and in our view it is a bad bargain for the community.
Karen, I would say the only reason why "hunkering down" (did Dr.Nabarro say, "hunker down"?) won't "work" is that the public is not ready to do that today, (nor next week, nor next month);
has not been told it may be a life-or-death priority for their families to figure out how to do so, and, been repeatedly reassured in the media by local authorities (paid with public money) who only say they "have plans" and run "vaccine drills", just "have 3 days" or "2 weeks" of food on hand... to "prepare" their fellow citizens for a pandemic influenza year.
That "$5.2 million in grants related to the plan, including research on whether to recommend face masks to the public" would be better spent locally stockpiliing imported maintenance meds, surgical needs, infant formula, teaching the public what they are going to need to know to cope without federal, state, nor mutual aid, so the public, including essential grid and other workers, can minimize collateral/preventable deaths.
Revere - What I understand you to be saying is that social distancing or isolation of well people does not constitute a public health plan for any community, but might provide some benefit on an individual or family basis (particularly during a pandemic peak). The University of Michigan did an interesting study on what they call "escape communities" in 1918 -- communities that suffered fewer cases of influenza than other communities. http://www.med.umich.edu/medschool/chm/influenza/index.htm. That study seems to illustrate both of your points: the only communities they studies had special geographic remoteness (and thus can't be duplicated in most of the world today), but the isolation seems to be a factor in these communities being "escape communities."
As a layperson, I appreciate all of your explanations and perspectives. Thanks.
Thanks, Revere et al, for those clear explanations. I should have seen the difference between the personal and the public.
I appreciate that there's a blog like this where I can not only read clear and balanced information but ask questions that are so well answered.
Yesterday while discussing the local effects of a severe pandemic with local officials, I was accused of being alarmist because I was saying "What if the CFR does not attenuate down to (insert whatever % makes you feel happy), but stays at anything like these present levels?"
The question was then asked, "So how will we keep from getting infected?" Aha ! Exactly !
And I would ask, how will we prevent our families from becoming infected if we are out in the community helping, and we bring the virus home? We had better have very good understanding of decontamination technique, at the very least.
The Australian "plan" is that there will be a CFR of 0.6%. Yeah right.
RobT: I don't think many things most people can do will be successful in warding off infection. Remember, though, that it is likely most people who are infected (and most people probably won't be infected in a pandemic any more than they are now) will survive. The mortality could be very high and occurring in a short period of time, frightening, but there isn't likely to be a good way to avoid it if it comes around. That might be wrong and you should do whatever you think is right for you and your family. But I think that's what the evidence indicates and we should be getting our communities ready for this.
Putting the whole burden on individuals to take care of themselves is the least likely to get us through.
regarding 'The Director of ..(CIDRAP)...says what needs to be said: are we sure this emperor isn't naked?'
Finally, an analogy that goes to the heart of the issue. Shit may roll downhill, but so does stupidity.
What's been achieved if people survive a pandemic form of flu, only to die from starvation, dehydration, lack of access to their insulin or dialysis machines?
IMHO, these types of situation could easily double the actual death rates from 'just the virus'.
And, as far as I can tell, tptb are planning to get overwhelmed and have to react (or wait for someone else to have time to react?) to mass surges in cadavers in perhaps ways the surviving public will find untimely, unhelpful, and traumatizing.
(And then say, "We had no idea it would be so bad, how could we have known?", and, claim we still have to listen to their "leadership" because "now is not the time for blame and finger-pointing..."("now"; "emergency", "martial law", ect.)
Can we just have the "Pre-Pandemic Preparedness Investigation Commission Hearings" now? Can't see it happening afterwards.)
Revere, you said:
"Managing the consequences means you get together with others in your community to solve the problem of how you are going to get through 8 weeks of significant morbidity, mortality and absenteeism. You ask if you have enough supplies and equipment (like respirators) for the critically ill. You arrange for overflow capacity, which you may have to pay for by making the health care system less efficient and more redundant by having excess resources. You examine those areas where "just in time inventory" is disastrous if supply lines are interrupted, e.g., fuel and energy supplies, a short list of pharmaceuticals like insulin, a few antibiotics, blood pressure medications, etc."
Every one of the things you mentioned are things that I've heard many of the regular posters say will be inevitable.
1. There aren't going to be enough respirators. Period (And if there was, not enough people knowing how to use them)
2. There aren't enough "excess resources" available. If they aren't available in a Pandemic, they aren't available now, in large numbers.
3. You can't change the JIT inventory, without changing the entire world economy.
And to ask all this for a "low probability" event? (I know, that's arguable).
Honestly, I hear that we are pinning our hopes to vaccines and antivirals, that won't work. But I'm not sure your plan is any better, pinning your hopes to something that can't work.
I've been giving these community preparedness issues a lot of thought lately. Revere is right, it's no good to just look out for ones self or one's own immediate family. But at the other extreme, expecting the " big government" (federal, state, county or city) to come to your aid is not only unlikely to occur, but potentially counter-productive if it did. Mass food and water handouts such as was done after Katrina and other natural disasters aren't going to work if there is a pandemic for a couple of reasons: one is the govt workers expected to coordinate and deliver such emergency aid are likely to be too ill themselves to do so. The other reason is that distribution of the handouts would require large masses of public to gather together at the distribution centers, increasing the likelihood of them catching and/or passing on the virus.
I think what is needed are small community centers, each servicing no more than 300 people, to store and make available emergency supplies, advice, and health care to the local community. Large cities could be subdivided into small workable neighborhood units this way. Firehouses, churches or community centers could be predesignated as emergency aid centers; and water, medicines and other supplies warehoused there in big storage containers. If they don't get used now for a pandemic, oh well...there's always some disaster or another coming upon us every few years. I think we might be able to mobilize this kind of effort ourselves in our own immediate communities through local city council members, red cross centers, churches and service organizations. If we can get them to buy into this plan, they can hit up the state and federal government for the funding to cover the costs.
Anonymous said: "Every one of the things you mentioned are things that I've heard many of the regular posters say will be inevitable.
1. There aren't going to be enough respirators. Period (And if there was, not enough people knowing how to use them)
2. There aren't enough "excess resources" available. If they aren't available in a Pandemic, they aren't available now, in large numbers.
3. You can't change the JIT inventory, without changing the entire world economy."
Communities can order more respirators to have on hand. If they wait for a pandemic to start somewhere, suddenly everyone will be doing the same thing and there won't be enough. But if they order ahead of time, they will have more than they would have. It might not be enough, but there will be more. They also need to start compiling lists of people who know how to intubate. Our university has a lot of students who were trained to do this but don't do it any longer. They could help out. Even ten more people who can intubate would be a big help. It won't meet the complete need, but it will meet some of it.
Surge capacity. They can start to increase capacity by building redundancy into the system, figure out how to convert regular beds to critical care beds and how to use beds that exist for other purposes to health care beds (motels, hotels, dormitories, etc.). They need to do this ahead of time to make it work best.
JIT. You don't have to change the way business is done, now. You just have to do it for a handful of things you know you will need. That's quite possible and do-able.
Whatever the plan is, we all know that when the time comes we'll just be making this stuff up. We need to look ahead for two reasons. One is the obvious, practical one, that we can do better if we think ahead. The other is that by empowering people and giving them something to do we will be increasing the chance that they will become engaged in helping the community instead of giving up and hiding.
An interesting exercise in preparedness is to make a list AND THEN OBTAIN enough supplies and equipment to ride out a 3 to 12 month disruption in the public/government supply chain. I did this, and it took some serious cash and time to implement it. I really cannot see how this could be carried out at the community, state or federal level. The expenditures would be staggering, not to mention the level of commitment from the officials in charge.
I believe the best way to deal with a disaster is to take reponsibility for you and your family, and help others in your neighborhood if at all possible. Relying on someone else is naive in the extreme. BTW I think the "government" is being honest about the situation, they have said if the shit hits the fan don't expect the Feds to ride in and save you. Amen. And, I never expected them to.
I saw this plan if you want to call it that two days ago and got on the phone with my regional guys and the bottom line was this, you are all right. Right about respirators, lack of community involvement, too much community involvment, not enough food, too much government interference, no meds, no redundancies. At the expected one month mark of the wave, they will know what they are going to have roughly by modelings and its not a good scenario at all folks. They are extremely worried that H5N1 will come roaring across this planet in the Indonesian way and this is about 80% mortality. They actually would like to see MORE people sick and surviving that people getting it and dying. This is from the regional PIO.
Nothing has made it slip its mortality against infection rate and that it has just caught them up. Social distancing and all of the other things just might not work at all because of the eventuality that at about the 1 month mark people are going to flat be out of everything. That means they have to venture out into people situations. I am military and hold briefings and that means my kids too. Required reading material each day in the kitchen.They are a tough little group. They know that Dad will not sit around and let this happen as long as there are supplies to be moved, situations that can He can fix or that there are people-Americans that need help. They also are in the knowlege that Dad might not come back if it comes. I even went as far as to buy some very long range radios to cover the 30 miles of separation we will experience. My blockhouse is the alternate EMA site for my county. I have planned well but neighbors who are separated by only two houses I have had a Hell of a time to get them prepared. They just dont believe it.
I was told by the PIO that the system will grind to a halt roughly at the one month mark one way or another and Revere might agree with that from his experience. Power grids will snap at about the one month mark from the first isolation or quarantine, maybe a little more or less. When that goes we will have Governors turned into barons and unless those guys declare it a national emergency in their state, they will be able to do anything they want. What if they do declare it? Wont change anything. Medical facilites at even a 5% mortality will turn the hospitals into death houses. 58,000 in Tennessee in a fast manner alone. Cases run into the hundreds of thousands. That 58,000 is based upon care being available. I suggest its low by about 1/2.
As part of the non plan plan Harvard sent out surveys to the doctors and 1 out of 9 responded that they would go in if a pandemic flu was underway. Mind that its partially not their fault, its the system. So many are specialists and I asked my favorite Ortho person Dr. Ana P. if she would come and she said that she would if she were called directly because thats the oath. On the other hand she said, "What could an othopedics doc do?" She said I dont know how to run a ventilator. I might get someone intubated but to actually treat someone is a different story is what she said. This is from one of the best doctors I know and like Revere one that flat cares about the outcome.
Revere has this one pegged but to unpeg it isnt a Bush problem or a State problem, its our problem. We have to finally be responsible for ourselves and that is a scary thought to many people. We have always had big government around to bail us out in degrees of ineptness. We always knew they would be there eventually. Not on this one. They will hold the army out until the last minute and then send them in as the situation disintegrates. Where will it be? The NE, SE and the key recovery points to protect infrastructure for recovery. My opinion? They are expecting high numbers and will not acknowlege it because to do so would cause a panic now. Answers? I havent got many except to say to prepare. No big answers from this end of the fence except to say think of it as ants. Lose the queen and they chose a new one. Lose the workers and they grow a new one. Hit that mother with a can of Raid and then tell me how many make it out. H5N1 is a can of Raid.
stu: I think you mistake my intention here (which is my fault for not spelling it out). I am neither saying you should wait for someone else to take care of you or that you shouldn't make personal plans. My purpose is different.
I have spent my life in public health. The solutions we talk about here and that I think will ultimately be important are the ones that apply to a community, not to individuals. We know that those are the things historically that have made the difference (public health, not medical care, which is individually oriented). I have no problem with people who are able to providing for themselves and their families. I encourage it.
What I don't think is appropriate is to abandon the community mobilization that will make the difference. No matter how dire the circumstances, people will be trying to help their neighbors. That's always been the way it is. People rise to the occasion, no matter how cynical the view ahead of time. Not everybody. Maybe not most people. But always a significant number.
We can both encourage this and make it easier to do so for each other. Again, experience tells us that communities that mobilize that kind of mutual aid will do better than communities that don't, so it is an essential element in preparation. That's what we aren't seening enough of in this "plan." There is too much emphasis on everyone looking after themselves (not a bad thing) but communities that go beyond that will do better than those that don't.
I hope this clarifies my views on this.
Hi Revere,
I understand your points, and agree that some things would best done as a group, but it will difficult to faciliate in a pandemic. I would be concerned about the consequences of contact with infected individuals, unless I had protective gear and a decontamination station I'd be reluctant to even go out.
"They are expecting high numbers and will not acknowlege it because to do so would cause a panic now"
Tough- it wouldn't cause a "panic"; it would cause the responsible people to try and prepare, some people to still be in denial, and some troublemakers might make trouble before enforcement/military is sick.
Cause a lot of outrage at the current politicians and public bureaucrats who had all this time and didn't put out plain, unspun, warnings. It would be well-deserved outrage.
There are scientists and others who do think it can still make a positive outcome what choices individuals and sectors and communities make, and have better ideas than just go through the motions and keep to the status quo, and I'd rather have them for barons, if anybody. (And I would think the military and health care workers, grid workers, farmers, parents of minors, ect, might also; what kind of situation/recovery will there be given the present course? )
Stu mentions the expense and time it takes to obtain enough supplies to ride out a 3 to 12 month chain. For most people, who are barely able to cover their regular living expenses month to month, this is so daunting as to make them give up ahead of the game and just hope for the best (that a pandemic never arrives) or second best (that if it does arrive the gub-mint will step in and save the day at no expense to them.) Keeping that in mind, to convince people to prepare at all one must keep it super cheap and super simple, I have created a bare bones budget pandemic preparedness list. This is down to the "just enough to keep us hydrated and fed" level, with the minimum for health care and entertainment. For a 30 day period of isolation, it would cost a single individual about $225 to stock, a family of 4 about $520, which is not too bad. Families could buy about 1/4 of the supplies each week so that in a month's time they would have all they needed. My thought is that perhaps once they have started this, they will find it easier to add to the supplies to make a more complete set, but even without additions it would work. Some of the other preparation lists I have seen include things that would only be needed if one were forced from one's home, as in a hurricane or earthquake. My list presumes the isolation is occuring at home, and the only disorder there would be is lack of utilities (no electricity, no water supply). I realize this doesn't take care of "community needs" or health care emergencies etc.; but until we can get individual households to actively plan their own isolation and survival, the rest is a moot point. I am going to try to attach this to my own little website, www.freeoriginalbooks.com so you can access it if you want to. Go to the "Services" page and look for an entry "budget pandemic plan".
This is an interesting thread, and I'm way late to the party. A few things occur to me.1. Read Greenhammer's description of his neighborhood "awareness meeting"2. It is no harder to cough into your sleeve than into the air, if it might help, why not do it?3. There is no way in hell a quarantine can be enforced. Given that, many well informed people will voluntarily isolate/quarantine themselves, so educate them and then let them know when itis time to practice "social distancing". I couldn't hurt, and it might help.4. Finally, remember that if 30% of us get infected and 5 (or even 50)% of us die, 70% will remain unscathed. That's cold comfort to someone who is in the 5%, or whose loved one is, but is it is cold, hard fact. Pandemic flu will not be the end of the world, at least not for most of us. What we really need to focus on is that we need to do the things that will keep society up and running while half of us are off the job being sick or taking care of those who are. Then, we will need to bury our dead and move on.Maybe we can restructure society to consider the common good. (but I wouldn't bet on it)