A recently published Commentary in the Journal of the American Medical Association (JAMA) raises some interesting and serious questions about conventional efforts for pandemic flu preparedness. The author is John Middaugh of the Florida State Health Department, a long time public health professional. The last I saw him he was in Alaska, so he seems to have put quite a bit of distance between his current and former places of employment. Indeed the question of people distancing themselves from each other is a central theme of the Commentary:
Although continuing to invest in diverse aspects of the national pandemic preparedness effort, new resources and attention should be devoted to societal values and cohesiveness. The question, "What if all the planning for social distancing and nonpharmaceutical interventions does not work?" should be addressed. How will individuals be able to work together to support each other and maintain the functions of communities and society in the face of catastrophic illness, morbidity, and death? How can educational efforts teach individuals to fear what is appropriate and not to fear what is not appropriate?[snip]
Physicians, other health care professionals, and public health policy makers must recognize that a pandemic will sweep through a community very quickly, and that most individuals will have mild disease, fully recover, be immune, able to help others, and continue to work. In 1918, citizens throughout the United States rallied to help each other in face of the catastrophic pandemic. [cite omitted]
Considering that the current national approach is based on limited evidence, care should be taken to ensure that current policies will not cause more harm than good. Has the current synthesis of scientific evidence and practical experience led to plans that will provide communities with the greatest opportunity to survive the next pandemic of influenza? Investing in maintaining interpersonal bonds and social discourse in the midst of overwhelming tragedy may prove to be the most effective preparedness planning for the next influenza pandemic. (JAMA; subscription firewall)
This is the dilemma. Community resilience enhances overall outcome but social distancing is advocated for individual protection. Middaugh observes there is little scientific support for some of the recommendations, other than they seem like common sense. But might each person acting in what they think is his or her own interest actually be worse off because the community is weaker?
Perhaps we are drawn to Middaugh's argument because it seems similar to the drum we have been beating here for three years. The way to prepare for a pandemic is to strengthen the public health and social service infrastructures. That means investment, paltry and lost in the noise in a 3 trillion dollar budget, but still requiring a much greater allocation than now. Indeed Bush's proposed budget has cuts in public health and social infrastructure. We are not saying exactly the same as Middaugh but we are locating the problem in the same place. Communities that are atomized with weak interpersonal ties have done worse in pandemics than those that are socially robust and resilient. Middaugh asks if the current recommendations for pandemic preparedness will have unintended consequences by weakening our bonds with fellow citizens. We suggest ways to strengthen those bonds via investment in public services.
Two sides of the same coin. Unfortunately that coin is pretty small compared to what is needed.
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Two sides of the same coin. Unfortunately that con is pretty small compared to what is needed.
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Thats not a Froidean slip is it ?
DARWIN
Revere, a couple of things either disturb or, confuse me. If I have misunderstood your above statements I apologize. It wouldn't be the first nor, the last. But, I am going to respond to what I think it is you are proposing.
First, your argument is predicated on a low CFR. If H5N1 is responsible for the next pandemic, I remain unconvinced it will suddenly lower the rate from over 60% to 2.5%. How severe the actual rate is will have a huge impact on how individuals react to the situation. I continue to hope I am wrong.
Secondly, I am also somewhat sceptical of individuals suddenly increasing interpersonal ties. In 1918 we had far fewer people migrating to new locations. And when they did, there was a significantly greater likelihood they would use chain migration rather than a bold move to a new spot without any close ties. Our society is far more mobile and much more likely to include a move where we know no one. We are now a nation that does not interact with our neighbors to anywhere near the same degree our ancestors did. So, how do you propose to cement interpersonal ties in people who have resisted doing so for the last decades? It takes an effort, work in fact, to make connections with strangers. How many of us are willing to do that and why would we?
Ties require trust. Our news media encourages distrust. There is no more likelihood of living next door to a murderer or a rapist now then there was in 1950. But, how we interacted in 1950 and how we behave now towards our neighbors, is vastly different. The threat is the same but the perception of the threat is not. In order to encourage a significant number of people who are willing to volunteer their services during a pandemic, you are going to have to virtually re-program them. You are also going to be doing it under pressure from the news media to maintain the status quo of mistrust. You are asking people to put their lives at risk and, not go to work but rather out into the streets to help their neighbors. You want them to risk life and salary for a stranger. While I too am cognizant of some people who always rise to the occasion, I wonder how many there actually will be even with a huge campaign of 'get to know your neighbor'.
Realistically, I am sorry to say I don't think it is going to happen to any significant degree. I do think however, it will be more likely if more individuals are prepared in advance. If I have more food, a way to keep warm during a power interruption, and other precautions planned in advance, it will enhance both my willingness and my ability to reach out to my neighbor. But until that happens, I think it will be every person for him/herself, and the rest be damned.
Darwin: LOL. I hope not. Correcting it now.
Shannon: The more cohesive the community the better it will do and the less cohesive the worse it will do. So we should encourage things that promote social solidarity and think carefully about things that don't. I think that's what Middaugh was saying and I agree with it. I don't know if the CFR matters for that, but insofar as there is high CFR it might matter more IMO.
I honestly believe this is the source for the development and spread of religion. Some argue religion has an evolutionary connection. I cannot argue against that concept. However, when I went to church for the first it me on months I could see the simply sense of community. Within that community trust, respect and caring form. I don't put much faith in a deity, but the structure stimulates community and hence a resilience against difficult times. Outsiders are on their own the community supports itself. Just like an ecosystem requires a biodiversity for resilience, so does a human population. Tight communities will fare best during a pandemic - I have no doubt. However, if the mortality rates remain what they are, and infectious rates are average, I, like Shannon, think most communities do not have the required resilience to combat additional stresses. These stresses could be a failure in police services, food distribution, electrical services, governmental structure etc etc. I wish I knew the critical value at which these additional stresses would be triggered. It would make the difference between community success or not.
Just some thoughts and I have no idea if they have any merit.
Probably,
in a pandemic almost everyone will be exposed to the virus, most within the first 2 months,
some will develop disease, some not. Those who recover will be immune for some months.
Social distancing can only delay this exposure, and maybe also reduce the fraction
of exposed people who remain asymptomatic. They may develope immunity through
asymptomatic infection or vaccine or are finally infected with a less virulent virus.
Correct ?
anon: If social distancing delays the disease, there is the hope that a vax might arrive in the extra time for the uninfected. I would anticipate (maybe incorrectly) that the second wave might infect survivors of the primary wave, but survivors would have an enhanced survival rate.
Regarding the cooperative -v- social distancing issue, my feeling is that possibly the optimal social structure for survival might turn out to be a mixture which varies with virulence.
I suspect the answer might be nuclear (extended family size, 10-30 people) cells that minimally communicate and trade with around 6-10 nearby cells employing strictly established protocols for trading.
I would expect those protocols to evolve rather rapidly. (Darwinism at work.)
The answer to Anon is predicated on heroic, self sacrificing medical researchers slaving to produce a vax. In the event that a vax is not found, those nuclear structures would provide a seed culture as the virulence (hopefully) attenuates.
I follow Shannon's post; during the pandemics, self-protection in terms of social distancing and reducing personal contacts is a wise decision. To prevent one's self to become infected victim as a bioreactor is a responsible attitude.
To develop more cohesive community should be carried in normal condition and time. And the meaningful network is maintained constantly when we are in good well beings. Like religion to be practiced regularly, not in panic situation.:-)
I think that the evidence for for non-pharmaceutical intervention (social distancing) alone is sketchy and anecdotal at best. In review statistics from 1918 Spanish Flu that CDC and HHS use the actual infection rates in the different cities is highly disputed. Also even the best historian can not agree which cities took which measures. I think that the most prdent course is one which tight knit groups in the community (e.g. Church groups)band together and plot their own survival plan. Regarding the governments efforts all I can say is "shame shame on you". You spent 3 Billion dollars on Tamiflu which you can't figure how to distribute. It sits in a warehouse somewhere with an expiration date only a few years in the future yet no one even tries to rotate the stock. The original plan was for the state to figure out how the Tamiflu was to be distributed as the Federal Government could not. Now the state too has given up on the idea and has transferred the entire responsibility of preparedness to the community. The Tamiflu is not even going to be distributed. Meanwhile all attempts at preparedness by the community are stymied due to the fact that the Federal Government refuses to waive laws (COBRA, HIPAA, EMTALA, FDA, EPA, etc.) that would be necessary for a proper preparedness plan. The current Health Emergency codes transfer power to the State Public Health department but not the community. This not going to do anything to help the community. We have one Public Health Physician for our 15 county district! If the Federal and State are not going to provide us help they should at least stand aside and allow us to prepare without fear of legal reprisals or of the State officials "reallocating our property" from those of us who have prepared to those that have not.
In 1918 we had far fewer people migrating to new locations.
And in 1918, the proportion of the population who were essentially autonomous and self-reliant was far greater than it is now.
America in 1918 was still predominantly rural and agrarian. In many cases, what are enormous metroplexes today were at best large towns.
There were no critical dependencies upon imported energy and imported manufactured goods. Communications and transport were slow, so instead of just-in-time deliveries, there were ample local stores of warehoused merchandise to be drawn upon.
And people, most critically, had the skills and the mindset to take care of themselves and their families when they were called upon to do so.
Today? Most Americans are urban and suburban. The majority of them have never set foot on a working farm or ranch in their lives. Food doesn't come from a plot or a pasture for them: it comes from a supermarket, as it has for their whole lives. Until one day when that mechanism may stop. At which point things will get ugly.
I've seen what happens when modern urban Americans have to endure even relatively modest deprivations, say, having to go without grid power for a day or two, or without water in the mains. It's not pretty. They are confused and helpless and angry. Dangerous to themselves and to others.
My guess is that anything over CFR5.0 and a high attack rate would crumple the social and economic fabric of this country like a wet cardboard box being stomped on. It would take down the global economy, upon which we are now highly dependent for daily functioning.
Remember that a five percent case fatality rate, indexed against the three hundred million (and rapidly rising) population of modern America, is fifteen million dead. Nothing comparable to that has happened in living memory. It's hard to find parallels in the entire national history. It would be a trauma comparable to that of the Civil War, but far more economically damaging than that was.
The hell of it is that there is no speed-of-light problem here. It's technically and economically and medically possible to greatly increase the resilience of modern US society. The issue is, rather, cultural. A metacompetence problem. Americans don't perceive that they have to prepare, and so there will be no political consensus to do so on a national scale, unless and until it's too late for such effective action. And I don't know how to crack the nut (or crack the thick skulls) of that collective ignorance.
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You spent 3 Billion dollars on Tamiflu which you can't figure how to distribute. It sits in a warehouse somewhere with an expiration date only a few years in the future yet no one even tries to rotate the stock. Posted by: Gregory Walter MD
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There is no need to rotate stocks now, likely not even in the next years. The expiration date refers more to the gelatine capsule than the substance.
Many stockpiles by governments are not in blister packs but in larger containers to be mixed in a syrup. And there is an easy solution to a capsule as well.
Currently it is no issue and if it becomes an issue its mainly a legal issue (to expand the expiration date) and a matter of time for the ongoing expiration tests of different preparations.
Once the flu goes pandemic, as in 1918, everyone will be exposed sooner or later. You can run but you can not hide.
Those who hide and escape infection in the first wave may find out the 2nd wave is even more deadlier, as it was in 1918. Don't try and outsmart mother nature. Some isolated towns in 1918 tried to close themselves off and failed miserably and suffered more than those towns who allowed nature to take it's course. In todays global economy, nations doing the same will suffer the same fate.
Those who are susceptible to the influenza, will sicken. The vast majority will live, some will die, perhaps many.
During the outbreak, no one will really know what the final toll will be, so there will be uncertainty and fear.
Essential services must still must be provided for, food distribution, health care, electricity, gasoline distribution, banking, police, fire, body removal, funerals, etc.
Group gatherings will be discouraged, no parades, no sporting events, schools must be closed, as would movie theaters, etc. And people still need to work, many live from pay check to pay check, but those who are ill would be discouraged from going to work, unlike today when missing a day of work due to illness is frowned upon, and some companies have plans for people to work from home in a pandemic.
Social interaction will continue, more via phone and internet than person to person obviously, but that is a far better situation than 1918. If a close friend or family is in need, are you going to ignore them?.
No. In 1918, you would not even know a close relative or friend had sickened or died at home unless you went to visit them or someone came in person to tell you.
Fear is your worst enemy in a pandemic. Governments role should be to control or limit this fear, so that life goes on, but our government feeds off your fear since it allows them to control you and become more powerful, and they focus on quarantines, forced isolation, martial law, all which would make things worse.
The critical need in a pandemic from a local health care view is tents or buildings (schools, domed stadiums, etc) converted temporarily to hospitals, beds, nurses, and a triage setting to screen potentially infective persons prior to being admitted to main hospital for other purposes, emergency surgery, heart attacks, etc. In such an emergency, government should assume all health care bills for the uninsured.
This requires no significant investment, just good planning that focuses on solving the problems that will be most relevant during a pandemic.
In 1918-1919 the death rate from flu and pneumonia was 8.2 per 1000 people (or 2.5 million deaths from influenza and pneumonia today). Almost 1/2 of deaths occurred in cities and towns with over 100,000 in population as of 1910, and our country was hardly an agrarian society in 1918 but a mix of urban and rural. Today we have a significant suburban population as well with easy access to health care w/o taking public transportation.
Poverty and working conditions in the cities were harsh, especially for new immigrants of which there were many, and we had no welfare umbrella in those days like we do today. There were no great stores of food in warehouses and supermarkets like today, much food was brought into the cities daily or weekly from the farms and was perishable. Most people travelled by public transportation and not in cars like today.
People forget that in 1918 we were in the midst of a World War and many people in Europe were hungry, sick, under tremendous stress for other reasons than influenza, conditions that depressed their immune systems, and there were no antibiotics, so 50 million died (the war killed only 9 million).
Secondary infections causing penumonia from bacteria were a major factor in many deaths attributed to the influenza, and there were no antibiotics. Troops in the US were in densley populated barracks where flu could spread like wildfire. People travelled by train, spending many hours and even days to get from one city to another and confined to cabins where 1 sick person would expose everyone in the cabin to the flu.
I suspect far more people today will be saved from prophylactic use of antibiotics in a pandemic than antivirals like Tamiflu which may not even be effective against the pandemic strain, or vaccines. Yet we only permit cattle, hogs and chicken to be given antibiotics prophylactically, so I doubt there are any plans to distribute antibiotics to people in case they come down with the flu and prevent a secondary infection.
Good analogy Marquer.....
We are preparing to weather a 5.% event and is expected suddenly. Suddenly what do they do if its 10 or my very hopeful that its only 40%?
And prepare like it will be 80%. You can always rotate it out and give it to the food banks before expiration in the meantime. Its like I said before. Where in heck in the US hasnt something happened recently. Power has gone down for more than a day at a time in the last 40 on three instances. I whip on the ginny, pop a top and get to watch the game. It was mighty cold for some people in Memphis over the weekend (20's) and they had no light or heat. They opened up shelters but in panflu there wont be any because they would be infection houses.
You guys in Ohio east to New York and on into Boston this is a big deal. No fuel means no lights and likely in winter. Toughening a community? It doesnt take a village, it takes everyone removing themselves from the village idiot status and taking responsibility for themselves and family first. Then you assist others. Anyone depending on government for this one is going to draw back a bloody stump when they reach their hand out for aid.
Power has gone down for more than a day at a time in the last 40 on three instances. I whip on the ginny, pop a top and get to watch the game.
I have been observing increased grid fragility on the West Coast. The utilities here are not building the sort of tough infrastructure that they once did. Money must be saved for the executive bonus funds! Add to this a shortage of line crews when things do break.
My understanding is that some huge percentage of Pacific Gas and Electric's high voltage line workers are now over age 50. The utility is frantically trying to keep these people from taking early retirements (spending a few decades climbing up and down outdoors in all weather takes it out of the body).
Once those skilled workers do leave, it's Katy bar the door. Typical California high school graduates these days don't know the difference between a volt or an amp, can't add or subtract, and very likely don't speak or read much English. Or if they have some rudimentary English, it's a slurred, slangy, barely intelligible ghetto-barrio patois. Best of luck training up a transmission line crew starting with that lot. I am betting, like Randy, on the household generator. And am betting that we may have to rely on it for a long time.
It was mighty cold for some people in Memphis over the weekend (20's) and they had no light or heat. They opened up shelters but in panflu there wont be any because they would be infection houses.
Americans collectively have forgotten about cold. In all of this hysteria (perhaps justified, perhaps not) about global warming, we fail to recall (because we are warm and toasty right now with the grid up) what a deadly thing bad winter weather can be (and will be, with the grid down).
I know people who own an architectural-showplace New West yuppie house out in the Rockies, in an area where it is common to see -30F overnight lows in deep winter.
If I were living there, I would have an Army Arctic sleeping bag for every resident and guest, stashed inconspicuously in the basement. Those big windows that show off the big mountain views are going to result in big heat losses really fast if the grid goes down. And if the grid stays down, it doesn't matter how well insulated the house is -- it will equilibrate with outside temps over time.
Do they have the kind of kit that I am recommending here? No. It has never occured to them that they might someday need such. The only blankets in the house are electric ones, or light stylish yuppie throws. I don't think that is going to work out too well in the dark deep freeze.
They do have a fireplace. But they use it decoratively. And do not have a large wood cache. I don't think they realize how fast a cord of wood goes away when it is the only heating and cooking source for a large household.
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