Our Responsibility Is To Teach The Basics

I’m going to cheat a bit and use some of the wonderful material that’s been posted already, both by commenters and by blog posters. This is from a recent online interview of Nedra Weinreich:

Many of the people who are leaving comments are those who have been working on and thinking about this issue for a long time (professionals and private citizens), and their input is extremely valuable.

And in reading the input we can see a few important themes emerging from the conversation on the HHS blog.

• The information about pandemics does not seem to be disseminating as well as it needs to, at least up until now
• There is a role for government, using its authority, in disseminating information (and in legitimizing others to do so)
• Once legitimized, there is also a role and responsibility for community leaders and members to disseminate information, using whatever social and professional networks are available

Sister Patricia Talone wrote:

Education, information, and repetition will help the public to prepare for a pandemic. But, while facts are important, we need to change hearts. We need to remember that we are our brothers’ and sisters’ keepers, that we are responsible not just for ourselves and our families but for the common good. Until we move into a more communitarian mind-set we will not even be able to engage the notion of “public health.”

So, let’s do all of that. Since we are in the position to communicate, and it’s our responsibility to do so, what are the pandemic preparedness basics that people need to know? What are the possible outcomes that motivate us to work for the common good?

Much of what follows has been pointed out by our commenters. For many of us, the impetus for understanding the possibilities goes back to 1918. We know the Great Influenza killed upwards of 50 million people worldwide, and that pandemics have happened before (more here in The Need For Personal and Community Preparedness). We know that, while it’s unpredictable, some previous pandemics have occurred in multiple waves (Congressional Budget Office report), each with different effects on the population:

The pandemic would probably spread across geographic areas and vulnerable populations in waves. In any given geographic region, each wave could last for three to five months, and a second wave could appear anywhere from one to three months after the first disappears.

At any given time in the midst of a pandemic, a third or more of the workforce may be out (illness or caring for family members), and that statistic most assuredly includes health care workers, first responders, key parts of the Just In Time economy delivery system, and the utility infrastructure workforce.

We also know that children can spread illness throughout a community and when packed into schools, are easily infected and bring viruses home. It is for that reason that CDC suggests closing schools for up to three months in case of a severe (category 4 or 5 ) pandemic. That closure can’t take place at the last minute; flu can spread before one appears to be ill. So, to be effective, closure would have to be early and sustained in order to delay or reduce the impact of a pandemic on a community, and parents will insist upon it to protect their children. Taking into account the school closure, the Department of Homeland Security (April, 2007) states that

The population may be directed to remain in their homes under self-quarantine for up to 90 days per wave of the outbreak to support social distancing.” (page 7 of 37)

There’s quite a bit more in that DHS document, including

Since a community will continue to require public services, service organizations must take a pro-active stance and be prepared to recognize hazards associated with a potential outbreak and implement prevention and protection measures for their workforce as soon as a suspected outbreak occurs.

So, there’s a community factor, a workforce factor, a school factor and health care factor (adding in the over-burdening of the medical system with so many patients being ill). But we also know that vaccine will not be available for up to six months after a pandemic starts (production time, and not knowing which virus to use in advance), that there will be shortages of hospital beds, antivirals, and personnel (’staff’ and ’stuff’), requiring rationing at some level for at least some things.

Note that I have not mentioned H5N1 until now; if the pandemic were to occur with this particular virus, with its current 60% case fatality rate, and its propensity to affect young people, things would even be more grim (1918 was devastating with a CFR of 2.5%). The next influenza pandemic could be H5N1 or, the current H7N2 infection in Wales, or an H9 not yet on the horizon.

So, with that in mind, and with 90 days suggested by both DHS and CDC for severe pandemics, and with the severity, timing and viral type not predictable, what’s the community to do? As individuals, we have to take responsibility to start preparing now., As community leaders, we need to help HHS get that message out, in whatever ways we can. It is a shared responsibility, and not simply one for HHS to do alone (or for community leaders to do alone, for that matter).

And, as has been pointed out by commenters, that acceptance of responsibility has already happened. It is for all of the above reasons that the online community has discussed the need for stockpiling of food and water for up to three months (to match the 90 days cited by DHS, and the three months of school closure for severe pandemics suggested by CDC) and started the process of stockpiling food and water, and thinking through the implications of school closure, workplace disruption and voluntary canceling of social events, or in some cases, self-quarantine. It must be an individual, a family, a community responsibility to consider preparation, and to work out ways to help those vulnerable populations that cannot help themselves (Sister Talone’s point about the common good).

The Feds have a vital leadership role in all of this (well expressed by the commenters). And not everyone will prep, and not everyone that does so will prep for three months. But our responsibility, nonetheless, is to get the message out as best we can, with whatever tools are available to us, that there’s a recommendation for prepping and a reason to do so. We’d be shirking our responsibility if we did not at least try to teach the basics and having done so, communicate the need to prep.

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Challenges we face:

I’ve been pondering the question of what challenges we, as leaders, and as a nation, face in preparing for a possible pandemic. In my opinion, one of the biggest challenges we face is our dearly held value of independence. It manifests itself in many guises: freedom, rugged individualism, autonomy, “don’t fence me in.”

Last night I sat transfixed before the television screen as the national news told the story of the Atlanta man now quarantined with XDR TB. The story fueled public panic and sensationalism about the case. Thankfully, the New York Times and the Atlanta Journal-Constitution were more informative than histrionic.

As an ethicist, I know that all the facts of a medical case are seldom told in the press, and there is always a story beneath the story. So I cannot presume to judge the issues of informed consent, autonomy, compliance, etc. existing in the case. But it does seem paradigmatic of a typical U.S. response to restrictions upon us. In the face of limitations - flee, resist or assert yourself.

Recently I witnessed this at O’Hare Airport standing in a long line of displaced passengers. Flights had been cancelled because of “weather.” One irate man shouted to the clerk, “You can’t do this to me - I am an executive platinum member.” As if that had anything to do with weather, delays or cancellations.

Education, information, and repetition will help the public to prepare for a pandemic. But, while facts are important, we need to change hearts. We need to remember that we are our brothers’ and sisters’ keepers, that we are responsible not just for ourselves and our families but for the common good. Until we move into a more communitarian mind-set we will not even be able to engage the notion of “public health.”

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Preparing for a Pandemic

Albert Ruesga’s comments about the lessons we have (or have not) learned from Katrina are right on. For anyone who has visited New Orleans after Katrina, it is patently clear that the poor - including the working poor - who still live there continue to suffer. There is one clinic in all of St. Bernard’s parish, operated by Franciscan Missionaries of Our Lady Health System. This clinic tends to the needs of the elderly, those trying to renovate their homes. Sit in the waiting room for even one hour and you will witness saddness and despair, as well as tremendous heroism on the part of both patients and providers.

In a pandemic, those who have cash, computers, faxes, etc. will be able to stay home and avoid contact with those infected. This is not true of the millions of persons struggling just to tred water financially.

Hospitals, particularly those in poor, inner-cities are already struggling beyond the breaking point. Ruesga’s urging of bolstering of the safety net for the poor is absolutely correct. Although I do not have much hope that this will happen in the near future.

Furthermore, as an ethicist, I am keenly aware that the ethical community is still pondering, even agonizing over the terrible decisions that medical personnel had to make during Katrina.

Hospitals, clinics, urgent care centers and physicians offices are not sufficiently prepared to make ethical decisions necessary in a pandemic. This is not to say that health care professionals are not moral persons, but, for the most part, we live in a time of “rescue medicine.” The Iraq War has advanced medical skills in this area, saving the lives of many soldiers. Physicians and nurses see their vocation to save patients. Triage in a pandemic will be quite different than in an ordinary ER situation.

Hospitals and clinics can and are educating their staffs about the probability of this disaster. But we need the help of the media to get the message out to the public that this will not be “medicine as usual.”

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Leadership and Listening

I need to persuade local folks that planning for a pandemic is reasonable, prudent and necessary. This is a simple objective but an enormous task. “Local folks” means Boards of Education, businesses, and ordinary citizens have a role to play in planning, in addition to faith groups, public health officials and city/town officials. The whole community. It can only be done as a community and in manageable pieces. For them, the direction of why to do this (and to some extent how) needs to come from the state, and the state feels that, in turn, it really needs to rely on the Feds. This is understood by all parties. Progress is being made on all fronts (albeit slower than optimal for implementation purposes). What’s needed is:

• Validation
• Legitimacy
• Cooperation

As a pandemic planner, I can share information for educational purposes, centered around why we need to categorize pandemics like hurricanes (category 5 is severe) , why we need to be St. Louis and not Philadelphia, why parents need to be aware that the schools may need to close (and for as long as three months in case of a severe pandemic - kudos to HHS and CDC!!!) and why individuals as well as schools, organizations and businesses all need to prepare. I can use my hospital platform. I can persuade, wheedle and cajole, plan, teach and reason. I can suggest it be part of an all-hazard approach, and I can support the major efforts by our local public health officials in order to give the same message with different voices. So there’s a lot that a local planner can do, but not everything.

On line, I can write essays and blog posts, convey information, provide links and sources, and even provide a virtual gathering place to exchange information, including ‘best practices’ when it comes to personal preparedness, local presentations or international and state plans. That was the purpose of starting Flu Wiki, and it (and the other online sites) fill that need in much more detail than is available at the excellent (but non-interactive) pandemicflu.gov. In short, I can make the best case I can as to why folks should pay attention to this, even though the threat is over the horizon and not in plain sight. And there is validity to this approach:

Governmental plans for an influenza pandemic are missing an important opportunity to improve US preparedness, according to two new reports: They are not reaching out to communities and grass-roots groups that could refine plan details and increase public support.

Meanwhile, ad hoc communities and preparedness alliances are forming—in the real world and online—with minimal input from government planners. And, confirming the reports’ concerns, some members of those communities say they have networks and resources to offer to official efforts, but are frustrated by their inability to make themselves heard.

Meanwhile, institutional planners need justification for the money spent on supplies, planning and personnel (what Dr. Eric Toner at UPMC calls ‘staff’ and ‘stuff’). And infection control nurses and others need support to question their institutions as to whether pandemic plans exist and what their actual status is. They need clear answers and ‘I don’t know’ is more acceptable than ‘you don’t need to know’.

That message isn’t only for institutions. Many individuals feel that even two weeks of prep are not enough and that if the schools will be closed for 12 weeks, and if waves of illness are potentially six weeks and multiple (unpredictable, but with historical precedent), even larger stores of food and water may be needed. That’s a lively and vibrant debate, and you’ve heard from commenters already how they feel about that in the different posts. They are ready, regardless of length, to do their part to personally prep and persuade others to prep (see also Michael Coston’s post, The Stuff That Solutions are Made Of).

However, individuals and even experts advocating preparedness can’t bring that “official stamp of authority” that preparing is valid, reasonable and legitimate. This must come from government. All parties concerned want a clear message from HHS (and also from state Departments of Public Health, and federal and state Education Departments). People who prep are not hoarders, fringe people or whacky survivalists. Institutions who prep are not wasteful or off-mission and businesses who prep are not imprudently taking their eye off the bottom line.

In addition, resources need to be mobilized for vulnerable groups who cannot do this by themselves. All of this need not be done by government, but the motivation to do it will require it come from official sources. Those who are slow to come to the planning table (like state and federal prisons and corrections departments) cannot be brought there by any other means except official stimulus.

We need HHS and the Federal government to do what CDC does with risk communication: be first, be credible and be right on the issue of pandemic preparedness. We need a crystal clear message that the respective organizational CEO’s (including governors) need to take this seriously, and truly appreciate the efforts that individual and community planners are making on everyone’s behalf. Only then can our collective efforts begin to take hold.

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The Stuff That Solutions Are Made Of

· What do I need from the Department of Health and Human Services — or others — to be able to make a contribution?

While a pandemic would be an overwhelming event, one that no government could possibly handle on their own, we have a secret weapon at our disposal, one that could well change the course and outcome of a crisis.

That weapon? We, the people.

Ordinary citizens like you and I. We are the stuff that solutions are made of. The States and Federal government can make plans, and prepare on a macro level, but ultimately we are the ones who will have to answer the call in our communities.

We’ve grown accustomed to treating our nation like a 5 star resort, where if a problem with the accommodations crops up, we call the front desk and complain.

“Hello? I’d like to report a pandemic in my room. Please send someone up right away. Thanks“

Under normal circumstances, that’s how things work. We pay our taxes, and in return we expect the government to handle the big problems for us while we concentrate on working, raising our families, and chasing the fabled American Dream. We aren’t always satisfied with the results, but that’s our system, and so we generally sigh, accept what we get, and go on.

Sometimes though, perhaps once in a generation, a crisis comes along that is simply too big for the government to handle alone. When that happens, they must turn to the people for help. The last time the government did this was during World War II, and history shows it was the right move. In fact, the efforts on the home front made the difference in the outcome of that war.

The corollaries between then and now are remarkable.

In 1941, we watched from a distance as the war in Europe raged on, and while we we’re sympathetic to those fighting aggression and annexation in Europe, we felt we were protected by two vast oceans; that it wasn’t our war. We lent support to England and Russia with the lend-lease program, but were unwilling to join the fight.

It wasn’t until after Pearl Harbor, and the destruction of the Pacific Fleet, that we felt our backs were against the wall and our nation rallied. It was, we realized, no longer a European problem; it was our problem too.

After the shock of December 7th, we rapidly mobilized a great nation.

Millions of men and women flocked to recruiting stations to enlist, knowing full well they were going in harm’s way. My father was one of them, all of 17 years of age when he joined the navy. From cities and farms they came, because their nation needed them.

During those early dark days of 1942 the outcome of the war was in real doubt, as we’d joined in late, and were starting with a diminished military and an economy still lagging from the effects of a decade long depression. There were many who believed the war was lost before it started, and we should simply capitulate.

But a miracle of sorts occurred. Not unlike the one we need today.

On the home front millions more joined the war effort.

Housewives took off their aprons and donned tool belts, went to work in shipyards and airplane factories, and the legend of Rosie the Riveter was born. Ordinary citizens, many too old for active service, volunteered to become block wardens and aircraft spotters. Teenagers rolled bandages or served donuts for the Red Cross, and volunteers worked in VA hospitals and USO clubs around the nation. Everyone recycled for the war effort, housewives collected grease, and people accepted the need for ration coupons and meatless Tuesdays.

The media, radio and movies mostly, rallied the nation with what today is considered blatant propaganda, but there can be no doubt that their efforts enabled us to meet an almost impossible challenge. Bing Crosby, Bob Hope, the Andrews Sisters, and hundreds of other celebrities lent their voices to the war effort. They told us to buy war bonds, and we did. They reminded us to recycle, and we did.

They told us to believe in ourselves, and that we could win.

And we did.

We went from a badly weakened military to a fighting force in a matter of months. In time, hundreds of aircraft began to roll off of assembly lines each week, and by the end of the war, the Navy was launching a new liberty ship nearly every day.

It was a remarkable achievement.

Looking back, it took more than a government and a military to win that war. It took the help and full cooperation of the American people. Right now, while we face a different threat, the solutions are the same.

As in 1940, we aren’t preparing for the battle to come, we are sleeping peacefully, unaware of the gathering storm. Unlike 70 years ago, we need to reawaken the American spirit and rally the nation before we see an attack on our soil.

The government, despite their best efforts, cannot fight a pandemic alone. They will need our help. But for that to happen, they must be willing to enable our participation.

During WWII, there were people called ‘dollar-a-year-men‘, business executives and community leaders who served their nations at little or no pay. The government paid their expenses, but they donated their time. They did it because they felt it was their patriotic duty: an old, but honorable concept. They weren’t part of the government, or the military, but we’re recognized by those entities as genuine partners in the war effort. They lent their time, support, and expertise, because they realized their country needed them.

We need to reawaken that spirit. Enable it, and encourage it.

One of the best reservoirs of talent available to the government today are members of flu forums, sometimes called flubies, who already are well informed, passionate, and ahead of the curve on pandemic preparation. Some of them are already giving presentations in their communities, but there are many more who would, if encouraged.

Pandemic flu preparedness isn’t something that can be adequately conveyed to the public in 30-second public service announcements, or drive-by newspaper articles. The subject is too complex, and people need to have their questions answered. In my experience, it takes an hour just to hit the high points.

The best, and perhaps the only effective way to get the message out are through community town hall style meetings.

We need knowledgeable people who can do responsible presentations in every school, church, community center, and civic organization in the nation. Citizens need to know how to prepare, what to expect, and how to deal with it. But in order for this to happen, the government must enable, encourage, and most importantly, sanction these presentations.

The message can be standardized, and presented without raising undo alarm. But it mustn’t be watered down or sugar coated. The public won’t panic if they are properly informed. Panic only comes from an absence of knowledge. While the primary message should be about pandemic flu, this is also an opportunity to present an ‘all-threats‘ preparedness message, one that would pertain not only to a pandemic, but also to hurricanes, earthquakes, and other natural disasters.

Imagine the cumulative impact of having hundreds of community pandemic awareness meetings each month across this country? The message would be picked up by local media, and the word would be spread by attendee’s to families and friends. We would have an opportunity to instill a preparedness meme in our country, which would serve us well in any crisis. And we can tailor each presentation to the audience, increasing its effectiveness.

Retired doctors and nurses, and yes, even old retired medics like myself, can begin teaching home flu care and preventative hygiene classes in our communities. The government has already acknowledged that most flu victims won’t be able to receive hospital care. The next step is to empower people to care for their loved ones in a pandemic.

Local health departments are understaffed and under budgeted. They don’t have time to visit every civic organization, trailer park clubhouse, church and school to deliver this message.

Thirty years ago, during the Swine Flu scare of 1976, as a young medic I was enlisted by the local Health Department to do exactly that, and during that summer I spoke at dozens of venues. These presentations were considered a great success, and the audiences were very receptive.

Oh, I understand the reluctance. Can you trust us? Can we be professional? Can we deliver the message without sparking undo panic or alarm?

I believe the answer to all of those questions is ‘yes’.

Many of us in the flubie community are products of the cold war. Most of us are in our 40’s or 50’s. We grew up under the specter of the A-bomb. We learned to ‘duck and cover’ as children, and knew not to look at the flash. We remember the civil defense films, shown in every classroom in the nation during the 1960’s, and the tense days of the Cuban Missile Crisis. At the age of 8, I probably knew more about fallout shelters and radiation sickness than most Americans know about pandemic flu today.

We didn’t panic, or act recklessly then, and we won’t now.

In fact this early tempering on the forge of the cold war was probably responsible for my becoming a paramedic, an Instructor for the American Red Cross, and a member of my county’s Civil Defense team. Admittedly a misspent youth, but one I am unapologetic for.

If you can’t trust us, whom can you trust?

Start small, if need be. Initiate a pilot program. Go to the flu forums and ask for volunteers. Pick the best dozen representatives you can find. We’re all on record; it wouldn’t take much to determine whom you can trust. Give them letters of introduction and some preparedness pamphlets and see what they can do in their communities.

You might be pleasantly surprised. It doesn’t always take a multi-million dollar advertising campaign to get the word out.

I get very little traction talking about pandemic flu in my community because I’m a private citizen, with no bona fides. As far as I can see, there is little or no pandemic preparation or awareness here, and no one wants to listen to a retired paramedic. I have no official standing, and so I am easily dismissed.

Legitimize our efforts, enable us to get our foot in the door, and you will have an army of hard-working, dedicated foot soldiers in the field.

Give us enough levers, even small ones, and we’ll help move the world for you.

It’s really as simple as that.

Community education, while vital, is just the beginning.

While there is much planning going on at the Federal and State levels, distressingly little appears to be happening at the community level. Most local governments are waiting for direction and funding from higher up, or are ignoring the problem altogether. Few communities have the budget to gear up for a pandemic, and so few are actively doing anything to prepare. Many, mistakenly still believe the State or Federal government will move in to handle any crisis.

To solve this impasse we need community volunteers, working in partnership with local governments, to prepare for a pandemic. We should be thinking along the lines of a State or Federally sanctioned Volunteer Pandemic Corps, where citizens can band together to help their communities solve local problems.

Once again, members of flu forums who have considered and discussed these issues could be major assets to these organizations.

How do we ensure the delivery of food and supplies to local communities? How do we distribute needed medicines to families? Who will check on the elderly, or infirmed, during a pandemic? What about single parents who are stricken by the virus? Who cares for them, or their children? What becomes of the 27 million Americans who live alone if they become ill? Who will step in to take over the jobs of fallen essential workers?

These are problems that will require local solutions, and yet are beyond the scope and capacity of most local governments. Somehow, we must find ways to deal with them.

It should be noted that those of us over the age of 40 may be particularly useful in a pandemic. This virus, much like the Spanish Flu of 1918, prefers young adults and children. Thus far, 90% of its victims have been under the age of 40. Baby boomers, such as myself, run less of a risk of infection or death than do younger people.

Since the goal of any rational society is to protect the next generation, some of us who are less vulnerable must ultimately step up and take on some of the risks during a pandemic. No, its not a pleasant thought. No one wants to go in harm’s way. But it is the responsible thing for us to do.

It is my hope we can create an army of graying volunteers, thin of hair, but not of spirit, to do those jobs during a pandemic we wouldn’t wish upon our children.

If a volunteer can drive a truck, check on a neighbor, hand out a flyer, join a neighborhood watch, work a telephone, tend to the sick, cook a meal, operate a Ham Radio, or watch the child of someone who is ill, they can be an essential relief worker.

You don’t have to put on a uniform, or wear a badge, to be a hero to your community. All you have to do is think like one. And act like one. Pretty soon, you’ll be one.

No, not everyone will volunteer to work during a pandemic. I understand that. Not everyone is suited for it. There are personal risks involved. It takes a special type of person, often one without family responsibilities, to undertake this sort of assignment in a crisis. But there are more of them out there than you know. You just have to ask them to come forth.

Officials are often loath to ask for help from the public. They see it as an admission of failure on their part. But the real failure would be in not asking, when the need is this obvious. They can’t handle a pandemic alone. They know it. We know it.

It’s time to reach for a solution.

Cynicism towards all levels of government runs rampant in our society. People, quite frankly, don’t trust the government. They feel disenfranchised, isolated, and patronized. The government correspondingly has grown wary of its own citizens. We’ve gotten to the point where we talk at each other, instead of to each other.

While it may sound idealistic, working together to fight a pandemic could help heal that rift.

Even if a pandemic doesn’t occur in the near-term, by working together on solutions, we would become a stronger, safer, and more unified nation. We’d be better prepared for the next earthquake, hurricane, or flood. And those are threats we know we will face.

Trust is a two-way street. If the government can show some faith in its citizens by asking for their help, citizens will naturally begin to trust the government more.

An unavoidable side effect, I suppose.

But it’s one, in time, I believe we could learn to live with.

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