Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold). Image provided by CDC/C. Goldsmith, J. Katz, and S. Zaki.
A Failsafe Pandemic Response Plan for State and Local Governments
By Grattan Woodson, MD, FACP
The pandemic plans currently in place at all levels of government may turn out to be inadequate to cope with a truly severe event. The 2 million US deaths projected by the US DHHS Pandemic Influenza Plan in their “severe pandemic scenario” is not the worst case by any means. In my view, a better description of these estimates is the worst case they can possibly hope to cope with. A local plan that limits its worst case to this projection will have the same chance of succeeding as a levee built for category 3 hurricanes has of withstanding a category 4 storm. A truly severe pandemic is likely to have wide-ranging effects on the medical, social, and economic life of our country whose force will overcome these plans just as Hurricane Katrina spilled over the levees in New Orleans in August 2005.
Those elected to state and local office know their people and their needs better than anyone else. The voters chose them to lead during a crisis or emergency and have invested them with the power and authority to carry out these functions. A major influenza pandemic is sure to alter the calculus of governing to a very basic level that most officials rarely think about or consider. In the time before the pandemic begins, the world appears so highly ordered, secure, and relatively peaceful it seems irrational to think we could be facing a dire threat from an infectious disease. Anyone bringing up this possibility prior to recent events would be not have been considered credible.
This essay is addressed to political and public health leaders at the state and local level who are likely to end up with the lion’s share of the responsibility and blame for the way the pandemic affects each local community. The federal authorities have made it clear that they really won’t be able to help out significantly if the event is as severe as some, including me, think it will be.
At present, most emergency plans contemplate the timely arrival of outside assistance during the pandemic. A fallback pandemic response plan should not count on help arriving from outside. This is prudent because a major influenza pandemic will severely affect almost every state at virtually the same time. State and local officials need to prepare for the possibility that no US government department or agency will be able to respond to this crisis in a meaningful way irrespective of their plans to do so.
State and local plans depend upon an intact local hospital and public health infrastructure as an integral component of their pandemic response plan. An alternative approach would recognize and plan for the there being only enough staffed hospital beds to accommodate a fraction of the critically ill patients. A logical fallback option is needed to compensate for the incapacity of the present system should it fail to be able to provide for the sick.
Should the primary pandemic response plan be overcome by events, do you have a fallback plan? Most local planners don’t. This document was written to address this with the hope that it will not be needed. The proposals found here is a bare bones plan that is contemplated for use in as a last resort. The primary goal is the maintenance of public order rather than attempting to try and provide a direct medical response to the emergency. These alternative proposals are simple, inexpensive, rely on available resources, do not require additional staff training and most of all practical to implement. Think of this plan as a failsafe option should one be needed.
Alternative Recommendation 1: The primary responsibility of state and local government is the maintenance of law and order, not provide medical services to their community.
Rationale: While in prospect, most think of the bird flu pandemic as a medical problem requiring a medical solution, this is only half correct. The private sector is responsible for the majority of healthcare delivery in the US and it will bear the brunt of this emergency and its consequences. State and local governments have relatively few health resources available and should recognize that they are not prepared or equipped to provide direct patient care during this crisis. While the population will suffer greatly from illness and death due to the disease, a secondary deadly risk is a breakdown in civil order caused by the pandemic. While no one can do much to prevent the pandemic, state and local officials are uniquely positioned to do much to control and lessen the risk of anarchy. It is crucial that they focus on preserving law and order within their respective communities and in the state as a whole, something that they can and must do and not divert there resources into a futile attempt to deal with the direct medical needs of their communities.
Alternative Recommendation 2:State and local leadership, police, fire and rescue, and National Guard troops should be given priority for scare medical resources like antiviral drugs, vaccines, and advanced medical care.1
Rationale: The health of those tasked with providing leadership and maintaining security must be placed over the every other group to prevent an even greater disaster from occurring than we expect from the direct effects of the pandemic. Security is essential to every citizen of the state and must be maintained. Adding the danger of anarchy to the terror and helplessness in the face of the medical consequences of influenza would be a true nightmare. To prevent anarchy and the resultant mayhem, those tasked to protect and serve the citizenry and its political leadership must remain as healthy as possible. For this reason, these individuals should be placed at the top of the priority list for receiving scarce medical resources.
Recommendation 3: The political and command leadership at the state and local level must maintain positive control over those tasked with carrying out law and order in the field.
Rationale: Regular police and military units are trained to operate under the positive control of their commanders. Positive control requires the ability for the commander to communicate with units in the field and for those units to be able to report back to the commander. This method should be independent of a functioning electric power grid and telephony system.
Alternative Recommendation 4: Ensure potable water is available to those presently dependent on central water systems.
Rationale: Central water system reliability is tied to the power grid. If that becomes unreliable, the electric pumps that charge the water systems in all urban and suburban areas will cease to function. Rural citizens depend on similar water systems and well pumps. These too will be affected by a power grid failure. Having access to clean water will soon become every citizen’s first concern. Resort to drinking of unclean water will result in a host of water born diseases, especially diarrhea that will exacerbate the already severe morbidity and mortality caused directly by influenza. Controlling access to potable water can be an effective measure for the maintenance of law and order.
Alternative Recommendation 5: Sponsor the development and dissemination of home influenza management guidelines and training.
Rationale: The hospital system is unlikely to be able to respond to the demands placed upon it by a severe influenza pandemic. Even if the hospitals remain open, the DHHS Pandemic Influenza Plan expects 8 of 9 patients with flu will be treated at home. Citizens need simple low-technology treatment guidelines for how to do this. They need advise about what supplies to have available at home to treat their family members ill with influenza. This information is presently not widely unavailable.
Alternative Recommendation 6: Establish stockpiles of inexpensive basic household and medical supplies useful for the home treatment of influenza.
Rationale: The successful provision of a home-based approach to providing care to the influenza patient requires certain basic resources. These include thermometers, automatic blood pressure monitors, salt, sugar, baking soda, aspirin, acetaminophen, diphenhydramine, cough syrup, and a handful of generic prescription drugs. Having these simple items stockpiled and pre-positioned within communities for use in the event of a pandemic is consistent with the role of state and local government and a practical indirect medical response to the pandemic.
1 This is in contrast to the recommendations of the US CDC who places healthcare providers, first responders, and vaccine and antiviral manufacturing employees at the top of the list. Then come children, elderly, and adults with chronic disease. There is no mention of security forces or the country’s political leadership. In my opinion, these priorities are appropriate for the typical flu season or an minor pandemic but are inappropriate for a major one.