Stephen Flynn and Irwin Redlener
We may have dodged a bullet – for now. If the strain of Swine Flu virus that is currently circulating the United States remains mild, our plans and capabilities for responding to a nationwide health care crisis will not be put to the test. That is a good thing because if our pandemic preparedness were to undergo a stress test today, it would fail.
Because panic can lead to misdirected energies that result in harmful outcomes, the Obama Administration and local leaders like New York's mayor Michael Bloomberg deserve high marks for providing a measured and reassuring tone in the face of the initial fear and uncertainty surrounding the H1N1 outbreak.
But now the hard work must begin.
President Obama needs to quickly seize upon this crisis to mobilize state and local governments and everyday Americans to better prepare our hospitals, communities, and homes for the task of protecting and saving lives during a virulent pandemic.
The sobering reality is that we have been living on borrowed time. Lethal, new, non-seasonal influenza outbreaks typically strike three to four times a century and we are overdue.
The H1N1 virus has all the microbial evolutionary attributes for producing our millennium's first deadly pandemic: it is a new virus compounded from several distinct strains for which people have no natural immunity; it is transmissible among humans; and, it has caused fatalities in unexpected age groups.
The relatively mild form of the virus we are seeing now could mutate in the upcoming flu season in the southern hemisphere. Then we could see it back in our own communities next winter in a more virulent form.
According to the U.S. Department of Health and Human Services, a full-blown pandemic would result in approximately 90 million Americans become ill, and depending on the flu’s potency, with anywhere from 865,000 to 9,900,000 requiring hospitalization. To put that number into context, consider that the entire inventory of staffed hospital beds within the United States is 970,000 and virtually all of them are currently occupied.
We are simply not prepared for this kind of outbreak:
• The emergency health care system is incapable of managing the surge of millions of "worried-well" and sick.
• Most of our communities do not have tested plans for the timely distribution of antivirals, vaccines, or protective equipment.
• Within many state and local jurisdictions, confusion remains over who will be in charge during a major medical emergency.
• There is no consistency among states on vaccine prioritization or the best infection-control polices.
• At the family level, too few of us have drawn up emergency plans or stocked up on essential supplies at our homes.
In short, our national leaders would be doing us a disservice if they fail to channel the recent public anxiety over Mexican Swine flu into a national campaign to improve our preparedness.
Here is what needs be done right away:
• The federal government should survey states and localities and make emergency funding available to restore staffing at public health departments. Our first line of defense is the disease surveillance, reporting, and contingency planning these public health officials provide. On the current perilous trajectory, the public health workforce is projected to be 9 percent smaller than in 2005 when the pandemic flu risk first started generating serious concern.
• Hospitals with state and local government support need to have plans and incentives in place to make sure the health care workforce is adequately trained and available to help during a major infectious disease outbreak. Every hand will count, especially since we are already experiencing a nationwide shortage of approximately 100,000 nurses. An April 2009 report of an AFL-CIO survey of 104 health care facilities in 14 states reinforced the findings of earlier studies that many medical professionals and workers may not show up for work during a disease outbreak. The reasons include the need to stay at home to provide childcare during school closures or attending to sick loved ones. Equally worrisome, the AFL-CIO survey found that only 43 percent of the facilities have provided pandemic flu training to their employees.
• Managing a lethal pandemic will require innovative action to meet the surge in demand for medical care, including setting up temporary triage centers outside hospitals and using alternative care sites. These auxiliary facilities will be needed to separate the "worried-well" from the truly sick, and to provide spill-over space to isolate those with contagious disease from other bed-ridden patients. The alternative of having an estimated 45 million Americans seeking emergency outpatient services during a pandemic will not work. Today, more than half the nation's 4,000 emergency rooms are operating at or over capacity. One reason why the emergency care system is under such stress is that it has become the only medical care option for the nearly 50 million unfortunate Americans who do not possess health insurance. The severe recession is making this situation worse.
• The federal government needs to provide states with firm guidelines, matched with funding support, and work to resolve the liability issues associated with using locations like conference centers and hotels as temporary mass emergency facilities.
• To help deal with expected staffing shortfalls, Washington also needs to work with state governments to quickly adopt pre-credentialing systems and to clear away the legal barriers so qualified volunteers can help out during a public health emergency.
• Over the next three months, distribution plans must be tested nationwide at the community level to ensure that vaccines or antiviral medicines such as Tamiflu and Relenza can reach an at-risk or infected population in time to be effective. Antivirals need to be taken no later than 48-hours after the appearance of flu symptoms, with some experts suggesting that a 24-hour window would be far better. Our large national stockpile of drugs will be of no help if communities don't have the means in place to rapidly distribute them. One good idea is to turn to the U.S. Postal Service for help, but first we need to make sure that the mail carriers receive training and have early access to antiviral drugs and protective gear.
• Organizations like the American Red Cross that play such an important support role during times of disasters need a helping hand by corporate and individual donors. Like many charitable organizations, the Red Cross has seen recent and dramatic drops in giving, forcing them to make significant staff reductions.
• Finally and most importantly, as individuals we need to take responsibility for keeping ourselves informed about what we can do to stay healthy during a disease outbreak. We also need to make ourselves more self-reliant. Families should have in place a family emergency plan to include storing a supply of food, medicines, facemasks, and alcohol-based hand rubs. Whether healthy or sick, we might have to confine ourselves to our homes for several days while a pandemic plays itself out.
By skillfully managing the risk communications associated with the Mexican Swine Flu pandemic, the Obama Administration has earned public credibility for dealing with a national medical emergency. This asset now must be investing into providing the galvanizing leadership the nation requires to think creatively and to act quickly on correcting our dangerous deficit in national pandemic preparedness.
Editor's Note: Stephen Flynn, Ph.D., is the Ira A. Lipman Senior Fellow and a homeland security expert at the Council on Foreign Relations and author of The Edge of Disaster: Rebuilding a Resilient Nation (Random House, 2007). Irwin Redlener, M.D., is the Director, National Center for Disaster Preparedness at the Columbia University Mailman School of Public Health and author of Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do Now (Knopf, 2006).