A Journey Through The World of Pandemic Influenza

A Journey into the world’s slums

Several times over the life of this blog I have written or mentioned the world's mega-slums, vast slums attached to mega-cities (defined as having populations of at least 10 million). A phenomenon that has long held a certain fascination for me and I have undertaken a more disciplined study of them.

Slums and mega-slums are a natural adjunct to the subject of pandemics, if only from the sheer number of people who populate them. Although statistics are rather imprecise, given the nature of the "unofficial residents", they are precise enough to allow for generalized conceptualization of the issues.

According to the UN's Global Report on Human Settlements 2003: The Challenge of Slums approximately 1 billion people live in what they define as a slum community. Defined with the following indicators to arrive at the baseline global estimates:

• Inadequate access to safe water
• Inadequate access t sanitation and other infrastructure
• Poor structural quality of housing
• Overcrowding
• Insecure residential status

One billion is shocking enough but even more so when contrasted with the total urban population of three billion. That's one in every three urban residents (roughly half of all people live in an urban environment). By anyone's measure, that's a bunch of folk.

One billion people equate to almost the entire population of China or India (and many of the urban slum and mega-slum dwellers find themselves in those two countries). As I said: That's a bunch of folk.

The domiciles of these informal communities (a more neutral term) are generally small, cramped, rudimentary structures with no means in-home personal hygiene. These things alone mean the residents will suffer far greater morbidity with the accompanying mortality everyone else will face (whatever that ends up being) aggravated by (generally) barely subsistence levels of nutrition and high levels of other endemic diseases.

Diseases caused by contaminated drinking water or mosquitoes and often life limiting or threatening: hepatitis, dengue, malaria, encephalitis, typhoid fever and cholera to name a few of the more common. As if it's some sort of cosmic joke not only do these communities have a severe shortage of safe drinking water, most contend with terrain altered by their very habitation to such a degree that when it rains it floods, and fecal contaminated rainwater inundates everything, inside and out.

Generally, either occupations are low paying unskilled menial jobs, within the city proper, or they are entrepreneurial. The entrepreneurial nature of much of the income generation places it to one degree or another outside of the legal system, either criminal or civil. Unlicensed businesses rob the wider community of license fees and criminality ranges from petty crimes, to prostitution, to illegal drugs.

Given the informal and unofficial nature of these communities, most residents have a greater likelihood of being victimized by crime and thuggery than being the perpetrators of such. Life is generally tenuous and demanding but not bereft of dignity and cultural vibrancy. The one thing residents have in abundance is hope for a better future – if only they can manage to hang on one more day, one more week, one more year.

It is difficult to use generalities given the disparate countries and cities the informal communities spring from. Generalities are just that, generalities, and there is no attempt on my part to say that there are not exceptions. Not all residents of informal communities are poor, nor do all find their way out. Some are born into, and die, in "non-person" status. Some are cold blooded brutal parasites. And, some have lives so tragic as to wilt my soul. But, most are families, trying to survive, making the best of what little they have and hoping for that golden ring to appear before their eager grasps.

 

A billion people living on the margins.

A billion people at extraordinary risk (known euphemistically as At Risk Populations) during a time that may well end up defined as an extraordinary risk, a severe influenza pandemic.

How many will be lost?

We don't even know (with any authority) how many live, there is no expectation that their deaths will be any more accurately accounted for.

Informal lives – informal deaths – in informal communities.

Credibility and Cognitive Biases

Significant news on the PanFlu and H5N1 front has been rather slow, mostly just more of the same. More plans coming out, more plans to plan, more chickens and ducks dying, more statements of "we've made progress but there's much left to do", and Indonesia's Health Minister Supari is still being most frustratingly obstinate.

Most of the news of note has been about everything but PanFlu or H5N1. Floods, soaring fuel costs, scarcity of food, politics, the US Supreme Court's ruling on the Second Amendment, the findings coming in from the Mars lander Phoenix, an ice-free Arctic this summer. On and on.

The world is a busy, busy place with many important things, some crucially so, intruding upon our limited time and attention spans.

My own life has once again taken an unexpected turn. This past Monday I assumed the Accounting Manager's position as it again became vacant. It has taken a bit of "extra attention" this week as the department undergoes some rather significant reorganization. Since we do not have to hunt a replacement, nor suffer as we train them, this transition, the third this year, is going quite smooth and already showing very positive results – even if I say so myself.

Just as I seemed to be unable to escape taking on a role that I did not want, nor seek, I have been unable to escape a recurring theme of late:

Credibility.

The credibility of our public officials. How the public perceives the credibility of those who advocate on the PanFlu issue. The credibility of the message itself. Who has credibility to parlay into results. Who lacks credibility. Who risks their credibility by speaking up in ways counter to the officially sanctioned public message.

What struck me very recently – no, what knocked me square in the solar plexus, was the realization that those who professed concern for credibility didn't express the same, or for that matter – any – concern for truth or intellectual rigor.

When I made the choice to become actively involved in the pandemic issue I chose to view the public as capable of accepting that a range of potentials existed. Ambiguity, a dearth of hard facts, and evolving knowledge notwithstanding, I believed, and still do, that what we do know deserves to be openly discussed and dissected, and doubly so for what we don't know.

[…]In some cases, people can exert direct personal control over the risks they face (e.g., through diet or driving habits). In other cases, they can only act indirectly, by influencing social processes (e.g., the allocation of law enforcement funds, the enactment of environmental legislation, the siting of hazard facilities). In all cases, they need a diverse set of cognitive, social, and emotional skills in order to understand the information that they receive, interpret its relevance for their lives and communities, and articulate their views to others. They can acquire those skills through formal education, self-study, and personal experience. However, as diligent as they might be, individuals are helpless without trustworthy, comprehensible information about specific risks.

[…]Effective risk communications require authoritative and trustworthy sources. If communicators are perceived as having a vested interest, then recipients may not know what to believe. They may accept the message at face value or reinterpret it in ways that attempt to undo perceived biases. As a result, the impact of communications will be blurred, and the communication process further complicated. Not knowing whom or what to believe can make risk decisions seem intractable (Fischhoff, 1992). Such confusion and suspicion can erode relations between experts and the public, as well as open the door to less credible sources. Such failures of communication can be deliberate, as when communicators attempt to manipulate the public or simply fail to take their duty to inform seriously. However, they can also be inadvertent, as when communicators fail to realize the complexity of their task or the opportunities for failure.

[all emphasis added]

Risk Communication: A Mental Models Approach Morgan, Fischhoff, Bostrom and Atman

 

We all understand that credibility is crucial, whether we are the recipients or the deliverers of an important (potentially life effecting message), but how do we measure it? Do we trust those whose job it is to inform us? Do we trust those with letters trailing their names? Do we trust what a famous celebrity tells us? Do we trust a snarky ex-cop-cum-accountant?

I've chosen whom I view as credible and knowledgeable, and yet even with the information they provide I always – always—run it through my own logic filters. Most times that serves me quite well. On occasion, however, my logic filters don't perform as well as I would like or assume, since like other human beings I have cognitive biases. And, yes, the last I checked I really was a human being.

As I have journeyed I have recently had to come to grips with the cognitive biases I am prone to, even if only in hindsight. Since I have become hyper-aware of how my own shape and inform me, I have also become watchful for them in others.

Being alert to the things that underpin words, I have become aware of a disturbing tendency:

When people begin to spout off about their credibility or the perceived credibility of the PanFlu threat that consistently translates: "I've watered the message down so I'm not judged a scaremonger, my credibility is more important than the truth. Besides, the public is too stupid to effectively handle it so why should I risk my own credibility?"

I don't view the public as stupid, incapable of understanding the myriad facets of all a severe influenza pandemic would likely entail. I have believed most have made conscious choices on the threat of a potential near future severe influenza pandemic. Just as I have made conscious choices on the issue; choices of what and who to believe, what and who to dismiss. But, ya'll out there have cognitive biases as well, so maybe the choices weren't so "conscious" after all, or at least to the degree that I generally go on about (latest here).

This communication thing is far more complicated than I ever knew and I'm learning fascinating things as I feverishly try to address my own naive communication skill-sets. As I've come to understand it I am a "core-dump" person when it comes to information assimilation. That means I want "The facts, all the facts, and nothing but the facts". Which, not surprisingly, shows up in what I have posted over the course of this blog's couple of years of existence.

And that brings me back to credibility: Given my "core-dump" mentality I don't view a "fact" as having credibility – it's a fact after all. And when it's not a "fact", that means it's an assumption, presumption, hypothesis, supposition, extrapolation, or out-and-out guess. Of course, I am assuming the information is promulgated in good faith thus no need to account for lies, falsehoods, half-truths, and anything deliberately misleading.

It's unfortunate that much about what a future influenza pandemic has in store for us resides in the "other than fact" column of the ledger. As a result, the weight we give "other than facts" is highly informed by our perceptions of the credibility of the person making the claims. That is not a bad thing, in fact, that is a very useful and serviceable "logic filter" in and of itself.

I am quite comfortable in "the land of presumption" given my years in law enforcement. In court proceedings things are often presumed factual until proved not: a rebuttable presumption. The most well known example is a defendant's presumption of innocence until proved guilty.

Science has something of an equivalent:

[…] Scientific realists acknowledge (in fact they insist) that scientific knowledge is always provisional, always subject to revision if better evidence is discovered, and most of them have no quarrel with the thought that social factors and extraneous agendas can shape priorities, lines of enquiry, funding, education, and the like.

Why Truth Matters (Benson, Stangroom 2006)

 

I do not find fact and presumption (or hypothesis, logical assumption, inference) untenable dichotomies, even with a "core-dump" mentality, but rather necessary correlates in our search for understanding. Perhaps this also explains why I have no "credibility issues" when I post and discuss what we do know versus what we think we know. To me "being wrong and willing to be proven so" is a wonderful part of the process – it protects us – allowing us (hopefully) to get past the ego to continually search for more perfect understanding, and on those rare occasions to go from postulate to indisputable fact.

But what happens when the person informing us of something so heavily burdened with "other than facts" is also quite consciously guarding their credibility?

We get silence.

Many can't admit, even to themselves, that the watered down message, or outright silence, is self-serving. No, instead, they blame the audience: The public is too stupid to understand, much less channel that understanding into anything other than blind panic.

I'm not certain about anyone else but I tend to be insulted when someone thinks I'm stupid. Even if it's only an ego-protective self-serving cognitive bias on their part.

Personal Preparedness

This blog is pretty much all about the potential threat of a severe influenza pandemic as I see it, and the "why" behind my belief. I don't write a lot about preparedness, only that we need to be prepared.

You see, the way my brain is wired, if I am threatened I take action, which, in the case of PanFlu, meant educate myself on the issues and stock my family's needs for several months of self-sufficiency. To me becoming personally prepared was axiomatic.

Oh, and yes, I said "several months of self-sufficiency".

 

I recently had a discussion with a Fellow Flubie (we, the Flu Obsessed) and I made the off-hand comment that I was not a "prepper", (someone who believes in self-sufficiency against life's unfortunate vagaries, as a way of life), and further that "prepping" didn't hold any fascination for me. This person looked at me as if I had suddenly morphed into an alien being. You see, this person knows the level of preparedness I have attained and my words didn't match up (in their mind) to my known actions.

Am I "quibbling" over a label? I don't think so. I don't view "being prepared" as a way of life, I view it as a positive action in the face of a quantifiable threat to my life and wellbeing, and, more importantly, to that of those I love and cherish.

That doesn't make me a "prepper", and that sure doesn't make me a survivalist as some might be tempted to label me. It makes me a responsible member of my community.

As someone who will not be attempting to gain access to food and services which may be very limited and strained, if not totally depleted, I and my family will not be contributors to a public crisis.

Since I will not be occupying my time with attempting to find food and water during a time of likely supply chain disruptions I will not be out risking infection and bringing that infection back among my family.

By not having to be out in public to secure life sustaining supplies and using up my supply of personal protection equipment (PPE) as I attempt to guard myself from infection, I will, should the need arise, be free to help those around me and in my community, better utilizing that limited supply of PPE I have stashed.

Since I am a trained First Responder, though many years stale, there may be a small but critical role I could perform, thus freeing up the more current and valuable personnel. In times of crisis there are parts we all must play: sometimes that's just staying out of the way, and sometimes it's contributing in whatever small way we are capable.

That is what personal preparedness means to me, and that doesn't make me a "prepper". It makes me a responsible citizen.

Pandemic vs. All Hazards preparedness

I make no secret of the fact that I feel including the threat of a severe influenza pandemic in the All Hazards approach to preparedness to be short-sighted and egregiously ill-informed. To say nothing of intellectually lazy and criminally negligent.

First is the obvious, at least to me: a severe influenza pandemic will be like no other disaster this country, my country, the United States of America, will face. There are unique issues and unique problems not inherent in any other known threat save a general and widespread nuclear attack.

Instead of preparing for a severe influenza pandemic and thus ensuring a strengthened response to any other disaster we could face, we have strengthened our capacity to respond to other disasters and lumped a severe influenza pandemic among them.

Now, I am inspired to say that most people might not see the problem there. After all, being prepared is being prepared, no? To that I say: No. Emphatically.

Glad you are asking why…

As I stated above, only a general nuclear attack would cripple the entire country like a severe influenza pandemic will. Every other disaster or threat would be far more localized, even if resulting in a vast number of casualties/fatalities. The region specific crisis would allow other parts of the country to lend assistance and so the region in need would only have to hold out until help and material arrived (officially 24 – 96 hours). During a severe pandemic there would be no help from outside our respective regions, perhaps not even from outside our own communities.

All other disasters and threats are not only "finite in space" but also much more "finite in time". A pandemic, on the other hand, may affect a community anywhere from eight weeks up to two years, although at varying degrees of overall community threat and crisis. It's why the personal preparedness message geared toward All Hazards carries a general "two weeks of food and water". That is the official assumption of the time frame a person/family would potentially need to be self sufficient during times of disaster recovery. And for every other disaster that is generally good advice.

During the pandemic of 1918 the vast majority of death and illness was concentrated in one 12 week stretch; the rest of the eighteen months saw vastly lower levels. But even if we only considered the 12 weeks to be our personal and community's "threat window" how does being self sufficient for two weeks prepare us for those twelve? What, exactly, are we to do for the other ten?

Those touting the two week recommendations may have some explaining to do on the other side of a pandemic if it happens sometime in the near term and it happens to be severe. Let me rephrase that: Those touting two weeks will have some explaining to do.

 

My second issue with the inclusion of a severe pandemic in All Hazards is a bit more complicated but I feel the more important.

As stated above a severe influenza pandemic presents unique challenges and unique threats. It is also a complicated issue because so much is unknown and much is unknowable until the time comes that we find ourselves existing within the pandemic.

The first thing that one must come to grips with is the stark reality that we may face a pandemic even worse than that of 1918, the last severe human pandemic. Much debate is ongoing about whether H5N1 must attenuate its current virulence in order to attain sustained human-to-human transmission capability. Granted, a pandemic worse than 1918 is not the most likely, or so our best minds tell us. But as I often say: Not likely doesn't equal impossible.

Within that issue we have embedded the issues of how rapidly the virus would lose virulence once it began circulating in humans, given that humans are not the natural host, wild waterfowl are. How many will become ill? Planning assumes approximately 30% of the population will acquire symptomatic illness (have symptoms of illness), but that may be wildly optimistic in an unmitigated pandemic, and may even be on the optimistic side for one that is.

These issues are critical to planning and preparations and it takes tackling at least some science to arrive at reasoned answers.

 

One need only glance over these charts (here and here) from the report Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations (found here) published by the journal Chest to begin to see that a severe pandemic is inherently different. Please note the times estimated for critical care and mechanical ventilation, as well as the length of time before outside assistance could be expected to arrive on scene. Then, for a truly eye-opening read I recommend the report itself. It is a report that I would make mandatory for anyone involved in any official level of pandemic planning.

 

Which brings me to the crux of my issue #2 with the All Hazards approach to pandemic influenza preparation:

By including a severe pandemic with all the other threats we may be at risk from we have allowed our public officials to not put in the time to educate themselves on the myriad and interwoven unique issues. We have allowed them to not make the tough and expensive and concrete choices that would be morally demanded of them if a severe influenza pandemic were an issue that stood on its own threat merits.

We have allowed them to do just enough so they can say they did something, all the little "somethings" that don't require sticking their tender necks out by specifically committing funds and actions toward what is (currently) labeled a low probability/high impact event.

 

I will again quote (slightly out of context) HHS Secretary Leavitt's Pandemic Planning Update V:

Since our last Update, we have entered a new phase in our preparations. The milestones are farther apart but no less significant. We are now tackling some challenging issues that can only be resolved with the collaboration of the full range of stakeholders — State and local officials, public health and medical professionals, religious leaders and ethicists, the business community, organized labor, non-governmental organizations, and individuals from all walks of life.

This quote is out of context because he is referring to the need for further planning, and I say it's time to start tackling and addressing the issues themselves. It's time for that proverbial rubber to meet the roads. In order for that to happen the pandemic issue must be extricated from All Hazards and addressed with the specificity it requires.

Secretary Leavitt closes his update:

We don't know if the H5N1 virus will spark the next pandemic, but we know that it's just a matter of time before something does. There is simply no reason to believe that this century will be different than any past century. The difference now is that we better understand the threat, so we can increase our preparedness for a pandemic before it comes, in order to diminish its potential impact.

The Federal government cannot mount an effective response to the threats that we face as a nation without partners at every level of government and throughout society. It is every American's continued commitment that will make our country a safer and a healthier place.

That last sentence brought a chuckle (albeit a cynical one). Sure couldn't prove that by our demands for actions from our officials and leaders thus far. And since we, the "every American", are quiet, our officials and leaders are happy to be just as quiet and inattentive. We have, after all, given them our permission to be so.

 

SZ

We all make choices

There are generally only five groups of people who trumpet the potential threat of a severe influenza pandemic that H5N1 poses. Those are governments, some scientists, the media, the World Health Organization (WHO), and the cyber flu community, otherwise known as "the flu obsessed" or "Flubies".

Interestingly, those groups encompass three important segments of a society: government, media, and the citizenry.

I get into degrees of "snit" when I read someone's post on one of the flu forums that bemoans "people not being told" about the threat of a severe influenza pandemic and the requisite actions required to be prepared to meet that threat. Depending on how operative my very small supply of patience is that day is reflective of how bad the snit is.

People are exposed to "the message" nearly every day, and in 2006 it was many times a day in nearly every communication medium and venue in existence, at least in the US.

The message consists of the possibility that we will experience a pandemic in humans of H5N1 avian influenza, and that the pandemic may be severe. Severe is officially defined as a pandemic with approximately 30% of the population falling ill and 2% or more of those dying. In the U.S. those figures 30%/2% translate to 1.9 million deaths.

It is because the message carries ambiguity that people tend to not "hear" it, it's not because they aren't being told in the first place. The message must contain the high level of ambiguity that it does because we don't know if H5N1 will cause the next pandemic (it may be some other pathogen) and we don't know how severe the next pandemic will be if and when it arrives.

We, those that concern themselves with the issue of an influenza pandemic, can only deliver the message; we have no control over whether folk choose to "hear" that message. An example from today is found on the UK's Timesonline :

 

Armed Forces could not help civilians in flu pandemic

June 14, 2008 Michael Evans

The Armed Forces would struggle to cope if the country was hit by a pandemic flu, with more than 50 per cent of military personnel laid low, an internal Ministry of Defence document indicates.

The Royal Navy, Army and RAF would be so badly hit in the "worst-case scenario" because of their close working environment, particularly on warships, that no military personnel would be available to help the civil authorities, the study says.

"The priority ... will be maintaining critical military operations with little or no spare resource to provide military assistance to the civil authorities," says the internal MoD document, which is in the form of a guide for defence personnel.

In past crises, ranging from floods and foot-and-mouth disease to national strikes by firemen and petrol tanker drivers, the Armed Forces have played a key role in assisting the civil authorities.

However, with dire predictions of heavy flu casualties - up to 750,000 deaths and more than one million people needing hospital treatment - it is accepted officially that the Armed Forces would have to spend all their time ensuring that there were sufficient personnel to carry out basic military tasks and maintain operations abroad.

Experts have predicted the inevitabiity [sic] of another flu pandemic - there have been three global outbreaks in the past 100 years - and that it might come in several waves of three to six months over two years.

    [All emphasis added]

There is absolutely no way that I accept the premise that people are not being told of the potential threat. I cannot, not with the evidence my own eyes see every single day, and have seen for several years now. Those that believe "the message" is being withheld from "the public" not only believe the withholding to be fact, but, sadly, and embarrassingly, they believe it is being withheld for a reason.

The reasons posited generally run "we don't want to panic the sheeple", or "let's not upset the economic status quo", or "it would cause financial markets to suffer". Since I argue that the message is not being withheld, I don't feel it necessary to refute the reasons given for such withholding.

 

Of course, people are free to believe what they believe. It's true for those who believe the message that a potential severe influenza pandemic is a genuine threat and it's true for those who choose to believe there is no threat. But make no mistake—it's a choice. Some have made that choice with conscious deliberation and some have not, instead they make something akin to an intuitive leap of belief—or disbelief—without any intellectual rigor or analysis. That is their right as free-thinking (or not) sentient beings.

But let's not assign fault or malfeasance to others for the choices made by those we, the flu obsessed, would want to believe as we believe: that a future severe influenza pandemic is possible, the threat doesn't necessarily exist in the remote future, and there are concrete things we ourselves can do to mitigate the severity on a community as well as personal level.

To state it plainly: should a severe pandemic happen it's all about your community and your personal situation. They are intimately and inextricably intertwined.

 

 

Choices—we all make them.

 

SZ

It’s the Community Stupid

It would be easy to assume we know all there is to know about "the flu". The reality though is we don't. In fact, some of what we thought we knew has proven to be wrong or partially wrong, and with every new finding we also find new questions that need to be answered.

Our ignorance is also demonstrated in our attempts to prepare to meet the real challenges a severe pandemic would present. It's understandable that we don't know what would be the best thing to do (known as best practices) very few alive have experienced a severe pandemic since the last one began in 1918.

 

This blog carries a quote from Health and Human Services Secretary Michael Leavitt from the early part of 2006: "Any community that fails to prepare with the expectation that the federal government will come to the rescue will be tragically wrong". That was over two years ago. Since then the amount of time spent just wrangling over what will be needed and who will be responsible for said "whats" is staggering. And that wrangling is still ongoing.

This from A Report from Secretary Michael O. Leavitt March 17, 2008

[snip]

State and Local Preparedness

 HHS has stressed repeatedly in State pandemic influenza summits with governors and in numerous other meetings that preparedness for pandemic influenza must be a shared responsibility among governments at all levels, the private sector, and individuals. To the extent that potential partners refuse to apply their talents and assets unless the Federal government foots the bill, they are abdicating their responsibility and thereby placing their communities at higher risk than need be.

Since 1999, HHS has provided funding to State and local public health departments to enhance their preparedness for naturally occurring, accidental, or terrorist-induced emergencies. This has included strengthening relationships with public safety and emergency management agencies. Since 2002, HHS has provided all States and territories as well as four major urban areas with some $2 billion to enhance surge capacity in hospitals and other healthcare entities.

HHS is also leading an effort involving eight cabinet departments of the Federal government to help States refine their plans for countering pandemic influenza. The primary focus of the planning guidance, technical assistance, and readiness assessments is to help all agencies of State governments — not just health departments — understand what they can do to help mitigate and otherwise counter an influenza pandemic.

This involves State public health departments looking inward to do what is necessary to continue their respective operations. But it also involves looking outward to establish and test partnerships with other agencies of State governments, local governments and the private sector — including both for-profit and not-for-profit entities. State-based partnerships are one of the most promising ways to prepare for pandemic influenza.

[all emphasis added]

 

I have been peripherally witness to the efforts of two highly informed and intelligent Flubies (what those involved in the cyber flu community frequently call ourselves) that could not be more different in their approaches and philosophies. One believes we must find the means and message that will move the federal government to more direct and specific actions and the other the same at the local level.

 

As I am a rather frequent and vociferous participant in the cyber flu community I often find myself defending the federal government. Those who know me know that I get in a bit of a snit when the government, at any level, intrudes upon my life, or picks my pocket. I find "government" onerous, and those who are employed to interfere with my self determination to range from a mildly annoying to barely tolerable. I am, at heart, a Libertarian. I believe in the principle of Individual Sovereignty, Locke's state of perfect freedom, minus the religiosity of course.

Given these philosophical beliefs one would be tempted to ask why I, staunch Libertarian that I am, continually seem to defend The Government and their pandemic preparations (or lack thereof).

The answers are quite simple: The federal government cannot do it all. The federal government cannot pay for it all. The federal government cannot make anyone else do what logically needs to be done. That said, it will not prevent the federal government from bearing the blame for the myriad failures and resultant deaths, because as human beings we always need someone to blame, and as human beings that is rarely, if ever ourselves.

 

Personally, I am so disgusted and so discouraged that I can't help but sit here and say—yet again—why bother. Until we as a nation can take personal responsibility for our own well being and that of our own communities we will face a pandemic ill prepared at best, and probably not prepared at all in reality.

To paraphrase James Carville: It's the community stupid. But we will not learn that lesson until we view it with hind sight.

 

SZ

Medical treatment for First Responders during pandemic

Last month an AP story titled Who should MDs let die in a pandemic? Report offers answers hit the wires and Flublogia; here is the discussion as it unfolded on P4P.

The concept of medical triage is not new to those who have been following the issue of PanFlu (Pandemic Influenza) and on several occasions I have raised the issue of Law Enforcement Triage, and this story touched both, in a big way. Unfortunately, it hit at a very inopportune time for me to address it in depth, and only now does my time allow the attention it deserves from the very narrow perspective of our law enforcement and fire fighters.

Who should MDs let die in a pandemic? Report offers answers
LINDSEY TANNER, AP Medical Writer
May 4, 2008 9:23 PM

CHICAGO (AP) - Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding who to let die.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals ''so that everybody will be thinking in the same way'' when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

Their recommendations appear in a report appearing Monday in the May edition of Chest, the medical journal of the American College of Chest Physicians.

''If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing,''the report states.

To prepare, hospitals should designate a triage team with the Godlike task of deciding who will and who won't get lifesaving care, the task force wrote. Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific, and include:

-People older than 85.

-Those with severe trauma, which could include critical injuries from car crashes and shootings.

-Severely burned patients older than 60.

-Those with severe mental impairment, which could include advanced Alzheimer's disease.

-Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force. He said the report would be among many the agency reviews as part of preparedness efforts.
[snip]

James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans even if they don't follow all the suggestions.

He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.

Bentley said it's not the first time this type of approach has been recommended for a catastrophic pandemic, but that ''this is the most detailed one I have seen from a professional group.''

While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.

Devereaux said compiling the list ''was emotionally difficult for everyone.''

That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.

''You never know,'' Devereaux said. ''SARS took a lot of folks by surprise. We didn't even know it existed.''

 

I titled my last post "Rules" since it dealt with the rules countries are in general agreement on when dealing with each other. I made mention that some "rules" are loosely defined and some are immanent, so universally understood that they do not need to be codified, although in service to a civil society they are.

Aristotle held that sometimes what was just by nature, "natural justice", was not necessarily just by law, i.e., dependant on society's rules. We are all aware that there have been many laws throughout human history that could hardly be considered "just"; valid legally, but a violation of natural law.

 

There is an understood "contract", "unspoken rule", a "natural law" if you will, when a police officer or fire fighter is injured or wounded in the line of duty everything that can be done will be done until all hope is exhausted. That is as it should be for those who risk limb and life to protect us.

The reason these guidelines are relevant is because, as everyone who understands the implications of a severe pandemic knows, medical supplies, mechanicals, and personnel will be in short supply, if not absent altogether. The reason they are so shocking is because those who would otherwise receive medical care would likely survive, if only until their next medical crisis in the case of the chronically ill. Stated plainly: It is assumed that treatment carries a high probability of success.

 

Setting aside the question of the likelihood of having any advanced medical care available during a severe pandemic, where, exactly, will our severely injured/wounded police and fire fighters fall in this triage scheme?

It is widely assumed that during a pandemic personnel levels will be affected, heavily dependent on the pathogen's virulence and pathogenicity. Official assumptions place absentee levels at 25% or more. The staffing levels for our first responders is apportioned according to current, non-crisis needs, just as the staffing levels for any well run and fiscally responsible business. Those that do show up for a shift will be performing their jobs without the safety margins built in with a full squad/squadron.

One assumption leads to another: With reduced manning levels the incidents of injuries requiring medical care are likely to rise in lock-step. Under normal operations the likelihood of suffering something life threatening is quite small hour-to-hour on average, given training, equipment, and—adequate personnel to mount a tactically sound response (police or fire), but that is under normal operating conditions.

 

Our social contracts are being re-written against a future threat. How long will our police and fire fighters remain blissfully ignorant of these issues? I've read any number of outraged rebuttals from the elderly and social advocates, but you in uniform serving and protecting us remain silent.

It is important to understand that guidelines are to be applied uniformly, strictly speaking that leaves no room for considerations of how you found yourself requiring treatment.

Where are your voices? Will you wait until you are severely injured and denied treatment to speak? If so, I have my doubts that anyone will be in a position to hear your outraged arguments—or those of your fellows and family.

 

SZ

 

Rules

Life has rules. They are everywhere and cover pretty much everything. Some rules are loosely defined and others immanent (Natural law), the nuances of Hobbs and Locke aside. International Treaties fall closer to the Natural Law side of the sliding scale, if not solidly upon it.

International Treaties generally fall into two categories, those that agree to perform a specific action and those that agree to refrain from a specific action. Countries can adopt a mutual defense treaty with others [action] and countries can adopt a treaty banning above ground testing of nuclear bombs [refrain from action]. The Kyoto Treaty [alternately known as The Kyoto Protocol] is an example of a treaty that parties agree to both action and inaction with its ratification.

Historically it has been the treaties of restraint that carried the greatest probability of international penalties or sanctions. These certainly have not been evenly and consistently enforced, and often countries gamble as to what the international community's reaction will or will not likely be. A few examples of reaction testing can be found in the nuclear development programs of some countries, and not one suffered (Iraq was a broader issue).

In fact, it has been demonstrated several times in our recent past that flaunting a treaty produces positive outcomes for countries as the international community resorts to what amounts to bribing a country to cease offending actions. There are few enforcement options and pretty much zero will to enact those few. Either countries live up to their treaties or they don't and the rest of the world pretty much has to accept it.

 

This week Indonesia caused yet another stir with Health Minister Siti Fadilah Supari's interview statement that her country will no longer announce H5N1 deaths as they occur, but rather on some yet to be officially determined schedule, from a month to upwards of six—or so. Here is a representative story of the many that covered the incident, but since I am late to the table I suspect I don't need to post on yet again.

 

Supari's gamble may pay off, literally as well as figuratively, and hey, more power to her. I hope she is successful in whatever it is that is driving her actions. The world moves on, and it's time that it move on without Indonesia. But I can't help wonder what Hobbs and Locke would think of these developments.

At one time a person's word was nothing short of a sacred bond, broken only by the lowest of scoundrels and a country's word was pretty much a bankable asset. Yes, the world moves on, and not always in the right direction.

 

SZ