Fear and Loathing over the `Q’ word

#218

Over the weekend, a document called Department of Defense Influenza Pandemic Preparation and Response Health Policy Guidance, dated December 23, 2005 and produced by the office of the Assistant Secretary of Defense, surfaced on the net and was widely circulated. Although nearly a year old, it was posted on a publicly accessible military website about a week ago. It appears to be genuine, and it has caused a bit of a stir among the flubie community.


With the specter of an H5N1 Avian Flu pandemic on the horizon, it is reassuring that the military is taking it seriously, and is planning accordingly. There are some references in this document that are worrisome, however.

Contained with its 38 pages are 11 references to Quarantines, and this has sparked extensive debate among flubies. Opinions have ranged from `So, what?’ to it being an ominous blueprint for martial law.

As stated in Appendix III of the report:

Goal of Community Containment and Infection Control Measures. The goal of community containment and infection control measures in the community, used in Phases 3-5, is to contain infections at their source or, if containment is not possible, to prevent or slow the spread of the disease. Public health measures during this time should be tailored to maximize impact on preventing and slowing disease transmission while minimizing, to the degree possible, restrictions on individual movement.


III. Planning for Community Containment (primarily for Pandemic Phases 3-5):

A. All installations should establish community containment plans that include triggers/thresholds for implementation of containment measures.

B. The plans should include the identification of appropriate outpatient, treatment, isolation, and quarantine facilities and communications networks.

C. All installations should exercise the plans with traditional partners (e.g., public heath and healthcare workers) and non-traditional community partners (e.g., transportation workers).

IV. Considerations for all Pandemic Alert and Pandemic Periods (Pandemic Phases 3-6):

A. Developing and implementing community-wide risk communications plans with key messages for each phase of the pandemic.

B. Community-wide infection control education including decreasing social contact and social distancing, and hygiene (coughing, sneezing, and handwashing and optional use of masks).

C. Medical evaluation and isolation or quarantine of persons who are exhibiting signs of influenza-like illness.

D. Delivery of medical care, food, and services to persons in isolation or quarantine taking into account special needs of children and persons with disabilities.

E. Protocols for monitoring and, when necessary, enforcing quarantine measures.

F. Mental health services for persons in isolation or quarantine, as well as to family members of affected persons and other community members.

G. Telephone hotlines for reporting influenza-like symptoms and for obtaining directions for self care or instructions to report for professional medical care.

H. Developing protocols for staff members that include training and triage decision trees/algorithms.

V. Considerations for Community Containment in the Pandemic Period (Pandemic Phase 6) when widespread transmission is occurring and medical resources (people, supplies, and space) may be constrained.

A. Community-based containment measures:

1. Measures, including quarantine, that affect groups of exposed or at-risk persons.

2. Measures applying to use of specific buildings.

3. Measures that affect communities.

a. “Snow days” for at least an initial 10-day period and self-shielding (choosing to stay home).

b. Alternative/additional location fever clinics.

c. Cancellation of public events and closure of offices, churches, shopping centers (commissary and exchanges), schools, child care facilities, and public transportation.

d. Widespread community quarantine (home or community-based) with provisions for supplies and service for monitoring and enforcing, when required.

B. At termination of Phase 6, scaling back community containment measures.


From the outset, let me state that the military’s job is to plan, at the behest of the government, for nearly any contingency. I’m sure, somewhere in the vaults of the Pentagon, we have a set of plans for the Invasion of Canada, but that doesn’t mean we are massing troops on the border with that intent.


The use of community quarantines on US soil, if attempted, will likely be a miserable failure. Most public health officials don’t believe they will work, and the manpower requirements to enforce them are likely beyond the capability of our military.


Containment of the virus, through quarantines, only makes sense if there are one or two isolated outbreaks. In all likelihood, by the time the virus makes its presence known in this country, it will have spread far and wide, and so any quarantine will be the equivalent of closing the barn door after the horse escaped.


Sure, you might slow the spread slightly, but you won’t stop it. And at what price?


Will they try it?


I suppose, someone, somewhere, might think it’s worth a shot. I expect frightened citizens, in areas as yet unaffected, will clamor for it, and in the short run it may be politically popular. Some states and communities may even attempt a reverse quarantine, not to contain the virus, but try to keep it out.


And no, I don’t believe that will work either.


If the Avian Flu is as bad as some have predicted, desperation measures will likely be taken at all levels of government; local, state, and federal. Civil rights, and the constitution may take a backseat for the duration. The President of the United States has at his disposal a raft of executive orders that give him, and the military, unprecedented authority during a national crisis. None of these give me a warm feeling inside, and the potential for abuse, and arbitrary implementation certainly exist, but I am comforted by the fact that they have been on the books for decades and have never been used.


Martial law may be a necessity in a pandemic, and if it is declared, it won’t be pretty.


But neither will a pandemic, and the possible social upheavals that may accompany it. There may well come a time when we will welcome a military presence in our neighborhoods to help restore order, remove the dead, and deliver badly needed supplies. We need to remember that these are our sons and daughters wearing the uniform, not an invading army. Most, I believe, will do the right thing.


Call me a Pollyanna, but I just don’t subscribe to the theory that the military is salivating at the possibility of occupying the homeland. They’ve already got their hands full in Iraq, and certainly don’t need to add that to their plate.


The government, and that includes the military, are in a lose-lose situation here. If they do nothing, if they fail to plan for every possible contingency, they will be faulted for whatever happens, even if they would have been unable to make much of a difference in the long run.


If they plan for the worst, they are immediately accused of being up to no good; just waiting in the wings to declare martial law, suspend elections, and plunge us into a dictatorship.


I’ve no doubt that the government has the ability to mess things up in a crisis. They will likely make some very bad choices along the way. And attempting a quarantine policy might be one of those bad choices.


A severe pandemic would bring together the worst of all possible worlds. Millions sick and dying, a breakdown in social order, supply chain and delivery breakdowns of unprecedented magnitudes, and the need to make truly horrendous decisions. Who gets fed, or antivirals, or the precious little vaccine that might be available? How do you turn millions of people away from hospitals? How do you maintain order? Do you even try to enforce the law?


I fully expect there to be chaos. And it’s right that the government, and the military try to anticipate what may be needed. But no battle plan ever survives the first encounter with the enemy, and I doubt that these plans will fare any better.


Anyone who expects that during a pandemic that things will be normal, that the government will run like a well-oiled machine, and that mistakes won’t be made, will be in for a rude awakening.