# 562
It's been 16 months since President Bush alerted the nation of the need to prepare for the next pandemic, and ordered all states and the Federal government to devise, or revise, their pandemic plans. Dutifully, nearly every state has complied, and we now have 50 state plans, and a Federal plan that combined, probably exceed 10,000 pages of charts, graphs, and pretty pictures.
What they seem to lack, across the board, are specific guidelines for anyone except State and Federal government agencies. And even those are pretty vague.
There is no consensus between states, and the Federal government, of even what we should be preparing for.
In South Carolina, they apparently are anticipating twice the normal seasonal influenza deaths during a pandemic according to their SCDHEC web site.
Seasonal flu kills approximately 36,000 people nationwide and approximately 1,400 South Carolinians each year; death is most often caused by complications, such as pneumonia
South Carolina could experience approximately 3,600 deaths due to complications affecting a greater number of people.
The Federal government speaks in terms of a 50 fold increase over a normal year. And there are some who feel that may be low.
I guess South Carolina didn't get the memo.
A visit to the Texas DSHS (Department of State Health Services) website shows that they are apparently still working off a draft pandemic plan dated October, 2005. Under their assumptions for a pandemic, they state:
In general, experts estimate that an international outbreak (pandemic) due to a new hemagglutinin variation of influenza may have a 25-50% attack rate meaning that, in Texas, between 5 and 10 million Texans could become infected. An estimated 4% of those, between 200 and 400 thousand Texans, may likely require hospitalization. Case fatality rate estimations range from 1.5% to 5% indicating that at a conservative 25% attack rate between 75 and 250 thousand Texans may die, while at 50% attack rate between 150 and 500 thousand might die as a result of their illnesses.
Texas apparently expects a 4% hospitalization rate, compared to Florida, which expects a 10% hospitalization rate. Texas presumes between 2% and 5% of those afflicted may die, while in South Carolina, they expect roughly .0036% will die.
I suppose, were I smart, I'd move to Texas where my odds of needing hospital care during a pandemic are, according to State officials, far less. Better yet, I should move to South Carolina, where my odds of dying apparently go way, way down.
The variances between state plans, all across the nation, show similar differences. Some states are planing for a repeat of 1957 Asian Flu, others are looking at the 1918 Spanish Flu for guidance, while still others are somewhere in between.
Apparently, after 16 months, we can't even get everybody on the same page.
Somewhere in nearly every state plan is the admonition that local communities must prepare for a pandemic, but rarely are specifics mentioned. Most local communities have no substantial pandemic plan, and without guidance, and the funds to put one together, are unlikely to create one.
The Federal government website pandemicflu.gov speaks of individual families stockpiling food, water, and medicine to weather a pandemic. They advise:
Store a two week supply of water and food. During a pandemic, if you cannot get to a store, or if stores are out of supplies, it will be important for you to have extra supplies on hand. This can be useful in other types of emergencies, such as power outages and disasters.
Yet some local health departments around the country are strongly advising having 30, 60, or even up to a 90 day supply on hand. In Lee County Florida, last year, they advised a 40 day supply.
Once again, no consistency.
Doctors in the United States, and elsewhere, have been pretty much kept out of the loop regarding how they should react to a pandemic. There have been discussions about the need for guidelines for triage, and the allocation of vital medicines, hospital beds, and ventilators, but no solid recommendations as to who should get them.
No one, it seems, is willing to make any hard decisions.
Apparently every doctor, every clinic, and every hospital is on their own when it comes to pandemic planning. Most are waiting for Federal guidance and legislation to protect them during a pandemic, and little or none has been forthcoming.
We are told the government has a national strategic stockpile of medications, ready to be dispatched to any area of the country in a crisis, but I've seen no detailed plan as to how those medications will actually get to the patients who need them.
To be effective, Tamiflu needs to be taken within the first 48 hours of infection. Assuming hospitals and doctor's offices are over run with patients, and a good many of those will be operating with staff shortages, how are patients even going to be seen during a pandemic? Getting in to see a doctor now on 48 hours notice is nearly impossible.
There are vague references to setting up toll free hotlines for people to call to get advice, or to somehow get a voucher for antivirals, but as far as I know, none have been setup, or tested. Will infected people have to go out in public to pick up meds, or will there be some form of home delivery? Will the government promote a `bird flu buddies' plan, as we've seen in the UK?
Given the low levels of medications actually in storage, this may be a moot point a month into a pandemic, but it still needs to be addressed.
The gaps in our pandemic plans, at least the ones publicly available, are staggering. Perhaps there are secret plans, well laid, that will deal with these problems. I hope so. But to date, I see huge gaps and wildly optimistic assumptions, and very little serious planning.
I understand the reluctance to allow the Federal or State government to micro manage individual sectors during a pandemic. But the alternative it seems, is to allow each sector to flounder without a coherent plan. The attitude seems to be, it isn't up to the State or Federal government to decide these things, and so nothing is done.
If it is inappropriate for the Federal Government to make some of these decisions (and it may well be), shouldn't they at least be providing serious, and substantial guidance to the private sector and local governments so they can do it?
If that is happening, I'm not seeing it.
We've been alerted for 16 months, and as a nation have produced thousands of pages of planning, and most of it will be of little practical use during a pandemic. But hey, they've got a plan.
A pandemic could strike with little advance warning. We may have only days, or a few weeks to prepare, once one starts. Given that absenteeism rates are anticipated to be 40% or more across the board during a pandemic, I'd like to know:
How food deliveries will be assured at the local level during a pandemic. Does the government plan to step in? FEMA? The National Guard? Anyone? If not, then people need to know, and prepare for more than 2 weeks.
How people will actually receive the medications from our National Strategic Stockpile. Will each state have to set up their own distribution process? If so, what has been done to prepare for that eventuality?
How will municipal water and sewer plants be able to operate, and continue to receive chemicals needed to operate?.
How will fuel refinery, and delivery, be maintained? What level of production and delivery can we maintain? How will fuel be allocated?
What steps are being taken to ensure that power plants remain operational, and that outages caused by storms, or other causes, can be repaired.
How will hospitals continue to receive supplies, and pharmacies be restocked, during a pandemic.
How will hospitals continue to operate at all with a 40% absenteeism rate? Even without the burden of flu patients, the daily influx of patients with heart attacks, strokes, and appendicitis will continue.
If your doctor becomes ill, or dies during a pandemic, how do you get Rx refills? It's not a trivial point, given the number of people who rely on daily medication for heart problems, diabetes, or high blood pressure. Ask the residents of New Orleans, after Katrina, what it was like getting medications when their drug stores were closed.
Exactly what parameters will be used when allocating scarce medical supplies and equipment? Who decides? Is it going to be left up to each individual hospital or doctor? If so, what sort of legal protection will they receive when they have to make the hard choices about who to save, and who to turn away?
And speaking of protection; doctors, pharmacists, and EMT's are going to be at risk during a pandemic from desperate, and possibly violent people demanding treatment for themselves or a loved one. How are they to be protected? Remember, law enforcement will be suffering the same staff shortages as every other sector.
What provisions are actually in place to handle the removal and disposal of two million dead from homes? I've seen calls for devising plans, but am aware of few that have been actually solidified.
These are but a handful of real life, serious considerations that must be addressed during a pandemic. Yet, I've seen very little in the pandemic plans to deal with them.
If a pandemic is truly a threat, then shouldn't we have these answers by now?
I know, maybe some of these problems are unsolvable. I accept that. I recognize that during a pandemic, many things will simply not work. People will go without necessities. Many will perish. But we can solve some of these problems, or at least lessen their impact, if we try.
What we need is some consistency, realistic consistency, across the board in every state. Doctors deserve guidance, and legal protection, during a pandemic. We need workable plans to deal with shortages and absenteeism. It isn't enough that State and Federal Agencies shrug and say it isn't up to them.
What we need, and should have had for a long time, is a full time Federal Pandemic Flu Czar, and a Czar for every state. And they need the advice of the best people in the field to guide them.
We need an infrastructure with the authority, and resources, that can make the decisions that must be made before a pandemic strikes. Leaving it up to the private sector, and a mish mash of vague state and local plans simply won't cut it.
We've been extremely fortunate that a pandemic hasn't happened yet. Perhaps that good fortune will continue, and we will never have to deal with these issues. I hope so.
But hope is not a plan.
Note: Technically, apparently we have a `flu Czar'. The HHS's Assistant Secretary for Preparedness and Response (ASPR), Craig Vanderwagen, MD, whose duties include being the point man on pandemic influenza. And I'll bet you've never heard of him. I hadn't. Not until I Googled the office for this article.
And that's the problem.
