Wednesday, March 23, 2005

Pandemic "To Do" list: some initial thoughts

If there isn't a pandemic this year, there will be one at some point. So I started to make a To Do list of things we need to think about in preparation. I don't mean a "Pandemic Influenza Plan." I mean a To Do list. Consider this "shark bait" to be torn to pieces by wiser minds.

I'll start it off. Feel free to add/correct/delete things that will need to be done. Then we can set about trying to get someone to start doing them in our local communties. For if there is a pandemic, it will be everywhere and have to be fought at the local level--everywhere. This is not a situation where "federal stockpiles" can be rushed to the scene of a disaster. "The scene of the disaster" will be everywhere.

1. The rationing problem

Whenever it happens, I will be very surprised if we have enough of most of the things we'll need. So we have to think of an ethical, humane and pragmatic plan to ration antivirals, vaccines (if they exist), etc.

Some questions: Who gets what first? Who gets what at all? Some possibilities:
  • Essential services such as health care workers (which ones?), public safety, transportation, communications, ?
  • Highest risk or those where intervention might stop the epidemic fastest (e.g., the elderly or healthy young adults/children).
  • Lottery?
  • Market forces (highest bidder)? (I should hope not, but you know this question will arise)
  • Citizenship status? (I should hope not, but you know this question will arise)
And some way to assure the security of scarce supplies to prevent them from being looted or diverted into a black market.

Obviously we all have views about how to do some of this, but we need some kind of mechanism to think this through together and debate it in our local communities, assuming we have the luxury of a little time (of course, if the immediate threat recedes, we'll probably waste the time handed to us).

2. The care-giving problem

There aren't enough hospital beds for even a moderately bad epidemic. In many big cities emergency rooms are frequently on "diversion" (they send cases to other hospitals) already. In an epidemic we will have to make use of alternatives.

Some possibilities: hotel and motel beds (every room has a bathroom); increased use of Visiting Nurse assistance to keep very ill people at home.

The nursing problem will be particularly important. Hospitals beds that aren't staffed are essentially worthless. But if 25% of the workforce is sick there will be an acute shortage of nursing care. Some alternatives: organizing retired nurses, trained volunteers (requires a training program, of course), etc. This would require rosters, a way to contact people and some means to assure minimal skill level, perhaps on a tiered basis.

Mortuary space, enough caskets, burial arrangements, grief counseling. We need to organize the funeral homes.

3. Equipment

There are probably not enough respirators to handle the huge increase in adult cases that would need them, and certainly not enough pediatric respirators to handle a disease with a proclivity for the young. Do we even have an idea of how big the shortfall is? Do we have any inventories that would allow a local area to re-distribute them according to need?

What other critical equipment problems do people foresee?

This is just a start and meant only to get people thinking about what needs to be done and how it might be accomplished. All of these things can be done without huge resources and done locally. I'd love to hear about folks getting some of them started.

Obviously a strong and vigorous public health infrastructure would be the best solution, although a pandemic would stress even the strongest system. But we don't have a strong and vigorous infrastructure and neither this Administration nor our public health non-leadership is securing us one. Indeed, our public health infrastructure is going right down the toilet. Maybe addressing this important task can help jump start a re-invigoration of public health from the ground up. At the moment, that seems to be the only place it can come from.