Tuesday, March 21, 2006

How not to prepare for a pandemic

Last week The Boston Globe carried an Op Ed piece ("Preparing for Pandemic") by Mr. Manuel Cortazal, identified as the managing editor of the American Journal of Infection Control. He is neither a doctor nor an infection control nurse. But he is a loose cannon.

Like a lot of pieces of this nature it starts out reasonably enough, pointing out that bird flu is appearing in countries like Nigeria and India whose public health system is not equipped to recognize, much less cope with, a genetic change in the virus that would allow easy transmissibility between people.

He then moves on to reprise the Bush administration strategy, which he characterizes as having three components: preparedness in the form of local response plans; surveillance for advance warning; and response and containment, again left to local authorities. Cortazal views these elements against Bush's sorry performance in the Katrina disaster. Preparedness was on paper and not real. Surveillance means nothing without capacity for response. And the ability to respond is sorely lacking in almost all jurisdictions as a result of neglect and budget cuts: "The federal government cannot assume that local authorities will be able to manage relief activities in response to a pandemic."

To this point Cortazal is pretty much on target. But then comes the punchline and this Op Ed rapidly runs off the rails:
The president's plan pays scant attention to quarantine measures, which many experts believe were the key to the containment of SARS. Also, it is weighted heavily toward vaccines and antiviral medications. Yet, national stockpiles are woefully inadequate and won't reach desirable levels until 2008. Owing to the glaring lack of vaccines and antiviral medications, quarantine may be the most effective response to an outbreak.
Cortazal apparently doesn't know the difference between isolation and quarantine (the former is the segregation of the sick, the latter the segregation of the well who might become sick), or if he does, doesn't realize that quarantine as a way to prevent the spread of influenza is considered fruitless by most experts in the field. He also doesn't understand the difference in the epidemiology of SARS and influenza, nor recognize that even in SARS the influence of quarantine is doubtful. Nor that its burden will fall preferentially on the least powerful while those with means and status will have little difficulty evading its provisions. He compounds his dreadful judgment by advancing its obvious consequences:
Officials responding to a pandemic outbreak will have to deal not with mass evacuation but with keeping citizens in place. State and local authorities have no experience in coping with the complexity of restricting the movement of entire metropolitan areas, which, ironically, is the opposite challenge that Gulf Coast emergency managers had faced.

It may come as a surprise to many that the federal government does not have broad police power to impose quarantines, a responsibility constitutionally vested in the states. The disarray among local, state, and federal agencies in the wake of Katrina vividly demonstrated the constraints on cooperation and coordination following a catastrophic event. If a regional outbreak, for want of cooperation among government agencies, were to spiral out of control, the deadly virus could spread nationwide.
The very idea that influenza could be regionally contained in the US is as stunningly naive scientifically as it is dangerous socially. It would, as he implies, also require adjustments to what is considered constitutionally valid, something this Administration has no compunction doing under the cover of public fear.
The unnerving prospects that await us, should an outbreak occur, call for unified leadership that recognizes the limits of state and local preparedness and the need for employing quarantine measures. Rather than delegating planning and response to myriad local health departments, the nation's governors and the president must urgently agree on plans to quarantine affected areas and prepare for the multitude of people who will need healthcare.
Cortazal's suggestion brings us inescapably back to Bush's quickly dropped suggestion that he might use the military to enforce quarantines in the event of a pandemic. It went over badly then and it should go over badly now. It won't work but will do much harm to those already stressed, powerless and overburdened.

This stuff is dumb and dangerous. The Association for Professionals in Infection Control and Epidemiology, the professional association of hospital infection control nurses that publishes this journal, should keep this guy on a shorter leash.