Making it Happen

Making it happen. Now, there’s a concept we can agree on. So, let me give a hat tip to the two previous posts from Mike Coston (Breaking The Barriers) and Admiral John Agwunobi (Ideas Are Welcome). Mike talks about the need to tackle the pandemic severity threat head on, while Dr. Agwunobi shows a notable willingness to listen and learn (and for the sake of this discussion, let’s assume that’s official HHS policy). Combining those things would, indeed, be a “best practice” way to make it happen.

There are HHS tool kits in development, a focus of the DC summit. We’ve not seen them, and the plan is for deliverables this summer and roll-out in fall (see Stephanie Marshall’s presentation):

Overall HHS Communications Objectives:

• Raise awareness of avian and pandemic influenza and the impact a pandemic could have on human health
• Support states and local community plans, prepare for and respond to a pandemic
• Educate key stakeholders and the public about the role they play in preparing for a pandemic and the necessary steps.
• Create a foundation of pandemic awareness and knowledge to support future response and recovery efforts
• Instill and maintain public confidence in the nation’s public health system and its ability to respond to a pandemic influenza outbreak
• Speak with one voice, as a global citizen and as a nation

I like the “many voices, one message” approach because it will take those many voices to reach everyone, and starting to reach out should not wait until summer or fall. HHS can surely help with the toolkits that are envisioned. But tools exist right now that can help further the message.

For example, a group of concerned experts have put together a downloadable .pdf entitled Influenza Pandemic Preparation and Response - A Citizen’s Guide. With a superb foreword by David Heymann (WHO), this guide is free for the taking and would make a great handout at small meetings, or an email link to send, or as an authoritative source of pandemic information in any setting (more details here):

Since 2003 three major classes of avian influenza virus - H5, H7 and H9 - have caused sporadic human infections, and because of the instability of the influenza virus, any one of these viruses is thought to be capable of mutating in such as way as to cause a human pandemic. Presently the most widespread of these viruses is the H5N1 avian influenza virus, or simply H5N1. Since first reported to infect humans in 1997 at the time of an H5N1 outbreak in chickens in Hong Kong, the H5N1 virus has spread in poultry populations throughout Asia, the Middle East and some parts of Africa and Europe causing a pandemic of influenza in chickens; and occasional human infections in persons who have come into contact with infected chickens. Since 2003 there have been just over 300 reported human infections with H5N1, all having caused severe illness, with an overall death rate of 61%.

In addition to toolkits from American Red Cross, Santa Barbara has put together an automated slide show (with narration), which could be used in a local presentation by anyone, and Larimar County CO also has an excellent teaching slide show called Pandemics Happen. Folks online have for some time been trading presentations like this to help ourselves teach our communities. Want more slides? You can build a nice compliment to Secretary Leavitt’s 50 state historical round-up by using some of the quotes from this blog:

Dr. Agwunobi:
Advanced preparedness is critical and individual preparedness and a culture of self sufficiency are essential. No one can afford to wait until after an emergency begins in order to prepare….

No one can predict with certainty what the next pandemic will look like. There are no guarantees or promises that can be made regarding its impact on society. The next pandemic may be mild, as in 1957 and 1968, severe, as in 1918, or somewhere in between. The next pandemic could even be worse than 1918. There is simply no way of knowing.

Are there people willing to go out and do this, to actually go back to their communities and discuss panflu prep? Are there people willing to support HHS and CDC? Sure there are. But it can’t happen without the federal government validating the pandemic threat and the need for preparations (HHS has already validated us, now we need to validate the threat of H5N1 and other flu viruses, as David Heymann does above). No one wants to go out there and have a local health official refuse to attend, or attend and downplay the risk of H5N1 or the need to prepare (and that is an all-too-often occurrence right now, as the online folks can attest to - please hear that, HHS). Public health folk need to consider the public as a full partner; only then can Stephanie’s articulated HHS Communications Objectives goals be met. HHS needs to help us so that we can help HHS by fostering resilient communities, with the authorities backing us up. That’s how we can make it happen, and that’s how we can best prepare for whatever comes.

See also The Stuff Solutions Are Made Of.

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Prepping For Your Pets, And Other Flu Stories

One great thing about the internet is the variety of angles one can take to look at the same issue. Here at the Pandemic Flu Leadership Summit, we tackled some substantial issues such as the wisdom of communicating H5N1 preparation vs. an any-pandemic prep vs. an all-hazards prep. Each approach has merit. We all recognize that were it not for H5N1 and its virulence and threat, this HHS summit and blog would not exist. We also recognize that H5N1 is not guaranteed to be the next pandemic virus (it could be an H7 or an H9 or a more common H2). We further recognize that even for those who agree to apply the precautionary principle (action to reduce risk should not await scientific certainty), an all hazards approach may be necessary and prudent for the widest buy-in that does not dilute the result (and that last bit is key, since the goal is to get folks to adequately prepare and not to come up with a plan that is insufficient in scope).

With that in mind, and always on the lookout for best practice, Minnesota’s Code Ready program is worth highlighting. As the Strib relates:

Box upon box of pasta and rice, a couple hundred cans of fruits and vegetables, 120 gallons of water. Powdered milk. A first aid kit. A lantern. A weather radio. Plastic sheeting. Duct tape. Bleach.

All in your basement.

State health and public safety officials want Minnesotans to stock up in case of a flu pandemic, terrorism emergency or other widespread disaster. They’ve launched a $500,000 state campaign dubbed “Code Ready” encouraging Minnesotans to develop plans of action and assemble survival kits for emergencies small and large — from three days to a year.

I had the opportunity to discuss this with a spokesperson for the Minnesota Department of Health, who described to me many of the same discussion points (all hazard vs panflu) in preparation for the web site, which features a prep calculator based on family members, their ages, and, yes, pets. You can choose to build a prep kit for 3 days, a week, a month, or a year. The idea is to get started and then build. While this way, both all hazard and flu prep users can custom build their preps to suit their needs, pandemic flu was the issue that drove the project. More from the Strib:

As of last week, about 1,700 people had gone through the site’s pages to create their own kits. Ten times that number have viewed parts of the site, officials said, with hits coming even from Asia, Africa and Australia.

There’s been another 5,000 contacts in the offline awareness campaign. In addition, a survey done by the University of Minnesota last September for baseline purposes, and repeated this coming September, will look at Minnesotans and their prep attitudes, and whether the campaign has had impact.

Including pets in the equation seems like a great addition. Without that emotional kick (be it pets or kids), the reason to use the kit falls flat:

“It’s ridiculous. It’s just way too much stuff for anybody to have at home. I can’t imagine what they’re having us prepare for,” said Tracy Eberly, who lives in south Minneapolis. “If society breaks down to the point where we need all that food, trust me, we’ve got other problems.”

Nonetheless, there’s a start here that would be great to see everyone make. After all, there’s going to be a need for food AND addressing of those ‘other problems’ should a category 5 pandemic break out. That’s why planning needs to be so extensive, and why it needs to be done in advance, and if it can be done in a way that changes attitudes as well as supply facts, all the better.

That “pet planner” addition may be the necessary tool for more than a few to take this issue seriously. And maybe it’s a good way to bring veterinarians to the table, and add another professional society to the mix. Right now, whether it’s, CDC, HHS, the states or the professional societies, we need information out there for the public from every credible source we can get. Many voices, one message: panflu prep is necessary, important and possible. After all, your pets and your children expect and deserve nothing less.

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The End Of The Beginning

As the memory of those parting airport thunderstorms fade, what remains are the positive experiences of the recently conducted HHS summit. This isn’t about being nice (or not nice) to HHS, but rather an outcomes focused look at tangible and intangible results.

From CIDRAP’s reporting on the conference:

At a press conference that followed the forum, Stephanie Marshall, director of pandemic communications for HHS, said the agency would launch two more personal-preparedness promotion efforts in the months ahead. Later this summer officials will release tool kits, tailored to four different sector (business, healthcare, faith, and civic), that leaders can use to teach people more about pandemic flu and what they can do to prepare.

Marshall told CIDRAP News that the forum yielded ideas that will help HHS tailor the tool kits for each sector. “We received a lot of thoughtful input yesterday,” she said.

In the fall, HHS will target 5 to 10 diverse communities for more intensive communication campaigns about personal preparedness, Marshall said. “We certainly would like to include the appropriate representatives from the leadership forum and blog summit in these localized efforts,” she added.

And as for my own participation,

Greg Dworkin, MD, who took part in the leadership summit and is one of 13 experts who have led the blog discussions, told reporters he lauds the HHS for offering such an open live and online forum. The sometimes heated blog postings over the past weeks show there are many interested people who want good information from a federal source on individual and family preparedness, said Dworkin, founding editor of the FluWiki Web site and chief of pediatric pulmonology at Danbury Hospital in Danbury, Conn.

The HHS leadership forum helps validate the efforts of the many people who have already heeded pandemic warnings and started preparing their communities, their families, and themselves, he said.

I never describe or think of myself as an expert. But I do know the blogosphere, and the posts I refer to are not just at this blog, but at others. In addition to Flu Wiki and Pandemic Flu Information (good – but not the only – places to take the temperature of flu bloggers), here are some other reactions:

Pandemic Flu is not something I think about
By Denise, 12:18 pm, Thu 14 Jun 2007

… Pandemic flu doesn’t sound like a very interesting topic to spend a couple of hours blog surfing, does it? Well it is - very interesting. Don’t take my word for it, go surf it yourself.

and

Leadership and Moral Courage

…Vocal Flubies from all over Flublogia descended with the energy of a burst dam. We are a passionate and opinionated lot we Flubies. Our voice was finally going to be heard and we were determined to make it count.

I think the bloggers and the blog officials will be awhile recovering from the force they released. If you haven’t yet, and I just can’t imagine that to be the case, drop by the HHS PFLF and have a read. As has happened any number of times in Flublogia, History was made, yes history with a capital “H”. Now we will just have to wait to see if it’s a sympathetic and meaningful history or simply a sad footnote.

You might add impatient to passionate and opinionated, but then again, this is simply a slice of the American public. Try talking politics or baseball dispassionately.

Finally, there are pleasures (Sister Patrica Talone is as warm and approachable in person as she is online) and regrets to share (Nedra Weinreich and Michael Coston and Pierre Omidyar, among others, were not there for their wisdom and counsel, and I didn’t meet some of the other blog participants, though I read them all) . The participants, too numerous to mention, taught this so-called expert things I didn’t know every time a comment was made and an idea discussed. These human contacts are worth far more than any press conference or single blog post. And they mean most when we use those contacts going forward to build a message of pandemic preparedness.

You can’t push the public ahead of where they are ready to be, but you can’t use that as an excuse to not make the effort, however difficult it is, and however far uphill. Also, tactical disputes should not obscure broad agreement on strategy. Those of us committed to the idea that pandemic preparedness is an important message will use whatever tools are available. If HHS provides them, terrific (I love when someone makes my job easier). If not, we will make our own. If we fail at any of it, we will simply learn how to fail better next time (fear of failure is no reason not to try). And that, ladies and gentlemen, is a commitment.

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SARS And H5N1: The Precautionary Principle

While we’re still in week 3, and looking at getting the job done there’s an important piece of this we need to get out on the table, and very relevant for answering the question “What do I need to succeed in communicating the importance of preparing for a pandemic?” It’s to take a look at the virus we know is out there, H5N1, and make sure it is central to our thinking.

This is a nasty, vicious killer of young people (90% of H5N1 deaths are less than 40 years old), and while we do not know that it is the next pandemic virus, no one can assure us that it is not. Mutations are a normal part of viral evolution, and the virus has changed since 1997 when it appeared, and 2003 when it reappeared, in Hong Kong. The next set of mutations can set off events we’d rather not think about, let alone experience. After all, the 1918 pandemic was bad enough with a 2.5% case fatality rate, but H5N1 has a 61% case fatality rate overall (80% in Indonesia). Those are staggering numbers to consider and comprehend.

Now, isn’t that just an alarmist way of looking at current events? isn’t it true that we don’t know for a fact that H5N1 will be the next pandemic virus? Well, here’s the thing. H5N1 is out there, and it is not going away because it’s established itself in the bird and animal population (cats in Indonesia are not excluded from this virus, and there’s speculation that they may have some undefined role in viral spread). Each human exposure is another chance for viral mutation. And we have an important precedent to look at, both from Hong Kong and Ontario. I am, of course, referring to SARS. And here, we have a blue ribbon review of what happened in Canada when SARS broke out, what was done, and what could have been done better.

The independent Commission to Investigate the Introduction and Spread of Severe Acute Respiratory Syndrome (SARS) was established by the Government of Ontario as an investigation under section 78 of the Health Protection and Promotion Act. Mr. Justice Archie Campbell of the Ontario Superior Court of Justice was appointed Commissioner.

The Commission investigated how the SARS virus came to the province, how the virus spread and how it was dealt with. Its final report was completed in December 2006 and made public on January 9, 2007. It was transmitted to the Minister of Health and long-Term Care on January 4, 2007.

Here’s an excerpt:

SARS had Ontario’s health system on the edge of a complete breakdown. The wonder is not that the health system worked so badly during SARS, but that it worked at all. SARS also badly hurt Ontario’s international reputation, setting up an unfortunate link in the minds of many in other countries between Toronto and a mysterious deadly disease. Worst of all, SARS demonstrated how many earlier wake-up calls had been ignored, and how few of their warnings had been heeded…

We must remember SARS because it holds lessons we must learn to protect ourselves against future outbreaks, including a global influenza pandemic predicted by so many scientists. If we do not learn from SARS and we do not make the government fix the problems that remain, we will pay a terrible price in the next pandemic. (bolded mine).

There were some specifics from the report that need highlighting (vol 1, p.16):

Common problems and themes emerge from the stories of both [hospital] outbreaks. They reflect seven systemic problems that run like steel threads through all of SARS, through every hospital and every government agency.
• Communication
• Preparation, planning
• Accountability: who’s in charge, who does what?
• Worker safety
• Systems: infection control, surveillance, independent safety inspections
• Resources: people, systems, money, laboratories, infrastructure
• Precautionary principle: action to reduce risk should not await scientific certainty

Here’s more on the precautionary principle (page 10):

Perhaps the most important lesson of SARS is the importance of the precautionary principle. SARS demonstrated over and over the importance of the principle that we cannot wait for scientific certainty before we take reasonable steps to reduce risk. This principle should be adopted as a guiding principle throughout Ontario’s health, public health and worker safety systems.

H5N1 is a real threat. Robert Webster and Elena Govorkova , writing in the New England Journal of Medicine, said

Clearly, we must prepare for the possibility of an influenza pandemic. If H5N1 influenza achieves pandemic status in humans — and we have no way to know whether it will — the results could be catastrophic.

So, given what we know about the potential threat of H5N1 (which is considerable), and mindful of the precautionary principle, as well as the duty to inform, does it not make sense to prepare for worst case as well as mild case scenarios? It is in this context that discussion of how to stockpile (including suggestions of how long, and what, to stockpile, including medicines), and folding pandemic preparation into an all-hazards approach run into stormy weather. Planning for a worst case scenario ought to cover mild case scenarios and assist all-hazard preparation. Planning for a mild case scenario does no such thing. Mild scenarios do not consider loss of electricity, for one, or mass casualty events, nor do they consider the effect of illness on a vulnerable JIT economy. We will not be closing the schools for mild events (though they may close on their own when parents don’t send their kids – and don’t ever underestimate parents).

And while it is true that we can not predict the next pandemic, or whether H5N1 is the next pandemic virus, the precautionary principle suggests treating H5N1 as if it is. After all, that’s why there’s such interest in this topic in the first place. Let’s acknowledge it and move forward with that in mind. After all, preparing for H5N1 prepares for any pandemic we get.

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The Public Is Ahead Of The Government

One thing about blogging is that you get to refer to current events (with links) in your blog posts. One thing about group blogs is that you get to respectfully disagree with some of your distinguished fellow bloggers, and yet still work for a common goal. This, too, is part of getting the job done.

To be fair, any public health official who is an advocate of preparation for pandemic is, in my book, wearing a white hat. But the public is not going to react well to mixed messages about the severity of a pandemic and the length of prep needed. Even a ‘mild’ pandemic’ can overwhelm our medical system (table is by Eric Toner, MD of UPMC’s Center for Biosecurity) already straining to keep up with day-to-day emergencies). To drive that point home, Secretary Leavitt went to each of the 50 states and discussed not the (relatively mild) 1968 pandemic, but rather 1918. The Secretary’s opening remarks for each state are here. In my home state of CT, I heard this message about 1918 from the Secretary:

At its peak, the pandemic claimed more than 1,600 lives in a single week. But the total number it took in Connecticut will never be known. Reports are incomplete; the pandemic was too overpowering. But its echoes of terror, of suffering, and of loss remain.

When it comes to pandemics, there is no rational basis to believe that the early years of the 21st century will be different than the past. If a pandemic strikes, it will come to Connecticut.

The American College of Emergency Physicians says:

We must take steps now to avoid a catastrophic failure of our medical infrastructure and we must take steps now to create capacity, alleviate overcrowding and improve surge capacity in our nation’s emergency departments.

Meanwhile DHS is asking tough questions and reviewing more severe scenarios.

The population may be directed to remain in their homes under self-quarantine for up to 90 days per wave of the outbreak to support social distancing.” (page 7 of 37)

So, given the range of possibilities of severity for a pandemic (ranging from hurricane-style category 1 through 5 - and a cat 1 hurricane on your doorstep is no small matter), and given the state of our medical care system and the vulnerability of our JIT economy, it is prudent and enlightened self-interest for the public, aware of all of this (it is in the public record), to ask for stronger preparation guidelines and, above all, stronger leadership, in informing and advising our fellow citizens.

If fire and police and first responders and hospitals are being given a tough message about what might come, the same message needs to be given to the public. This is where the obligation of the authorities to inform the pubic comes in, and it’s an important lesson from the SARS experience in Toronto. Just tell the truth and don’t sugar-coat the message. Say ‘I don’t know’ when you don’t know. And say, ‘we’re in it together, so we’ll figure it out together’. The public won’t panic, but it can sense a mixed message from 100 miles away. We can and must do better than that.

Here’s another example of the public getting the message:

Fairfax County houses of worship are starting to plan for the unthinkable but possible: a pandemic flu that could sweep the country, sickening and killing millions.

More than 125 leaders from churches, synagogues, temples and mosques met recently at the Fairfax County Government Center to grapple with questions ranging from the practical to the theological as they began preparing their communities for the possibility of a flu outbreak.

I look forward to the June 13 conference, where some of this can be hashed out. Those that are preparing need to be supprted in their efforts, and it is HHS’ obligation to do so.

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