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Friday Interview: Pandemic planning

N.C. plans for next major influenza scare

No one likes the flu, but imagine a flu season that proves more widespread than those we have been accustomed to dealing with: an influenza pandemic. It’s a possibility discussed during a recent speech for the John Locke Foundation’s Shaftesbury Society. Mark Holmes, vice president of the North Carolina Institute of Medicine, delivered the speech. He also spoke with Mitch Kokai for Carolina Journal Radio. (Click here to find a station near you or to learn about the weekly CJ Radio podcast.)

Kokai: The main thrust of your speech dealt with the ethics involved in planning for an influenza pandemic, or a pandemic in general. First of all, let’s let people know, what is a pandemic, in case they’re not sure.

Holmes: Well, a pandemic is an epidemic that occurs on a worldwide scale. We have an epidemic on every continent and it’s a widespread public health event.

Kokai: And this is something we have had in the past, but it’s been a while.

Holmes: It’s been a while, and that’s why there is a lot of interest in it at this point. On average we have about three pandemics per century. There was one in 1918, one in 1957, and one in the mid-60s. And the last two were pretty mild compared to the Spanish flu of 1918. So by some extent we’re overdue for one, which is why there has been a lot of federal interest — well, worldwide interest — in planning for it.

Kokai: And a pandemic, when it does occur, can be pretty dangerous and deadly.

Holmes: Yes. If you see a trend of, say, life expectancy or mortality rate for the United States in the 1900s, and you see this enormous spike in 1918 when the Spanish flu was going throughout the nation. And the mortality rate — we’re talking maybe one to two percent, which doesn’t sound that alarming but compared to all the historical trends — it is quite a remarkable event. Now of course we don’t know whether the next one is going to be one that looks like the Spanish flu, or one that looks like the last two in the ’50s or the ’60s, which statistically, we know there’s a pandemic, but you really don’t see the same mortality blip.

Kokai: Now we’ve set the stage — there is this sense that perhaps we’re overdue for the next pandemic. So what’s happening now to get us as ready as we can be?

Holmes: Well, the real focus on planning in the last five years is the H5N1 strain of the avian flu.

Kokai: Bird flu.

Holmes: Bird flu, as many people know it. And we’ve seen signs of it looking like it might mutate into human transmission. The way that this works is that we know that this H5N1 is a bird flu, and when it stays with a bird flu kind of strain, humans aren’t susceptible to it. The fear is that a person who has a human version of the flu will become infected with the avian flu, and then the H5N1 will mutate into something humans can transmit, and become infectious with. And that’s sort of the fear. So once the World Health Organization (WHO) started seeing signs that this is something we really need to be concerned with, and the high mortality rate of the 300 or so people who have been infected with H5N1, there’s been a worldwide focus on this. And the World Health Organization has taken a lead on this. As you might imagine, viruses don’t respect country borders.

Kokai: Or county borders.

Holmes: Or county borders, to that extent as well. So, with the WHO taking the worldwide lead, each country is really pouring a lot of resources into this, and we know that there’s been a huge federal response in both funds planning for national strategy as well as providing resources to states and local governments to prepare and do the best that they can to think about this. Of course the issue with pandemic flu is that, although most public health experts and epidemiologists remain convinced that we’re going to get it some day, we don’t really know when, we don’t know what strain it will be, and so we’re focusing on the H5N1 strain. But it could be the H7 or the H9, which would mean the vaccines that we stockpiled might not be as effective. So it’s a big insurance kind of issue here where we have to prepare for something that would be disastrous if it occurs — or when it occurs depending on who you speak with — so all we can do is do the best we can and prepare, recognizing that we won’t really know what we’re dealing with until it starts happening.

Kokai: Mark, the topic of your discussion [to the John Locke Foundation’s Shaftesbury Society] specifically was the ethics of dealing with and planning for the next pandemic. What are some of things that we need to keep in mind as these plans are moving forward?

Holmes: We had a task force with about 35 members on it from across the state, representing different constituencies if you will — groups that will be affected by this. And the first thing we did is sort of set ground rules — basically an ethical framework. What are the principles we need to think about while planning? And they include things like truth-telling, inclusiveness, transparency. One I think that was really important, is sort of driving a lot of where the task force went, is this issue of reciprocity. And that is, if society asks an individual to do something, then that individual should expect something from society, depending on what particular we’re talking about. A classic example will be if we’re talking about vaccinations. The national vaccination plan has a priority of healthcare workers, which makes sense if you think they’re going to be highest at risk and we need them to keep going so that they can effectively treat the high hospitalizations that we’ll have. Well, the reciprocal side of that is that if I give a healthcare worker a vaccination, or if society, say, gives a particular worker a vaccination, there is a reciprocal duty of the worker to show up for work and treat. So also on the flipside, if we’re asking someone to come in, we owe them the resources to enable them to be suitably protected. So I think reciprocity was probably one of the key issues that drove a lot of the issues that we’re talking about here, and the central ethics behind the planning.

Kokai: I think one of the other key issues that you run into will be the issue of freedom and liberty. Okay, we have a pandemic — just how much should the state or the federal government be allowed to limit where people can go and what they can do? Has that been an issue you’ve been dealing with, too?
Holmes: Absolutely. There were four issues that the task force really looked at. Two of them can be combined into one — the duty of healthcare workers to work, and the duty of critical workers to show up for work. Those are essentially the same because healthcare workers are healthcare workers, but slightly different issues that they’re dealing with. But critical workers would be people who run the electricity and make sure the food still comes to the grocery store. The third issue was allocation of scarce resources — who gets vaccinations, who gets ICUs, and what are the principles involved there.

Kokai: Sounds like economics.

Holmes: Exactly, yes. And the fourth issue was exactly what you mentioned, and the way that the task force framed it was balancing individual rights with protection of the public from harm. And there are great data that epidemiologists have looked at from 1918, and if you look at September 25, 1918, there was a parade in Philadelphia called the Liberty Loan Parade. There are these pictures of just crowds; it’s a tickertape parade. What you see if you look at mortality rates not seven days later — Philadelphia mortality rates spike through the roof. What happened is, you have this mass gathering of people, a couple people are infected and they’re literally two feet from everyone around them, and that’s where Philadelphia really faced this pandemic head on. Then you contrast this with cities like St. Louis, which, once they had their inkling of something, stepped quickly and closed all the schools, kept everyone home. And their mortality rate was much lower, much more manageable. The primary issue with, or one of the ways you can deal with the pandemic, is managing the surge — that is, you might have the same number of hospitalizations, just spread them over a longer period, so the hospitals are better able to keep up. So the public health side of your question is, what are the individual rights and liberties, and there are certainly strong public health issues to keep everyone at home and that sort of thing. However, the task force really looked at this and said, we need to respect individual rights and liberties and find the balance. What’s the proper balance between striking these, and the task force came up with guidelines such as the least restrictive, absolutely necessary effective mechanism — language like that. So this was certainly in the mind of everyone. And from a practical standpoint, experts in this field indicate that after the first couple weeks, there probably won’t be a lot of government closing borders and that sort of thing. People will be able to go around and it will be prudent for you to stay home, more like often like the language we have on a snow day — please stay off the roads unless it’s an emergency. And we know how well those are often followed. But we might have different circumstances as people look around and see that it’s a little different putting a car in the ditch versus catching a pandemic flu. So to a large extent, the burden is going to be on the individual.

Kokai: If people want more information, is there a good Web site for them to find out more?

Holmes: Our report is on the Web site, which is www.nciom.org. The federal response plan, which is also useful, is pandemicflu.gov.