an ounce of prevention - on pandemics

8/3/2019 An Ounce of Prevention - On Pandemics

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228 an ounce of prevention chapter 12: specific threats 229

Planning for a Pandemic or Perhaps Other EventsFlorence Nightingale made a major contribution to the nursing-pro es-sion and also to the feld o statistics. In 1857 she developed a particulartype o chart showing the causes o mortality among soldiers during theCrimean War. Nurse Nightingales diagrams, known as rose charts,showed that soldiers were in greater danger in the hospital than on thebattlefeld.

On the other side o the world, soldiers during the US Civil War knewthey were o ten better o staying out o feld hospitals because o thedangers o secondary in ections and complications.

Today we need innovative statistical analysis and good guesses rom lay people to prepare or a potential in uenza pandemic. Will we be bettero in hospitals, hiding in our homes or evacuating our cities?

I public policy is going to save lives, good research must isolate why people get sick, what might keep them sa e, how to make them well, and what communication techniques will alter their behaviour.

Crisis management and risk analysis call or assessing the likelihood o anevent as well as its potential impact. Prudence dictates preparing or anunlikely event with massive potential impact. A highly likely event withminimal impact does not deserve the same level o attention.

The Asian Development Bank predicts that a pandemic could cost the world economy $60 billion. Thats worth an ounce o prevention, regard-less o the likelihood.

Reasonable people make prudent risk decisions around the home. Weuse locks, bolts and alarms to keep intruders out because o the potential

impact o a break-in. But we tolerate litter on our ront sidewalk becauseits hard to s top and the impact is limited.

So, the act that a pandemic hasnt happened is irrelevant to proper risk analysis. Some say we are overdue or a pandemic because the last onecame more than 40 years ago and they occurred more requently thanthat in the twentieth century. But thats junk sciencea ocus on one variable ( requency) to the exclusion o countless others. Very ew peopledied rom the recent bird uthe toll was in the low hundredsyet themortality rate among those a ected was high. Some take solace rom the

act that there were very ew cases o human-to-human transmission.

Others worry about the potential impact i human-to-human contact


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Even i the World Health Organization used sound methodology toestimate that up to 350 million people might die, thats still a smallerpercentage o the world population than died during the Spanish Flu. In1918 the worlds population was about 1.8 billion, while today its about6.5 billion. It is irresponsible to quote these guesstimates out o context.

Lessons from SARS The Severe Acute Respiratory Syndrome event was statistically irrel-evant. Eight thousand cases worldwide and 800 deaths is meaningless ina world where two million people die rom diarrhoea each year, morethan 40,000 North Americans die rom ordinary u, about 50,000 dieon highways and perhaps 5,000 die rom ood poisoning. In years past, without 24-hour news networks, these deaths might have been missed ormisdiagnosed.

The lessons o SARS are more qualitative. We know that health-care workers were at risk unnecessarily. A pandemic is both a public-healthissue and an occupational health and sa ety issue. It can be argued thathealth-care workers need more protection than others because theyregoing to protect the rest o us. The same is probably true o the police,the military and other emergency responders.

Early in the Ontario outbreak, one Toronto police o fcer predicted theremight be 10,000 deathsits not just the news media that like a goodstory. In what was meant to be a reassuring gesture, Ontarios premierand health minister dressed in hospital gowns and masks to tour a hospi-tal, but that image probably compounded the ear and spread the wordabout SARS. Also spreading the word were daily news con erences by public-health o fcials announcing the latest toll. Reporters present knewthat o fcials had been arguing about acts and perspectives behind thecurtains just be ore the con erence began urther spreading uncertainty and ear.

Risk communication with an angry and ear ul public will be vital be oreand during a pandemic. When trying to change behaviour and percep-tion, o fcials must be candid and empowering.

Another lesson was both cultural and technical. Why did it take SARSto get hospitals to install sanitizing gel and signs promoting cleanliness?One hospital CEO riend o mine tells o spending tens o thousandso dollars to install sinks or hand-washing but having great di fculty

getting physicians to use them. Studies show that among the dirtiest

proli erates. Still others guess that it will not be any o the current strainso u that become a pandemic but a new strain, rendering currently avail-able drugs ine ective. The real issue is potential impactnot an irrel-evant statistic on the likelihood o the event or, worse yet, the actual yearin which it might happen.

Pandemic Background We had three pandemics in the twentieth century. The so-called Span-ish Flu in 1918-19 probably killed as many as 100 million people. (Isay probably because records were not accurate and the pandemichappened during a war. The o fcial toll is about 40 million.) The 1957-8

u may have killed two million, and the Hong Kong Flu in 1968-9 may have killed about a million. The World Health Organization estimatedthat an avian u might kill between eight and 350 million people. Thatsa huge range.

More troops were killed in World War I by the u than on the battle-feld. Soldiers were crammed together in troop ships, trains, barracks andthe trenches. This spread the disease.

However, it is scientifcally improper to extrapolate what might happentoday rom what happened then. Sanitation has improved, which canhelp. Building-codes orbid lone toilets and require washrooms to havesinks or hand-washing. There is no world war in progress. But the popu-lation travels and commutes much more, which can hinder. Communica-tion is better, which can help. Medical procedures are much improved. There are countless other variables.

The u virus wasnt even isolated in a lab until 1933, long a ter the Span-ish Flu pandemic had passed. Some scientists and physicians at the time

thought the virus might be spread by dusty books. What else has changed? There were two waves o u in 1918 and againin 1957, giving responders time to act, but theres no guarantee that a

uture pandemic will behave the same way. We have an aging popula-tion that may be more vulnerable but is much ftter than older people inprevious generations. Those who lived through 1957 and 1968 may havedeveloped some immunity to certain strains o u. Studies o past u viruses show it may not just be vulnerable populations such as the sick, very young and elderly who are at greatest risk. There can be healthy groups in their teens and twenties who have never been exposed to major

outbreaks and can there ore be at even greater risk.


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A philosophical discussion o a problem does not solve the problem. A listo what a pain it will be not to have 30 percent o the work orce, no snowor garbage removal, ood delivery and so on is not a crisis plan. It is justcomplaining and a waste o time. The other waste o time, or the mostpart, is job descriptions. In a pandemic 30 percent o those people will besick anyway. A crisis is no time to be reading a sick or dead persons jobdescriptionits a time or action, and more action until no more actioncan be taken! Imagine a fre-fghter at your home reading a job description.

Insurance A pandemic is also an insurance matter. Individuals and organizationsneed to examine their policies. It is essential to clari y how an insur-ance policy will classi y bird u. Whether its classifed as a disease or anenvironmental hazard will a ect coverage. Something transmitted romperson to person is normally considered a disease, but breathing in the virus rom the air could be considered pollution.

Business travellers should veri y that theyre covered abroad. Transport

home, including ight cancellations, will be issues i they get sick.Contamination o goods and property also presents complex problems.Insurance may cover decontaminating buildings, but what o buildingsonly suspected o being contaminated? I customers wont buy goods

rom a actory or warehouse because its in an a ected jurisdiction, willinsurance pay to disin ect the acility to reassure customers, even i theprocedure isnt needed? Can you insure against negative perception? There will be similar questions about suspect goods in transit, includingmedical and hospital supplies.

What is to be Done? As in personal health, one doesnt need a statistic to eat better, exercisemore, stop smoking and enjoy regular mental down time. There arebenefts to being well prepared, regardless o whether we ever have apandemic. Preparation or a pandemic will serve our communities well insevere weather events, terrorism, and even normal times.

Heres the worst-case scenario in a pandemic. Thirty percent o the work orceincluding health-care workersis dead, sick or pretendingto be sick to avoid catching the u. Moreover, even reasonable, rational,decent health-care workers will be stealing drugs rom hospitals to give

things in hospitals are physicians ties and pagers (ties have been bannedin British hospitals). Hospital workers go or co ee breaks and mealsoutside their hospitals and return, wearing the same gowns and scrubs. They wear the scrubs home on public transit, even though most mustknow that some organisms can live on the cloth or a week. Theyreendangering their amilies and the public, and this should be banned.Even physicians dont have their lab coats washed o ten enough. Theirony is, all these neglected precautions were standard procedure 50 or100 years ago.

Finally, we may have learned not to be distracted by irrelevant anddistracting data but instead to look to action or solutions. Take a look at an example rom a hospital crisis plan I read. It contains the seeds o death, injury and loss.

The plan had one ull page discussing how important water is to a hospi-tal. Drinking, bathing, laundry, cooking and other activities were listed. The plan even cited US Navy research calculating that 246 litres o wateris needed per bed, per day.

I there were an actual water shortage, none o this in ormation would beo use, except maybe how much is needed. I you dont have any water,fnding water is the issue, not wallowing in how di fcult it is not to haveit. There are plenty o solutions:

l Get sta to drive to the nearest stores and buy bottles o water.l Distribute plastic jugs to sta . Have them flled at home and

brought in every day.l List tanker-truck companies able to deliver potable water.l List methods o rationing, independent laundries that pick up and

deliver and where to get portable toilets.l List abandoned wells.l Discharge patients early.l Use hand sanitizers or cleaning and juice or drinking.l Flush toilets with recycled water.l Create mutual-aid agreements with oil refneries, waste-disposal

companies or others with tanker trucks that can suck up non-potable (white) water out o lakes, rivers, streams and the oceanto ush toilets.


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Just in case we need to make people stay put or a while, condos, apart-ments, sports arenas and o fce towers should be required to keep some

ood, medical supplies and water on hand. We need to ban lea -blowersthat spread animal eces and disease. We need to ban the internationaltrade in wild animals or pets or as meat.

Health-care acilities have the most at stake. In an outbreak they may belocked down early, but they can extend their use ulness. Theres a truism

in the military: In times o war, everyone gets promoted in rank. It willbe retired health-care workers, students, technicians and trained medicsrom the military and service groups who may be flling in or nurses and

doctors who get sick. Hospitals can also extend their use ulness physi-cally by scouting nearby sites. Perhaps a store ront can become a walk-inclinic. Schools and theatres will certainly become triage centres. Hockey rinks will store bodies.

Even i the pandemic never happens, good preparation will still make ormore environmentally riendly cities, sa er communities, more resilientinstitutions and a stronger economynot bad unintended consequencesat all.15

Whos in Charge?Canadas task orce on counter-terrorism identifed a problem in thechain o response command. Whether its terrorism, a pandemic or asevere weather event, multiple agencies can step on each others toesand prevent response rom taking place. Thats one o the things thathappened in the New Orleans hurricane.

When Canadian authorities held a news con erence a ter arrestingsuspected terrorists in the Toronto area, there were at least eight di erentagencies representedlocal police orces, RCMP, CSIS and so on. Thatcaused my riend General Ron Cheriton, who headed that task orce, tolaugh and remark that not much had changed since his report.

With pandemic planning, provinces delegate the responsibility to munic-ipalities. The mayor usually asks the deputy fre chie to write a plan.In that plan is usually a line stating that high-need people such as theelderly, sick and disabled will be the responsibility o social-service agen-cies. Yet there is usually no money, direction, training or extra peopleallocated to these small agencies. Thats a secondary crisis in itsel .

them to their loved ones. Some will be giving their hospital patients akedrugs. Hubris or amiliarity with risk will cause many health-care work-ers to neglect necessary precautions and spread the disease in malls andon the transit system. There will be a black market in both ake and realdrugs, as well as in gloves, masks and sanitizer.

Heres what all organizations can begin doing tomorrow:

1. Encourage hand-washing, because some sanitizing gel doesnt work.

2. Put hand-sanitizing gel (the kind that works) and pop-up sanitiz-ing tissues in multiple locations in the o fce or plant.

3. Encourage employees to keep their homes, schools and clubs sa er.

4. Promote telecommuting by unding small home o fces.

5. Stockpile a small amount o ood and water. Encourage employeesto do the same.

6. Sign co-management and supply agreements with neighbours,competitors and anybody else who can help in times o crisis.

7. Investigate your supply chain and delivery mechanisms through-out the world to identi y alternative ways o getting raw materialsand selling fnished products. I a channel is blocked, you will needto re-route.

8. Establish an inventory o retired workers and document theirskills. I 30 percent o the regular work orce is out o the game,theyll keep the economy going.

9. Circulate a questionnaire to inventory employee skills.

10. Train workers in frst aid.

11. Use the chamber o commerce, board o trade, industry associa-tions and service clubs to lobby governments to help.

Governments need to promulgate legislation and municipal bylaws to getour communities ready. We need designated evacuation sites with stores o

ood, water and medical supplies, perhaps in sports stadia and shopping-malls. We need a plan to use rail lines in evacuations, because highways will be clogged. We need to know exactly where a city bus will run out o

uel as it evacuates neighbourhoods and buildings and put something inplace at that spot. Investments in public transit will help, especially i wecreate redundant systems that can handle peak need or still move peoplei one system (bus, LRT, erry, monorail, subway) is disabled.


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Theres a joke among crisis managers about who is in charge. Thesenior public o fcial who tours a disaster scene receives de erence romresponders but is a net drain on response. S/he eats a ew sandwiches,gets a picture taken and maybe flls a sandbag in a ood. All responsestops or about 20 minutes or the photo opportunity.

In a pandemic we need a clear chain o command. Someone needs theauthority to orce containers ull o toys o highways and trains in order

to move critical medical equipment. We will also need individual initia-tive. It will be individuals in condos, o fce towers and apartment build-ings who set up the makeshi t acilities that will save lives. Governmentscan legislate, but individuals per orm.

Case studies have shown that con usion will prevail. When an El Alcargo plane smashed into an apartment building in Amsterdam, emer-gency responders clogged the highways trying to respond. O fcialscontradicted themselves on procedures and the number o dead. But anindividual sports-arena manager took it upon himsel to open his doorsand com ort survivors. Individuals per orm well in crises, organizationsusually do not.

(Edited and reprinted rom the authors article in The Winnipeg Free Press on the occasion o his chairing the frst National Summit on PandemicPlanning or the International Centre or In ectious Diseases.)

an ounce of prevention - on pandemics

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