The Coming Pandemic: What the Experts Say

influenzaThis week I had the opportunity to attend a global conference on disaster management, one ‘track’ of which was focused on health emergencies. There is certainly no unanimity about what we should be doing to prepare for and cope with a future pandemic (a pandemic is an infectious disease outbreak that is both virulent — i.e. deadly — and highly transmissable human to human), but over the course of the conference a consensus became apparent. I think this consensus reflects a growing sense of maturity and awareness of the lessons of history and our limited ability to anticipate or predict events in complex environments.

Here are what I think were the twelve most important areas of expert consensus about the next pandemic:
  1. Most people cannot be expected to plan ahead or prepare for it: It is not in our nature to plan for eventualities until and unless we are convinced they are virtually certain and imminent. We can send out all the information we want on emergency preparedness and emergency kits. Most people will ignore it until it is too late.
  2. Public expectations of what government will do to prevent, mitigate and manage a pandemic are substantial, growing and largely unrealistic. This is another instance of the phenomenon of learned helplessness, and it’s exacerbated by governments that are prone to overpromise things to assuage gullible voters. After Katrina, we should know better.
  3. Isolation of communities won’t work: We are all too interdependent today to be able to cut our community off from the rest of the world for any length of time until a pandemic is over.
  4. Closing borders and air routes won’t work: Pandemics spread very quickly and easily and use multiple alternate routes to ‘work around’ blockages. Short of an immediate, very early, complete shut-down of all long-distance transportation (which is impossible — no one has the capacity to engineer this), a true pandemic will become global.
  5. Except for expert professional users, masks won’t work: The use of masks and other protective equipment requires a complicated series of steps to be rigorously followed. Even health professionals, who are trained in these procedures, often miss a step and get infected.
  6. It is the duration and recurrence of a pandemic that will wreak the most havoc, not its virulence or transmissability: Pandemics can easily last 18 months or more, and can recur in ‘waves’ after life has almost returned to normal. We can all manage extraordinary procedures for a short time. Few of us can cope when these situations become chronic.
  7. The economic consequences of a pandemic will be much more severe than the health consequences: A pandemic will likely drastically curtail both business operations and consumer spending on non-essentials. It could precipitate a recession or even a 1930s-style depression. It is harsh to try to compare economic costs with human ones, but, as with 9/11, costs and losses in the trillions, by most people’s standards, dwarf deaths in the thousands.
  8. The codependence of telecom and electrical systems poses a huge vulnerability in a pandemic: Information flows, and the continued functioning of health facilities, are critical to mitigating tragedy during a pandemic. Maintaining our telecom systems now depends on maintaining electricity — most phones are now digital and powered by the grid. Blackouts caused by storms, sabotage or simple equipment failure will take much longer to recover from because of personnel shortages, and repairs require a functioning telecom system to report and coordinate information.
  9. The tools that will work in a pandemic are those that are (a) simple to use and maintain, (b) intuitive to understand, and (c) available at the point of use: So, for example, satellite phones will be needed when regular cell phones are disabled, but most people don’t know where to get them, or how to use them, or that they only work out-of-doors. Emergency generators are hard to learn to use and require frequent proper maintenance. Antivirals need to be administered according to a strict, complicated regimen. Every complication, every extra step, reduces the effectiveness and value of tools that could otherwise save lives. And surveys indicate most people will be looking at simple sources — TV and newspapers, not the Internet — for pandemic information.
  10. Resilience, practice and improvisation skills are more critical than good planning in a pandemic: Redundant systems, people who have been through emergency situations or rehearsals, excellent, evidence-based decision-making skills, trained facilitators who can make effective ad hoc use of volunteers who have natural immunity, and people with the competence to adapt to quickly changing circumstances, have been shown to help in emergencies far more than having a detailed plan. Plans can’t predict what will happen in complex situations, so they’re only useful when scenarios play out ‘according to plan’, which they seldom do.
  11. Science and technology will not reduce the certainty of a pandemic: Viruses and bacteria evolve faster than science can invent ways to defeat them, and as we get better at creating antimicrobials we actually accelerate the evolution of immune microbes. We can never catch up. There will be a pandemic, and it will be soon.
  12. Antivirals and vaccines will be of limited use: Antivirals are complicated to use, have a short shelf life, have side-effects, and may not be effective against novel disease strains anyway. Vaccines take months to develop, by which time most of the damage may already have been done. Due to a phenomenon called cykotine storm, those with strong immune systems may be the most vulnerable to pandemic disease (this happened during the Spanish Flu in 1918, and happens in H5N1 poultry flu). What will most determine who lives, who gets sick and who dies is the natural immunity of each individual to the particular virus, and its virulence. And if it turns out you have natural immunity, you will be needed (see point 10).

Are you ready for this? What do you think most people will do — panic and overload the phone lines and help lines, or stay calm andrise to the occasion?

Category: Science and Health

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10 Responses to The Coming Pandemic: What the Experts Say

  1. lugon says:

    Thanks, Dave. May I? :-)One thing that will probably work, more or less, is what jargon-lovers call NPI: non-pharmaceutical-interventions.Pharmaceutical measures won’t be enough. Antivirals will be scarce and maybe not effective; a portion of whatever doses there are will be hoarded (I may need it later) or inappropriately used (too late or for people with no illness). And vaccines, if technology and regulation doesn’t change, will be too little, too late.In Australia, 3 deaths in children have caused enough trouble to be able to predict that hospitals will collapse soon even in a not too deadly pandemic.So what are NPI? If you’re obviously ill, you shouldn’t breathe near others. If, at some point in time in the past few days, you’ve been in close breathing contact with someone who is ill, you shouldn’t breathe near others. For the rest of people, we need to find ways not to breathe near others as much as we can; this is most important for children (highly effective catchers and transmitters in interpandemic times, and quite likely in pandemic times too) and for whoever happens to be more at risk of complications (cytokine storms, co-infections or whatever), including pregnant women, the elderly, those with chronic diseases, etc.When should they be implemented? The CDC recommends “as soon as the first case or outbreak is confirmed in your country, state or whatever”. You, or your public health people, will have to learn the details. Of course, Paris may be effectively closer to NYC than some far-off village in the USA.For how long? This depends on the severity of the specific pandemic flu. If it appears to be killing 1 or more in every 100 ill, then schools (or so the recommendation goes) will close for up to 12 weeks. It it kills 1 in 1000 ill, then maybe “only” for 4 weeks. This would be repeated in subsequent waves until there’s an effective vaccine – and until it’s available wherever you happen to live.Will there be a recommendation to do all of the above, or maybe we can get away with just closing schools? Again, it depends on the “pandemic severity index”: if it kills 1 in 100 or more, then it doesn’t make sense to close schools and have children meet up in the malls, does it?It’s been suggested that families might coalesce in threes. Two parents (the two with non-essential jobs) stay with 6 children at the largest home. The remaining 4 adults stay in the middle-sized home and go to work, possibly with staggered shifts for work and transport, wearing simple masks when near others, and generally trying to work from or at home if they can. The third home (the smallest in size) would be available for quarentine (of the healthy who contacted the ill) and isolation (of the ill). How long this might be mantained is anyone’s guess right now.If a certain percentage of people do a number of these things, they are protecting each other, because you contact less people and, very importantly, those you contact have a lesser probability of being infected.What do we need to make these strategies work? Electricity and communication people might want to try quarantine at work, maybe with their families, while civil society leaves them clean grocery boxes outside the door. Present US recomendation, admittedly in a hush voice, is that citizens should have 2 weeks of non-perishable food and other things; not that this will see them through a 12-week long pandemic wave, but, if done (a big “if”), it would buy some “time to think”. And states and local entities should be ready to close schools as soon as it’s recommended, because it’s much less useful to close them 1-2 weeks too late; this really makes a difference, just like putting of a fire now or later does make a difference.These are pre-pandemic times.In pandemic times we’ll need resilience, flexibility, resilience and flexibility.And the change from pre-pandemic times into pandemic times may happen in no time.So, just an opinion, it may be best toopen the space in our communities now.Thanks for your blog!

  2. gbreez says:

    12 weeks of non-perishable food for 1 person is a great deal of food. For a family of 3, it is a huge amount. For 3 families, wowser. You need not only the food, but for some of that food, good animal-proof containers. You need space. You need rather a great deal of money, though one could stock up over a period of weeks or months depending on how much time we have. I find this all staggering. But, I plan to start now. I come to this site to ask a smart man what he thinks is going to happen and how to prepare. If he tells me and I ignore the advice, well, more fool I. Thanks for the advice.

  3. Lynn says: this site might help you determine all you need to be prepared on many areas… it is LDS based site, but lots of good practical advice even if you do not believe the religious aspects… especially on what and how to store food… even a calculator etc.. but remember a rule of thumb… store what you eat and eat what you store.. so you rotate and keep stuff fresh.. just like the other advice.. it will not work unless you know how to use the stuff you store.. or your body might not handle a lot of whole wheat or grains unless you are used to eating that way…Thanks for the insight… it all sound realistic.. but scary..even though I have heard a lot of it before… thanks

  4. Doug Alder says:

    If a Spanish Flu type or worse pandemic hits, civilization will utterly and totally collapse and stay that way for a very long time. This will almost certainly happen if governments do not take precautions to protect critical resource professionals (nurses, doctors, network engineers (electrical and communications infrastructure)right from the start and that is likely to be haphazard at best even here in North America, never mind in all those 3rd world countries we rely on for goods and services. It will get very ugly, very fast and panic will reigh. What most people do not take into account is that people today do not have the survival skills that our grandparents and great-grandparents had. Food transport networks will get shut down – where will millions in the large cities get their food from? Ugly, very ugly. It will be a massive cleansing of the human race.

  5. Caroline says:

    Dave — Thank you for writing this blog!I agree with almost all your points. Except the first one.I take myself as a case in point.I am a serious procrastinator, and the very last person you would expect to “stock up” on anything or prepare in advance. That’s not my style. Let what happens happen. I’ll find a way to deal. I go with the flow.But — someone sat me down one day, a public health official involved with pandemic planning for his state — and explained to me, basically, what you just said — your points 2 through 12. That showed me this simple fact:Pandemic influenza is a threat like no other.Therefore, if I wish to have the best chance of getting myself and my family through one OK, I do in fact need to prepare ahead.And, I did. (And yes that means food for at least 12 weeks! Which is hard but can be done! And, I’m not rich! And, we hate canned food and preservatives!)And, I contacted all my close friends and family members, and gave them the same speech, and told them that they needed to prepare. And, they have (to some extent).So I firmly disagree with point number one. Many people may prepare for a pandemic ahead of time, if we take the time to tell them that they need to and explain why. No one will prepare if we don’t expect them to or ask them to, or if we say it is too hard.I don’t buy that people won’t prep for hurricanes or snowstorms, so they won’t prepare for this. I don’t care about those disasters. Their disrutption lasts maybe 3 days to a week. (Usually).Pandemic influenza is a threat like no other. It will last much longer and we won’t be able to help each other out and we won’t want to be near other people if we can help it.Some people WILL prepare for it ahead of time, if they know how to and that they should. Some won’t it is true. But based on my own experiences, many will.What can people be told to do?Set aside some money for emergenciesand do it now. Yes it is hard, but you need to do it.Set aside some food and water for any interruption in supplies. Yes it is hard, but you need to do it. Cook more from scratch and eat more whole grains and beans. We’re supposed to be doing that anyhow, right? Eat less non-nutritious foods and plant a garden. Get some respirators (what a lot of people call masks). Learn to wear them correctly.If you can drive a car safely, you are smart enough to learn to wear a respirator. You just need to know that it is important. and you can learn. I have faith in you!It is hard to get a good fit with a cheap N95 respirator. You can get a better seal with a more expensive one that has an exhale valve. Yes, it costs more, but you will want some respirators in a pandemic, and you will want to know they are providing protection. Good luck to anyone trying to prepare themselves or their communities for a pandemic! I know it is hard and can seem overwhleming, but it is important, and it must be done!thanks for your blog, Caroline

  6. Caroline says:

    Dave — I forgot to add this.I don’t know what plans are in Canada, or what planning assumptions are being made.Here in the US, some people are starting to get the idea that there’s at least a chance that the next pandemic might be particularly virulent. That it might even have a fatality rate along the lines of what we are seeing right now in Indonesia and elsewhere — over 50% of those infected die, and the death isn’t an easy one, even with medical care.Although some agencies here appear to be planning along the lines of a mild pandemic – where people get sick for 2 weeks and mostrecover and go back to work — at least some agenciesin the US have been told to plan with more significant assumptions.The following is taken from a US Department of Homeland Secuirty planning document called: Pandemic Influenza: Best Practices and Model Protocolslinked here: which I am reading such things as:”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 practices.”and this document brings up the following questions to be considered by the agencies planning for the next pandemic:”The planning assumptions above raise the following questions which need to be addressed during the planning process:- How will citizens get food, supplies, fuel, and access to healthcare services?- Will the supply chain be able to maintain the stock of essential consumables and supplies?- Will control measures be implemented to prevent price-gouging?- Will family financial concerns influence the ability or willingness of families to self-quarantine?- Will control measures be implemented to cover those that are income dependent for purchasing essential items on a weekly basis?- Will financial institutions forego strict adherence to financial policies and contractual requirements during a pandemic?- Will foreclosures or repossessions occur during the outbreak?- Will vigilantes develop in neighborhoods or communities?- Will society experience a breakdown?- Will a black market develop? – Will the theft of resources surface in an illegal distribution market?- Will counterfeit prophylaxis and/or PPE surface?- Will healthcare facilities and citizens become victims?- How will local government react to these potential problems?”I was wondering if these types of planning assumptions and questions about the social and economic ramifications of a pandemic had been addressed at this Global conference, when talking about a possible pandemic?

  7. says:

    I agree that some will be prepared. I’ve got 6 weeks food/water, 1-2 wks entertainment. (important!) Caution on the mask issue. There is literature that states that masks will have little effect for many reasons. Also, only the folks who are WELL should be using the respirators as they allow air OUT. If you are ill, this is cross purpose for a mask…Recommendations for reducing contamination is voluntary quarantine, stocking up ahead of time, not using distributed money (that too will be a carrier, stock small denominations and wear gloves), and learn and practice aseptic hand washing technique. Anything that comes from the community after outbreak may be suspect as a carrier.That said…my cousin who is a nurse anesthesiologist once had to maintain a quarantine for a suspected anthrax outbreak for 36 hours in a hospital. She said that people had to be physically restrained even though they knew the situation and that they would be released in a short period of time.How are people going to respond to weeks of quarantine?My last two concerns are martial law and reported government detention centers. These are two things that cannot be predicted at this time, but we saw both put in place during Katrina. Neither were pretty sites. There are substantial rumors that more ‘centers’ are being created (based on a contract with a large company)I pray for a brief pandemic and no one noticing me hiding out.I’ve seen enough ugly as a nurse for almost thirty years, I really don’t want to see more. Whatever I can do to educate, support and encourage folks to get ready, I’ll do.Remember Katrina.

  8. Bannor says:

    One of our members, brought reference of this article to our website. It was fascinating to read your commentary and see how closely the consensus of a global disaster conference parallels the discussions and often, conclusions, of those in the microcosm of our forum. Many of us have been following and debating both the pandemic potential of H5N1 and the implication of the same for several years. If you would be willing, we are very interested to know what conference on disaster planning, who attended and what went into the formation of that particular consensus? Would you be wiling to share more?

  9. Into the Woods says:

    Charmagick: A couple of points:First, from what the CDC has said, insufficient informations is available to say whether or not mask use by untrained members of the public in community settings will be effective or not. Mask use (like other NPI) need not be 100% effective to contribute signifcantly both to individual safety and to limiting the spread of a pandemic.Second: Mask use is recommended not just for those that are well. Mask use in enclosed areas like airplanes and clinic waiting areas may also help in protecting others from exposure to potentially infectious droplets that could otherwise be expelled from the wearer.The best thing for each of us to do is read the advice given by the CDC for both community use and health care use (for circumstances where family members will be providing health care in their homes while the health provider system is overwhelmed or unavailable.)Interim Public Health Guidance for the Use of Facemasks and Respirators in Non-Occupational Community Settings during an Influenza Pandemic“”This document describes interim guidance for the use of facemasks1 and respirators2 in certain public settings during an influenza pandemic. Very little information is available about the effectiveness of facemasks and respirators in controlling the spread of pandemic influenza in community settings. In the absence of scientific data, this document offers interim recommendations that are based on public health judgment and on the historical use of facemasks and respirators in other settings. In brief, these interim recommendations advise the following:

  10. Hi David, We’re having a webchat on Thursday, July 17, 2007, 9:30 am New York time with Lucas Gonzalez, author of the first comment here. Please join us! Also, I am interested how our Minciu Sodas laboratory might work for you or organize around you.

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