Ever wonder if the US is still capable of technological innovation? Follow me here, and you might be surprised at what's happening behind the scenes of something as non-technological as philanthropy.

Can a company as wildly successful as Google leverage their tech wizardry to do good by doing well? In this Jan '08 article by Julie Fagnani for the onPhilanthropy blog, the question is addressed:

In 2004, Google founders Larry Page and Sergey Brin made a commitment to address some of the world's most significant challenges. The commitment included a considerable contribution of both capital and man power.

There's a definite tech slant to Google's mission:

Like a traditional nonprofit, Google.org operates by supporting partners with targeted grants.  But its unique structure also allows for Google.org to make for-profit investments and to lobby for policies that support its philanthropic goals.

Google.org is separate from the Google Foundation. Established in 2005, the Foundation is a 501(c)(3) private foundation that is managed by Google.org and supports its mission and core initiatives through grants.  Thus far, Google.org and the Google Foundation have committed more than $75 million in grants and investments.

Two aspects worth commenting on are energy and public health. On the energy side, Darksyde wrote this yesterday: Google to Invest 10 Million in Alternative Geothermal Energy and on the public health side (also from Jan '08), Larry Brilliant, of Google.org: Internet 'is pandemic early warning system'.

So what has the internet got to do with pandemics (beyond this, anyway: Pandemic Flu Preparation and the Role of Internet Communities)and who's this Larry Brilliant guy?

Here's a nice description from Bruno Giussani, the European Director of the TED Conferences (Al Gore is a TED speaker, and Bill Clinton won a TED prize in 2007):

I had never heard of GPHIN until Larry Brilliant made it a key part of his "wish speech" at the TED conference [TED stands for Technology, Entertainment, Design] in February [2006], where he received the TEDprize and was therefore entitled to express a "wish" asking the attendees (a very high-powered and tech-oriented crowd) to help him realize it. Here is what Larry wished for:

To build a powerful new early warning system to protect our world from some of its worst nightmares.

(Read: from deadly pandemics).

The system should be transparent, with basic information freely available to everyone, preferably in their own language, and will be housed in a neutral country, independent of any single government, any single company, any single UN agency, but will offer its alerts, data, access to all.

Brilliant pointed to an existing Canadian system, GPHIN, as the nucleus that could form the basis for what he dubbed INSTEDD, for International System for Total Early Disease Detection (of course, the TED in the word is a hat-tip to the prize).

Here's Larry, giving a TEDtalk, if you have 26 minutes to spare:

Having met both Larry and Peter Carpenter (of InSTEDD) at various times, I wrote Peter and asked him what they're up to these days. Peter wrote back:

InSTEDD is dedicated to harnessing the power of information and communications technology (ICT) to address the challenge of improving collaboration and information flow for early detection and response to emergencies, emerging infectious diseases, and natural disasters.  We are developing a software platform designed to enable communication and virtual teaming among worker in the field, interoperable information sharing between users of different databases and software applications, and collaborative decision-making among health and disaster experts.  We are currently testing and evolving these technologies at our first Field Innovation Laboratory in Phnom Penh, Cambodia and we are working closely with the Cambodian Ministry of Health to develop custom ICT solutions for event reporting in remote rural locations,  early and accurate outbreak detection, and coordination of rapid response teams. InSTEDD plans to expand field operations throughout Southeast Asia and into Africa in the near future.

So, all those guys out in the field tracking ill patients and sick birds would actually have a better way to communicate with each other, whetehr it's using simple and durable hand-held communication/recording devices, or allowing database and software communication to easily take place. InSTEDD, btw, also was the driving force for written pandemic flu preparation instructions for this Citizen's Guide .pdf designed to help anyone figure out what's going on and what to do, including this English version for American citizens.

Note the emphasis on natural disasters; the techniques could prove useful whether it's a tsunami or a pandemic. That's what we call the all-hazards approach.

So, in the end, Google and InSTEDD have been involved with collecting data, collating it and making it easy to use for both professionals  and ordinary citizens. That sounds like something Google should be good at. And doing what you do best to help others? It doesn't require a tech degree to figure out that that just might turn out to be a good thing.

The next President has a problem on his hands, known to public health officials and non-partisan flu bloggers, but all too rarely discussed in the general press. Indonesia, the world's most populous Moslem country, and the epicenter of H5N1 infections in humans (135 confirmed human cases and 110 deaths) has decided that the H5N1 virus should be owned by Indonesia, and sold to whomever they deem worthy. In the meantime, Indonesia has stopped reporting human cases in a day-to-day basis,  rebuffed WHO requests for a shared approach, and condemned humanitarian assistance fro the US by demanding NAMRU-2 (a Navy health lab stationed in Jakarta for many years) leave the country and let Indonesia manage its own internal problems.

Richard Holbrooke and Laurie Garrett write up the folly of this approach today in the Washington Post.

Here's a concept you've probably never heard of: "viral sovereignty." This extremely dangerous idea comes to us courtesy of Indonesia's minister of health, Siti Fadilah Supari, who asserts that deadly viruses are the sovereign property of individual nations -- even though they cross borders and could pose a pandemic threat to all the peoples of the world. So far "viral sovereignty" has been noted almost exclusively by health experts. Political leaders around the world should take note -- and take very strong action.

The vast majority of repeated avian flu outbreaks the past four years, in both humans and poultry, have occurred in Indonesia. At least 53 types of H5N1 bird flu viruses have appeared in chickens and people there, the World Health Organization has reported.

Yet, since 2005, Indonesia has shared with the WHO samples from only two of the more than 135 people known to have been infected with H5N1 (110 of whom have died). Worse, Indonesia is no longer providing the WHO with timely notification of bird flu outbreaks or human cases. Since 2007, its government has openly defied International Health Regulations and a host of other WHO agreements to which Indonesia is a signatory.

Moreover, the Indonesian government is threatening to close down U.S. Naval Medical Research Unit Two (NAMRU-2), a public health laboratory staffed by Indonesians and U.S. military scientists. NAMRU-2 is one of the world's best disease surveillance facilities, and it provides health officials worldwide with vital, transparent information. The Indonesian government has accused NAMRU-2 scientists of everything from profiteering off its "sovereign" viruses to manufacturing the H5N1 bird flu in an alleged biological warfare scheme. There is no evidence to support these outlandish claims.

For those of us concerned about tracking emerging infectious diseases, be it by government agency or private citizen networks, Indonesia's approach to intellectual and sovereign property is both dangerous and short-sighted. Viruses know no international boundaries, and as the Toronto experience with SARS shows, an infectious disease problem in Asia can quickly become an infectious disease problem in North America. There are great sensitivities about such things. By international agreement, there'll be no "Hong Kong flu"designation in future. All H5N1 flu viruses will be known by a boring and bland string of letters and numbers:

The initiative, which was encouraged and approved by 3 international agencies (the World Health Organization [WHO]), the World Organisation for Animal Health [OIE], and the Food and Agriculture Organization [FAO]), set out to unify the nomenclature system to simplify interpretation of sequence and surveillance data from different laboratories and to remove stigmatizing labeling of HPAI virus (H5N1) clades by geographic reference.

Many other positive things could be accomplished by international agreement, including tracking and mitigating the next influenza pandemic, which could easily start in a remote village in Indonesia with a story just like this from the IHT on aug 8, 2008:

JAKARTA, Indonesia: Health workers rushed to a village in western Indonesia to test for bird flu Thursday after 13 people were hospitalized with symptoms of the disease and dozens of chickens died, a government official said.

It will take days for test results to come back, said Memed Zulkarnaen, spokesman for the National Bird Flu Commission, adding that the condition of those suffering from high fever and respiratory problems "appears to be improving."

The 13 were admitted to two hospitals in the past week after chickens started dying in Air Batu, their village on Sumatra island, 680 miles (1,000 kilometers) northwest of the capital, Jakarta. The birds tested positive for the H5N1 virus.

This is what Holbrooke and Garrett and public health officials and countless flu preppers are worried about. Preliminary reports are that these suspected cases are negative, but the lack of transparency about reporting, coupled with Indonesia's stated hostility to international cooperation make this an extremely pertinent and timely WaPo column.

The pandemic threat has not gone away just because other stories supercede it in the media. Alas, it sees that it will take a crisis to break through the indifference, and in that, we are no different than we ever were. And that is a public health problem and an international shame.

Here's this month's editorial in the prestigious international science journal Nature:

That the H5N1 strain of bird flu has not yet caused a pandemic is no cause for complacency. Preparations for the inevitable must be redoubled to mitigate the potential devastation.

Five years after the deadly H5N1 avian influenza virus exploded into a global epidemic in birds, it has infected more than 300 people. Happily, it has not yet evolved into a strain that can transmit easily between humans — an event that would trigger a pandemic that could kill tens of millions. But as long as H5N1 continues to be present in animals, that risk persists. And with so many other flu strains out in the world, all constantly evolving, a flu pandemic is inevitable.

The title of the editorial (The long war against flu) seems apt. H5N1 emerged as a major problem for humans in 1997 (Hong Kong) and again in 2003, and since then has been closely followed by the World health Organization, CDC and others (a text timeline through 2005 can be found here). We started writing about flu pandemics here at Daily Kos in 2004, asking the question "Pandemic - what's that mean? And what's that got to do with politics?" (and the answer is still "plenty." See Barack Obama's NY Times op-ed in 2005.) These diaries (Flu Basics: Science And Threats and Flu Basics II: Politics and Players written in May, 2006 are still, alas, relevant. More on Obama from the American Academy for the Advancement of Science 2008 election page (McCain's page is here, with no pandemic mention):

Senator Obama has said that preventing an avian flu pandemic is one of his national security priorities. He refers to his work with other Senators to provide $4 billion to the Centers for Disease Control to combat avian flu and to build a stockpile of antiviral drugs that had been in short supply.

See also question 6 of 14 Science Questions the Next President Should Answer:

Pandemics and Biosecurity. Some estimates suggest that if H5N1 Avian Flu becomes a pandemic it could kill more than 300 million people. In an era of constant and rapid international travel, what steps should the United States take to protect our population from global pandemics or deliberate biological attacks?

So taking stock years after the President's National Response Plan was published (November, 2005), after the cable media hype died down and after billions of federal, state and local dollars and man-hours (and quite a few diaries here at Daily Kos), it's worth a re-assessment of where we are at (for comparison, see 2005's Council on Foreign Relations: Pandemic Flu And Where We Stand.)

Declan Butler, Nature's senior science reporter has a terrific Q&A this week on the H5N1 topic, entitled whatever happened to bird flu?. Bottom line: we can't get rid of it in poultry in Southeast Asia (and Egypt and other places in Africa) so it sits there smoldering, waiting to infect humans, and waiting to potentially mutate to make it easier to catch. H5N1 remains a risk to humans.

And are we prepared? Not so much.

Like hurricanes, pandemics can't be predicted. We don't know when the next category 5 storm will hit and where, but the inevitability of severe weather is matched by the inevitability of flu pandemics. As we all now know, there were three in the last century (1918, 1957 and 1968) and the 1918 pandemic was truly devastating. Note the spike in mortality representing the 1918 pandemic.

Thjis is what would happen if the same severity pandemic happened today (modern medicine and all - click for bigger pic):

For that reason (mortality, and especially child mortality), the mitigating efforts of public health and national security agencies have taken place.

There are lots of holes in where we are. Not enough personal preparations have taken place (at least2 weeks of food and a water supply for every American are advised), and not enough information has reached the public (it's there if you go and get it.)

Our vulnerabilities are not so obvious, but our inter-related world and Just-in-Time economy contribute to our lack of resilience. For example, last week, I wrote about the price of oil and natural gas contributing to the price of latex exam gloves as an example of the nail-shoe-horse-kingdom chain of events that impacts on the cost of health care (and why it is not easy to rein in - see Health Reform: An Integrated Problem In An Integrated World), but the critical supply chain for food and goods is just as relevant for pandemic discusssions, as is our fragile electrical grid. The following pics come from Michael Osterholm at CIDRAP, U of Minnesota, and outlines the regional dependence of electricity on coal.

Our coal inventories are dangerously low (in terms of potential interruptions) Imagine if the folks who run the coal trains (and the mines) become ill.

This is why posts like 2007's Flu Stories: Is the Internet At Risk In A Pandemic? are relevant. So are energy stories, particularly when placed against the backdrop of worldwide food price hikes and potential and actual food shortages.

In the end, the risk of H5N1 (or some other flu virus such as an H7 or H9 strain) mutating and becoming a pandemic virus remains. Inevitably, a pandemic will happen (H5N1 being on the more severe end of possibilities.) What we can do is prepare ourselves for the inevitable, and in the process take a long and hard look at what we are doing on the energy front as well as the effects a natural disaster would have on surge capacity (see 2008's Pandemic Challenges For Hospitals.)

Whether it's rebuilding public health infrastructure, or including public health in health reform, or understanding the integrated just-in-time way of life we lead and protecting that as well, preparing for a pandemic will help us cope with whatever comes next. It'd be nice to know just what that 'whatever' is, but we're not always that lucky. Ask the folks in New Orleans whether more preparation time should have been spent, and whether we are spending enough time worrying about natural disasters now.

What have the Olympics, oil and commodity prices, and supply and demand have to do with either pandemic preparedness or health reform? And what do either have to do with politics?

Pandemic preparedness is still an issue; pandemics are inevitable, and we are not yet prepared for one (follow the links for more, and go here to learn how to prepare). Health reform, which can mean either expanded access and coverage or cost control (it's both, actually along with rebuilding public health infrastructure and improving quality of care) is also obviously an issue. Yet, one problem seemingly separate from another problem quickly runs together to induce a major headache for the world, and one that is going to to be a major headache for the next President.

Here's an illustration of how that works: take the example of latex examining gloves. It's a staple of personal protective equipment (PPE) for health care workers for infection control, and a much needed barrier to protect against the spread of influenza (both seasonal and pandemic). One company, Medline, with 30% of the market share, is a big player. So this announcement raised eyebrows when it was released this week:

Hong Ray Enterprises of Shijiazhuang, China, the world's largest manufacturer of vinyl exam gloves and a major manufacturer of nitrile gloves, has notified Medline Industries, Inc., and other U.S. customers that they are facing "force majeure conditions" and that they will be unable to meet their normal agreements to customers. Hong Ray is Medline's largest exam glove supplier.

Force majeure means that large scale circumstances beyond control free the company for liability and obligation. In this case:

In its letter to Medline and its other U.S. customers, Hong Ray cited a long list of events and government actions that have led to its inability to fulfill its contracts. These include a fire at a major raw material manufacturer, dramatic changes in government policy impacting labor, taxes and credit and pollution-control measures associated with the Beijing Olympics.

According to Amdur, Hong Ray's situation is by no means unique.

"All of our suppliers are facing enormous and unexpected obstacles in fulfilling their contract obligations," said Amdur. "While Hong Ray is the first factory to formally declare 'force majeure,' other factories, including those that manufacture latex gloves, face similar circumstances. In Malaysia, for example, the government recently declared a change in pricing for natural gas, almost tripling the price overnight."

So, much needed medical supplies will either be absent or raise your medical bills just as surely as rising oil prices impact the airline industry.

"We are moving quickly to secure adequate supply for our customers through alternative factories, at ultimately a much higher cost. It is crucial that we act fast for exam gloves, however, because it's a high demand item that can spike in times of crisis situations such as SARS and the pandemic flu."

And with that background, look at the numbers from a previous post in March:

Those with insurance are satisfied with their own health care coverage (83% to 93% depending on the question), but fear paying more for care (41%) or losing coverage altogether (29%). That >80% satisfaction is a key finding, because people satisfied with what they have a) don't want to give it up and b) are less likely to push for change. And when asked to rank health care along with other important issues facing Americans, Democrats tend to rate health care as more important than either independents or Republicans, so the push for health reform is not unanimous by any means.

Another important difference is that Republicans are more worried about cost-containment and Democrats more interested in expanding coverage. This leads to the following caveat; while much of the public agrees with the goal of  increased coverage, there is no agreement about the best solution to get there.

The slides are from kaiser.edu, which is a great resource on health care information. In conjunction with the Roper Center at the University of Connecticut, a list of recent health care polling can be found and put to good use. For example, from a Feb 08 AP/Ipsos poll:

(People have suggested various ways that the government could act to try to fix the economy. How much do you think each of the following would help fix the country's economic programs: a great deal, some, only a little, or no help at all?)...Increasing spending on domestic programs like health care, education, and housing

43%  A great deal
27   Some
16   Only a little
14   No help at all

Does that mean that increasing dollars for increasing price of gloves, oil, etc is what people had in mind? Not likely, any more than donors to colleges want their dollars to pay for electricity and heating oil when what they wanted was increased scholarships or educational programs.

But the reality of rising commodity prices (including food), international supply chains and a just-in-time economy put us at risk for key shortages that will, if not a sexy headline-grabbing issue, nonetheless need to be dealt with both in enacting health reform and preparing for pandemics.

The only way to approach this is with a sober, reality-based approach, and it's going to require the next President to understand the science behind the politics. That's why the public prefers the next President to know something about science, and why the 14 Science Questions the Next President Should Answer include

6. Pandemics and Biosecurity. Some estimates suggest that if H5N1 Avian Flu becomes a pandemic it could kill more than 300 million people. In an era of constant and rapid international travel, what steps should the United States take to protect our population from global pandemics or deliberate biological attacks?

14. Health.  Americans are increasingly concerned with the cost, quality and availability of health care.  How do you see science, research and technology contributing to improved health and quality of life?

in addition to questions about innovation, energy, national security and research. There's no way this approach is going to to be simple or easy. But whether it's the all-at-once or sequential approach, there's no question that a science-based and evidence-based approach to health care policy and politics is the right way to go. And those kinds of approaches will recognize that cost is a factor in the direction health reform goes, and will need to account for it, even as universal care remains the goal. Start with children if you want consensus

As you may know, President (George W.) Bush vetoed a bill passed by Congress that would create a program to spend 35 billion dollars to provide health insurance to some children in middle-income families. Do you think Congress should vote to create that program by overriding Bush's veto, or do you think Congress should vote to block that program by sustaining Bush's veto?    

Congress should override veto 61
Congress should sustain veto 35
No opinion 4

and get everyone to where they need to be. But in this environment, cost and complexity and going to need to be accounted for, one way or another.

After nearly four years of writing about bird flu, pandemics and emergency preparation, you'd think I'd be tired of the topic. Think again ;-0  There's a great deal of activity under the surface, and though the media isn't covering this regularly, and though other considerations vie for attention (and rightly so - the economy, the price of gas, the Iraq war, health reform, NOLA reconstruction and other issues are all compelling and important), the risk of a pandemic remains... and the efforts of thousands of people on line and off continue to make a difference.

In honor of yesterday's marathon DNC RBC session, here's a couple of comments from two Senators in the news lately who recognize the risk, and have been working to mitigate the consequences. From 2005, Barack Obama:

If we're lucky, we'll have at least a year, or perhaps several years, to prepare for a flu pandemic. But we might not be so lucky. And regardless of whether it is this particular strain of avian flu, H5N1, or another deadly strain, the time to act is long overdue if we want to prevent unprecedented human suffering, death, and economic devastation.

International health experts say that two of the three conditions for an avian flu pandemic in Southeast Asia already exist. First, a new strain of the virus has emerged to which humans have little or no immunity. Second, this strain has shown that it can jump between species.

The last condition--the ability for the virus to travel efficiently from human to human--has not been met, and it is the only thing preventing a full blown pandemic. Once this virus mutates and can be transmitted from human to human, we will not be able to contain this disease. Because of the wonders of modern travel, a person could board a plane in Bangkok, Athens, or Bucharest and land in Chicago less than a day later, unknowingly carrying the virus. Indeed, we learned this lesson from SARS, which moved quickly from Asia to Canada, where it led to many deaths.

As my colleagues know, one of my top priorities since arriving in the Senate has been increasing awareness about the avian flu. In April of this year, I introduced the AVIAN Act, which is a comprehensive bill to increase our preparedness for an avian flu pandemic. This bill was incorporated into a larger bill, the Pandemic Preparedness and Response Act, that Senator Reid and I introduced two weeks ago. We need to move this bill as quickly as possible.

That bill did not pass, but co-sponsor Hillary Clinton was also a cosponsor of the subsequently passed Pandemic and All-Hazards Preparedness Act in 2006,  an important law that established the primacy of HHS in a public health emergency, and established within HHS the office of the the Assistant Secretary for Preparedness and Response (ASPR) to:

(1) serve as the principal advisor to the Secretary on federal public health and medical preparedness and response for public health emergencies; (2) oversee advanced research, development, and procurement of qualified countermeasures and qualified pandemic or epidemic products; (3) maintain the Strategic National Stockpile; and (4) provide logistical support for medical and public health aspects of federal responses to public health emergencies. Transfers to the Assistant Secretary functions of the Assistant Secretary for Public Health Emergency Preparedness.

According to Govtrack.us,

This bill passed in the Senate by Unanimous Consent. A record of each representative's position was not kept.

In Oct of 2007, Clinton, on the release of the Trust For America's Health/American Academy of Pediatrics joint report on the impact on children of both a pandemic and pandemic planning (schools will close in a severe pandemic for up to 6 to 8 weeks) said:

I am pleased to see that Trust for America’s Health and the American Academy of Pediatrics have released this report highlighting the needs of pediatric populations during a pandemic influenza epidemic. As our public health system works to prepare for both a potential pandemic and seasonal influenza, we must ensure that our efforts to protect our health extend to children as well.

I can't find much, if anything that John McCain has said or done on the topic (post if you know of something). Many of John McCain's votes on pandemic related issues were actually votes on Iraq troop bills with pandemic (and other issues) added on (those votes broke along party lines). But what we can say is that Clinton and Obama have been following this topic for at least three years whereas McCain's interest is unknown.

That leaves the next President, whoever it is, with an unpredictable attitude towards public health and pandemic preparedness. One can predict that in an attempt to be Not Bush, current policies will change. In my view, that can be a good thing (less bioterror, more natural disaster preparedness would be appropriate). So, with that in mind, this story raised some eyebrows last week:

A strain of bird flu has moved a step closer to developing the traits required to create an epidemic of the disease in humans, scientists warned on Monday.

Researchers who analysed samples of recent avian flu viruses found that a strain of the virus called H7N2 had adapted slightly better to living in mammals.

Tests on ferrets proved the strain could be passed between animals but scientists said the evidence suggested that bird flu could be transmitted between humans.

It followed on the heels of this one from early May:

Pandemic flu threat remains substantial, health experts say

The world still faces a substantial threat of a flu pandemic and countries need to speed up preparations for a global outbreak, health experts said Tuesday.

"We can't delude ourselves. The threat of a pandemic influenza has not diminished," said Keiji Fukuda, coordinator for the World Health Organization's Global Influenza Program.

It was a reminder that we don't know when and from which virus the next pandemic is coming from, but we know with certainty that sooner or later, we'll have to deal with a worldwide pandemic influenza. The last time the world saw one was in 1968.

It's also a reminder that there's much more to be done in pandemic preparedness. Local, state and national drills and exercises, and personal preparations (at least two weeks of food and plans for water, including pets) are quietly happening throughout the country, but more needs to be done in each of those areas. Communities need to become resilient enough so that if and when schools close, alternate plans for the vulnerable, special needs kids and working parents can be made.

Remember, working on pandemic preparedness means that your local public health infrastructure becomes more robust and resilient as well. That helps communities, no matter what comes. The alternative, including rationing scarce resources when we run out of staff, space and stuff to take care of people, is a grim necessity that must be considered in advance so that difficult choices can be made fairly and equitably at a local level (and if you think yesterday's rules committee was messy, try doing one of these exercises.)

A reminder from Barack Obama:

If we're lucky, we'll have at least a year, or perhaps several years, to prepare for a flu pandemic. But we might not be so lucky. And regardless of whether it is this particular strain of avian flu, H5N1, or another deadly strain, the time to act is long overdue if we want to prevent unprecedented human suffering, death, and economic devastation.

That's exactly right. Use the time we have, remember the recent examples in China and Myanmar, and consider this a teachable moment. We have less of them than we know.

So here are some cheery headlines to catch your eye:

US: Hospital ERs overwhelmed, one-day study finds (May 5)

A one-day snapshot of emergency room conditions at 34 U.S. hospitals shows they are all overwhelmed and none is prepared to handle a big event like a disaster or attack.

Bird flu pandemic risk just as real and probably growing (May 8)

Experts are warning that the risk of a human bird flu pandemic remains just as real and is in fact probably growing.

Doctors debate who would be allowed to die in pandemic (May 5)

Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding who to let die.

Together, they illustrate a dilemma. On the one hand, US hospitals are already strained, and can't really handle any more stress (see  Medical Crisis: The Shape Of Things To Come). On the other hand, any kind of major disaster, be it a Katrina-size storm or a pandemic, will add more patients and more demands to a medical system already maxed out, particularly when it comes to emergency departments and intensive care units (see Pandemic Challenges For Hospitals.) From the WaPo back in February:

The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say.

It's a problem. After all, from wildfires to tornadoes, natural disasters happen. So what does one do? A relatively new approach to major disasters after Katrina is to realistically appraise the numbers and try and figure out how hospitals can cope... see Hospital Surge, Exercises and Pandemics. And when they can't, well, at that point, when patients outnumber the available beds and equipment to take care of them, tough decisions need to be made.

...an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and U.S. government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health-care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

For anyone interested in the details, the medical journal CHEST has made the task force report available (in several parts) for free.

Now, whenever we talk about hospital surge and rationing, there's bound to be people that get upset. But in reality, it's much better to talk about these things in advance rather than avoiding the topic, having no plan and having a disaster hit. And limited beds, limited supplies and limited personnel (shortages of space, staff and stuff) will force these unpleasant rationing choices upon us, like it or not. That's why California and New York have both looked at versions of this. In addition, the nature of infectious disease outbreaks, with the possibility of quarantine and isolation, have raised civil liberties issues of a different sort (see The ACLU, Pandemic Preparedness, and You).

So, step back and look at the big picture. The sheer size and scope of disasters require a completely different approach than medical 'business as usual', yet that means bringing in ethical and legal issues (e.g., rationing) that our political candidates like to avoid (except when they are accusing the other guy of advocating it). But don't let the politicians fool you. As illustrated in today's post, looking at rationing is now a mainstream part of evaluating hospital disaster care, and an arguably appropriate response to shortages.

The California Department of Public Health recently released the first comprehensive surge guidelines for health care during a catastrophic emergency.

The new "surge capacity guidelines"  - which authorities hope will serve as guidlines for hospitals nationwide, especially in the event of a pandemic - calls for letting older, sicker patients be allowed to die in order to save the lives of patients more likely to survive a catastrophic public health crisis.

By the way, this is a topic (health reform, disaster preparedness and the state of disrepair of public health infrastructure) the Presidential candidates need to address. At the same time, looking at "gut-wrenching dilemmas" needs to be done openly and with the input and participation of the public. You certainly don't want decisions like these to be made without you, do you?

Have you ever participated in a school fire drill? If you have, you've been part of a live disaster exercise. And like fire drills, the health system (including hospitals and public health) need to run their own drills to see what works and what needs to be done better so as to be better able to handle a natural disaster like the California wildfires or a pandemic. We ran an interesting drill last weekend to practice how my local area would respond to an influenza pandemic.

Part of the the health reform task is to make sure that natural disasters such as hurricanes, wildfires and (yes) influenza pandemics can be approached and mitigated by improving medical and public health infrastructure. One way to do this is to examine and improve the ability of hospitals to care for an excess number of patients for at least short periods of time. However, this can lead to concern about playing the fear card, and overdoing response. Despite those concerns, there's need to plan for surge.

California has led the way, with careful definitions:

A healthcare surge is proclaimed in a local jurisdiction when an authorized local official, such as a local health officer or other appropriate designee,3 using professional judgment determines, subsequent to a significant emergency or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources and/or emergency medical services. The local health official uses the situation assessment information provided from the healthcare delivery system partners to determine overall local jurisdiction/Operational Area medical and health status.

Healthcare surge is not the frequent emergency department overcrowding experienced by healthcare facilities (for example, Friday/Saturday night emergencies). It is also not a local casualty emergency that might overcrowd nearby facilities but have little to no impact on the overall healthcare delivery system.

As defined above, a healthcare surge will directly impact a provider's ability to acquire and manage resources under their normal procedures.

This means that during times of stress to the system, usual standards of care will need to be switched to what's called 'essential care', the provision of which will mean different standards than what the public is used to.

An influenza pandemic is an example of the type of natural disaster that would require health care surge. As an update of where we are at with H5N1 and bird flu, try this piece from the Times (UK):

It is now five years since the present outbreak of H5N1 avian flu first infected people. Though 379 people have since contracted the virus, of whom 239 have died, it has yet to start a pandemic.

As its name suggests, bird flu remains predominantly an avian disease. While it is very dangerous to humans who catch it, this has happened only rarely, after close contact with infected birds.

This week, however, brought some alarming news. Writing in The Lancet, a Chinese medical team confirmed that a 52-year-old man who contracted H5N1 in Jiangsu province last December almost certainly caught it from his 24-year-old son, who died. It is the best-documented case of human-to-human transmission to date.

That is important because, if this virus is going to start a pandemic, it must first acquire the ability to move readily from person to person. Not enough people are ever going to catch it from birds to constitute a global threat. The Chinese case, like a previous suspected human-to-human incident in Thailand, has thus raised fears that H5N1 might be mutating in worrying fashion, and it was duly reported around the world.

The details of the Lancet study, however, are less troubling than they at first appear. This investigation of this cluster of infections, indeed, is somewhat reassuring because of what it shows has not happened.

It has not become easier to catch, and human-to-human (H2H) transmission remains rare - but not unknown. Similar H2H spread was also documented in Pakistan last year, in a case that involved a family member traveling to the United States. But whether the next pandemic is H5N1 or some other virus, pandemics are inevitable. Since it's not a matter of "if", but "when", planning has to occur to cover the areas where we will be short. In other words, since 20-30% of the public will be ill, pandemics will cause the health system to run short of staff, space and stuff... the exact things that surge tries to alleviate.

There's only one problem... no matter how hard you try, you'll still run short. And for that reason, even creative solutions will need to be coupled with unpleasantry in the form of rationing. Whether it's rationing of space or of resources, triage of pateints will be an inevitable consequence of too many ill and not enough resources.

More on the flip...

Do you prefer the statistics about home foreclosures, or would you rather read reports about people losing their homes? Do you read the health care analysis diaries or case reports of disasters that hit the uninsured?

Both statistics and case reports tell a story, and they both impact decisions, but in very different ways. The same is true for stats about influenza and stories about children dying from influenza. Both scenarios were on display this week, both in Atlanta (CDC pandemic drill) and Hong Kong (seasonal influenza outbreak). Let's explore that a bit more.

Back in February, 2007 the Center for Disease Control and Prevention (CDC) was confronted with this mock scenario:

A 22-year-old Georgetown University swim team member just back from Indonesia eats dinner with his teammates but then develops a fever and doesn't accompany them to a meet in New York.

That is how a flu pandemic in the United States started.

It's a terrific thing, by the way, that these drills are taking place. Drilling and practice makes the actual response that much stronger, and while no exercise can be completely realistic, systems glitches will occur and be caught and improved on for the next time.

With outbreaks in multiple states, the exercise picked up where it left off a few months later, April 2007:

It's near the end of a 48-hour simulated flu pandemic. The Centers for Disease Control and Prevention's top brass are packed into a conference room glassed off from the hubbub of its Emergency Operations Center at CDC headquarters in Atlanta.

It's a chance to practice decision-making in case of a real pandemic. The gathered staff are discussing how to screen all international travelers for flu symptoms.

CDC director Julie Gerberding interrupts.

"I have a question," she says. "Just what is our containment strategy in Pea Ridge?"

She's talking about an actual place — Pea Ridge, Ark., population 2,346. But according to this fictional scenario, a dangerous new strain of Asian bird flu has found its way halfway around the world to Pea Ridge.

The scenario-writers have given Pea Ridge a small expatriate community from the Marshall Islands in the South Pacific. In the pretend pandemic, a Marshall Islander gets infected with the new flu in Indonesia and brings the virus back to Pea Ridge. That's the kind of thing that can happen when air travel is so fast that people can fly from anywhere to anywhere else before they develop flu symptoms.

In this recent CDC simulation, Gerberding needs to find out what's being done to stop the virus from spreading beyond Pea Ridge.

Flash forward to March 2008, where I joined the CDC exercise for two days as a (mostly) observer. That conference room is just behind the CDC's Emergency Operations Center, pictured above during this week's continuation of the exercise. Each of the 50 monitors is manned by someone coordinating one or another of the fuctions CDC needs to fulfill in a pandemic, such as collecting state data on hospital beds, or sharing their expertise and advice to local and state offcilas on infection control,  quarantine and legal issues. There are liasons with key government partners like State and DoD (in the scenario, military personnel on an overseas ship are affected). It's now day 6 of the pandemic, according to the exercise, and the CDC Director, Julie Gerberding, is calling the Georgia State Emergency Manager to find out if Georgia schools are closing (the answer is: not yet) to assess the impact on CDC employees if their kids are sent home.

That's important information for many reasons. School closure (more properly termed student dismissal – the buildings remain open and might be used for alternate treatment centers or school lunch distribution) is a linch pin in the community mitigation strategy that CDC recommends in a severe pandemic (see this brief discussion on community mitigation from Dec 2006). However, the dependence on local decision making means that smooth execution of well-laid plans is not assured. For example, here's what happened in Atlanta this week (bolded added):

The CDC was very accomodating in allowing the observers access to senior staff and section officers on duty, including sitting in on an hour briefing/conference call with the affected states (whoever played those roles, the accents were perfect - Arkansas sounded nothing like Michigan). States had varying ability to update CDC with real time case numbers ("I'll get back to you on that" must have been the most commonly heard line of the day), and difficulty with adjusting on the fly to requests for extra personnel ("we need you to send 20 staff, varying qualitications, to support screening activities at your state's busiest airport") and rapidly changing policy requests. That was especially evident when the states were asked to consider community mitigation strategies including student dismissal. Some states pushed back on that, with an observation that it would be a) difficult b) disruptive c) expensive. In addition, in some states, there was no clarity as to whether decisions would be made at the local, county or state level (states with only a few cases were less ready to pull the trigger; Hawaii was quite worried about the effect of all this on the tourist industry).

[Remember, the above is role playing, but very realistic role playing. Some states might be more ready, some states less. If they wanted to make a point in the exercise that states were not ready to simply throw a switch and turn on non-pharmaceutical intervention, practice social distancing, close schools, etc, on a moment's notice on a call from CDC, that point was made.]

Update [2008-2-10 13:32:53 by DemFromCT]:: A reader reminded me via email that Maryn McKenna wrote an excellent article in 2006 outlining the emergency departments and their ability to cope. See Anatomy of a pandemic: Emergency departments woefully unprepared for bird flu outbreak. I am neither the first nor the last to cover this area.

Introduction

Problems like pandemics, surge capacity and disaster preparation do not go away by ignoring them. Hopefully, by putting some of these issues in perspective, we can better appreciate the time, dollars and energy spent on mitigating that which cannot be stopped. At the same time, we can appreciate the efforts being made by your public health people which, if invisible, are still none the less remarkable. And finally, we can appreciate how strained the current health system is... it would not take much these days to push things over the edge, despite the remarkable resilience the health system has shown.

Discussion

The Washington Post had an interesting story last week about the challenges hospitals face in preparing for the next flu pandemic:

The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say.

The Bush administration's plans, which run more than 1,000 pages, contemplate the nightmare medical scenarios that many experts fear, but critics say federal officials have left too much of the responsibility and the cost of preparing to a health-care system that even in normal times is stretched to the breaking point and leaves millions of people without adequate access to care.

"The amount going into actually being prepared at a community level is not enough," said Patrick Libbey, executive director of the National Association of County and City Health Officials. "We are still talking about rearranging with little additional resources the assets of a system that are built on such a thin margin now that you have significant amounts of people without access to care, and hospitals that are periodically shutting down their ERs and the like."

These concerns aren't just reflected in news stories quoting public health officials. At a recent emergency management conference I attended, I heard the same concerns expressed by hospital representatives from all over the country. There's a reason for this... despite the great work by creative people trying to figure out how best to cope, there's just not enough of the three components that make up what's called surge capacity, the ability to flex up hospital care quickly to meet the needs of the population it serves (.pdf link). Those components can be thought of as "staff" (nurses and other health care workers and caregivers, "stuff" (from intravenous medicines to bedsheets to actual beds) and "space" (everything needs to be housed somewhere). California alone is spending hundreds of millions of dollars on this (good that they are), and given the efforts on the one hand and the concerns on the other, it's worth spending a Sunday essay reviewing what the big deal is. It's your tax dollars, and (for one disaster or another), your community (click this link).

Dr Eric Toner (from the University of Pittsburgh Medical Center's Center for Biosecurity) has been working on these issues for some years. Two of his slides illustrate the problem that an influenza pandemic would cause. In the first, the total US hospital beds availability is presented, and contrasted with what would be needed for both a mild moderate (similar to the 1968 pandemic) and a severe (based on 1918) pandemic. SNS is the strategic national stockpile, set aside for grave emergencies and under the control of HHS and DHS.

There's a series of posts I've done for Daily Kos about how the Feds are preparing for an influenza pandemic, including disaster preparedness, and pandemic preparedness, as well as a review of the National Response Framework that the federal government uses to approach disasters and disaster management. A recent position paper by the ACLU has brought this back into the headlines. How far the Feds can and will go to contain a pandemic and protect your health is an important topic both to discuss and to track. The ACLU report provides an opportunity to review selected aspects of this topic.

Background

Flu pandemics are different than other disasters because they are extensive (they happen everywhere), significant (a quarter of the population might be affected, with a third of the population unable to report for work because of illness or health care obligations for dependents and others) and require careful planning to help prevent spread of disease as well as to mitigate the disruption a pandemic would bring to our worldwide just-in-time economic system. One aspect of this planning includes the use, and consideration of, isolation and quarantine at the beginning of a pandemic outbreak, when containment is still theoretically feasible (although many experts doubt if containment is indeed ever feasible). From Flu Wiki:

Isolation and quarantine are two public health strategies designed to protect the public by preventing exposure to infected or potentially infected persons.

In general, isolation refers to the separation of persons who have a specific infectious illness from those who are healthy and the restriction of their movement to stop the spread of that illness. Isolation is a standard procedure used in hospitals today for patients with tuberculosis and certain other infectious diseases.

Quarantine, in contrast, is very unusual and generally refers to the separation and restriction of movement of persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious. Quarantine of exposed persons is a public health strategy that is intended to stop the spread of infectious disease.

Both isolation and quarantine may be conducted on a voluntary basis, and this is usual, or compelled on a mandatory basis through legal authority.

Back in 2005, George Bush held a news conference in which he proposed military intervention.

The United States may need to quarantine regions of the country if localized outbreaks of a pandemic flu occur, US President George Bush said today during a press conference in Washington, DC.

Bush suggested expanding presidential power over state-run National Guard operations to implement such quarantines in the event of a pandemic.

By executive order (April 1, 2005) pandemic influenza was added to the Public Health Service Act of 2003 as a quarantine disease. However, there was considerable push-back from the public health community at that time (link is to a Boston Globe op-ed from George Annas:

WHENEVER THE world is not to his liking, President Bush has a tendency to turn to the military to make it better. The most prominent example is the country's response to 9/11, complete with wars in Afghanistan and Iraq. After Hurricane Katrina, Bush belatedly called on the military to assist in securing New Orleans, and has since suggested that Congress should consider empowering the military to be the ''first responders" in any national disaster.

On Tuesday, the president suggested that the United States should confront the risk of a bird flu pandemic by giving him the power to use the US military to quarantine ''part[s] of the country" experiencing an ''outbreak." So we have moved quickly in the past month, at least metaphorically, from the global war on terror to a proposed war on hurricanes, to a proposed war on the bird flu.

Of all these proposals, the use of the military to attempt to contain a flu pandemic on US soil is the most dangerous...

Planning makes sense. But planning for ''brutal" or ''extreme" quarantine of large numbers or areas of the United States would create many more problems than it could solve...

Public health in the 21st century should be federally directed, but effective public health policy must be based on trust, not fear of the public.

Since then, and until recently, the voluntary nature of quarantine and containment has been stressed by CDC, HHS and federal disaster planners.

Contemporary Concerns

On Monday of this week, the ACLU issued a strongly-worded report entitled Pandemic Preparedness: The Need for a Public Health — Not a Law Enforcement/National Security — Approach, co-authored by George Annas, the same author of the Boston Globe editorial from 2005 (more after the flip).

Well, originally, the title (respectfully stolen from Effect Measure), referred to a new H5N1 human case in Burma, which joined Indonesia (two separate cases) and China (father-son) in reporting human cases this week. But, the big news is the breaking story in Pakistan.

Pakistan Has Eight Suspected Human Cases of Bird Flu (Update4)

By Jason Gale

Dec. 16 (Bloomberg) -- Five members of a family in Pakistan are among eight people who may be the country's first human cases of bird flu, the World Health Organization said. At least one brother died.

Pakistan's national laboratory found the lethal H5N1 avian flu strain caused the infections in three brothers and two cousins from the same family, according to information from a Dec. 15 WHO statement and Gregory Hartl, a WHO spokesman in Geneva. Another brother from the U.S., who attended a funeral for one of the victims, and his son tested negative for the virus at a hospital in Nassau County, New York, Hartl said.

Medical teams have been sent to Pakistan to assist local authorities in investigating the cases, in which two people had only mild symptoms, Hartl said. Doctors are monitoring for signs avian flu may be adapting to humans by killing fewer people, fostering its spread.

``It's too early to make any definitive conclusions'' about the outbreak, Hartl said in a Dec. 15 telephone interview. ``We are still in the middle of it.''

New York State health officials were informed Dec. 7 that a man from Nassau County who had returned from Pakistan told his doctor he might have been exposed to avian flu, said Claudia Hutton, director of public affairs for the state department of health in a telephone interview.

Pay attention to the bolded part, above (the NY State Health Department and CDC did). It represents both a familial cluster (raising the possibility of human-to-human transmission), and the speed at which a pandemic can spread worldwide. A more complete list of the outbreak and the large familial cluster it represents (a vet and 4 brothers, with a few cousins thrown in for good measure, spaced over 2 months) can be found at Flu Wiki's Forum. [Here's a summary from Effect Measure]. From Helen Branswell (CP):

Meanwhile, U.S. public health authorities have confirmed they conducted H5N1 testing on a man who had recently visited Pakistan and was complaining of mild respiratory symptoms. The man, who officials will only identify as having a link to the cluster, is said to have been concerned he might have been infected.

"The individual went to his private physician after returning from Pakistan, and discussed this with his physician," said Claire Pospisil, a spokesperson for the New York State department of health.

Pospisil said the doctor contacted the local health department in Nassau County, where the man lives, and they collected samples for testing. The tests came back negative.

David Daigle, a spokesperson for the U.S. Centers for Disease Control, said the CDC sent its plane to Albany on Dec. 8 to collect specimens for confirmatory testing. Within hours a CDC lab verified the state lab's findings.

"He was negative. There was no doubt about it," Daigle said from Atlanta on Saturday.

The idea that someone could be exposed to H5N1 in Southeast Asia and then fly to NY is completely plausible, and likely just happened. Some heads-up thinking by the local doc [and the patient] got the testing done in a timely manner, but had the testing been positive (and it could easily have been), there'd be quite a few headlines about this issue.

No headlines today? Well, let's use that as a teachable moment to cover two frequent criticisms of flu blogging: hype and fear-mongering.

Now, for all the concerns and accusations of media hype, there really is a paucity of news about H5N1 (Daily Kos excepted) and not a surfeit. Here is a google news search documenting that which used to be in 2005, and that which is now (click for bigger pic). Note that by region, this has overseas interest.

As for fear-mongering, as long as H5N1 remains in the environment, it will remain a threat to humans. And as long as that's so, we will report and write about it.This isn't fear-mongering (a term bandied about by folks who don't like to read about these things, for whatever reason), it's education. It is also prudent awareness of a candidate (H5N1) for a natural disaster (flu pandemic) that's as inevitable as the next "storm of the century", and as difficult to predict (both in timing and intensity). Hopefully, that will lead to some preparation steps (see below). And do note that the NYer tested above informed his doctor of his risk factors and got tested. Without that education (from news and elsewhere), you can't expect that level of public cooperation.

And, of course, thanks to the internets, there's more news to tell.

See Flu Wiki's Sunday wrap-up for the week's documented human and bird cases, courtesy of the wiki volunteers who track cases around the world - helpful to CDC and WHO and other public health officials as they do their work (more than a few have written me that they stop there to get the morning news - this is netroots activism applied to public health!). Not only are there new human cases scattered throughout Asia (including Pakistan, Burma, China and Indonesia, all of whom are less than than transparent about internal news), there are also new bird cases of H5N1 in Germany, Poland, Russia, Vietnam, and Saudi Arabia (and the hadj is soon, 1.5 million pilgrims expected).

Tongue-in-cheek? Not entirely.

De Nile, that river in Egypt, is part of the human condition. In fact, some of the response to bad news can be characterized as an adjustment reaction. As the American Psychological Association notes, the best way to cope with stress and disaster is to encourage resilience.

Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress -- such as family and relationship problems, serious health problems, or workplace and financial stressors. It means "bouncing back" from difficult experiences.

Research has shown that resilience is ordinary, not extraordinary. People commonly demonstrate resilience. One example is the response of many Americans to the September 11, 2001 terrorist attacks and individuals' efforts to rebuild their lives.

The best way to be resilient, of course, is to recognize threats and plan for them.

As with global warming, or other natural disasters (pandemic being just one), peak oil is something that many people have heard of but try not to think about, except when gas prices get depressing (or it's 75 degrees in Toronto in January). The folks at Peak Oil Blues are anticipating the adjustment to a post-oil world and planning for an oil-less future. Is that going too far? Or is the rest of the world just suffering from Panglossian Disorder?

I have spoken elsewhere about the label "Doomer," and I’ve come to believe that this frame is outdated. Instead, I would like to suggest that we must stop asking ourselves, given the lateness of the hour, why there are those pessimistic about the future, and begin asking, instead, why there are those still blindly and enthusiastically optimistic about it. Could this be a disorder, in itself? Here’s my proposal:

Panglossian Disorder: "The neurotic tendency toward extreme optimism in the face of likely cultural and planetary collapse."

Here's a reprint in the Energy Bulletin (for easy reading), with some of my favorite subtypes:

Temporal Subtypes:
Scarlet O’Hara-ism- "I’ll just have to think about that tomorrow." A strategy of denial that allows the person to temporally compartmentalize the feared event(s).

Futurism: "Sure, that will happen, but it will occur after all of us are long dead." A belief that something that might happen in the distant future is no concern in the present.

Y2K features : "They said everything would collapse with 2000, and it didn’t." A belief that any prior concern about societal problems that didn’t occur demonstrates the impossibility of any others happening in the future.

And a few more:

Subtypes with Delusional or Magical Thinking:
Meglomatic Features:"This simply won’t happen to me." A belief in one’s specialness, which will save them from the consequences affecting those around them.

...

Doubting Thomas Features : "Peak Oil is a scam by the Oil Companies to raise prices!" Minimizing the possibility of the crisis by the belief that some one or some group has ultimate control over its happening.

...

The Flintstonian : "The stone-age didn’t end because they ran out of stones." A belief that modern innovation is eternal.

Frank Zappa-ism : "As soon as things get really bad, they’ll come up with something." A belief that necessity is the mother of invention.

Magical Thinking : "Don’t worry, we can build a car that can run on air!" Proposes solutions that are clearly outside the realm of physics.

McGiveristic Features - A belief that massive planetary problems can be solved with ordinary/common items found readily at hand. Eg.: "Pig dung will be the next fossil fuel." Or "Coke Cans can be turned into solar panels."

Trouble is, there's a grain of truth in all of this. How you react to potential natural disasters and whether you apply the precautionary principle (action to reduce risk should not await scientific certainty). Canada suggests doing so for infectious diseases:

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).

So, thinking about disaster becomes a prudent exercise in rational awareness rather than a disorder of  logical thought.

Voters were ready to hand control of the government to Australia's opposition Labor party, headed by former diplomat Kevin Rudd, who has promised to boost relations with China, pull some troops from Iraq, and re-make Australia as a leader in the global effort to stop global warming. The defeat appears so complete that the 68-year-old Mr. Howard, Australia's second-longest-serving prime minister, appeared likely to lose his own parliamentary seat, which he has held for 33 years.

If anything (think global warming), the recent elections in Australia suggest that when it comes to natural disaster, a lot more people "get it" than you think.

Click the links for previous Sunday Kos Essays on pandemic preparedness and the National Response Framework.

While we've been writing about H5N1 and the threat of a pandemic for three years on Daily Kos, passage of time doesn't make the threat any less. Today we'll touch on surveillance. The combination of a domestic turkey outbreak in the UK (possibly from wild birds and still under investigation), along with the suggestion of another human to human (H2H) cluster in Riau, Indonesia, tells us that the threat of a flu pandemic is still out there and very real, but without robust surveillance, how would we know that?

David Heymann from the World Health Organization writes:    

"As long as the H5N1 virus is circulating in chicken populations in the world, there will be a threat of a pandemic."  September 7, 2007

   Dr. David Heymann
   WHO's Assistant Director-General for Communicable Diseases
   Global pandemic a real threat: WHO

Well, it's not just chickens these days and it's not just third world countries that are affected. The most recent H5N1 outbreak [yes, it's confirmed] in birds is in turkeys in the UK.

Bird flu virus contained, says farm

A cull of 28,000 poultry on five farms linked to a bird flu outbreak in East Anglia will be completed today. The owners of Redgrave Poultry in Diss, Norfolk, the farm at the centre of the outbreak, are optimistic that the virus has been contained. Government advisers are baffled, however, about the outbreak’s source.

For the second time in a year, the UK has to deal with H5N1 infections in poultry. In the first case, Bernard Matthews, the largest poultry dealer in the country, was faced with an H5N1 infection likely spread from infected poultry from Hungary. This time, a free range turkey farm in Suffolk reported the deadly virus, which sparked an exclusion zone within which the poultry cull took place.

The source of the infection is unknown, but it is identical to the strain found in recent outbreaks in southern Germany and the Czech Republic (see FW summary).

Interestingly, DEFRA (the British agency that oversees poultry surveillance and testing, is threatened with budget cuts in a scenario where they can barely keep up with the threat.

POULTRY producers last night called for increased surveillance of wild birds after an outbreak of avian flu in East Anglia was confirmed as the feared H5N1 strain.

More than 6,500 birds, including some 5,000 free-range turkeys, were slaughtered yesterday at the farm in Redgrave, Suffolk. The farm is near a large pond used by wild birds and government scientists said initial tests "suggest a possible wild-bird source" for the disease.

As David Heymann notes, if H5N1 is in the environment, it is a threat to humans. This is a lesson the Indonesians are learning  the hard way. These maps, produced by Flu Wiki volunteers, show recent Indonesian cases, including suspect cases that may suggest a human H2H cluster:


click pics for bigger versions; more after the break

Click the links for previous Sunday Kos Essays on pandemic preparedness and the National Response Framework.

One of the great things about the SCHIP discussion (wherein the Bush Administration and Republicans are on the wrong side of the will of the American people) is that it has brought out the canards and straw men of "socialized medicine" as the reason to vote against (the real reason is to try and shore up an unpopular President politically; even many Republicans voting to sustain Bush's veto hate being in that position, and know they're getting hammered over this at home). The trouble with that position is that this isn't 1965, where reactionary forces could rail against Medicare as "socialized medicine" with impunity. In fact, polling repeatedly has brought up the response Who cares if SCHIP is socialized medicine?

But do Republicans really want to argue on the basis of what's "socialized" and what's not? Will we return to turnpikes run by private companies or will we continue to drive on socialized interstates (pushed by that Commie pinko President Dwight Eisenhower)? Do we send our kids to socialized public schools or do we support vouchers for private education (that's a hot one)? Or do we take a third way and educate our kids at home (lots of folks do for various reasons)?

Hey, how about fire departments? Does anyone have a problem with a socialized fire department? Well, apparently, some do. Did you know that with enough money, you can buy special treatment?

A private fire crew dispatched by a national insurance company that caters to wealthy clients is guarding 22 high-end homes threatened by the Castle Rock Fire, a blaze that has forced the evacuation of hundreds of million-dollar homes west of Ketchum.

The crew will protect only homes insured by AIG Private Client Group, an insurance company that offers "loss-prevention services" to its wealthiest customers. A truck and two-man crew sent by AIG from Montana arrived in Ketchum about 2 p.m. Wednesday to start dousing properties with Phos-Chek, the same fire retardant dropped from U.S. Forest Service aircraft...

The private crew has been granted access to areas closed to residents, but not all officials with public fire agencies were thrilled by the sight of the truck scooting through a smoky web of government fire crews.

"That sounds ridiculous to me," said Kim Rogers, a Ketchum Police Department spokesman, "especially since we haven't lost any structures. I mean, this is a Forest Service fire, not a private fire."

Nevertheless, the crew has Forest Service blessing.

More...  

AIG this year expanded its Wildfire Protection Unit to 150 ZIP codes in California and Colorado, up from 14 when it was formed in 2005. The unit has had the busiest week since its inception as fires burned at least 719 square miles (1,861 square kilometers) from Santa Barbara to San Diego, destroying 1,342 homes and 34 businesses and causing at least seven deaths.

But why bother hiring AIG when you can hire Blackwater? Naomi Klein, writing in The Nation:

I used to worry that the United States was in the grip of extremists who sincerely believed that the Apocalypse was coming and that they and their friends would be airlifted to heavenly safety. I have since reconsidered. The country is indeed in the grip of extremists who are determined to act out the biblical climax--the saving of the chosen and the burning of the masses--but without any divine intervention. Heaven can wait. Thanks to the booming business of privatized disaster services, we're getting the Rapture right here on earth.

Just look at what is happening in Southern California. Even as wildfires devoured whole swaths of the region, some homes in the heart of the inferno were left intact, as if saved by a higher power. But it wasn't the hand of God; in several cases it was the handiwork of Firebreak Spray Systems. Firebreak is a special service offered to customers of insurance giant American International Group (AIG)--but only if they happen to live in the wealthiest ZIP codes in the country. Members of the company's Private Client Group pay an average of $19,000 to have their homes sprayed with fire retardant. During the wildfires, the "mobile units"--racing around in red firetrucks--even extinguished fires for their clients.

One customer described a scene of modern-day Revelation. "Just picture it. Here you are in that raging wildfire. Smoke everywhere. Flames everywhere. Plumes of smoke coming up over the hills," he told the Los Angeles Times. "Here's a couple guys showing up in what looks like a firetruck who are experts trained in fighting wildfire and they're there specifically to protect your home."

And your home alone. "There were a few instances," one of the private firefighters told Bloomberg News, "where we were spraying and the neighbor's house went up like a candle." With public fire departments cut to the bone, gone are the days of Rapid Response, when everyone was entitled to equal protection. Now, increasingly intense natural disasters will be met with the new model: Rapture Response.

And were we kidding about Blackwater? Nah.

There's many dark moments these days for the CDC, like the suppression of the CDC Director's comments on global warming by the WH. Think Progress's story on this has some excellent links. From Forbes:.

"It was eviscerated," said a CDC official, familiar with both versions, who spoke on condition of anonymity because of the sensitive nature of the review process.

   The official said that while it is customary for testimony to be changed in a White House review, these changes were particularly "heavy-handed," with the document cut from its original 14 pages to four. It was six pages as presented to the Senate committee.

On pandemic flu and disaster prep, as everything else, CDC is better, as they always are, when they stick to science and not politics. But there's a long way to go in terms of how prepared we are for disaster (we're experiencing one in CA right now – watch how slow motion everything about the response seems, even when it's not).

The recent joint report on pandemic preparedness from Trust For America's Health and the American Academy of Pediatrics (reviewed here) highlights deficiencies in pandemic prep that neglect or underserve children. An new statement by freshman Democratic Congressman Chris Murphy (CT-05) supports the report

Today, Congressman Chris Murphy (CT-5) announced his support for greater efforts to protect America’s children against the risks of pandemic flu.  Specifically, Murphy commended the work of the Trust for America’s Health and the American Academy of Pediatrics which just released a report, ‘Pandemic Influenza: Warning, Children at Risk’, outlining steps that can be taken to help protect children from contracting and spreading the virus.

       "Our nation’s children would be among the hardest hit if a pandemic flu outbreak were to occur.  This report does a great job of highlighting some of the ways that we can work to ensure that the health of our children is among our highest priorities when preparing for a possible pandemic flu outbreak," said Murphy.

       The report goes so far as to warn that in the event of a severe outbreak, 9.9 million Americans could be affected resulting in as many as 1.9 million deaths.  Proactive steps like immunizing kids would make us more prepared for an outbreak.  The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices recommends vaccination for all children from six months to four years old.  However, influenza vaccination rates among this age group are low - four out of five children don’t receive the vaccine.  

"We teach our kids to share in life, but often that lesson extends to their germs.  We have a responsibility to do all that we can protect them from a flu outbreak.  I’m very pleased with the work that the Trust for America’s Health and the American Academy of Pediatrics has done in addressing this critical issue.  I look forward to working in Congress to help further this important work to help protect the health of our nation’s children," said Murphy.

and joins Senators Hillary Clinton and Pat Roberts in supporting the idea of planning beforehand for disaster. It's good to have congressional leadership on this, wherever you can find it (and we have some outstanding freshman)..

More liveblogging on the CA wildfires here, and more on pandemic flu prep here. For a good web site on disaster planning for your own family, see MN's codeReady site and create your own custom plan - before disaster strikes.

Oh, and get your flu shot while you're at it. Flu season's just about here.

Update [2007-10-24 10:13:57 by DemFromCT]: What do you do if there's not enough pandemic vaccine to go around? You allocate priorities. The CDC and HHS are looking for comments on whether you think the priorities are correct. Note that firefighters and first responders are category A (highest priority).

The title was shamelessly stolen from my friends (the reveres) at Effect Measure in a piece reviewing an important joint report on pandemic preparedness from Trust For America's Health and the American Academy of Pediatrics.

Whereas we have been discussing the topic of H5N1, pandemic preparedness and community resiliency for some time, it is refreshing to see the professional societies like the American Academy of Pediatrics get more involved with this. TFAH is an excellent NGO that's been following the panflu issue, as well as keeping an eye on where the government spends its money (they presented at Yearly Kos this August in Chicago).

As for H5N1, the current worrying candidate for a pandemic flu virus (right now only a few cases of human to human transmission have been documented), it's still around infecting and killing humans. Endemic in birds and infecting humans in twelve countries, H5N1 has sparked interest and concern enough to catalyze considerable local, national and international planning to prepare for the next pandemic (which may be H5N1 or some other flu virus novel to humans). Conventional wisdom says:

The H5N1 virus has already mutated, though there has been scant publicity, and it has spread from person to person in a couple of families in the Far East. If the strain behaves like the 1918 virus, Professor Oxford suspects that the news will be broken by an observant journalist, who will have noticed that the local strain of H5N1 has begun spreading rapidly. However, it will be less virulent, and the mortality figures will be less startling than they were when H5N1 was caught only from birds. The usual pattern is that, after mutation, mortality drops but the rate of infection rises.

but we don't know that mortality HAS to drop, only that it's expected to.

With that as background, the TFAH/AAP report examines the peculiar status of children in regard to panflu prep and what's being done that particularly benefits them, as well as what needs to be done to fix holes in the plans. The report has gained the attention of the politicians – here's Hillary Clinton's statement

I am pleased to see that Trust for America’s Health and the American Academy of Pediatrics have released this report highlighting the needs of pediatric populations during a pandemic influenza epidemic. As our public health system works to prepare for both a potential pandemic and seasonal influenza, we must ensure that our efforts to protect our health extend to children as well.

and here's one from Pat Roberts (more statements from others to come next week).

From the TFAH/AAP report's introduction and overview:

Scientists around the globe have been warning about the risk of a potential pandemic influenza outbreak. Pandemic flu is caused by a new, severe strain of the flu virus capable of producing severe disease and spreading rapidly person-to-person worldwide. Unlike the seasonal flu, a pandemic flu virus poses a novel threat since humans would have no previously developed immunity against this new virus strain, putting most people at high risk for infection. This could result in a large percentage of the world’s population being infected by a rapidly spreading virus in a very short period of time.

The goal of panflu prep is to mitigate the effects of 25% or more of a given population (your town, your school, your business) being ill at the same time.

That part is certainly true. And, while the recommendations are child-specific, the need for everyone to do a little to promote preparedness remains true as well.

One thing we do know is that not all pandemics have the same characteristics

It is possible that exposure to other flus over the years builds some cross-protection (and while it is equally possible that cultural issues such as the young being responsible for egg collection and poultry tending may influence the numbers, they are what they are: the current H5N1 infection is a disease of children and young people. Nearly 46% of those affected are < 19 years and 90% are less than 40). NEWER Pic:

Parts I, II and III of the Preparing For Disaster series were posted on previous Sundays.

For an excellent example of a web site than can help you and your family prepare for disaster, see MN's codeReady. The site will help you create a custom emergency plan based on the number of family members, including pets.

The trouble with the complex federal disaster response (known as the National Response Framework), discussed in parts I and II of this series, is that it hasn't been implemented so no one really knows how it will work. And, like most government plans, there's just about no involvement from ordinary citizens outlined in the plan (that's not unique to this plan). Developed by the feds with (some) input from others, it was reviewed in congressional hearings on September 11, 2007.

The Bush administration's new federal disaster-response plan drew harsh criticism yesterday from state and local officials only a day after it was unveiled, prompting fresh calls by House Democrats to make the Federal Emergency Management Agency a stand-alone Cabinet-level agency.

In one of only three House hearings held yesterday, all scheduled to mark the anniversary of the Sept. 11, 2001, terrorist attacks, state and local emergency managers said the new plan offers insufficient detail for guiding the actions of officials in charge of handling specific incidents and leaves unclear the chain of command, from the president to workers on the scene...

But yesterday, Robert C. Bohlmann, emergency manager for York County in Maine and spokesman for the International Association of Emergency Managers, warned at the hearing about a "major disconnect" between that legislation and the new National Response Framework (NRF), which states that the secretary of homeland security is in charge of managing domestic incidents.

Testifying before a House Transportation and Infrastructure subcommittee, Bohlmann said the framework -- streamlined to about 78 pages from its predecessor, the 427-page National Response Plan -- lacks substance.

"The draft NRF that we have reviewed appears to be more like a public relations document rather than a response plan or framework," Bohlmann said. Earlier this summer, state and local officials had complained that the Department of Homeland Security ignored the input they gave to FEMA and commandeered the drafting process.

Criticism includes the complexity of the various scenarios.

Tim Manning, director of homeland security and emergency management for New Mexico and spokesman for the National Emergency Management Association, whose members include his counterparts in the 49 other states, said he "could not object more vociferously" to the framework's concept that separate operational and strategic plans will be developed for 15 federally designated disaster scenarios.

"When you scale up to the level we're talking about, to have very duplicative plans with 30 variations will be disastrous," Manning said.

Transportation Committee Chairman Rep. James L. Oberstar (D-Minn.) said it may be time for Congress to revisit the issue of separating FEMA from the DHS. Del. Eleanor Holmes Norton (D-D.C.), who chaired the hearing, asked congressional investigators to review state and local officials' criticism.

Touching on Manning's criticism, we saw in Part II that some disasters simply aren't covered by the ESF scenarios (such as food distribution problems because of a flu pandemic). As to whether FEMA should be separate, it certainly did not function well as part of DHS. At the same time, FEMA's role is designed to be limited. it is supposed to wait to be called in by local disaster managers and to help coordinate rather than be the source of manpower and equipment (staff and stuff) supplied by others. However, FEMA itself recognizes that may not be enough and is starting to draw up plans of its own.

The Federal Emergency Management Agency is quietly drawing up plans for a handful of disasters: devastating earthquakes beneath San Francisco and St. Louis and catastrophic storms in South Florida and Hawaii, FEMA's chief said Thursday.

In a departure from its traditional expectation that states develop such responses, the agency is forming "base plans" for responding to specific calamities, FEMA Administrator R. David Paulison said in an interview Thursday with The Associated Press.

FEMA officials expect to finish plans for a massive Bay Area quake by the end of the year and are at work on another response blueprint for a large quake on the New Madrid fault, which runs from southern Illinois to northeastern Arkansas and lurks beneath St. Louis, Paulison said.

FEMA also is preparing for a Category 5 hurricane in the Miami area and has nearly completed response guidelines for a failure of the 143-mile dike around Lake Okeechobee, northwest of Miami, he said. About 45,000 people live in flood-prone areas around the lake.

Also, the agency recently began assembling response plans for a catastrophic hurricane in Hawaii, Paulison said.

Waiting is not a recipe for success.

FEMA has adopted a more aggressive stance toward disasters since Hurricane Katrina devastated parts of the Southeast in 2005. Paulison called it a "culture change" at FEMA.

Paulison, who did not mention a base plan for the New Orleans area, said the old model of waiting for states to plead for federal help was a recipe for "sequential failure."

"We've got to go in as partners. We've got to stand side by side," he said.

"We're going to move in early, we're not going to wait for the state to ask for things before we start moving them, we're going to anticipate what the needs are, and then when they ask for them, we're going to be there," he said. "The worst that can happen is they don't need them."

The following was originally submitted prior to Yearly Kos 2007 to the Journal of Netroot Ideas (JONI), which is on hiatus. JONI is expected back in time for Netroots Nation in summer 2008.

Since the formal and official federal response to disaster, including pandemics, is complex and untested on a large scale, resiliency preparation on an individual and family level would be a great way to anticipate and prepare for natural disasters from earthquakes to ice storms to pandemics - in advance. Community resilience can thereby be enhanced from the bottom up, as well as the 'top down'.

As for pandemics in the news, see "Pandemic: Bird Flu" - Science Channel
(Sunday, 9 PM – TV Program examines possible scenarios for widespread influenza) (Link) and (schedule Link)

Abstract
The preparations required to mitigate an influenza pandemic are beyond anything public health or government officials can do alone. An on-line community, with the help and participation of experts, can come up with solutions and ideas  to supplement the work of official agencies, especially where existing solutions are absent or incomplete. The community/interactivity model pioneered by political blogs  can be successfully adapted to the public health sphere. Non-governmental internet resources  can provide public debate, participation, and other tools that both engage and educate the public on how best to prepare.

Description
Flu Wiki is an interactive "wiki" website, accompanied by a conversation space structured like a traditional web log or "blog". A blog (web log) allows anyone to add comments to an author’s on line published piece (although that function can be turned off at the blog owner’s discretion). A wiki is software that not only allows content addition by an author like a blog, but allows collective editing to produce a final product. This means that any reader can add information and edit the author’s original core piece. While that may seem anarchic, the ability to use many eyes to find and correct errors has been written about in Nature , who found the science content of  Wikipedia about as accurate as the Encyclopedia Brittanica (both contain errors, and any encyclopedia should be considered a starting point only).

No registration is required to add material to the wiki. Registration is required for comment in the Forum. Both sites are moderated by the same individuals; inappropriate comment and commercial links are removed.

The software used for Flu Wiki is PmWiki. The current Flu Wiki Forum, the conversational space for the on-line Flu Wiki community, runs on Soapblox.

Citations
Flu Wiki has been cited as a reliable source and community communications model in Science , Nature , the Harvard Business Review ,  the University of Pittsburgh Medical Center’s Biosecurity and Bioterrorism  journal, the American Academy For the Advancement of Science  and  the library sciences journal Medical Reference Services Quarterly.

Introduction To The Pandemic Flu Issue
The next pandemic is a matter of "when, not if", and the current H5N1 (bird flu) in the news is a real threat. Robert Webster and Elena Govorkova , writing in