What, me worry?

One of the most vexing problems in public health is how to respond to hypothetical events that would be really, really bad if they were to happen, which we think are unlikely, but to which no definite probability can be assigned. Actually, the philosophical underpinnings of the very concept of probability are often pretty shaky in these situations; it isn't even clear what we mean by calling some events unlikely.

Like everybody else, I tend to have opinions even when I don't know anything, so here's what I think about one scenario that tends to worry folks, intended to illustrate how we might think about such problems.

Pandemic flu: The 1918 flu pandemic is still within living memory (though not my own, I'm happy to say). It is not clear, however, whether such deadly strains have emerged in the past. There have been outbreaks of more than usually virulent influenza since 1918, but nothing to rival it. The currently circulating H5N1 bird flu strain worries experts because human immune systems are naive to the H5 form of the hemagglutinin protein, and it may be that the 1918 strain arose in birds, so maybe this is potentially the big one. But nobody knows if this strain will ever become pandemic in humans, or if it does whether the mutated form will be anything like as dangerous as the 1918 strain.

I certainly don't know. Among the portside chattering classes, there is that faction that says the threat is overhyped and it's all a plot to sell Tamiflu or impose martial law; and the opposite faction that says progressive people should be concerned about this as an essential social responsibility and an example of real threats that get ignored in the massive hype over the Global War on Terror.™

Fortunately, however, this one has an answer that should satisfy everybody. It doesn't matter what may happen with H5N1 influenza, the threat of a widespread infectious disease emergency, whether regional, national, or global, involving some virus or possibly another kind of pathogen, is definitely real and in fact, inevitable. Preparation for such events is fairly generic - it isn't specific to H5N1 flu. And that even includes vaccine production. A highly effective vaccine can't be developed until the specific problem strain emerges, so what counts is having vaccine production methods and facilities that can respond quickly and produce enough vaccine for the world within a short enough time to matter. That kind of preparation will benefit us no matter what viruses confront us.

But other kinds of preparation are probably more important, at least to those of us who are deeply concerned about social and political problems. The key response to such emergencies happens locally. Federal agents aren't going to parachute in, we have to be prepared to act in our cities and towns regarding such questions as closing schools and businesses, providing emergency medical care, emergency dispensing and inoculation, communicating with the public, quarantine and isolation, filling in for sick people in essential functions, and so on and so on. Plans and procedures need to be in place to work effectively with special needs populations, people with limited English, cultural minorities, and so forth -- all of which create an opportunity to democratize local government and build stronger communities.

At the national level, we need to have a real debate about responsibility for public health emergencies, and defending open and democratic society in the face of fear and danger. One very concrete way to see this is in the question of whether federal responsibility for a public health emergency belongs with the Department of Homeland Security, or the Department of Health and Human Services. What should be the consequences for civil liberties? What should we ask people to do voluntarily, and what coercion should be used? Do we guarantee to always tell the people the truth? If there are to be any emergency powers granted to any federal agencies, what is the procedure? How long do they last? What mechanisms exist for accountability and review?

And then there are infrastructure questions -- hospital surge capacity; the public health workforce; coordination and collaboration among health care, public health and public safety agencies at the local, state and federal level, with clear collaborative relationships and lines of authority established in advance; planning and training; and so on.

There are many issues touching directly on social justice, democracy, and public priorities embedded in emergency preparedness, as Katrina proved beyond any doubt; and we are woefully unprepared. It doesn't matter whether you believe H5N1 flu is inevitably going to wipe out half the human population before the end of 2008, or you think the whole thing is the biggest crock since the world was going to end on January 1, 2000. Something is going to happen some time, and it makes sense to think in advance about how we will respond. After all, the Cheney Administration used the 9/11 attack to give us Iraq, Guantanamo and the Patriot Act. We should make sure that doesn't happen again.