It's only a few weeks before schools break for the summer. A nationwide early dismissal of classes will put a powerful brake on an outbreak that is on the verge of becoming explosive. Millions of lives may depend on decisions made in the next 48 hours. TPTB must find a way to make it happen.
It's often said that 5 minutes into a disaster, all plans go out the window. We say that not because the plans are useless, but because the best plans cannot take into account the infinite number of ways that events will unfold differently than you anticipated. Here's one (almost) amusing example, a screenshot from pandemicflu.gov that says we are in WHO Pandemic Phase 5 and US Pandemic Phase 0, even though the US now has the largest number of confirmed cases outside of Mexico.
This is because when the plans were being written, the biggest threat on the horizon was avian flu H5N1. A pandemic seemed most likely to start from a country far far away, such that the first human case in America would not happen till some time after the beginning of WHO Phase 6. (see this chart for Federal Response Stages)
Since we are (still) not in Phase 6, the Federal Government Response Stage remains awkwardly stuck on 0. ;-D
But, that's ok. As the CDC has repeated in the past few days, it doesn't matter what we call it as long as we do the right thing. I agree wholeheartedly. Still, this issue is important because when it's time to activate those plans, like now, we need to apply the same logic: it doesn't matter what the original plans said as long as we do what those plans were intended to do.
Now that cases are appearing all over the country, and with the tragic death of the first child, it's time to activate the community mitigation strategies. Here we encounter the same problem, as stated in the CDC swine flu website, posted on April 28, 2009 02:45 PM ET:
The previously published United States government guidance on community mitigation relies on knowledge of the Pandemic Severity Index (PSI) to characterize the severity of a pandemic and identify the recommendations for specific interventions that communities may use for a given level of severity, and suggests when these measures should be started and how long they should be used.
The substantial difference in the severity of the illness associated with infections from the same virus, the relatively low number of cases detected in the United States, and insufficient epidemiologic and clinical data to ascribe a PSI, present a formidable challenge in terms of assessing the threat posed by this novel influenza A virus until additional epidemiologic and virologic information is learned.
Quite. Especially if you have some rather weak links in the system. And especially if the plans depend on these links for activation/implementation.
Like other federal guidance, the CMG was written with the assumption that implementation decisions will be made at the local level. However, just like the Federal Response Phase 0 situation, reality is very different from what's in the book. For example, there is huge variability in how familiar state and local PH are, with either the original CMG guidance issued in Feb 2007, or the more recent Federal Guidance for States released in 2008, with this chart created to inform the timing of activating interventions.
This chart may look familiar to us diehard flubies, but government moves slowly, and many state and local PH had not gotten round to integrating the recommendations in this (and other) federal documents, before the current H1N1 pandemic is suddenly upon us. For example, the pandemic flu preparedness and response plan for NY City, has a publication date of July 2006, with a cover letter signed by Mayor Bloomberg. OTOH, while the NY State pandemic plan released in June 2008 does include community mitigation plus the triggers and intervals, it is not clear how the state vs city plans are supposed to work together. We have already seen how, despite having the most number of confirmed cases in the country, NYC continues to close one school at a time as cases are confirmed, as if infected kids will somehow magically only excrete virus in school, but not anywhere else on their way to and from school, hanging out with friends, being with their families, etc.
Texas, the state with the second largest number of confirmed cases, 1 dead toddler, and 2 others in critical condition, is not doing any better either. Watch this Houston official saying reassuring words to the public after the death of the first case of swine H1N1. I'm especially astonished by the logic expressed by Dr. David Persse from the Houston Department of Health and Human Services, that since this child was a patient transferred from elsewhere, his death "really doesn't change the landscape" of risk.
While WHO, CDC and other scientists scramble around the clock to collect information on the severity of this outbreak, it doesn't seem to disturb Dr Persee that the death of this child just overturned the widely held belief (or hope) that cases outside of Mexico tended to be mild. I suppose if you've spent substantial parts of your career differentiating between what counts and what doesn't count, for bureaucratic reasons, it would be hard to imagine there may be other reasons to start thinking differently, eg, that disease transmission respects no borders nor categorization, and that a sick and dying child may well be the tip of a gigantic iceberg of unidentified or incubating cases ready to explode into the community. In a sad mirror-image of CDC's approach, it appears that here the logic is, it doesn't matter what we do about it, as long as we count it correctly.
What are we left with then, this morning as the world stares into the abyss?
We are on the brink of a pandemic caused by a virus with less human-adapted genes than any other virus since 1918. The age distribution of fatal cases in Mexico is also reminiscent of that pandemic. With 1 dead and 2 on the critical list and 16 confirmed cases in Texas, hopes for a 'mild' outbreak may be receding. It's obvious that this virus is transmitting easily and rapidly, with an R0 possibly much higher than originally assumed when the CMG interventions, intervals, and triggers were put together. The situation is evolving faster than our ability to identify, diagnose, and report cases. The outbreak is reaching the classic 'explosive' point in NYC, the most populous city and home to Wall Street.
The stakes are high. It's time to activate community mitigation interventions, not piecemeal, not school by school, not driven by the residency status of a particular case, but as one would launch the New Deal or the Manhattan project, courageously and ambitiously. A country is nothing but a community of communities. The mechanism for mitigation may be local, but the benefits of success will cascade to every single community whether cases have been confirmed or not. Successful mitigation in the US will generate the data upon which other countries can base their mitigation.
Can this be done? I don't know enough about Fed vs state jurisdiction to tell. But these are extraordinary times, and there are many extraordinary heroes working tirelessly to combat this threat to humanity. I'm confident the will exists; I'm sure they will find a way. They cannot fail. They must not, for the future of our children are in their hands.