"If you go into a planning meeting and more than half (of) the people in the room are subject matter experts, you need to call timeout, go grab someone off the street, and run your ideas by them. See if they will work......we need regular people, normal people, like cab drivers or whatever..."
emergency response professional
Pandemic influenza may be a classic example of "wicked problems" - problems in public policy that are particularly intractable to solutions developed by traditional analytical methods and implemented via the usual hierarchical institutional structures of government. Conventional responses such as vaccines and antivirals will likely fall far short of bridging the gap between resources and needs. Historical experience and modeling suggest that the community mitigation measures recommended by the CDC may reduce overall morbidity and mortality to a significant degree. Implementation will involve multiple sectors of society. Mitigation of secondary consequences can be achieved in a variety of ways, most of which involve a high degree of citizen participation and consent.
Building individual and community resilience is crucial to counteracting the numerous local and systemic challenges that are likely to arise in a pandemic. Services are likely to be degraded and matching resources to need in a timely manner will test official responders to the limit. Experience from recent disasters show that private citizens are frequently the actual 'first-responders' who through intimate knowledge of their community are often capable of acting effectively to save lives. In a disaster as extended in time and globalized in scope as a pandemic, the general principle in professional disaster response that incidents should be managed at the lowest jurisdictional level should perhaps be extended to reflect that the lowest jurisdictional level will likely happen at the level of the individual and family unit.
Such local and practical knowledge is useful in planning and preparedness as well. Given adequate scenario-specific information and guidance, individuals are generally able to determine the most appropriate ways of preparing ahead of time. Citizen preparedness efforts should however complement and not replace official action. What is needed is partnership and coordination through sustained public and community engagement, to facilitate mutual learning, to establish working relationships and more importantly mutual respect and trust.
Adequate preparation for a pandemic will necessitate a certain amount of home stockpiling of essential items. This should however be the starting and not the end goal of individual and family preparedness. Through ongoing participation in "sharing the job of worrying", the motivated layperson with modest education can over time achieve a remarkably sophisticated understanding of the complexities of pandemic influenza mitigation, including especially the constraints of government. The establishment of local knowledge communities will significantly enhance official responses, provide the 'voices of reason' needed when issues of equity arise and public trust is critical, and most importantly enable citizens to improvise with appropriate innovative solutions to unforeseen circumstances. This goal, of empowerment of individuals and families, is intangible but perhaps more important to the wellbeing and eventual outcome of the community, than any amount of stockpiling of materiel can achieve!
The optimism inherent in the American spirit is a national strength and the source of the dynamism needed for innovative solutions to novel challenges. It can also be the source of significant cultural bias against attempts to establish a 'Culture of Preparedness'. In addition, as distinct from hurricanes or earthquakes that involve visible physical damage to infrastructure or persons, the disaster agent in an influenza pandemic is an invisible but potentially all pervasive threat with numerous complex consequences. This makes it potentially simultaneously difficult to comprehend and subject to speculations and extrapolations that may be difficult to disprove. There is therefore an intrinsic challenge in risk communication, in that the level of understanding required for an individual to start preparing for a pandemic may at the same time result in varying degrees of fear and anxiety that officials may find hard to dispel without negating the message for preparedness!
On the other hand, it is important to recognize that "fear and dread are appropriate responses given the scale of human suffering and economic upheaval that is possible." Such natural psychological responses are probably necessary if not invariable interim stages towards a more balanced and nuanced understanding that develops over time, and should not be confused with the archetypal 'mass public panic' that exists still as a popular institutional myth. In addition, the process of working through such 'adjustment reactions' is likely to result in more resiliency and should perhaps be considered an integral part of preparedness.
Changes in demographics mean that the next pandemic will have particularly severe impacts on families with children. Indeed, the vast majority of contributors to online unofficial pandemic-related information and preparedness resources are concerned parents. Many have moved from an initial overwhelming urge to protect their families against all possibilities of infection, to the awareness that an overall level of community preparedness offers better protection to their families than attempts at total self-isolation, resulting in a corresponding desire to promote pandemic preparedness in their communities. This evolution in thinking is aided and accelerated by an adequate understanding of the scale of potential mitigation possible with the community mitigation measures. This however is a sophisticated level of knowledge that is unlikely to be achievable overnight with a totally ignorant public.
An additional caveat on the road to facilitating this process lies in the natural tendency for professionals to be critical of citizen responses that are at variance with their professional judgment, to 'educate' the public out of seemingly misguided notions of what preparedness entails. While this is often (but not always) justified and may be necessary for reasons of significant public safety, there may be trade-offs in the public's loss of trust or even antagonism that need to be carefully evaluated. If knowledgeable and empowered individuals and communities is the end goal, then the road to empowerment is likely to lie in evidence-based persuasion, dialogue, accommodation, and acknowledgment of citizens' efforts, however amateurish and at times incorrect. If pandemics are indeed 'wicked problems', it is arguable that there may be less science than art (of intuition) in determining what constitutes real preparedness.
There are currently severe barriers to entry for non-credentialed citizens in promoting individual and community preparedness - the traditional view that experts know best is still the overwhelmingly predominant one. While subject matter expertise is important for accurate evaluation of scientific and other specialist data, current institutional bias is such that eminence is most often equated with increasingly narrow areas of specialization, attributes that are not well matched to the diffuse, 'complex adaptive' nature of the threat.
In addition, the extent of uncertainties of almost every aspect of influenza science and pandemic mitigation, and the need to seek safety (in numbers) and reassurance is such, that deferring to or waiting for expert guidance has become the default position for many local planners. This is an unfortunate state of affairs, and may put communities in danger when policies are either developed without taking into consideration their effects on the real life circumstances of individuals, or, worse, when 'waiting for guidance' becomes a chronic substitute for developing local innovative solutions.
The small internet-based community of 'preppers' consists mostly of non-credentialed individuals whose successes in preparing and developing solutions DESPITE the lack of official and consistent guidance, demonstrate clearly the extent to which individuals can be empowered to help themselves and their communities. Parental risk perception is the single most powerful driver for these individuals; professionals may find useful lessons in such grassroots experiences.
The following series of posters attempt to illustrate some of the 'talking points' raised in this overview. Ideas and opinions expressed belong solely to the author and do not represent those of Flu Wiki as a community of participants nor any of the other editors.
Conflict of interest: none
- Department of Homeland Security, Draft National Response Framework, Sep 2007
- Flu Wiki http://www.fluwikie....
- Hatchett et al, Public health interventions and epidemic intensity during the 1918 influenza pandemic. PNAS. 2007 104(18):7582-7.
- IOM Board on Global Health, Ethical and Legal Considerations in Mitigating Pandemic Disease (2007)
- CDC, Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the US
- Redefining Readiness Project, The Center for the Advancement of Collaborative Strategies in Health, NY Academy of Medicine
- Schoch-Spana, Monica, Realistic Expectations about Public Responses to Pandemic Flu, Briefing for the House Committee on Science, December 14, 2005.
- Working Group on Community Engagement in Health Emergency Planning, Community Engagement: Leadership Tool for Catastrophic Health Events, Biosecur Bioterror. 2007; 5(1):8-25.
"Parents are generalists, by definitions. Also survivalists. Kids don't come with instruction manuals. They throw curve balls at us every day, at the most inconvenient time and the most ungodly hours. We survive them."