Preamble
The present generation is the first to have the opportunity to prepare the country against the consequences of an influenza pandemic. It is a novel task requiring leaders to 'think out of the box'. It is also an unenviable task of enormous complexity. The UK government deserves to be commended for its willingness to repeatedly consult with the public and subject this complex, ongoing, and unfinished work to the scrutiny and criticism of any who cares to do so, with or without expertise or justification. We as citizens can only do it justice by giving our best to the process.
The current iteration of UK National Response Framework while fairly comprehensive in traditional public health and social policy terms, suffers from some conceptual flaws (or at least inadequacies) which may have contributed to significant difficulties in proper characterization and articulation of the nature of the pandemic risk, and in shifting priorities from conventional health and social policy perspectives to encompass the complexities required in 2 additional domains, that of security and continuity of infrastructure in a global networked environment, and of managing the effects of public perception and the sum total of many individual decisions. Not all risk areas are as amenable to intervention as others, but it is possible through some critical analysis to identify certain nodes that are most likely to have large effects. The scale of the response needs to correspond to the sum total of risks from the different domains, not just the one under consideration. Multiple interventions applied early and targeted towards such nodes is the preferred strategic approach to mitigation. Currently the recombinant haemagglutinin vaccine is the most viable option for providing us with a pandemic vaccine in 12 instead of 20 weeks; investing in and acquiring such a vaccine is a step that may be critical to the sustainability of our response and early recovery. There are two 'show-stoppers' that the government needs to pay special attention to: the logistical challenges for antiviral distribution, and a realistic look at the likely level of healthcare worker absenteeism. Both require community cohesion and public trust.
In the Beginning, There was the Word
A pandemic is potentially such a devastating event to society that we must take utmost care at every level when considering how and what national policies should be developed. While no consensus exists, there is at least a large school of thought in the cognitive sciences that suggests that the language we use have powerful effects on our thinking [1]. For example, the word 'framework' describes a structure rather than a plan of action to secure a goal (as implied by the word 'strategy', used in US national plans [2]). Since a pandemic is not intrinsically a structural problem, this creates a mismatch between the problem and the direction taken to generate solutions. Such mismatches can be the cause of great institutional hardships as all levels of government are constrained to work with the problem in the way that was originally defined by the leadership.
At the most basic level, the word 'framework' implies a passive, static, and institution-centric approach that is equated more often with bureaucracy, rigidity, and complacency than with result-oriented pragmatism, creativity, and competence. In comparison, the word 'strategy' is more likely to generate an agile, adaptive, and dynamic mindset more conducive to finding innovative solutions outside normal institutional memory. It is a lesson leaders should take to heart.
In addition, while it is true that the right institutional structure or framework is important to optimize our response to such a major challenge, a pandemic is a novel problem for which we do not have existing solutions nor much experience in developing them. We are learning by trial and error as we go along. Until we find solutions that work, we really do not know what is the optimal institutional structure for such solutions to become effective.
Institutional structure, process, or framework should therefore be subsumed under and be made to serve the goal of finding solutions to our challenges. In other words, solutions should precede structure and process, and not the other way round. High-level strategies articulated by the national leadership can lead the way and jumpstart this change.
All this is much more than idle semantic play. For example, in 2 years of daily conversations with online flu communities, the author has witnessed many instances of creative solutions that can and should be harnessed for the good of society. However, the most creative people are also often the most free-spirited, and most do not belong to any organization. While in theory government and institutions can reach out and discover 'best practices' and utilize them, in reality there is no common meeting place for the two sides. Often no mechanism is available for non-affiliated private individuals to work with official institutions. Trying to become eligible for the smallest grant program, for example, requires the individual to overcome enormous legal and financial barriers just to get in to join the queue.
This problem - the need to put in institutional mechanisms to connect with and harness the creativity of nonaffiliated individuals - is finally only recently recognized by the US government, to their credit, but only after the Herculean efforts of a few individuals just to create the space for dialogue! Still, it is better to have a solution or solutions trying to find a framework for dissemination, rather than having an empty framework with no solutions that will fit in it...
Words are made of powerful stuff. We need to focus our energy and attention on 'mitigation' rather than 'response', 'preparing' instead of 'planning'. Finally, the idea of 'readiness' needs to be introduced into our national lexicon as a matter of urgency!
But the most important word that we need to develop a comfortable working relationship with, is the word 'risk'.
Figure and Ground - The Pandemic Risk in Context
One cannot truly deal with a problem, or a risk, unless one can describe what it is. There is however a common perceptual error that can trip up the unwary - the classic figure and ground conundrum. The problem is most famously represented by the 'Rubin vase' (Fig.2). When we look at the picture, do we see the vase? Or do we see the profiles of 2 people facing each other? Which is the figure, which is the ground? And which is the more important to pay attention to? (The answer, in this instance, is both!)
Similarly, when we think of pandemics, are most planners dealing with it as primarily a public health and healthcare delivery challenge? Are they approaching it as strictly a well-circumscribed problem that needs only text-book solutions, or are they able to look outside of the problem at the landscape, the social, economic, demographic, and humanitarian context [3] within which 'the problem' is likely to unfold? More importantly, are they deriving useful information from constantly switching between figure and ground?
Overpopulation, Globalization, and Risk Harmonization
Pandemics do not happen in isolation. Epidemics have caused upheavals in human societies since time immemorial. The next pandemic is likely to happen under conditions that did not exist in previous generations. Since the last pandemic in 1968, world population has doubled, the number of cities with population over 1 million has increased 5-fold, with megacities of > 10 million sprouting all over the world, often in the most impoverished countries. A pandemic unfolding in any large urban area will have instant and dramatic effects worldwide given the 24/7 news cycles. Considered in that light, it becomes obvious that the problems resulting from a pandemic are much more serious than can be portrayed by the simple epidemiological assumptions that we make. While an influenza pandemic is a classic public health crisis, it is arguable that issues arising from the 'landscape' may contribute more to the sum total of societal consequences than the epidemic itself. [3]
The government has issued a set of epidemiological markers or assumptions to guide planning. While the general principle that response should be proportionate to risk is sound, the challenge lies in developing an adequate understanding and quantification of risk in the 21st century. Traditional public health measures such as attack rate (AR) and reproductive number (R0) developed as tools in more sedate times need to be interpreted in the context of dramatically different demographic and socioeconomic environments today.
In addition, countries are increasingly connected to and dependent on each other in complex and efficient ways [4] the effects of which are harder and harder to discern. This has created vulnerabilities that may remain hidden until a small event triggers a sudden systemic collapse. [5] A recent report from the World Economic Forum (Global Risk 2008) highlights 4 particular vulnerabilities of the global system [5], all of which can be triggered by a pandemic:
1. Systemic financial risk
2. Food security
3. Supply chain
4. Energy
It is sobering to note that in this same report on global risks pandemic influenza is rated 3 on a scale of 5 for likelihood in 2008, 4 out of 5 for economic impact, and the most severe 5/5 for number of lives lost.[5] In other words, this group of eminent risk experts has come to a consensus opinion that a pandemic is both a significant possibility and one of the most severe and destabilizing disasters that can happen to human society. This is in marked contrast to the UK government's assumption of 3% risk based simply on the fact that 3 pandemics have happened in the last century - an act of 'normalisation' that finds no justification in science or statistics - and the again unsupported expectation that many of the vital functions of society will be able to continue at 'normal business levels'. Similarly, the projected GDP loss of 0.75% in a moderate pandemic is a far cry from the 5% estimate from the World Bank and the UN. [6] These gaps in risk estimates may have arisen from a totally restrictive, linear, binary view of the problem.
A New Approach to Risk
The National Framework is the most important document that guides policy decisions at the regional and local level. Instead of the current 'laundry-list' approach, more emphasis should be placed on assessing and articulating broader risks and consequences (ie to explore more 'ground' in the figure-ground conundrum), to provide all levels of government with a more holistic understanding of the complex issues involved.
Good lessons can be found by reviewing the dynamic approach to risk used in compiling the Global Risk 2008 report, [5] especially the significant changes in methodology from the 2007 one. Interestingly, although "The global risk landscape at the beginning of 2008 is broadly similar to the risk landscape at the beginning of 2007." re-defining the risk landscape using social network analysis has produced a much more organic and realistic representation of the variety of risks that interact with each other, each of which can trigger and can be triggered in any number of ways by other risks in the global network. In this instance, the various risks (or nodes in the illustration) make up the 'figure', while the network and characteristics of the various connections form the 'ground' or the context within which the risks may affect us. Both components, figure and ground, nodes and connections, are important in our evaluation of risk.
Within this giant global network, pandemics are but one type of risk in a system that is increasingly fragile but efficient in distributing and harmonizing risk. While such harmonization may serve to mitigate the risks somewhat, unfortunately any 'slack' is almost immediately taken up by activities generated by hyper-efficient market mechanisms assisted by technology, such that the system is increasingly vulnerable to sudden catastrophic unpredictable failures, even without a pandemic.
The UK as High Risk
The UK is one of the most globalized nations. Because of our high degree of social, economic, and political connectedness [7] to the rest of the world, we are particularly vulnerable to any perturbations in the system. It is likely that the next pandemic starting in a distant country will bring serious secondary and tertiary consequences to our shores well before the virus arrives. While some of these consequences are foreseeable and therefore somewhat susceptible to mitigation, (Fig 9) the timing, precise nature of the trigger, and the severity and extent of secondary and tertiary consequences are not. [5] The risk of sudden catastrophic or cascading failures of infrastructure will be present, ongoing, and unpredictable. Risk assessment for planning purposes must make allowances for scenarios that are potentially much more dire and more unpredictable than historical experiences from previous pandemics of similar biological severity may suggest.
Critical Uncertainties in Influenza Science
H5N1 is not like any other influenza virus.
Current pandemic plans take into account scenarios with a range of severity derived from the 3 pandemics of the 20th century. However, what is troubling the world most is the H5N1 avian influenza virus, which by all accounts is not like any other influenza virus.[8] While for this and other reasons one cannot predict or assume it is going to cause the next pandemic, neither can we make plans based on the assumption that the next pandemic will fall within the range of and be similar to any of the three pandemics in the 20th century that we do know about.
Limits to Certainty - The 'n=1' Problem
Most of what we know about seasonal and pandemic influenza comes from studies of these 3 pandemics and interpandemic influenza disease. Note that this knowledge is all based on one single progeny of influenza viruses - descendants of the 1918 H1N1 and the reassortants derived from them in 1957 and 1968. Even though by convention we name the viruses according to their surface antigens and thereby they appear to acquire distinct identities, the fact remains that all current circulating human seasonal influenza A strains retain 5 of the 8 gene segments that are direct descendants of the 1918 H1N1.
H5N1 does not share such common ancestry. Do we know whether and to what degree our knowledge from human influenza infections can be extended to an avian H5N1 that has just acquired some human-adaptation to cause a pandemic? Not really.[9] In addition, there is no guarantee that the virus will change its characteristics should it acquire the ability for efficient and sustained human transmissions.[10] The clinical pattern to date has been remarkably and disturbingly consistent[11] across geographical regions and even across subclades. We simply do not know a) whether it has the capability of acquiring such changes, or b) how severe the disease would be if that were to happen. [9]
The 1918 pandemic showed that it is possible for a purely avian virus to cross the species barrier into humans and cause severe pandemic disease without reassortment[12]. Since then, H5N1 is the only purely avian virus that has been known to repeatedly cause severe and fatal human disease on such a scale. The high mortality especially for adolescents and young adults exhibited in H5N1 disease may well be a feature and not an idiosyncrasy of such primary infections. Again we simply do not know the answer to that question. [9]
It could have been a lot worse? - 1918 mortality in a different light.
In addition, the W-shaped mortality curve of the 1918 pandemic, with a reduction to below interpandemic levels for older adults, has been interpreted as a possible indication that older adults in 1918 may have had some pre-existing immunity due to prior exposure to a virus circulating before 1889. [12, 13] If that is the case, the extremely high CFR (70-100%) in adults seen in Alaska and some isolated islands of the Pacific [14] may have been more representative of the effects of a pandemic from such an avian virus on a truly immunologically naïve population. While there is no evidence that this was indeed what happened, such absence of evidence cannot and should not be construed as evidence of absence, only a reflection of our ignorance and the need to guard against complacency.
We must remember that human scientists do not write the rules of biological behavior in nature - there is no rule against a population-depletion type of disease for Homo sapiens. We put the world in grave peril if we forget that.
(see pdf version for a more readable chart)
IImpact on Children
As a corollary to that, there is the additional need to focus on the role in transmission and the consequences of a pandemic for children. [15] Children are important for many reasons:
1. They tend to have higher attack rates. [16, 17]
2. Higher morbidity results in significant demands on medical attention. [16]
3. They are the early transmitters in a community outbreak. [17, 18]
4. They spend long periods of time during a school day in some of the most population-dense environments that anyone can find. The following slides illustrate this graphically. [19]
5. Social interactions between children involve far more close physical contact than for adults. They also have poorer control over their behaviors, and their secretions!
6. Families today have fewer children compared to previous generations. Child mortality has plunged dramatically in the last century, such that losing a child has become a rare and catastrophic experience. Today's parents are far less able to tolerate any actual or imagined harm to their children.
How much pain can we stand? A Look at Age-Specific Death Rates
Parental bereavement is widely considered to be the severest trauma that any person can sustain. The pain is unrelenting and the grief prolonged. One bereaved parent is a personal tragedy. A nation of bereaved parents is a source of national trauma and collective discontent. The following slide shows the effect of a 1918-like pandemic on child mortality today (US figures) [20].
The Meaning of 1% - Figure and Ground Revisited
The real impact of child deaths are often obscured in the population data, and it is only when placed against the proper context, the age specific deaths against the background of very low childhood mortality in today's society, that the full extent of the impact can be elicited. The following table covers the full range of planning scenarios as set out in the National Framework.
In an unmitigated pandemic with moderate (35%) to high (50%) attack rates and 1% CFR, the number of child and adolescent deaths will be more than what would normally happen in 2 decades. This is the context, the background that we must turn our minds to, however uncomfortable it makes us.
A Confluence of Nightmares
Terrifying as these numbers are, a 50% AR and 2.5% CFR resulting in 7 decades of child deaths in one season is by no means the worst case scenario. There is at least the theoretical risk of a pandemic caused by H5N1 with no alteration in current disease characteristics, [6] including the peak CFR of 75% for those aged 10-19. In addition, if AR is partly a function of density of environment, then the kind of age-specific AR seen in the 1957 pandemic is entirely within the reasonable range of possibilities in our world today. A combination of a high AR and high CFR within the same age group will result in unspeakably high death tolls among our young.
The following table is generated from age-specific attack rates from the 1957 pandemic, and the age-specific CFR of a moderated scenario of a 20-fold attenuated H5N1 pandemic virus. Even assuming such a large degree of attenuation, the clear 'bulge' of deaths in adolescents is breathtaking, in comparison to baseline death rates.
No Such Thing as a Mild Pandemic
Changes in societal norms and public expectations, a general risk-averse culture, and the efficiency with which small individual actions by large numbers of people can become amplified, mean that even a mild pandemic today is likely to have consequences that surpass almost all other disasters in living memory. A graphic example of what a pandemic at the lowest end of the government's planning figures (ie 25% AR and 0.4% CFR) would look like for a city like London was described in this online blog "There is no such thing as a mild (unmitigated) pandemic" http://www.newfluwiki2.com/sho...
What IS the Risk - A Strategic View
To summarize, then, a pandemic creates a very complex risk landscape, with broadly 3 major components:
a) the epidemic itself, causing morbidity and mortality, being transmitted rapidly in an epidemic wave in a community
b) in the background, a society that is hyper-efficient in and totally dependent on trade, communications, and financial services, and deeply embedded into a complex global network of interacting systemic risks, plus
c) the sum total of many individual perspectives, the personal considerations such as the safety of our children, job security, whether we have enough food in the ladder, or concern for our community that may drive our decisions in various ways. Each of these decisions may not be significant but when multiplied by tens or hundreds of thousands can create additional perturbations to the system.
These 3 components combine and interact with each other to produce what one might call a 'total societal burden' of risk that will impact the likelihood of catastrophic systemic failures and/or significant social instability. Note that this does not measure the risk to an individual, but rather reflects, for the purpose of governance, the amount of vigilance and/or intervention needed to maintain continuity of critical functions and law and order..
Shifting again between figure and ground, one can say that a pandemic is a health crisis requiring responses such as diagnostics and antiviral distribution, re-configuration of our health services to deliver care to as many as possible, and provision of palliation to those we cannot help, to name a few health responses. It is also a security and humanitarian crisis, requiring the diversion of national resources to ensure the continuity of government and critical infrastructure, and to provide the basic requirements to sustain life such as food, water, and shelter to communities affected by the knock-on effects of the networked risks.
All that is response. However hard we try, the scale of the problem is such that there will be significant periods and/or many communities where our response will fall short, where pockets of systemic failure will cause perturbations to the whole system in addition to local instability and suffering. How and to what extent we can find solutions to fill this response gap, is the most important job of planners and policymakers.
From Risk to Mitigation
Of the three components, epidemic, systemic risk, and individual actions, the middle one, the networked global system, is probably the least amenable to intervention. As discussed above, as long as it remains functional and 'online', the system is hyper-efficient in re-distributing risks as well as benefits, with multiple mechanisms available for numerous players to siphon off whatever resources that governments or institutions attempt to pour in. In the financial markets for example, such interventions as injection of liquidity by central Banks which in normal times may be able to make a difference in re-establishing market confidence and stability, is unlikely to have the same effect in the middle of a prolonged megadisaster that overwhelms the resources of governments all over the world.
Unfortunately, such an assessment may well become a self-fulfilling prophesy, as governments with some justification refuse to sacrifice their scarce national resources for the illusive 'common good'. Similar issues arise between private-sector entities as well, eg different power companies connected to a grid. Mitigation of systemic risk is possible with extensive coordination at the international level. Such cross-sectoral work is happening - the office of the UN Systems Coordinator for Avian and Pandemic Flu works with between 500-1000 different organizations.[3] It is however a Herculean task which is unlikely to significantly change the risk environment any time soon.
The Need for 'Over-Kill'?
We are then left with the other two options, mitigation of the epidemic, and managing the effects of the sum total of individual decisions (some would call this the 'herd instinct'). The task is to find interventions based on either one or both of these domains that when combined are sufficient to counteract the effects of all 3 different domains combined. This is a critically important concept to bear in mind.
At the risk of stating the obvious, systemic risk causes problems that permeate throughout the system. In contrast, both the epidemic and personal decisions are relatively localized events at any point in time. This is what one might describe as a 'reverse leverage' challenge.
The scales are therefore heavily tipped against us, in that utilizing interventions at the local community level, one has to achieve very good results AND achieve them consistently in enough localities to counteract the effect of systemic stresses, whereas systemic disturbances can wipe out any gains achieved at the local level without warning!
To succeed, interventions need to be proportionate to the sum total of the combined societal risks (see 'total societal burden' above), not just the risk in the category where the intervention is applied. Nor should such interventions be assessed only according to the needs of the local community. Local officials need to constantly keep an eye on the big picture, the 'ground' where the community (as the 'figure') stands, to ensure that the response is sufficient to meet the collective needs of the region or even the country!
Without adequate understanding of risk as explored in this paper, the type and degree of interventions needed will often look like 'over-kill', and advocates of such policies often stand accused of fear-mongering. This kind of misunderstanding is prevalent, and much education and communication remains to be done to overcome such biases.
Mitigating the Epidemic
Stripped down to the bare-bones, an epidemic causes societal distress by a combination of 2 parameters, the AR, and the CFR. (ie AR x CFR = mortality, which is a marker for social distress). In theory, we can attempt mitigation of either one or both of these parameters.
Antivirals
Unfortunately, our track record in reducing CFR for H5N1 infections is very poor. [ref] There is insufficient evidence for us to have any degree of comfort that early administration of antivirals will make a substantial difference in mortality, even assuming little or no drug resistance and assuming problems with distribution/access have been resolved. (See below.)
For the purpose of changing outcomes at the individual level, we should continue our current policy of dispensing antivirals for pandemic patients. We should however be realistic in our expectations with regards to the degree of relief that can be obtained, since at the societal level, those who are sick and are now receiving antivirals are still sick, with all the ramifications for services and absenteeism. In other words, the use of antivirals for treatment, without concomitant use for prophylaxis for contacts, cannot be relied upon as a tool for significant mitigation of the epidemic itself.
Mitigation targeted at transmission (and therefore AR) is the major intervention for epidemic control. This one single component is so critical for pandemic preparedness planning that, in the words of a senior public health expert,[21] "the goal of every single decision is to reduce transmission", meaning that policy decisions that do not result in reduction of transmission are probably not good ones and should be re-considered!
Social distancing
The rationale for use of early, targeted, layered community social distancing measures including proactive school dismissal has been previously described. [22-30] The (albeit indirect) evidence of effectiveness of social distancing measures in changing outcomes in the 1918-19 pandemic continues to accumulate. [25, 28]. However the important point to note in the current context is the issue of natural avoidance behaviors. As experienced during SARS and other epidemic disease [31], the desire to remove oneself from possible sources of infection is as natural a behavior as removing one's hand from a hot object! Spontaneous social distancing will happen irrespective of official advice and however much or little the community understands about the nature of the disease [31]. Our ability to target this behavior and harness it systematically for the collective good will be one of the most cost-effective interventions we will use. Getting maximum benefits requires planning and meticulous attention to detail especially the timing of implementation. [29]
Vaccines
The following slide was presented recently in conference [32].
In addition to summarizing the 'multiple, layered, targeted' interventions that can be applied in combination, it proposes the use of recombinant vaccines relatively early in the epidemic cycle as a tool for mitigation.
In contrast to existing egg-based vaccines, cell-based vaccines can be produced in much larger quantities and in much shorter time-frames (8-12 weeks vs 20+ weeks). Recombinant technology which produces a pure surface protein antigen with no viral components nor genetic material[33], is the most promising process out of all the different candidates in the pipeline. It is receiving significant attention from the US government for good reason. The early availability of vaccines even just for a portion of the population is the light at the end of the tunnel. It is likely to be a significant morale booster not just for our citizens but also for overseas investors. An early return of confidence and investments will provide the much needed jobs and finances for recovery and regeneration.
The Power of Autonomous Personal Decisions
In any outbreak of a novel and deadly disease, the public is likely to adopt avoidance behaviors. Such behaviors can be utilized and incorporated into official social distancing policy. Good public education can assist in spreading the message that such measures protect everyone, including those who have to go to work. [29,30]
The more challenging and potentially destabilizing behavior at the beginning of a pandemic is indiscriminate hoarding of materiel and panic buying. The biggest problem from the policy perspective is that the fear of shortages is indeed justified. Officials are in a no win situation, as any admission of the possibility of shortages will exacerbate the panic buying, while denials will cause further loss of trust. The solution lies in public education well ahead of a pandemic. The panic can be reduced if a substantial proportion of families have at least 2 weeks of food and other essential supplies http://pandemicflu.gov/plan/in... at home. The government should issue such guidance to the general public in the next round of official guidance development. The engagement of the public as true partners is a requirement for social stability and not an optional item on the planning menu!
Parental Risk Perception as Most Powerful Driver
In the debate over social distancing especially school closure, those who are opposed often cite the effect of child-minding needs on staff absences and therefore continuity of operations. In theory one can compute such absences and the cost to society and debate whether such interventions are cost-effective. In practice, such computation ignores the issue of free will, and the fact that in an outbreak of a novel and potentially lethal disease, parental perceptions of risk to their children will in most if not all cases outweigh all other considerations, such that once their risk perception hits a certain threshold, irrespective of expert advice they are likely to take the precautionary measure of keeping their children home, even sometimes at the risk of losing their jobs. (see box p14)
It is particularly instructive when a group of public health professionals who were unable to come to a consensus over school closure (due to issues with 'evidence', among others) when asked whether they will send their children to school in a pandemic, every one of them (ie 100%) answered No. [34]
Such is the power of parental instincts to override professional judgments!
This anecdote is also instructive for the reverse reason, that professionals need to be wary of their own inability to think like ordinary people in their professional decisions. Many are likely to misjudge what the public would do, unless they adopt the habit of regularly stepping out of their professional identities, to step in the shoes of a member of the public.
Engaging Parents
Each individual decision by a parent to keep their child at home may have minimal impact for society. Collectively, of course, the effect can be substantial. Note that threshold values are by definition very powerful drivers (see box p14) and are unlikely to be overcome by the usual enticements such as extra pay or appeals to altruism. Mitigation requires the building of mutual trust and the sharing of information well ahead of a pandemic. In addition, officials need to be aware that in heightened states of collective anxiety, the public is likely to over-interpret any remarks made by officials or anyone deemed to be a person of importance. The solution lies not in tighter control of information but in more detailed and repeated explanations whenever comments are made.
Despite the repercussions for staff absences, parental risk perception may be one of the most powerful forces that build community preparedness. The vast majority of content contributors on internet flu forums are parents. Once they have become informed of the risk and started to prepare their families, many are likely over time to realize that they are only as safe as their community is safe, and that they need to help their communities build resilience and redundancy.
These informed and engaged citizens are valuable resources http://www.newfluwiki2.com/sho... both for their preparedness and for the knowledge they have acquired. Building a relationship of trust and sustaining an ongoing dialogue with these citizens may be one of the most cost-effective ways for government to ensure that come the next pandemic, when stores are empty, hospitals are full, and officials are called upon to make difficult choices, there will at least be a small group who understand and care sufficiently to extend a helping hand. One never knows who will be at the receiving end of that...
And Now for the Final Curtain - Two 'Show-Stoppers'!
Show-Stopper #1 Will Healthcare Staff Come to Work?
The issue of potential staff absenteeism is most acute in the case of healthcare workers. [35] Published studies are likely to underestimate the scale of the problem unless they use anonymous surveys. Internet forums provide a 'safer' environment where their real fears and conflicts are revealed. This is an area of critical importance to societal stability. What is needed is open and honest dialogue between employers and their staff, to help establish the conditions under which they feel safe to come to work. Most officials are still oblivious of the risk. The following 2 links to internet discussions are therefore required reading for officials and employers! http://allnurses.com/forums/f8...
http://www.fluwikie2.com/index...
Show-Stopper #2 How (Not) to Do Anti-Viral Distribution
http://www.newfluwiki2.com/sho...
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