Worst-Case Health, Business Scenarios

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Leaders Share Flu Pandemic Concerns

Federal Plan Prompts a Deeper Look Into Worst-Case Health, Business

Scenarios By Levine, Washington Post Staff Writer

Monday, November 7, 2005; Page B01

When the flu pandemic is here and the hospitals begin to overflow and

there is not near enough staff or medicine or ventilators for every

acutely ill patient, who will be treated?

" Are we going to do our best to save the next generation? " Diane

Helentjaris, a health director in a Virginia community, wondered

aloud. " Or are we going to do our best to prevent deaths? "

Her question hung for a moment in a room of health officials who had

before them a 19-page grid titled " Pandemic Influenza Issues and

Options. " The group was assembled on a beautiful morning last month

in a quiet conference center just north of Richmond. The setting, and

their dispassionate discussion, made the issues and the options seem

chillingly surreal.

There were medically and ethically thorny questions. Beyond the

doctors, nurses and other medical staff striving to keep people alive

through the pandemic, which hospital workers should get a vaccine, if

one exists? The cafeteria cooks needed to feed caregivers and

patients? The housekeeping staff keeping beds changed and wards

cleaned?

And what about the perils in the community? Should the utility

employees, sanitation crews and grocery-store truck drivers critical

for maintaining everyday services and order get preference? Should

schools be closed to try to contain the outbreak? Gymnasiums claimed

for makeshift quarantine units? Or would that further strip the

workforce because parents would stay home with their children?

" The decisions, " Diane Woolard of Virginia's Health Department

said, " are not going to be easy. "

The intensity of such discussions probably will deepen now that the

Bush administration has released its 396-page plan for what many

scientists believe is inevitable: the mutation of today's avian flu

into a new, virulent strain that it says could cause as many as 1.9

million deaths in the United States and a far greater toll worldwide.

" Communities as we know them will not exist during the pandemic, "

Woolard told her audience.

In this region, the Metropolitan Washington Council of Governments

estimates that hundreds of thousands of people could become sick in

the absence of a vaccine or with inadequate supplies of antiviral

drugs. Thousands would die.

The federal preparedness outline gives broad guidance on which groups

should be protected through priority treatment but leaves many

difficult details to state and local officials. It counts on them to

shoulder much of the country's response, without saying how to carry

it out. And state and local governments are, in turn, depending on

companies and nonprofit groups to devise their own contingencies to

reduce transmission while maintaining critical daily operations. Yet

relatively few businesses or organizations have focused much on the

ramifications of something that could fell a quarter of their staffs

and disrupt work for weeks, perhaps months.

" Giant does not have a formal pandemic preparedness plan, " said

, a spokesman for the grocery chain. " The feeling is that we

have enough employees -- we have over 25,000 employees. If the need

arose, we could move these employees around quite a bit to wherever

the greatest operational need within the company would be to keep our

stores open. "

A. Peck, president of the Greater Washington Board of Trade,

said, " It's not on the radar screen of most members. "

History suggests the folly of inattention. The pandemic influenza

that is considered the worst-case scenario swept the country and the

world with breathtaking speed. It appeared in Washington in September

1918 and, within one month, had killed so many that coffins and

gravediggers were in short supply.

Still, the region today is probably better prepared than many

metropolitan areas. The 2001 terrorist strike on the Pentagon, the

anthrax threats that same fall and the sniper siege the next year

made clear that an attack that upends and endangers life is more than

speculation here.

Local jurisdictions have since strengthened emergency systems and

coordinated across city and county borders. Hospitals have bolstered

their capacity to handle a massive surge in patients, added

decontamination units and stocked up on medications, masks and

protective gear.

" The biggest terrorist is Mother Nature, " said A. Elting,

medical director of the District of Columbia Hospital Association.

The association has been negotiating for several years to use

downtown hotels for hospital overflow during a catastrophe. Such

institutions as town University Hospital have looked at other

alternatives, including dormitories. Both might be needed in a

pandemic.

The anthrax and sniper incidents could be instructive for other

reasons. Dan Hanfling, a director of emergency management and

disaster medicine for the Inova Health System, remembers the impact

each had on the community.

During the anthrax scare, more than 1,100 people crowded his

emergency room in barely two weeks because they thought they'd been

exposed to anthrax bacterium; they arrived with terror on their faces

and nasal swabs in little bags. During the sniper attacks, people

changed their daily lives, some radically, as the shootings continued

across the metropolitan area.

In both situations, the biggest contagion was fear, he said, and the

public's reaction is a worrisome portent of what might happen in a

pandemic. In December, Hanfling surveyed staff at Inova Fairfax about

a future terrorist attack by chemical, radiological or biological

means. Between a quarter and a third of respondents said they would

not report to work if contaminated patients were in the hospital.

To sustain a major medical response with many staff workers absent --

perhaps stricken themselves or caring for sick family members --

would be daunting. A pandemic flu, Hanfling said, " keeps on giving.

People get sick. They keep presenting. "

The government's scenarios have terrifying precedent locally. In

1918, just 10 days after announcing the arrival in several East Coast

cities of Spanish influenza -- " the strange prostrating malady which

ravaged the German army and later spread into France and England with

some discomforting effects on the civil population " -- The Washington

Post reported one local death from the disease and several cases of

sickness. But, it reassured, " quarantine measures have not been

considered necessary by [D.C.] health authorities and will not be put

into effect. "

Later that week, there was another casualty and dozens of new cases

among the District's Army camps and general population. By Oct. 1,

1918, the death toll hit 18 and the number of cases 176. By Oct. 4,

schools were closed, athletic activities halted, theaters and movie

houses ordered to stay dark and public meetings prohibited.

By Oct. 7, " despite the sweeping precautionary steps, " the region

surpassed 10,000 cases and church services and public funerals were

banned. Officials warned people to stay away from

Washington. " Hospitals So Crowded No Facilities are Left, " a headline

blared.

With such history as a guide, it should be no surprise that

land's Pandemic Influenza Preparedness Plan talks of the need to

inventory all personnel who might be available to serve, including

retired doctors and nurses and veterinarians. Or that local health

departments are asked to " identify facilities/resources with

sufficient refrigerated storage to serve as temporary morgues, if

necessary. "

land's plan -- one of the nation's first, dating to 1999 --

probably will be revised because of the federal document. Changes

will filter down to such regional health directors as Ulder J.

Tillman, who recently briefed the Montgomery County Council on a

pandemic's projected impact within its boundaries: thousands

hospitalized or dead. (As for disposal arrangements such as body

bags, " they've been discussed, yes, " Tillman said.)

Until the past several months, health and government officials,

infectious disease specialists, emergency planners and first

responders have talked, mainly among themselves. Many nonmedical

businesses such as malls or manufacturing plants, for whom

telecommuting is not an ption, and such entities as churches, where

shared Communion cups or signs of peace and maybe even services,

could be suspended, have not taken up the issue.

Slowly, the circle is widening. In August, administrators from every

school system in land gathered to consider the possibilities. The

program's advertisement suggested: " Imagine teachers and students too

ill to come to school. Imagine schools shutting down for weeks or

even months. "

Just two weeks ago, one of W. Maxwell's bosses stopped by his

office and asked what the company would do " if we have an avian flu

pandemic. " It got Maxwell, vice president of emergency preparedness

at Pepco Holdings Inc., thinking and strategizing. How would the

company get the different types of masks workers might need? What

other protective gear should the company's utilities stock?

" These are the things we have to wrestle with, in terms of utility

workers being first- or second-line responders, " Maxwell said. " This

is the number of people who could respond. Where can we go? Where

can't we go? "

At Goodwill of Greater Washington, the conversation among department

heads will be guided later this month by an infectious disease doctor

from Washington Hospital Center. " We interact with the public so

much . . . at our donation sites, our retail stores, our contract

sites, " Vice President n Hurley said.

And at the most basic community level the PTA of Chesterbrook

Elementary School in McLean will hold a forum next week on pandemic

flu. Greg , a retired Navy engineer who has a second-grader

and a third-grader there, proposed the topic because of his own

concerns. A few parents opposed him, saying they did not want to

create a panic. But compared the situation to the Y2K

computer fears in the months before 1999 gave way to 2000.

" In large part, Y2K didn't happen because people prepared for it, " he

said.

Judy English, who heads the infection control branch at the National

Naval Medical Center in Bethesda, applauds such proactive

steps. " People should be talking about this in their PTAs, their day

care. " Ditto " hotels and restaurants and bars and jazz clubs. " Unlike

in 1918, they have advance warning and time to prepare.

" It should be on everyone's agenda, " she said.

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