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Re: Medical care, under dire circumstances
It is important for all of us to understand that during a severe pandemic, the centralized medical model will fail. There will be no ventilators. No hospital beds, not enough nurses or doctors or the legions that back them up and make the miracles they produce day in and day out in the hospital possible.
Below is a chapter on this from The Coming Pandemic Catastrophe.
By Grattan Woodson, MD
Chapter 7: The Collapse of Health Care Services
The vulnerability of the modern hospital-based health care system
Modern health care systems throughout the developed world have adopted a centralized model for providing medical services. The well-equipped set-up and staffed hospital bed plays a key role in this delivery system. A defining characteristic of these systems is the concentration of doctors, nurses, allied health professionals, and an array of specialized high-tech equipment, supplies, and armies of non-medical personnel resulting in modern medical centers. These centers have revolutionized the care of patients in many areas of medicine and surgery. The centralized model on which they are based is highly dependent on advanced technology and has the potential to focus intense services and procedures on a small number of patients at a high cost. In the United States, there are approximately one million set-up and staffed hospital beds and 100,000 respiratory ventilators.
A set-up and staffed hospital bed includes not just an available bed but also sufficient doctors, nurses, medical supplies, pharmacists, drugs, lab and radiology technicians, IT operators, physical plant engineers, janitorial staff, security, and administrators to service the patient in the bed. If any one of these inputs is lost, the centralized model breaks down, ceasing to function. During all three pandemics that occurred in the twentieth century, clinical attack rates in health professionals were as much as twice the rate seen in other groups. This single factor alone will significantly reduce the supply of set-up and staffed hospital beds. The miracle of advanced medical care seen daily in the modern hospital is entirely dependent upon having all the resources necessary available at the same time. The medical outcomes we realize today in these facilities would not be the same in patients treated in other settings, including the inadequately staffed and supplied low-tech temporary hospitals proposed by some public health officials to manage the excess of patients expected during the pandemic.
Over the past two decades, hospitals have reduced capacity, responding to economic pressure from the government and insurance companies to become more cost effective. In doing so, though, they have virtually eliminated their surge capacity, or the spare set-up and staffed hospital beds available for use in an emergency. Capacity utilization in the average hospital today is approximately seventy-five percent, and it is common today for all Intensive Care Unit (ICU) beds to be full.68 This is a regular event in many hospitals during the routine flu season, when all the critical care beds and available ventilators in many U.S. cities are fully occupied with flu patients for many weeks each winter.
U.S. hospitals will remain functional for a while
Most likely, the first victims of a bird flu pandemic in the United States will get excellent treatment within our acute care hospital system. However, given hospital capacity constraints, the assumption of the DHHS PIP that American hospitals will have excess capacity to accommodate an additional ten million seriously ill flu patients lacks credibility. The Congressional Budget Office studied this issue and determined that neither the Veteran?s Administration hospital system nor the U.S. military has the ability to augment the capacity of the private hospital system in any meaningful way.68 An increase in admissions to hospitals of a large magnitude would quickly absorb every available set-up and staffed bed. The DHHS PIP projects a 288% increase in the need for critical care ICU beds and services.11 Under these circumstances, patients in need of ICU services or ventilators would be unlikely to obtain them.
Modeling of this problem suggests that the U.S. hospital system is likely to be able to accommodate approximately one in three of the critically ill influenza patients the DHHS predicts will require hospitalization. This alternative estimate, detailed in the prior chapter on pandemic illness and death, indicates that two in three severely ill patients are going to have to find treatment elsewhere, with their home being the most likely place.
Flu victims will compete for scarce hospital beds with routine patients
One disturbing dilemma likely to evolve during the early days of a pandemic, irrespective of its severity, will be the competition for available hospital beds between critically ill non-influenza and influenza patients. At some point, many hospitals are likely to have a significant number of beds occupied by critically ill patients of both types with little hope for survival. There will be no room for new patients who are equally ill but whose chance of survival is good only if they have access to the benefits of hospitalization in a set-up and staffed bed. This situation will present us with heart-wrenching ethical dilemmas. If the patient with the poor prognosis keeps the bed, then both patients die as a consequence of their illnesses.71 If the patient with the better prognosis displaces the patient with the poor prognosis, then only one person will die but the one who dies will do so because of an act of man, a choice, rather than a result of nature. This is currently not the standard of care in the United States since normally there are an adequate number of set-up and staffed hospital beds to accommodate both patients. Under these circumstances, there is little doubt that professional staff and hospital administrators tasked with managing these challenges during the pandemic are likely to be subjected to both malpractice suits and possibly criminal prosecution.
In an attempt to avoid this nightmare, hospitals are likely to use a much more aggressive triage system during admission than currently in place. This solution is likely to run afoul of malpractice concerns, federal anti-dumping laws, and has the potential for considerable patient and family anger that is likely to result in violence. These issues and the usual criteria for removing patients from life-support treatments will require stringent review in light of the drastically altered circumstances of a severe pandemic. To the extent that these practices and methods have been codified by state legislatures or in the courts, a timely review and amendment of them may be impossible. This legal situation will introduce new levels of complexity to the problem, and these unprecedented predicaments will not have easy or comfortable solutions for anyone involved.
The decentralized health care model of the past
Before 1960, health care was characterized by its decentralized nature. In a decentralized health care system, the doctor or nurse visited patients in their homes where the patients? families provided most of the direct care. Visits to the hospital were rare and only undertaken when surgery was required or the patient was extremely ill. The centralized model is highly dependent on advanced technology, while the decentralized model primarily utilizes low technology practices that are appropriate for the setting. The centralized model has the potential to focus very intense services and procedures on a small number of patients but at a very high cost, while the decentralized model is capable of delivering low intensity care to an almost unlimited number of patients at a relatively low cost.
Home medical care during the pandemic
Once the pandemic settles in, the hospitals will be full, including waiting rooms, classrooms, and hallways. The medical staff will be sick themselves; some will be dead. The hospital will be running low on critical supplies with shortages of everything from gloves to body bags. At some point, a number of hospitals will simply be forced to close, as their dysfunctional state becomes more of a risk to the lives of the patients than a benefit. So, in my opinion, it would be unwise to depend on the centralized health care system to be there for long during a severe bird flu pandemic.
Under these conditions, many ordinary people will find themselves responsible for providing medical care to critically ill loved ones and friends in the home setting. Under usual circumstances patients this sick would be hospitalized, but what if this were not an option during the pandemic? An alternative to hospital care is good home care. This non-conventional treatment option has the virtue of being low-tech and flexible enough to withstand the same strains and stresses that will topple the conventional centralized health care model.
A decentralized delivery system, by its very nature, is much more resistant to disruption or breakdown under pandemic conditions. It does not use high-tech resources nor is it wholly dependent on the commercial or civil infrastructure to remain functional. The home care model is also able to adapt rapidly to changing conditions, such as a loss of electric and water utility service and continue to operate, while the centralized model is much more rigid and slow to adapt. The enormous capacity of a home-based treatment system can easily encompass the entire population of people expected to become ill with bird flu rather than just the small percentage the centralized model can serve well.
In The Bird Flu Manual I have laid out a detailed strategy for exactly how ordinary people with others that live nearby in their apartment buildings, condominiums or neighborhood can work together to provide good medical care to their sick family members and friends in the home setting. The book also provides advice to health care professionals left adrift by the closure or dysfunction of their conventional workplace on how they can participate in a neighborhood health care network in response to the pandemic.
A modified version of how ordinary people can provide good home care to their families and friends can be downloaded for free from www.BirdFluManual.com. The major difference between material provided in The Bird Flu Manual and the one in the online booklet is the assumption used in the Manual that consumers will have access to a select few prescription drugs as well as a number of over-the-counter non-prescription drugs useful in the management of influenza. The 17-page booklet, Good Home Influenza Care makes use of only over-the-counter non-prescription drugs. The home influenza care sections in the Manual are also somewhat more detailed than those found in the booklet.
While your doctor may deny your request for the prescriptions recommended in the Manual at this time, as the pandemic approaches and becomes increasingly likely, most doctors who were hesitant in the past are likely to see the need for their patients to stockpile both their regular medications and a select few prescription drugs useful for influenza treatment.
I sincerely hope that your hospital remains functional during the pandemic and is able to provide good care for the critically ill in your community. If not, the Manual or the Good Home Influenza Treatment booklet will provide consumers with guidance on how to provide the best possible home care to those with mild, moderate, and severe influenza.
Pharmaceutical and medical supply risks
Pharmaceutical production, inventories, and distribution
Today all pharmaceutical companies, wholesalers, and retail pharmacies have implemented the just-in-time method to control inventory.52,69 This management technique keeps inventories lean, freeing up operating capital for other purposes. A demand spike, especially if prolonged, for any drug will result in a short-term shortage until the manufacturer can scale up production sufficiently. Most drug makers can increase production quantities without the need to add equipment or staff. There is an upper limit that can?t be exceeded without sacrificing quality. To meet demand beyond this level requires the addition of manufacturing facilities and staff as was done in 2005 by Roche to meet the huge increase in demand by countries seeking to add Tamiflu? to their national strategic stockpiles.
During an influenza pandemic, the vast increase in demand for both OTC and prescription drugs useful in the management of flu will lead to prolonged shortages in a large number of these products. This includes OTC drugs for treatment of pain and fever like aspirin, acetaminophen, ibuprofen, and naproxen, cough syrup employing dextromethorphan, antihistamines like diphenhydramine, and decongestants like pseudoephedrine. These products will fly off the drugstore shelves faster than they can be replaced. Manufacturers will be operating at full capacity to meet this demand but at some point, flu-related absenteeism or a lack of raw materials will affect their ability to produce or deliver their products.
These same dynamics apply to prescription drugs, especially those useful in the treatment of influenza, its symptoms and complications. Obviously the antivirals Tamiflu? and Relenza? will remain in continual short supply beginning even before the actual start of the pandemic and extending during the entire pandemic period. Narcotic-containing cough suppressants and pain relievers, antiemetics in the phenothiazine class, prescription antihistamines, and oral and IV antibiotics will all be in continuous short supply or temporarily unavailable.
Disturbingly, few know that more than eighty percent of the raw materials for drug manufacture and in some cases the finished pharmaceutical used in the United States are imported, mainly from the EU and Asia.69 Disruptions in collection and processing these raw materials in the country of origin, their diversion to regional manufacturers or distributors to meet increased local demand, or interruption in the transportation or distribution of these materials to or within the United States are all easily predicable consequences of a severe pandemic. This can only aggravate shortages of the drugs that will already exist in the United States due to significantly increased demand.
Risky business: Our dependence on disposable medical supplies
Shortages of a wide variety of disposable medical supplies will also plague the delivery of quality health care and affect health care worker safety. The N-95 respirator mask has gotten most attention in this regard but this is just one of many items required for proper infection control within the hospital setting. The supply of everything from latex gloves, paper gowns, shoe covers, syringes, hypodermic needles, sterile saline for IV drug preparation, to the polyethylene IV tubing and intravenous catheters used to administer drugs and fluids will become terribly scarce very quickly after the onset of the pandemic. After initial shortages develop, intermittent re-supply can be expected to occur in the beginning months of the pandemic but the deliveries will never meet the increased demand. There will not be enough time to add manufacturing capacity even if this was warranted from a long-term business prospective, which it is not because manufacturers see that the increased demand will last only as long as the pandemic.
Manufacturers of disposable medical equipment and supplies will be able to ramp up production in the same way as pharmaceutical companies, but only so long as their employees remain healthy and their raw material suppliers can continue to deliver. In the event of a severe pandemic, worldwide influenza-related conditions are likely to reduce or even halt production. These conditions include absenteeism of the plant workforce, inadequate supplies of raw materials, and loss of critical inputs required to operate the plant, such as reliable electric, natural gas or water utility service. Civil disorder or the threat thereof could also result in plant closure.
If these conditions develop it is easy to predict they will be extremely disruptive to the operation of the health care economy, including provision of direct patient care and those responsible for the manufacture of drugs and medical supplies.
Absentee first responders and health care workers
There is growing uncertainty that medical first responders and health care workers will remain at their posts during the pandemic.45
First responders
The lessons learned by first responders to the 9-11 tragedies in New York City remain fresh in the minds of their colleagues everywhere. The collapse of the World Trade Center buildings killed hundreds of first responders, but many more who survived have become disabled due to inhaling the toxic air at the disaster site during the rescue attempt and ensuing weeks spent recovering the deceased?s remains. The U.S. EPA made public statements declaring the air within the vicinity of the disaster was safe. Subsequently we have learned that these declarations were false. The medical first responders and rescue crews believed them and remained at work for weeks within this toxic environment.
Some are now disabled with pulmonary fibrosis and other respiratory disorders and are no longer able to work. Others have been fired, with some being abandoned by the authorities. The front of our health care system in every city across the United States is composed of these same first responders. Given this experience, one wonders what their reaction will be when asked to risk their health during a severe influenza pandemic?
Health care workers
The health care system needs all its workers to operate properly, not just the allied health technicians and medical professionals. In hospitals, this includes the clerical, janitorial, IT staff, facilities maintenance engineers, nursing aids, kitchen, and security staff who do all the heavy lifting and clerical work needed to keep the facility open. Despite the fact that these health care workers are some of the lowest paid in the economy as a whole, no hospital could remain functional without them.
The sacrifice of those who serve
Hospital workers, medical first responders, and the ancillary and professional medical staff will by virtue of their work be repeatedly exposed to the pandemic influenza virus irrespective of the precautions taken. They will carry the virus home with them, exposing their families and friends. As was seen during the 1918 and 1957 pandemics, people in these professions are predicted to have some of the highest clinical attack rates and case fatality rates seen during the pandemic.
Most health care workers are presently unaware of this increased health risk they will be exposed to despite it being well known within the public health community. This fact, and because it is in the public interest that health care workers and first responders live to provide care for others, is why these groups are included in the CDC?s priority list for access to scarce antiviral drugs and vaccines during the pandemic. Unfortunately, the same protection does not extend to the families of health care workers or first responders or to the legions of non-professional hospital staff. No doubt, as the pandemic approaches and certainly once it arrives, these facts will become better known.
Health care workers and medical first responders are among some of the most dedicated people in our society, and many will remain at their posts irrespective of the risk, but not all. It is easy to see that health care workers in every category will be significantly reduced due to the combined effects of illness and death due to influenza and to those who resign their positions or simply fail to return to work due to concern about becoming ill themselves and/or infecting their family members.71 While volunteers can help keep the hospital clean, prepare food, and bath patients, when it comes to highly technical roles in the laboratory, respiratory, radiology, or ICU there will be no relief.
As soon as physicians, nurses, and health care administrators come to a more realistic appraisal of the conditions that could emerge during a severe pandemic, the sooner they can begin planning appropriately for it.
Preparing for this pandemic makes a lot of sense despite the fact that most hospitals and few doctors have done very little so far. Those that plan now will be in a much better position to weather the storm when it comes and recover more quickly once it is over.
This chapter was written with the coming H5N1 pandemic in mind where I project a CAR of 50% and a CFR of 8% in the developed nations and 12.5% in the underdeveloped ones.
What we will see as this long wave progresses across the world is not currently known. What is clear though is how vulnerable our centralized model is to a spike in demand, especially a prolonged one. It is simply unable to accommodate it.
The only answer for individuals interested in their families surviving a severe influenza pandemic under these circumstances is to prepare to provide good home care to their family and friends. You must not count on your doctor being available nor the hospital. While one or both might be, this is not something that the prudent should bet their life on.
GW
It is important for all of us to understand that during a severe pandemic, the centralized medical model will fail. There will be no ventilators. No hospital beds, not enough nurses or doctors or the legions that back them up and make the miracles they produce day in and day out in the hospital possible.
Below is a chapter on this from The Coming Pandemic Catastrophe.
By Grattan Woodson, MD
Chapter 7: The Collapse of Health Care Services
The vulnerability of the modern hospital-based health care system
Modern health care systems throughout the developed world have adopted a centralized model for providing medical services. The well-equipped set-up and staffed hospital bed plays a key role in this delivery system. A defining characteristic of these systems is the concentration of doctors, nurses, allied health professionals, and an array of specialized high-tech equipment, supplies, and armies of non-medical personnel resulting in modern medical centers. These centers have revolutionized the care of patients in many areas of medicine and surgery. The centralized model on which they are based is highly dependent on advanced technology and has the potential to focus intense services and procedures on a small number of patients at a high cost. In the United States, there are approximately one million set-up and staffed hospital beds and 100,000 respiratory ventilators.
A set-up and staffed hospital bed includes not just an available bed but also sufficient doctors, nurses, medical supplies, pharmacists, drugs, lab and radiology technicians, IT operators, physical plant engineers, janitorial staff, security, and administrators to service the patient in the bed. If any one of these inputs is lost, the centralized model breaks down, ceasing to function. During all three pandemics that occurred in the twentieth century, clinical attack rates in health professionals were as much as twice the rate seen in other groups. This single factor alone will significantly reduce the supply of set-up and staffed hospital beds. The miracle of advanced medical care seen daily in the modern hospital is entirely dependent upon having all the resources necessary available at the same time. The medical outcomes we realize today in these facilities would not be the same in patients treated in other settings, including the inadequately staffed and supplied low-tech temporary hospitals proposed by some public health officials to manage the excess of patients expected during the pandemic.
Over the past two decades, hospitals have reduced capacity, responding to economic pressure from the government and insurance companies to become more cost effective. In doing so, though, they have virtually eliminated their surge capacity, or the spare set-up and staffed hospital beds available for use in an emergency. Capacity utilization in the average hospital today is approximately seventy-five percent, and it is common today for all Intensive Care Unit (ICU) beds to be full.68 This is a regular event in many hospitals during the routine flu season, when all the critical care beds and available ventilators in many U.S. cities are fully occupied with flu patients for many weeks each winter.
U.S. hospitals will remain functional for a while
Most likely, the first victims of a bird flu pandemic in the United States will get excellent treatment within our acute care hospital system. However, given hospital capacity constraints, the assumption of the DHHS PIP that American hospitals will have excess capacity to accommodate an additional ten million seriously ill flu patients lacks credibility. The Congressional Budget Office studied this issue and determined that neither the Veteran?s Administration hospital system nor the U.S. military has the ability to augment the capacity of the private hospital system in any meaningful way.68 An increase in admissions to hospitals of a large magnitude would quickly absorb every available set-up and staffed bed. The DHHS PIP projects a 288% increase in the need for critical care ICU beds and services.11 Under these circumstances, patients in need of ICU services or ventilators would be unlikely to obtain them.
Modeling of this problem suggests that the U.S. hospital system is likely to be able to accommodate approximately one in three of the critically ill influenza patients the DHHS predicts will require hospitalization. This alternative estimate, detailed in the prior chapter on pandemic illness and death, indicates that two in three severely ill patients are going to have to find treatment elsewhere, with their home being the most likely place.
Flu victims will compete for scarce hospital beds with routine patients
One disturbing dilemma likely to evolve during the early days of a pandemic, irrespective of its severity, will be the competition for available hospital beds between critically ill non-influenza and influenza patients. At some point, many hospitals are likely to have a significant number of beds occupied by critically ill patients of both types with little hope for survival. There will be no room for new patients who are equally ill but whose chance of survival is good only if they have access to the benefits of hospitalization in a set-up and staffed bed. This situation will present us with heart-wrenching ethical dilemmas. If the patient with the poor prognosis keeps the bed, then both patients die as a consequence of their illnesses.71 If the patient with the better prognosis displaces the patient with the poor prognosis, then only one person will die but the one who dies will do so because of an act of man, a choice, rather than a result of nature. This is currently not the standard of care in the United States since normally there are an adequate number of set-up and staffed hospital beds to accommodate both patients. Under these circumstances, there is little doubt that professional staff and hospital administrators tasked with managing these challenges during the pandemic are likely to be subjected to both malpractice suits and possibly criminal prosecution.
In an attempt to avoid this nightmare, hospitals are likely to use a much more aggressive triage system during admission than currently in place. This solution is likely to run afoul of malpractice concerns, federal anti-dumping laws, and has the potential for considerable patient and family anger that is likely to result in violence. These issues and the usual criteria for removing patients from life-support treatments will require stringent review in light of the drastically altered circumstances of a severe pandemic. To the extent that these practices and methods have been codified by state legislatures or in the courts, a timely review and amendment of them may be impossible. This legal situation will introduce new levels of complexity to the problem, and these unprecedented predicaments will not have easy or comfortable solutions for anyone involved.
The decentralized health care model of the past
Before 1960, health care was characterized by its decentralized nature. In a decentralized health care system, the doctor or nurse visited patients in their homes where the patients? families provided most of the direct care. Visits to the hospital were rare and only undertaken when surgery was required or the patient was extremely ill. The centralized model is highly dependent on advanced technology, while the decentralized model primarily utilizes low technology practices that are appropriate for the setting. The centralized model has the potential to focus very intense services and procedures on a small number of patients but at a very high cost, while the decentralized model is capable of delivering low intensity care to an almost unlimited number of patients at a relatively low cost.
Home medical care during the pandemic
Once the pandemic settles in, the hospitals will be full, including waiting rooms, classrooms, and hallways. The medical staff will be sick themselves; some will be dead. The hospital will be running low on critical supplies with shortages of everything from gloves to body bags. At some point, a number of hospitals will simply be forced to close, as their dysfunctional state becomes more of a risk to the lives of the patients than a benefit. So, in my opinion, it would be unwise to depend on the centralized health care system to be there for long during a severe bird flu pandemic.
Under these conditions, many ordinary people will find themselves responsible for providing medical care to critically ill loved ones and friends in the home setting. Under usual circumstances patients this sick would be hospitalized, but what if this were not an option during the pandemic? An alternative to hospital care is good home care. This non-conventional treatment option has the virtue of being low-tech and flexible enough to withstand the same strains and stresses that will topple the conventional centralized health care model.
A decentralized delivery system, by its very nature, is much more resistant to disruption or breakdown under pandemic conditions. It does not use high-tech resources nor is it wholly dependent on the commercial or civil infrastructure to remain functional. The home care model is also able to adapt rapidly to changing conditions, such as a loss of electric and water utility service and continue to operate, while the centralized model is much more rigid and slow to adapt. The enormous capacity of a home-based treatment system can easily encompass the entire population of people expected to become ill with bird flu rather than just the small percentage the centralized model can serve well.
In The Bird Flu Manual I have laid out a detailed strategy for exactly how ordinary people with others that live nearby in their apartment buildings, condominiums or neighborhood can work together to provide good medical care to their sick family members and friends in the home setting. The book also provides advice to health care professionals left adrift by the closure or dysfunction of their conventional workplace on how they can participate in a neighborhood health care network in response to the pandemic.
A modified version of how ordinary people can provide good home care to their families and friends can be downloaded for free from www.BirdFluManual.com. The major difference between material provided in The Bird Flu Manual and the one in the online booklet is the assumption used in the Manual that consumers will have access to a select few prescription drugs as well as a number of over-the-counter non-prescription drugs useful in the management of influenza. The 17-page booklet, Good Home Influenza Care makes use of only over-the-counter non-prescription drugs. The home influenza care sections in the Manual are also somewhat more detailed than those found in the booklet.
While your doctor may deny your request for the prescriptions recommended in the Manual at this time, as the pandemic approaches and becomes increasingly likely, most doctors who were hesitant in the past are likely to see the need for their patients to stockpile both their regular medications and a select few prescription drugs useful for influenza treatment.
I sincerely hope that your hospital remains functional during the pandemic and is able to provide good care for the critically ill in your community. If not, the Manual or the Good Home Influenza Treatment booklet will provide consumers with guidance on how to provide the best possible home care to those with mild, moderate, and severe influenza.
Pharmaceutical and medical supply risks
Pharmaceutical production, inventories, and distribution
Today all pharmaceutical companies, wholesalers, and retail pharmacies have implemented the just-in-time method to control inventory.52,69 This management technique keeps inventories lean, freeing up operating capital for other purposes. A demand spike, especially if prolonged, for any drug will result in a short-term shortage until the manufacturer can scale up production sufficiently. Most drug makers can increase production quantities without the need to add equipment or staff. There is an upper limit that can?t be exceeded without sacrificing quality. To meet demand beyond this level requires the addition of manufacturing facilities and staff as was done in 2005 by Roche to meet the huge increase in demand by countries seeking to add Tamiflu? to their national strategic stockpiles.
During an influenza pandemic, the vast increase in demand for both OTC and prescription drugs useful in the management of flu will lead to prolonged shortages in a large number of these products. This includes OTC drugs for treatment of pain and fever like aspirin, acetaminophen, ibuprofen, and naproxen, cough syrup employing dextromethorphan, antihistamines like diphenhydramine, and decongestants like pseudoephedrine. These products will fly off the drugstore shelves faster than they can be replaced. Manufacturers will be operating at full capacity to meet this demand but at some point, flu-related absenteeism or a lack of raw materials will affect their ability to produce or deliver their products.
These same dynamics apply to prescription drugs, especially those useful in the treatment of influenza, its symptoms and complications. Obviously the antivirals Tamiflu? and Relenza? will remain in continual short supply beginning even before the actual start of the pandemic and extending during the entire pandemic period. Narcotic-containing cough suppressants and pain relievers, antiemetics in the phenothiazine class, prescription antihistamines, and oral and IV antibiotics will all be in continuous short supply or temporarily unavailable.
Disturbingly, few know that more than eighty percent of the raw materials for drug manufacture and in some cases the finished pharmaceutical used in the United States are imported, mainly from the EU and Asia.69 Disruptions in collection and processing these raw materials in the country of origin, their diversion to regional manufacturers or distributors to meet increased local demand, or interruption in the transportation or distribution of these materials to or within the United States are all easily predicable consequences of a severe pandemic. This can only aggravate shortages of the drugs that will already exist in the United States due to significantly increased demand.
Risky business: Our dependence on disposable medical supplies
Shortages of a wide variety of disposable medical supplies will also plague the delivery of quality health care and affect health care worker safety. The N-95 respirator mask has gotten most attention in this regard but this is just one of many items required for proper infection control within the hospital setting. The supply of everything from latex gloves, paper gowns, shoe covers, syringes, hypodermic needles, sterile saline for IV drug preparation, to the polyethylene IV tubing and intravenous catheters used to administer drugs and fluids will become terribly scarce very quickly after the onset of the pandemic. After initial shortages develop, intermittent re-supply can be expected to occur in the beginning months of the pandemic but the deliveries will never meet the increased demand. There will not be enough time to add manufacturing capacity even if this was warranted from a long-term business prospective, which it is not because manufacturers see that the increased demand will last only as long as the pandemic.
Manufacturers of disposable medical equipment and supplies will be able to ramp up production in the same way as pharmaceutical companies, but only so long as their employees remain healthy and their raw material suppliers can continue to deliver. In the event of a severe pandemic, worldwide influenza-related conditions are likely to reduce or even halt production. These conditions include absenteeism of the plant workforce, inadequate supplies of raw materials, and loss of critical inputs required to operate the plant, such as reliable electric, natural gas or water utility service. Civil disorder or the threat thereof could also result in plant closure.
If these conditions develop it is easy to predict they will be extremely disruptive to the operation of the health care economy, including provision of direct patient care and those responsible for the manufacture of drugs and medical supplies.
Absentee first responders and health care workers
There is growing uncertainty that medical first responders and health care workers will remain at their posts during the pandemic.45
First responders
The lessons learned by first responders to the 9-11 tragedies in New York City remain fresh in the minds of their colleagues everywhere. The collapse of the World Trade Center buildings killed hundreds of first responders, but many more who survived have become disabled due to inhaling the toxic air at the disaster site during the rescue attempt and ensuing weeks spent recovering the deceased?s remains. The U.S. EPA made public statements declaring the air within the vicinity of the disaster was safe. Subsequently we have learned that these declarations were false. The medical first responders and rescue crews believed them and remained at work for weeks within this toxic environment.
Some are now disabled with pulmonary fibrosis and other respiratory disorders and are no longer able to work. Others have been fired, with some being abandoned by the authorities. The front of our health care system in every city across the United States is composed of these same first responders. Given this experience, one wonders what their reaction will be when asked to risk their health during a severe influenza pandemic?
Health care workers
The health care system needs all its workers to operate properly, not just the allied health technicians and medical professionals. In hospitals, this includes the clerical, janitorial, IT staff, facilities maintenance engineers, nursing aids, kitchen, and security staff who do all the heavy lifting and clerical work needed to keep the facility open. Despite the fact that these health care workers are some of the lowest paid in the economy as a whole, no hospital could remain functional without them.
The sacrifice of those who serve
Hospital workers, medical first responders, and the ancillary and professional medical staff will by virtue of their work be repeatedly exposed to the pandemic influenza virus irrespective of the precautions taken. They will carry the virus home with them, exposing their families and friends. As was seen during the 1918 and 1957 pandemics, people in these professions are predicted to have some of the highest clinical attack rates and case fatality rates seen during the pandemic.
Most health care workers are presently unaware of this increased health risk they will be exposed to despite it being well known within the public health community. This fact, and because it is in the public interest that health care workers and first responders live to provide care for others, is why these groups are included in the CDC?s priority list for access to scarce antiviral drugs and vaccines during the pandemic. Unfortunately, the same protection does not extend to the families of health care workers or first responders or to the legions of non-professional hospital staff. No doubt, as the pandemic approaches and certainly once it arrives, these facts will become better known.
Health care workers and medical first responders are among some of the most dedicated people in our society, and many will remain at their posts irrespective of the risk, but not all. It is easy to see that health care workers in every category will be significantly reduced due to the combined effects of illness and death due to influenza and to those who resign their positions or simply fail to return to work due to concern about becoming ill themselves and/or infecting their family members.71 While volunteers can help keep the hospital clean, prepare food, and bath patients, when it comes to highly technical roles in the laboratory, respiratory, radiology, or ICU there will be no relief.
As soon as physicians, nurses, and health care administrators come to a more realistic appraisal of the conditions that could emerge during a severe pandemic, the sooner they can begin planning appropriately for it.
Preparing for this pandemic makes a lot of sense despite the fact that most hospitals and few doctors have done very little so far. Those that plan now will be in a much better position to weather the storm when it comes and recover more quickly once it is over.
This chapter was written with the coming H5N1 pandemic in mind where I project a CAR of 50% and a CFR of 8% in the developed nations and 12.5% in the underdeveloped ones.
What we will see as this long wave progresses across the world is not currently known. What is clear though is how vulnerable our centralized model is to a spike in demand, especially a prolonged one. It is simply unable to accommodate it.
The only answer for individuals interested in their families surviving a severe influenza pandemic under these circumstances is to prepare to provide good home care to their family and friends. You must not count on your doctor being available nor the hospital. While one or both might be, this is not something that the prudent should bet their life on.
GW
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