Challenges for Communities
Many pandemic response measures are organized through our own local communities. Will schools close due to too many sick students? Will hospitals be able to cope with a sudden surge in patients? Will local police be prepared to maintain order should people get anxious or desperate? These are, ultimately, local questions that need local answers. While many national authorities, from the CDC to the National Sherriff’s Association, provide recommendations and guidelines on how to prepare for and respond to a pandemic, a lot of planning and final decision making is left to local authorities and community members.
How ready is your community to deal with an influenza pandemic, whether mild or severe? This section looks at some of the major challenges communities face when building resilience against a major disaster.
Coming together
How many children in your community depend on free school lunches? Which large buildings in your town could be used for makeshift hospitals? Who will enforce the isolation of sick people? Who decides when large gatherings will be cancelled?
These are the questions many towns and cities throughout the United States have tried to answer in recent years as they have come together to discuss how to prepare for an influenza pandemic. The first challenge for any community is just that: bringing everyone to the table, from health and law enforcement officials to local hospital administrators and local business leaders, to identify the strengths and weaknesses of the community and to determine what is needed to draft a reasonable and sensible response plan.
Community mitigation options
One set of tools in the community response box includes non-pharmaceutical interventions. The CDC recommends a number of these measures, especially early on, to slow the spread of the disease; delay and reduce the peak number of cases; and buy time for a vaccine to be prepared and for medical systems to plan for a surge in patients.
Briefly, these
non-pharmaceutical interventions include:
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Isolation and treatment at home or in healthcare settings. |
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Voluntary home quarantine of sick people. |
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Dismissal of students from school and related activities. |
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Social distancing measures, such as canceling large public gatherings or working from home. |
On
Flu.gov, you can find the U.S Pandemic Severity Index, which uses the case fatality ratio as a trigger for increasing non-pharmaceutical interventions. (Learn more about the case fatality ratio in
Scientific Challenges.)
Non-pharmaceutical interventions pose two challenges for communities:
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They are potentially very disruptive and, depending on the severity of the pandemic, may or may not be accepted by the community. For example, when the novel H1N1 influenza outbreak in spring 2009 caused schools in affected areas to close, many parents openly questioned the decision, leading to a public debate. (Also see the section on school closures below.) |
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Many of these interventions have not yet been tested during a severe outbreak. Even when they have been, there is limited research that explains their effects or reveals unintended consequences. (One such study looked at the psychological impact of quarantine during the SARS epidemic in Toronto.) Exactly when and how these non-pharmaceutical interventions are most effective will be determined as they are introduced in various circumstances. |
School Closures I: Lessons from the early 2009 H1N1 pandemic
When the novel strain of H1N1 influenza first appeared in the United States in spring 2009, individual schools and school districts responded to a single case or cluster of cases by closing for as briefly as one day or as long as two weeks. At the peak of school closures, May 5, 2009, 726 U.S. schools were closed, affecting 468,282 students, according to the CDC.
After reviewing what did and did not work, the CDC in August 2009 issued
guidance for school responses to influenza during the 2009-10 school year, which advises closing schools only under conditions of increased severity. In the spring 2009 experience, the potential benefits of preemptively dismissing students from school were often outweighed by the negative consequences, including students being left home alone; health workers missing shifts when they stayed home with their children; students missing meals; and the interruption of students’ education. The CDC puts most of the decision making for school closures at the local level.
A
recent paper reviewing school closings in the 1918-19 pandemic revealed that school dismissal tends to be used as a measure to control infection after a contagious disease has spread through a community, rather than as a preemptive public health measure. Some innovative correspondence courses helped sustain education when the flu pandemic struck 91 years ago. Today, schools may turn to Internet-based instruction if widespread school closings are necessary.
The researchers also found that preexisting political and social tensions, unclear lines of authority, and poor communication can lead to less successful outcomes in controlling a pandemic.
School Closures II: A reality check on planning and consequences
Note: The following is an excerpt from a talk given by Betty Kirby at the December 2006 Nieman Foundation conference “The Next Big Health Crisis—And How to Cover It.” We are including it because school response measures in 2009 are based in part on the Department of Education pandemic plan Kirby discusses, and her questions remain as relevant today as they were in 2006.
Betty Kirby, Assistant Professor, Department of Educational Administration and Community Leadership, Central Michigan University
| “The U.S. Department of Education released its pandemic plan for K-12 schools. It was two pages in length and was meant to go along with the disaster plans that schools have. I was somewhat disappointed when I saw the checklist with four areas for schools to take care of: planning and coordination; continuity of student learning and core operations; infection control policies; and communications planning. Schools were asked to check off whether they had completed these tasks already, or were in progress or, as I suspect in most cases, not started. |
| What we should be thinking about and talking about is the interruption of school and what happens to children, parents and teachers. We should be talking to people who experienced Hurricane Katrina to find out what that was like for children who were not in school for a long period of time and who switched to different schools and whose families were reorganized. We should be talking, too, about maybe preparing our students with some conflict resolution curriculum, because it seems to me that they may very well be dealing with those types of issues in their home, and that might be more valuable than geometry. |
| How many children use the federal school breakfast program? Where do these poor children live? They live everywhere. They live in our rural areas. They live in our urban areas. What percent of hungry Americans are children? Take a look: 36.4 percent are children. So the schools have an important place in terms of providing nutrition. And when we get down to the heart of the matter, when we're talking about preparation for pandemic flu, it's the children. We need to take a look at who is there for them 180 days plus of the year. Kids know that they can go to their teachers. They trust them, and if teachers aren't prepared, they're not going to be able to help. Schools should be serving on the frontline. They're one of the best ways to get information out to the community. They can help us maintain public confidence. |
| For many students, school is the family. It provides safety, security and stability. For some students, home is a dangerous and a volatile place, and we're worried about kids who are going to have to go home for that amount of time. Finally, I think it is insulting to educators that we have not put them in a more prominent role in preparing for this. Teachers have the potential to serve as the models for resiliency and the harboring of hope for our children. In the beginning they will be there to quell their fears, and in the end they will be there to pick up the pieces.” |
Hospitals and emergency departments
In a pandemic, hospitals and emergency departments will have to contend with a surge of cases that they may not have the capacity or personnel to handle. Hospitals are running with little excess overhead. Emergency departments are overcrowded and often lack necessary specialists. Emergency systems are ill prepared to handle a major disaster. And neither is typically well equipped to handle pediatric care, an important point as children are the most highly infected group in the 2009 H1N1 pandemic (as of October 2009).
Medical care is highly labor intensive. Unlike in other businesses where plans may be in place to encourage telework or social distancing, healthcare workers can not work from home. They need special protections to be able to fulfill their professional responsibilities. Additionally, the healthcare workforce may be depleted by exposure to infectious disease, fears of illness, or the need to care for sick family members.
Healthcare facilities are also vulnerable to the nation’s just-in-time supply chain, which could experience delays in providing goods and services. They therefore may need to stockpile personal protective equipment (PPE) and other supplies. Food services for patients and staff also may be affected by a shortage in workers and disruptions in the supply chain.
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Vulnerable populations
Insurance issues, including lack of health insurance, may deter people from getting vaccinated. Issues about public and private insurers include fees, co-pays, out-of-network fees and the variable cost of vaccines.
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Also, the 2009 H1N1 flu appears to have a disproportionate effect on racial and ethnic minorities, perhaps from overcrowding in urban areas, underlying chronic conditions, or other susceptibilities. In addition, minority groups have lower rates of seasonal flu vaccination and pneumococcal vaccination for adults age 65 and over.
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The burden on local law enforcement
The image of a modern city struggling to survive in the midst of a catastrophe is indelibly etched in the American memory: Hurricane Katrina washed away not just people and homes but the entire civil order in New Orleans in 2005. For weeks, police enforcement was virtually non-existent. The citizens who did not evacuate the city were left on their own not just to survive the elements but threats from each other.
While pandemic flu strikes in a very different form, local police may be stretched very thin in a widespread outbreak, with up to 30 percent absenteeism for weeks or even months. In addition to their normal duties of keeping public peace, the reduced workforce may be called on to handle new and difficult tasks such as:
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Protecting supplies of vaccines, food, electricity and gas. |
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Providing security at overburdened hospitals. |
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Enforcing quarantining of uncooperative citizens. |
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Isolating whole sections of the population where an outbreak has occurred. |
Infection control? You can’t close a local prison…
At the December 2006 Nieman Foundation conference “The Next Big Health Crisis—And How to Cover It,” John Thompson, deputy executive director of the National Sheriffs Association, provided an image of what his organization tries communities to prepare for:
| “Let me give you a scenario. A community is hit with pandemic flu and loses 30 percent of its law enforcement officers. Don't expect the next community to send anybody, because the pandemic doesn't know towns and borders.” |
At the same time that pandemic flu decimates police forces, the public’s demand for services will multiply. If a 911 call is not answered, the average law-abiding citizen may go into survival mode, possibly resorting to arms to protect his or her family.
On a broader scale is the question of who will fill the vacuum if the police presence is insufficient to monitor city streets. The answer, Thompson fears, is gang members who will feel emboldened because there is no one to stop them.
Additionally, the National Sheriffs' Association handles more than just public safety. Prisons present a particular logistical and medical challenge because they are designed to keep people in, not flu out. If contagion rages inside prison walls, sheriffs have limited options: Keep the inmates in, perhaps imposing an unintentional death sentence? Or try to move the infected ones out, at risk of escape? And where would the prisoners be housed?
Thompson sees the press as the catalyst for getting such questions answered. “Journalists have the power to make people think about such things,” he says. “Every time you write a story or put something on TV, that is very powerful. It does affect us, and we're guided by it.”
Story ideas
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How well equipped is your local jail or prison to handle pandemic flu? What supplies are available? How would the prison cope with significant absenteeism among guards? Does it have the ability to put very sick prisoners on mechanical ventilators? If not, where and how do prison administrators intend to transfer a sudden surge of very sick prisoners or guards? What is the facility’s previous track record with respect to containing tuberculosis, measles or other airborne illnesses among the inmate population? |
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Would home-schooled children fare better during a pandemic? How well have schools in your area dealt with outbreaks of norovirus (a gastrointestinal ailment) or meningitis? How does/would dealing with a pandemic flu differ? |
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How well prepared is your community for a medical surge? The DHHS Office of Inspector General conducted an interesting study on this topic in a select number of states. |
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How much personal protective gear should a hospital store to be prepared for an influenza pandemic? And how much does your local hospital actually stockpile? This paper in the American Journal of infection control has some answers. |
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The uninsured and underinsured may have a big financial impact on health systems during a severe pandemic. A comprehensive report by the Trust for America’s Health suggests remedies such as an emergency health benefit to compensate healthcare providers, or for Medicaid, Medicare and private insurers to extend out-of-network-benefits to give patients access to a wider provider network. Are these options being considered? (Scan the report for many more story ideas on questions such as the ones above.) |
Sources
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Office of the Assistant Secretary for Preparedness and Response, the Emergency Care Coordination Center, and the American College of Emergency Physicians, “National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza.” ↑
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Trust for America's Health, H1N1 Challenges Ahead, October 2009 ↑
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Agency for Healthcare Research and Quality, “Key Themes and Highlights From the National Healthcare Disparities Report,” National Healthcare Quality Report, 2008 ↑