By David Brown
Washington Post Staff Writer
Thursday, May 4, 2006
The Bush administration plan for an influenza pandemic released yesterday hinges on sharing authority with global agencies such as the World Health Organization, and, at the opposite end of the spectrum, with governors, mayors and school superintendents.
The 227-page road map acknowledges that the federal government cannot -- and should not try -- to fully manage the response to an event that is likely to start overseas, eventually take hold in even the smallest U.S. communities, and last for months.
"The impact of a severe pandemic may be more comparable to that of war or a widespread economic crisis than a hurricane, earthquake, or act of terrorism," the authors of the plan wrote. "The center of gravity of the pandemic response will be in communities [and] the support the federal government can guarantee to any state, tribe or community will be limited."
At the same time, the road map -- developed to support an equally voluminous pandemic "strategy" unveiled in November -- lays out an ambitious agenda of more than 300 tasks for federal agencies, along with a timetable for completing them.
They include such tasks as helping improve a flu laboratory in Singapore and encouraging new cell-based vaccine-making technology in this country; devising plans to route all international flights to just a few U.S. airports during a pandemic; and helping local jurisdictions come up with plans for canceling school and triaging patients at hospital emergency rooms.
Nevertheless, many crucial questions about the government's response remain unanswered in the "Implementation Plan of the National Strategy for Pandemic Influenza."
They include how officials would decide who should get limited supplies of vaccine and antiviral drugs; whether the government would dip into those domestic supplies to help contain a foreign outbreak; at what point to trigger mass treatment of U.S. citizens in an effort to contain the virus here; and how travel and border-crossing might be limited.
"We recognize that we cannot make these decisions in a vacuum and must consult with our international partners to ensure that we adopt a consistent approach," Frances Fragos Townsend, President Bush's assistant for homeland security and counterterrorism, said at White House briefing.
The document anticipates that a flu pandemic would probably come in two or three global waves, each lasting about three months; in any given community, an outbreak would last six to eight weeks; at least one-third of the population would become ill, and workforce absenteeism could peak at 40 percent.
Mortality in the United States depends on many variables; the report assumes there could be 200,000 to 2 million deaths.
A pandemic on the scale of the Spanish flu that circled the world three times in 1918 and 1919, killing at least 50 million people, could result in the loss of 5 percent of the U.S. gross domestic product, according to Congressional Budget Office estimates cited in the report.
The administration's plan appeared to reflect the lessons of the severe acute respiratory syndrome outbreak of 2003 and the response to Hurricane Katrina last summer.
SARS, a virus that emerged in China, caused about 8,400 cases of illness in 28 countries and about 800 deaths. The WHO organized the global response in a way unprecedented for the Geneva-based agency. It coordinated disease surveillance, helped disseminate treatment strategies and influenced governments' behavior, advising against travel to Canada and forcing China to make a full accounting of its SARS cases. Many experts believe the SARS experience amounted to a dry run for a much more dangerous flu pandemic.
The Bush plan cedes to the WHO the lead role in managing this global health crisis -- something it has resisted on other health issues, notably AIDS.
"The World Health Organization represents the linchpin of international preparedness and response activities. . . . During a pandemic we will rely upon it to be a highly visible and credible coordinator of the international response," the plan says.
In particular, the authors wrote, "we will rely upon the WHO to confirm sustained human-to-human transmission of a novel influenza virus." That decision will trigger the global response and have repercussions through the United States even if there are no cases here. In practice, U.S. scientists will have a major say in making that crucial call, as the Centers for Disease Control and Prevention in Atlanta is a major source of the WHO's expertise.
The plan specifies that the Department of Homeland Security "is responsible for overall coordination of federal response actions for a pandemic." However, the disastrous response to Katrina seems to echo in a statement that, in effect, advises people not to wait for help from Washington.
Nothing in the plan "alters or impedes the ability of federal, state, local, or tribal departments and agencies to carry out their specific authorities or perform their responsibilities under applicable laws," its authors wrote.
Despite the $7.1 billion Bush has asked for pandemic preparation, Irwin Redlener, a physician at Columbia University's Mailman School of Public Health, said little of the money will go to localities. Most will be spent on vaccine development and building a national stockpile of antiviral drugs.
Local hospitals and health departments "cannot possibly fulfill what amounts to a string of unfunded mandates," he said.
This view was shared by Joshua M. Sharfstein, Baltimore's health commissioner.
"The key challenge from our perspective is to answer the question, How do we keep Baltimore running? How do we ensure the trash is picked up, the police and fire departments work, that businesses can stay open?" he said. "It would be immensely easier if we had additional resources equal to what we are being asked to do."
Leading Democrats in Congress also criticized it, with Sen. Charles E. Schumer (N.Y.) saying that "pawning [responsibility] off on the state and local government is not a solution." Sen. Edward M. Kennedy (Mass.) said the document "still leaves us without a coherent overall national plan."