By Christopher Lee
Washington Post Staff Writer
Saturday, February 2, 2008
The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say.
The Bush administration's plans, which run more than 1,000 pages, contemplate the nightmare medical scenarios that many experts fear, but critics say federal officials have left too much of the responsibility and the cost of preparing to a health-care system that even in normal times is stretched to the breaking point and leaves millions of people without adequate access to care.
"The amount going into actually being prepared at a community level is not enough," said Patrick Libbey, executive director of the National Association of County and City Health Officials. "We are still talking about rearranging with little additional resources the assets of a system that are built on such a thin margin now that you have significant amounts of people without access to care, and hospitals that are periodically shutting down their ERs and the like."
The Bush administration argues that it is doing a lot to help communities as part of its three-pronged strategy for dealing with the flu threat. It has doled out hundreds of millions of dollars in preparedness grants for hospitals and public health systems every year, subsidized the stockpiling of antiviral drugs, conferred with governors and encouraged resource-sharing plans among hospitals.
Its larger strategy involves partnering with other countries to quickly identify and contain potential outbreaks overseas, developing vaccines and other medical measures to limit the virus's spread if it reaches U.S. shores, and working with state and local officials to keep the economy and society functioning as normally as possible. But administration officials acknowledge that gaps remain.
"We're seeing substantial progress across the board in terms of various aspects of preparedness for flu," said William Raub, science adviser to Health and Human Services Secretary Mike Leavitt. "But I won't sugarcoat this. In virtually every area, we have a good way to go. . . . It would not take much of an unmitigated pandemic to overwhelm the hospital system."
A serious outbreak and its fallout would probably overwhelm medical centers, cause lengthy delays in emergency and routine care, and trigger shortages of beds, ventilators, drugs, masks, gloves and other supplies, experts said. Unlike a hurricane or a terrorist bombing, the crisis would drag on for months and affect communities nationwide at the same time.
Doctors and nurses would be swamped at a time when many of them and their family members would also be falling seriously ill, thinning their ranks and forcing some to choose between helping loved ones or patients. A vaccine, if one becomes available, could be difficult to transport and distribute, and imperfect vaccines and antiviral drugs used in the early stages of an outbreak probably could not forestall a pandemic. The "just in time" economy on which many hospitals rely for shipments of drugs and medical supplies, many of them from overseas manufacturers, would quickly fall apart.
"If we have even a moderate-sized pandemic, these supply chains are going down overnight," said Michael T. Osterholm, director of the Center for Infectious Disease Research & Policy at the University of Minnesota.
Osterholm and others said that a serious flu outbreak would be nearly impossible to contain and that building the medical capacity to treat the surge of victims would require billions more in sustained federal aid. Moreover, health experts say there should be greater attention paid to who will control scarce resources and to how people will get care at home and in other nonhospital settings.
"The priority focus within U.S. pandemic plans on controlling contagion has unwittingly diverted attention from the problem of caring for the sick," said Monica Schoch-Spana, a senior associate with the Center for Biosecurity at the University of Pittsburgh Medical Center and an assistant professor in the university's medical school.
Michael Greenberger, director of the Center for Health and Homeland Security at the University of Maryland, said the federal effort amounts to a "classic" unfunded mandate.
"If you look at the plan, the basic message is, 'This is going to be one hell of a problem, and you better get ready.' You better get ready. You the cities, you the states, you the citizens," Greenberger said. "The pandemic flu preparations in the United States are a tragedy."
Since late 2005, Congress and the president have devoted more than $6 billion to pandemic flu preparedness, although little has gone directly to states and communities. The vast majority has been spent on researching vaccines and building the capacity to manufacture and distribute them, and on antiviral drugs and overseas disease surveillance, analysts said.
Near the end of 2005, the government also allocated a separate $600 million, one-time pot of money for pandemic preparedness grants to states and localities, as well as another $170 million to help states buy antiviral drugs, but much of that money has been spent already. Other grants for state and local bioterrorism preparedness and hospital emergency preparedness total hundreds of millions of dollars annually, but they have declined in recent years.
Raub, the HHS official, said the government's strategy and funding are sound. Overseas surveillance could help delay a pandemic's arrival or lessen its severity, he said. And domestically, the goal is not to simply throw money around but to help states and communities develop plans -- even low-tech ones such as encouraging sick people and family members to stay home -- that could minimize the spread of flu while stretching medical resources.
"A lot of leadership will come from the trenches," Raub said. "None of this is a panacea, and I don't mean to represent that we've got this solved. But at least there are substantial public resources flowing with a focus on what we think are the practical things that, unglamorous as they are, can be done."
Health and hospital officials around the country vary in the degree to which they believe they are ready, but even those who say they have made good progress want the federal government to do more.
"So far we don't have supplies and that sort of thing in large quantities," said Ron Anderson, president of Parkland Health & Hospital System, which runs the county hospital in Dallas. "We don't know how we would treat all the people who would be coming in large numbers. I'm afraid this country doesn't understand that there isn't much surge capacity here, not only for pandemics but for any kind of biological terrorism or something like that."
In Northern Virginia, Inova Health System has focused much of its planning on regional collaboration, said Dan Hanfling, director of emergency management and disaster medicine. Inova has spearheaded a regional hospital alliance that has examined how best to deploy durable medical goods, drugs and other supplies, he said, and has purchased a "modest" supply of extra ventilators to help victims whose lungs have been devastated by flu.
Hanfling agrees that federal officials have provided leadership and some important funding streams, but he, too, said more needs to be done.
"The amounts of funding still pale in comparison to the tremendous need that exists," he said. "It's a big, complex, daunting issue. . . . It makes our current state of readiness tenuous, at best."
In Farmington, Maine, the Franklin Community Health Network, a nonprofit system serving 50,000 people, has developed plans to relocate existing patients and, if necessary, house its medical staff for weeks, said Richard Batt, the network's president.
Franklin Memorial Hospital, a 50-bed facility with $60 million in annual revenue, spent $100,000 to stockpile a month's worth of gloves, masks, drugs and other supplies at a warehouse, Batt said. Much of it must be regularly rotated into the hospital's inventory and replaced to keep it from deteriorating.
Batt, whose hospital has received about $10,000 in federal help, said federal funders have favored police and fire departments over hospitals and primary-care systems.
"In a pandemic, the action is going to be in the doctor's office and in the hospital emergency room and the ICUs," he said. "It isn't going to be with the fire department intercept squad. . . . You'll find that there are almost no resources going to this problem proportionate to the real risk it presents."