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 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 Jamie Miller, 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."
Robert 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 andgravediggers 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 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 Jeffrey 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 Georgetown 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 death 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 Maryland'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."
Maryland'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 which telecommuting is not an option, 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 Maryland 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 Michael 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 Brendan 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 Brandon, 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 Brandon 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.
Judith English heads the infection control branch of National Naval Medical Center and the D.C. hospitals' committee on infection control and infectious diseases. She applauds such proactive steps. "People should be talking about this in their PTAs, their day care," she said. Ditto "hotels and restaurants and bars and jazz clubs." Unlike in 1918, they have advance warning to get ready.
"It should be on everyone's agenda," she said.