2005-10-24-Unprepared for Bird FluUnderstanding Avian Influenza
2005-10-24-Unprepared for Bird Flu
By Bernadine Healy, M.D.
When the avian flu brewing in Asia hits our shores--as most experts believe will happen--and if it maintains its virulence as it morphs--as it is almost a sure bet to do--into a fast-spreading human form, infecting tens of millions of people, the scenario that unfolds will be unlike any other Americans have ever seen.
Hospital wards will be choked with thousands of victims young and old. They will be hooked up to respirators, lying in comas, and dying as their heart and blood vessels fail massively. Others will be waiting in the corridors. Our vaunted trillion-dollar health system has neither the medical reserves critically needed for catastrophes of this ilk nor systems in place to quickly create them.
Think for a moment like a doctor caring for pandemic victims as well as others who fall ill at the same time, and you will understand how desperate you and your fellow physicians will feel. Your ability to apply your training and insights to save the sick will be hampered because of rationing and shortages of modern medicine's basic commodities: intensive-care beds, safe blood, and experienced and well-equipped teams of healthcare workers knowledgeable in the special qualities of this disease. The National Pandemic Influenza Response and Preparedness Plan that may be released this month by the U.S. Department of Health and Human Services will focus on public-health measures to limit or control the pandemic but will say little about caring for the people who fall sick--that's seen as a state and local effort.
Old-fashioned doctoring. Our hospitals will be ground zero on the battlefield of this outbreak. We have 965,000 staffed hospital beds in this country; fewer than 100,000 of them are for patients needing critical care. This in the face of several million predicted flu-related hospitalizations in two or three waves over about 18 months. With little surge capacity to absorb waves of new patients, and relying on just-in-time pharmacies with limited inventories, how are our hospitals to deploy respirators, monitors, sensors, and heavy-duty medicines? As things stand now, we will have no choice, says Jim Bentley, the American Hospital Association's senior vice president for strategic policy planning, but to "learn to cope with 1950s medicine for a time."
Nor will the blood supply, ordinarily run at the margin, be in better shape for both flu victims and those needing blood for other illnesses. Critically ill flu patients will increase the usual blood demand--the bird flu has a penchant for dropping platelet counts, making patients vulnerable to bleeding. As blood banks dry up, they won't be easily replenished; donors in affected areas will be sick or unable to give because of the risk that they are carrying the lethal virus themselves.
There is a way to counter the blood problem, if we put it in place ahead of time. It's one the military uses and an approach I pushed, unsuccessfully, for the civilian blood supply as Red Cross president: a strategic reserve. It would consist of fully screened and frozen blood, with a shelf life of more than 10 years, not the 42-day life span of liquid blood. The plan never came to fruition because of concerns that it would not be cost-effective.
Where, moreover, will we find qualified healthcare workers? Few doctors have any experience recognizing and treating this virulent bird flu. There is no easy diagnostic test, and the flu can show up in patients in mysterious ways. The H5N1 strain targets the lungs but can spread to the brain and the gut and appear as an unexplained coma or a diarrheal illness. With bird flu, unlike regular flu, the young seem to face the highest mortality, probably because their robust immune systems overreact to the alien virus with a massive outpouring of destructive inflammatory cells and chemicals. This calls for a different approach to treatment. And healthcare workers themselves will be at risk as they care for patients isolated in pandemic wards. They must be assured top-priority access to antiviral drugs and vaccines when these are ready.
We need a frank and open public discussion if we intend to beat back the many challenges of caring for the sick in a time of pandemic. Catapulting medical care half a century backward is not inevitable, even if it looks that way at the moment, and the prospect is instantly abhorrent if you imagine that you, or those you love, are among the flu-stricken. Already, I see visions of Katrina: finger-pointing as the census of lost souls begins to add up, the feds faulted for not bringing in the cavalry. It doesn't have to be.