By Ford Rowan
Chair, National Center for Critical Incident Analysis

The Obama Administration is walking a tightrope in public statements about swine flu. On one hand it wants to show that it is actively addressing the potential pandemic but it does not want to trigger panic.

The President’s first public statement (on April 27) suggested swine flu is a “cause for concern” and he added “but it’s not a cause of alarm.” The New York Times headlined the story “Obama seeks to ease fears on Swine Flu.”

The new administration is under pressure to show that it is moving aggressively to cope with the threat – and not just because of concerns about health or the economic harm that a pandemic would cause the nation.

The impulse to act fast can lead to problems. In 1976 President Gerald Ford faced a similar threat of a swine flu outbreak; he ordered mass vaccination to prevent the spread of that particular disease. It was a disaster of a decision that caused more people to die from the shot (25) than from the flu (one death). Hundreds more suffered from a nervous disease caused by the vaccine.

The hunt is on now for a vaccine that will stop the current virus. Estimates on availability vary but most agree that first shots will not be available before winter of 2009. A lot of virus will travel to many locations in the meantime.

Finding a safe and effective vaccine is important, but there are other non-medical aspects that need to be addressed. The social and psychological impact of public health emergencies can be enormous.

Direct action by state and local governments is crucial. Citizen involvement at the community level will be essential to coping with the spread of disease.

The anthrax cases in 2001 taught how easily the federal government can lose its credibility. Two months into that crisis a national poll for the Harvard School of Public Health showed that nearly twice as many people would trust state or local officials as would trust federal officials to tell them about the risks of anthrax. The “local fire chief” had almost twice the credibility as the director of Homeland Security. And the fire chief was trusted more than the director of the Centers for Disease Control and the US Surgeon General.

What could go wrong now? Here are lessons from three recent public health problems, the anthrax attacks, the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 and the public health emergency in New Orleans after the levees failed in Hurricane Katrina in 2005.

  1. Avoid false assurancesIn the Anthrax case the federal government initially reassured the public that there was little to fear from the isolated cases. In the SARS outbreak foreign governments gave slow and low estimates of cases to protect their economies. In Katrina the federal government made promises of assistance that were not kept.
  2. Clarify rules and proceduresIn the Anthrax attack there was conflicting advice, particularly about the safety of the US Mail. In the SARS response in Toronto, public health trumped personal freedom of movement. In New Orleans after Katrina federal troops had to be sent in to stop looting, shooting, and chaos.
  3. Treat citizens equallyIn the Anthrax case postal workers (mostly black) received later and less costly health care than congressional workers (mostly white). In Toronto during SARS people of color were stigmatized because of concern the disease would be spread by Asians. In New Orleans the poor, the blacks and the elderly were the ones left behind to suffer the greatest problems from the flooding.
  4. Avoid governmental snafusIn Anthrax the federal government provided inconsistent information to the public and initially silenced some of its experts, permitting falsehoods to proliferate. In Canada during SARS thousands of persons were unnecessarily told they were “voluntarily” quarantined. During Katrina as the floodwaters rose the relationship between federal, state and local government sank.
  5. Beware of media amplification of riskDuring the anthrax attack the media focused on the unfair treatment of postal workers who died and the risk to everyone who opened the mail. During SARS Asians and health care providers were portrayed as suspected carriers of the disease. During Katrina the media focused widespread disaster, drowning deaths, and despair when survivors were herded into confined spaces with little water, food or medical care. Outrageous problems do not mean that the risks are out of control.
  6. Don’t expect Washington to save youWe all hope a vaccine is found, but until then the national scope of a pandemic would mean that people have to take care of themselves, their families and their neighbors. It’s not just a medical challenge. In all three of the earlier cases there were law enforcement issues, allegations of mistreatment of minorities, ethical controversies, uncertainty about the advice to give to the public most at risk, and decisions seemed to be made by the seat of the pants. In Katrina volunteers who wanted to help rescue people trapped by flood waters were turned away by federal authorities concerned about the risks. Many volunteers eluded roadblocks and the “Cajun Navy” managed to rescue many victims of the storm.

Encouraging volunteer activity in a nationwide pandemic would be crucial for providing care to persons sheltering in their homes. But little attention has been given about how it could be encouraged and – to the extent appropriate – coordinated on the community level. Most likely, people would self-organize activities and adapt to changing conditions. Such initiatives can pay big dividends but there are risks.

In most crises there are victims, survivors and rescuers. Curiously, the survivors sometimes think and act like victims. The transformation to a more productive outlook is facilitated when one becomes a rescuer. Helping others helps the one giving help. Those who recover from a bout with the flu will have lower risk of re-infection and can seize the opportunity to assist others.

There are potentially contentious ethical issues that could surface if swine flu becomes a pandemic. These issues include potential restrictions on travel, quarantine, triage standards for the rationing of medical care, ways to assure continuity of essential work without forcing employees to endanger their families’ health, ways to relieve economic disruption and provide food and supplies to homes. We will have to decide how we can help children continue to learn and the mentally ill to cope if the disease comes in wave after wave. How can we deter people from taking the law into their own hands to protect themselves?

President Obama correctly said on April 27 that swine flu is a cause for concern but not alarm. Mainly, however, it is cause for thoughtful action. Here’s a short to do list:

  • What should citizens do now to protect their families?
  • What should social groups, including businesses and faith communities do now to become more capable to help their neighbors in an emergency?
  • How can governments facilitate voluntary charitable acts by business and non-profit organizations?
  • How do we ensure the fair use of resources so that the poor, elderly, and minorities are not especially burdened?
  • Have we got a plan to avoid the stigmatization of ill persons?
  • How will we deal with potential civil unrest and criminal behavior?
  • How do we devise and explain medical triage so that it is fair and effective?
  • How can news organizations function when many journalists go from being spectators to being at risk themselves?
  • How do we empower people and help survivors of the flu become rescuers who care for their neighbors?
  • Are there steps that can be taken now to mitigate the economic impacts?
  • What can we do now that will help mitigate the psychosocial harm?

Some actionable advice is already out there on the websites of various government agencies. Beyond stockpiling food, social distancing and being prepared to shelter in place, citizens should take responsibility for their own safety. Elsewhere on this website is a summary of how people can maintain productive work and mitigate risk of disease.

There is much evidence that the federal government has learned from mistakes in past emergencies and that relations are healthy between Washington and state and local governmental agencies. But civic, business and religious organizations, as well as individual citizens will need to be active if a pandemic develops.

To get through a pandemic, we will need to help each other.