Progress for tomorrow: Preparing for the next disaster

Posted 4/20/06

Participants were Dr. Bill Atkinson, president and CEO of WakeMed Health and Hospitals in Raleigh, N.C.; Dr. Georges Benjamin, executive director of the American Public Health Association; Dr. Tom Inglesby, CEO of the Center for Biosecurity at the University of Pittsburgh Medical Center; and Dr. Arthur Kellerman, chairman of the Department of Emergency Medicine at Emory University Hospital. Dr. Bernadine Healy, health editor of U.S. News and the former head of the National Institutes of Health and the American Red Cross, moderated the panel.

HEALY: I often joke at U.S. News and say that I'm the physician-in-chief. Of course I'm the only physician at U.S. News, so that makes it very easy to be physician-in-chief.

But I would like to introduce our most distinguished panel. We have Dr. Bill Atkinson, who is the president and CEO of WakeMed Health and Hospitals in Raleigh – Raleigh, North Carolina, of course – and that is a private, not-for-profit, multi-hospital system, which is one of the top-ten health care providers in the state of North Carolina. Dr. Atkinson has more than 20 years experience as a hospital president and chief executive officer in both rural and urban settings.

Dr. Georges Benjamin is a well known figure in the public health community. He is the executive director of the American Public Health Association, which is the nation's oldest and largest organization of public health professionals. He came to the post from his position as secretary of the Maryland Department of Health and Mental Hygiene where he played a key role in developing Maryland's bio-terrorism plan, and Dr. Benjamin also has some experience with the anthrax attacks shortly after 9/11.

Dr. Tom Inglesby is the chief operating officer and deputy director of the Center for Biosecurity at the University of Pittsburgh Medical Center, and he is an associate professor of medicine and public health at the University of Pittsburgh School of Medicine and Public Health. Dr. Inglesby is the author of a number of widely cited publications on issues related to medicine and hospital preparedness.

And Dr. Arthur Kellerman, professor and chair of the department of emergency medicine at the Emory University School of Medicine – he also directs the Center for Injury Control for the Rawlins School of Public Health of Emory University and is a member of the board of directors of the American College of Emergency Physicians.

We've had a provocative morning session and two rather provocative speeches. I was walking out a few minutes ago and I asked someone what they were thinking, and the response was, I'm a little scared and more than I was when I came in this morning.

So with that in mind, I want to ask each one of the panelists as an opening question - from the trenches in a very practical way - and this panel is supposed to focus on what are the things that we can do in a very practical way - we're not talking about abstract - I want to ask each of you, when you go to bed tonight, what is going to be keeping you awake? Let's start with you, Dr. Atkinson.

ATKINSON: Thank you for the opportunity to be with you. I think every day we think about what we can do to help people have a better life, and that includes their healthcare and just the world around them. And this happens to be an age when we need to think about natural disasters and manmade disasters, and that's just part of the process. And so I think we think about how do we create a system that can take limited resources and try to make smart decisions to use those in a practical way to prepare the best we can for those things that might come about, whether it be an individual with an individual illness or injury or a community or a nation or a world that is faced with a disaster-type situations.

HEALY: Now, remember that was Brian Kelly's question to the first panel. Now, the question is, you said, to create. Are you saying we haven't created it yet?

ATKINSON: I think we're a lot further along than we were. And you know, we live in a – at least as relates to our nation – it's a very sophisticated healthcare system. It's not without flaws, but it is a system that gets better every day. I think events like this where you bring some of the best minds in the world together to talk about lessons learned and those things that are just very human - just those things you need to pay attention to; it helps us get better. Everyone who participates in this will go home with some lessons.

We are not fully prepared to handle the situations, the surge issues in emergency departments, especially in urban areas but certainly extending to some suburban areas and rural areas of the nation; it's a major problem now. And we deal with surge issues daily and we run well over 100 percent census every day in our system. And it's a problem. And it doesn't mean we couldn't handle an emergency, because I assure you we would. But it wouldn't necessarily be as effectively or efficiently done as we'd like it to be, and that's where I think streams of - while we talk about the revenue stream; they do need to be steady and predictable streams of revenue; but it's less about just the concept that we have to spend money, then we have to spend intellectual capital to make this work - and that's sharing ideas and coming up with better ways to do the things that we might not have thought very much about yesterday.

HEALY: Dr. Benjamin.

BENJAMIN: You know what, Dr. Healy, at the end of the day, every individual ought to be able to protect themselves, their families, and their communities from serious preventable health threats. And what keeps me up at night is the fact that we've not done that. We've not engaged the public in a way that makes them prepared. We heard a lot today about the importance of preparedness at the local level, and yet we've really not done the education, giving them the tools, or help them figure out how to do it, and I think that's the next step.

I really think it's about engaging the public and really giving them practical ways to get prepared, you know, making up a bunch of lists - which it's good that we have lists - is only one step. But one of the things I've learned from my many years in practicing public health and working with community groups is that you really need to reach out and engage those folks and show them how to do it, help them how to do it, and tell them why they have to do it. And until you do that, we won't be prepared.

HEALY: Dr. Kellerman.

KELLERMAN: What keeps me up at night is the knowledge that our trauma and emergency care system in this country is absolutely stretched like a piano wire. We have been pushed absolutely to the limit in terms of capacity to the point that they're giving nights, and I'm not sure we can handle an average night's 9-1-1 calls, much less a terrorist strike or pandemic influenza. Four years ago, U.S. News & World Report published a very important story on this problem. They gave it the priority of a cover story. It was entitled "Crisis in the ER: Turnaways and Delays are a Recipe for Disaster. What you Can Do." That issue was published on September the 10, 2001.

Nothing has been done about this problem since then. Now we're talking about international terrorism, now we're talking about pandemic flu, and yet on any given night, we have admitted patients in hallways at private ERs as well as public hospitals. We are diverting one half million ambulances a year because your emergency room is on diversion because it's too full. And we're having speeches and pronouncements about how we're better prepared today than we were yesterday, and we've not come to grips with the fundamental problem, which is where are the casualties going to go?

HEALY: Dr. Inglesby?

INGLESBY: I would say what keeps me awake at night is - on occasion; I try to be Buddhist about it and not stay awake late nights thinking about it – but if I have to think about it, I think it's the prospect of large-scale epidemics, be they from SARS or avian flu or other natural causes or bio-terrorist attacks and the potential that they could change the way that the country moves forward beyond those epidemics. They could be events that permanently change the way that we work together as a society. And so in short, I think it's the prospect of epidemics changing things in inalterable ways and the missed opportunities that we have now prior to those epidemics to try and ameliorate or become more resilient to those kinds of problems.

HEALY: I'm hearing a little bit of a disconnect in terms of the intellect and the passion or the emotion, which maybe Dr. Benjamin you got at in terms of not having engaged the individual, I think you said. Maybe you've engaged them intellectually. I suspect if you talk to anybody on the street, they'll say, yeah, I've heard of that pandemic flu or I certainly know about 9/11. But somehow or other, have we engaged them emotionally? And I'm going to ask you why is that? You know, if you look at disasters, and we all have had our different perspectives on disasters, when the public looks at CNN, turns on the television, looks at any TV station and sees people suffering in a flood, whether it's the tsunami halfway across the world, whether it is what happened in Katrina, happened in 9/11, there is an enormous outpouring of passion and commitment, and people open their pocketbooks – money is never an issue. Why is it that the preparedness that we've been talking about today hasn't captured the individual?

BENJAMIN: I think we have equated disasters with inevitability and confused the fact that what we're trying to prevent. While we may not be able to prevent a disaster - although to some degree we might – we can mitigate it substantially. You know, a disaster is not the time to be exchanging business cards or coming up with new solutions, and you need to do that up front. And so, we often do what we always do with disaster plans. We write great plans and we exercise those plans in a variety of tabletops and nice things. But we never really figure out how to integrate them in the real lives of people. And we continue to learn those lessons over and over and over again, and then we do after-action reports, and there are lots of dusty after-action reports all around this country, which have never been implemented into plans. They've never been integrated into reasonable solutions, and that has to do with accountability, and again I think, this sense of inevitability that - well, you know, this bad thing happens; it'll be terrible, but we'll get over it. Well, sometimes you don't get over it. And one of the things that we saw from Katrina is that the health status of the people that were evacuated from that continues to erode. And so, you know, we can do better and we should.

HEALY: Would you say that – we've had a lot of discussion about the pandemic. I mean, it seems to be the issue that people are seeing as perhaps one of the more imminent disasters, something that has a unique characteristic, and that is, theoretically, no one would be spared. I mean, it's not just going to be a certain high-risk area, if you're on the San Andreas fault or if you're in the hurricane zone, or if you're in a neighborhood that's likely to flood. But this is something that touches everyone. Why isn't everyone exercised about it?

BENJAMIN: I think people are exercised about it. If they're reading about it or they're seeing articles in the newspaper about it, it's worrisome. But it's complicated for them to figure out what they can do personally. I think we had two speeches today about the importance of community planning and people taking things on their own, but that's important - and I think all of us in the room, it's mom and apple pie - we all agree - but there are some things without which the local plans will be relatively ineffective. If we have no vaccine, if anti-virals aren't going to get there for a couple of months, if we have no technical guidance for how to prevent the spread of disease because there are only a few people in the federal government and a few local health departments who are smart enough to be able to think through these things, if the information sources like after anthrax 2001 are so poor, then people aren't going to know what to do and their plans won't be useful. I think we all would agree with the comment that if you believe the federal government is going to come in and bail out your community, then you're tragically mistaken, all agree, but I think we also all should agree that any community that gets no external assistance is going to be tragically forsaken, essentially. People can't bootstrap this entirely on their own. And so, I think people - there is a sense that the federal government is doing all that it can. People are going to pitch in. But it's not prescriptive enough. That advice, you've got to plan on your own, I don't think that's prescriptive enough to get people energized and on the streets planning.

HEALY: But I want to go back to the issue of heart. You know, philanthropy is a very interesting example of what shows. I mean, you're putting your money where your heart is, and that's what most philanthropic giving is, whether you're supporting a medical center or a chair, whether you're supporting someone after a flood. Why is it that people are not willing to write a check for preparedness, but they open billions and billions of dollars out of the personal coffers when they see the disaster on television?

KELLERMAN: I think the issue is that Americans don't think it's going to happen to them. And you know, it's two things. One, I think a lot of Americans have fear fatigue. What is the latest thing that I'm supposed to be scared of – whether it's obesity or secondhand smoke or the latest side effect for prescription drug – and their eyes glaze over after a while, and they lose the ability to discriminate against the stuff they really need to worry about versus the stuff that maybe is important but not as important.

And the second part is we all live in a fantasy world. It's not going to happen to us. And when I'm talking to a mom and dad whose teenage son is critically injured from a car wreck, half the time they're looking at me saying this can't be happening to me; this can't be real; I'm going to wake up; it's not going to be this way. This is why we have trouble getting people to focus on emergency care in general, because none of us in this room are ever going to be in an ER, none of us are ever going to have our life depending on having critical access to care. We're not going to be in the disaster.

SARS happened in another country. It might be one of the most sophisticated cities in North America, but it wasn't an American city, and so it wasn't as real. So I think unless it's real and we're living it, then it's an abstraction and we don't think ahead. We all live in a fantasy world.

HEALY: Now, you said something very interesting, which is the mom and dad with their child whose just been in a car accident – if we look at pandemic flu – actually smallpox for the matter is just less likely to be so disseminated. We're not talking about the potential for 90 million people affected. But if we look at pandemic flu, how many people who think they know a lot about the risk of pandemic flu know that it is their children – the young - K through 12, twenty-somethings – those are the ones that are most likely to die from it.

KELLERMAN: If it's like 1918.

HEALY: If it's like 1918, which all the public health people are saying it's likely to be. I mean, even the scientists who are comparing these viruses are saying this does not look like the '57. This looks like 1918. It has the spine of a bird flu. All right, and the experience from Asia, Turkey, is that it is the young. I think the mean age is about nineteen, as a matter of fact. And you know, those grandmas are plucking the chicken, too. The kids may be playing with it, but grandmas are plucking those chickens. But for some reason, we're seeing something that seems to be affecting the young people, which is what happened in 1918. If it's our children, and it could be children in every city in this country, 40 percent of Americans attack rate, why doesn't that stir the passions or is it that people don't know about it?

KELLERMAN: I don't they know about it for one, and also, I think that we're missing an opportunity with families to be teaching now what they can do and what their kids can do that doesn't involve anti-virals or vaccines. You know, we have a fancy term for it, you know, social distancing.

HEALY: How do you teach children to socially distance?

KELLERMAN: How do you teach children to socially distance? You don't. But how do you teach parents to know when they need to keep their kid out of school, when they don't go to the party or go to the theatre, when you stop shaking hands with everybody you meet on the street, when you start carrying alcohol to wash your hands 20 or 30 times a day. I mean, the fact of the matter is we may do more good with non-pharmacological counter-measures.

This is a virus that is transmitted the way a lot of viruses are transmitted. It's very infectious, but the fact of the matter is, we may not have modern medicine to save us. We may have to rely on the good old-fashioned things like social distancing or quarantine. That's the most effective strategy that helped the world out of SARS, much less transmissible than influenza. Nonetheless, I don't think we're getting that word out, and that is something every family can do and learn and understand now before they have to react.

HEALY: What about the children?

ATKINSON: May I add – I think if you look at the – just even what we see in surveys about the American public, three issues come to mind immediately – access to care, quality of care, cost of care – not necessarily in that order, depends where you are in the sequence on any given day. And then you begin to add those things that are perhaps less frequently talked about such as emergency preparedness. People assume in many cases that if they have something goes wrong at home, something breaks, or if they break, they'll just show up at an emergency department and it would be fixed. And I think it is correct that our nation's trauma centers and emergency departments are way over-taxed. We do need to have more capability and we need that yesterday not tomorrow. We need that today for sure.

On the other hand, it has been my own experience, and certainly the WakeMed experience in North Carolina has been that when we've gone out to tell the individual story, when we've been out to see businesses to say we need help with this preparedness.

An example – one of the beverage companies in our community, we went to them and said we want some of your former trucks. We want these trucks that carried the drinks yesterday, but we want them to carry supplies and to rebuild them. They gave them to us. We went out to other companies to select money for preparedness and stuff where the private sector helped the public sector or vice-versa. But I think someone has to imagine what the solution will look like, not wait for someone to give them that solution and make that fit locally. And there are great solutions to be found to some of these response communities without waiting for someone else to hand us an answer.

And my own experience has been again, in communities, you go to any small community in America - rural community - you go find people that support their local volunteer fire departments, their rescue squads, their EMS units that donate money, time, energy, this is just another type of emergency preparedness if the right message is put out there in front of the public, not only about the risk but the ability to do something about that.

HEALY: But do you think we have visualized a situation? How many people here know someone who died of the garden variety flu? We hear the number 30,000 people a year. Well, 30,000 in a hospital perhaps, but I'm talking about your next-door neighbor, people in your neighborhood. Typically that affects people who are often in nursing homes, the elderly, the frail, those with compromised immune systems. So what would it be like if everybody knew some young person, maybe in their own family, sort of the story that we were hearing this morning from Secretary Leavitt, the young person next door - you know, the five-year old that you were watching, babysitting for, the teenager who you were coaching at soccer, the young person who was a freshman in college - how many people recognize that a pandemic flu would be touching those people? And I'm getting back to this because isn't that what individual preparedness is? Is it knowing who you're trying to protect?

INGLESBY: Certainly, it's motivated by that. I think one of the things you're getting at is that if people have gone as far as imagining it with that clarity, which I think is relatively uncommon because it's very hard to do that and keep it in your mind - think about losing a child or a neighbor's child - they either put it in the box of the meteor hitting the planet and there's nothing that I can do and I hope it doesn't happen while I'm alive, or they put it in the box of presuming that the people who are smart and are dedicated and are working in the agencies of government and the healthcare system, are doing everything they can do, so what more can they add? I think that's a common thing that I hear all the time, and to some extent, the latter is true that people are always working as hard as they could.

But it isn't the case that the United States is doing everything that it could possibly be doing, if it believed that in fact 2 million people could die from a pandemic. And I think that the political question and the popular question should be are we basically limited at the moment by science and technology? Is that what's keeping us from having a vaccine or an anti-viral or some strategy that will lower the number from 2 million to 2,000? Is it a science and technology barrier or is it a political question? Is it basically we have not applied enough resources to the problem? There is a disconnect between the problem and the solutions that are being worked.

HEALY: Right, we're trying to be very practical. We're in the trenches. We want to –

BENJAMIN: Let's try to give the public some perception of what that means. They may not know influenza. But for every parent, think about the last time you heard about some kid in a college or a school who got meningitis – one case – and all of the activity around that one case. Now imagine 1.9 million of those. That's the scope we're talking about.

Think about what you did when you had one case and how you worried about whether you're going to send your kid to school, about the notices you got back to school, and then multiply that by thousands to millions. People haven't quite connected those dots.

But again, think about what they did when some kid in school got measles, and all the activity around that, or head lice - big event in schools. Not a lethal event, but think about all the activity around that. And then imagine a contagious disease. I mean, people get - haven't put the practicality around that.

You know, when your kid gets sick and you have to take off work and provide alternative care arrangements for that child and all of the things around that activity, that's a big event. Now imagine closing the school for three months. Now, we do that every summer and the world doesn't come to an end, but we send our kids to camp; we send our kids to other places. We have an alternative care arrangement that allows us to do that. But we haven't connected the dots and we haven't done all the out-of-box thinking to figure out what we would do if we had to close the schools for three months. I mean, that's the kind of thing we need to do if we want to try to get people's attention around this problem.

HEALY: And of course – and for younger children, that means our communities, right? If you're on the PTA - anybody on the PTA?

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Okay, would you take this – is that at issue, this being discussed at the PTA?

ATKINSON: It's not. But I think you can get a good –

HEALY: Why isn't it?

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ATKINSON: Well, it's a good question. And I think there are things around parents, for example. And I am a parent with three relatively young children, one in grade school all the way up through a college student – freshman – and when we look at that scenario, you are aware of the children who are killed in automobile accidents, and you become even more sensitized to seeing the kids that don't come home. You become aware of all those types of things that very much are in your life, and you're thinking about where your children fit in that context. We all know people who have been victims of cancer or other diseases that clearly come from causes such as smoking and other things in the public health arena that we have become more sensitized to. And I think this is just one of those examples of something that is a relatively new phenomenon, bearing in mind that most of the caregivers that are actively practicing today were not practicing in 1918, so people haven't seen it firsthand. They may have read about it; they know something about it; but they've not experienced this firsthand.

And it's very hard to get people to sort of come out of their shell, even caregivers, on a day-to-day basis because they're busy; they're overtaxed; they're trying to find solutions to very real problems that present this afternoon versus perhaps tomorrow. It doesn't make this any less important to talk about and do something about, but it's just very human to pay attention to those things that are right in front of you versus something that might be around the block. And it's like the tax process in this week of when you file your taxes. You might put it off to the last minute. It's not a good approach, nor is it safe, nor is it where we want to be in disaster preparedness, but it is human nature to do so.

HEALY: But is this something that should be on our list if we say four or five things that we're saying for tomorrow – preparing today for tomorrow? Is this something that needs to be brought to the individual, brought to the community? Or is this going to scare people?

KELLERMAN: Well, it doesn't do us any good to scare people. It also isn't any good to let people remain apathetic or indifferent. We need people to be determined. It's not just determined to take personal decisions and personal actions at the family level. But it is to engage local government, state government, and federal government to say are we doing the right things in the right way to meet the right threats.

I will offer the somewhat provocative observation that I think in the last several years, our government's single-minded focus with bio-terrorism has arguably left us less responsive or able to deal with terrorism and less able to respond to many biological threats because we have focused so narrowly on one class of agents that we have not taken the all-hazards approach we need in our hospital system, our emergency care system, and in our homeland security apparatus to respond to a whole range of threats from pandemic flu to a terrorist bombing.

HEALY: Although, isn't it true what we've been hearing all day is that start thinking individual – kind of what Dr. Benjamin just said - that government only can do so much; it's going to take a long time for the government even to get permission to come in; and you can't depend on the government – they have certain missions. You know, they will protect the borders; they'll help with rescue, but the government is not going to protect you. We heard Secretary Leavitt say that.

BENJAMIN: Yeah, I don't buy that argument though. One of the things I learned about being a health officer, both here in Washington, D.C., and in Maryland is if it looks like health, sounds like health, hurts people, it's yours. And one of the challenges is that while it is good to get people to engage in the personal and private planning, there are only some things that government can do. And government can provide consistency, government can provide guidance, government can provide funding. And so I'm hoping we're not hearing they're walking away from that responsibility. I'm hoping they're trying to spur us on to be more engaged.

But that means all parts of it. I think what Art was talking about was the need to – if you really want to have a robust health system, we know we have a hospital overcrowding problem. Let's fix it. The solutions are not hard. If we were an amusement park and we had waiting lines like we have right now to get into the front part of the amusement park, it would go broke and nobody would have a good time. And yet, we have a hospital system where people just order it up at the front door and we haven't done anything about the back room operations and getting people in. This is simple management. It's queuing analysis. It's simple common sense management, and yet we can't do that. Can government fix that? Sure - there are financial solutions; there are incentives; there are management tools. But if you really want to be serious about fixing this whole system, you need to do that.

INGLESBY: Bernie, can I answer your question before – should it be on our punch list of looking to the future? Absolutely, if getting the communities engaged results in particular actions, which I think they could. But, for example, getting back to panel two, I think someone was talking about how communities could help hospitals function in a crisis. When we're talking about pandemics, pandemics are going to go on and on and on. It's not going to be three days or four days -type crisis. So my sense is that communities are going to need to rely on all sorts of volunteers to provide medical care both inside the hospitals and alternate care places where people just need a bed and an IV, and in providing home care. So if you can organize your communities to do one particular thing, let's try and figure out how we take care of thousands of sick people at the same time, and get people organized around one particular purpose. I think that would be extremely useful and purposeful.

I'm a little worried about our over-reliance on traditional public health measures like washing hands and other things. I think this discussion about quarantining being some kind of panacea is completely off-track. And so again, I think that if you give - you don't want to falsely reassure people by saying, you, individual, you can take care of this yourself. I think communities can do a great deal themselves if they have particular things that they're trying to do - inform each other, tell people where they can get food and water, tell people about the power outages, which are going to roll - whatever it is, communication systems, provision of medical care. But to suggest that we can all individually become our own public health protectors, I think, is a little bit misleading, a lot misleading.

HEALY: Although in fairness, I don't think that was the message we heard, do you?

INGLESBY: No, but I think it's a message that you hear.

HEALY: Right, but I think what we were hearing today, even from Dr. Ben was that you just can't wait and hope that someone's going to come rescue you. I mean, there has to be some sense, and if everybody sees their part of this effort. And so, I don't think it's either/or, right? It's both. But, would you – yes or no – I mean, do you think that? It sounds like the government is talking a lot about this. Certainly, communities that have been hit are talking a lot about this, but is your next-door neighbor talking about it? I mean that's the issue. Are was as individuals falling down, or is that too harsh on we as individuals?

KELLERMAN: I think it's too harsh on we as individuals. I think the measure that we can take may help slow things down. The more we slow things down, the more time we have for effective counter-measures. But as Georges said, the best way to have a system to meet an extraordinary event, whether it's pandemic flu or an attack of smallpox, is to have a system that is functional, adaptive, and responsive on a day-to-day basis. Call me naïve, but I don't think government is some thing out there that we sort of hope it figures it out. We're government if we communicate and engage it, or we're not if we leave it alone. I think we can expect more out of our government at the local level, at the state level, and at the federal level. And we need to expect more from our institutions and organizations. Emory University is lucky. We have some of the best ex-CDCers in the country on our faculty. We've done an enormous amount of planning and organizational strategizing around pandemic flu over the last four or five months and plan to share that with every other health system in the country. That's a private enterprise-oriented effort. But it matches up with what you can do at the family level, and what we should be doing at the governmental level.

HEALY: Okay, let's go and look at the list of what family preparedness is all about. I mean, there are a number of things that we've heard about. And see what you – we hear about phone trees, having communication systems. In a time of pandemic, you would presumably have Internet – you know, we're talking about having supply of food and water and personal items for three weeks – at least for 72 hours. Are those things that people should be thinking about? Do you think that's being overstated?

BENJAMIN: No, it absolutely makes sense to do.

HEALY: But what percentage of the population do you think is –

BENJAMIN: Well, I think everybody should try to do it. I would think a very small percentage of the population has done it. And I think that one has to think about those preparedness kits in the context of where you live as well. So if you live in a flood area or a tornado area, your kits might be different; your needs might be different. If you live in a place that has huge snowstorms, your kit's going to be different. So you've got to put it in context of where you are.

ATKINSON: I think we hear from all the real-world cases, including terrorist attacks in New York and floods in North Carolina and hurricanes in the Southeast and earthquakes even that for the first 24 to 72 hours, in the best-case scenario, you're on your own, whether you're an individual, whether you're a community, whether you're a state. And that doesn't mean people don't want to help, but it takes a long time to connect the dots on where people have moved to, even if they shelter in place, where are they, where do you find them, what are their needs - communications lines goes down. The things we have heard and consistently today again, in those areas where I think government can help, the individual needs to prepare to take care of themselves including first aid courses and those things that are just common sense, not unlike civil preparedness in the '50s and '60s if you think about that. Very different perceived threat, but still the nation sort of ramped up about being prepared at the time, including shelters – construction of shelters.

Today, I would say that the things where government can help that we clearly recognize – you've heard it time and time again today – on communication systems that are hardened, communication systems that are not dependent on towers that can come down in storms, SAT phones - satellite phone communications, those things that are universal that are not necessary military in nature that you have to learn to use, real high-tech – the technology to communicate. But something that you can put in the hands of the house supervisor nurse that can communicate with public health, where other folks who have already got a busy life, but may have to all of a sudden be in the position at 3:00 in the morning to be the first officer to coordinate a hospital in this country before other personnel fall in to help, or the person that has to communicate with the police department or the fire department, groups that you usually don't communicate with in a normal situation. In natural disasters, we know that often comes too late. You're not even sure who to ask for if you were to call for help. But certainly in a pandemic when we want to discourage people to move around, I would think, communications from afar is something that could be very important because person-to-person contact is something you're going to want to avoid.

HEALY: So you're suggesting maybe having a list of phone numbers?

ATKINSON: A list and the technology that doesn't fail.

HEALY: But I'm talking about the individual access.

ATKINSON: Right, oh absolutely.

HEALY: I mean, you can have the tower that's up but if you don't know what phone number to call.

ATKINSON: Our emergency departments and our health and hospital systems in this nation spend a large part of their day dealing with people who have not used self-responsibility that put them in the place to be in that emergency department to begin with, including failure to put helmets on their kids on their bikes and those things that common sense should drive you to understand that it's an individual disaster waiting to happen when you ignore common sense when it comes to safety. And I think that's the same scenario here. Not everyone will think about that, nor can everyone afford to think about that. They may not have the resources to have that. But those people who can, I think we heard it said earlier, have an obligation to sort of take care of themselves because we need to turn the resources of our community to those people who are without, including those persons who perhaps have a handicap or some other thing that prevents them from being able to get out in a situation like this and fend for themselves. That's where communities ought to fall in to provide help.

HEALY: And what about masks? That's a hot issue this week. I know HHS just asked the Institute of Medicine whether or not masks could be reusable, if they were good for longer than eight hours – the N95 masks that people wear and the ones that became famous in Canada and in Toronto. And we saw pictures of people wearing even designer masks that had N95 capability. What do you think about masks? Should people have them in their back pocket or in their office or at home?

INGLESBY: It's a complicated question –

HEALY: I'm being very practical here, in the trenches.

INGLESBY: Practically speaking.

HEALY: Do you have a mask at home?

INGLESBY: No, we don't have masks at home, and I think for a pandemic, the problem is that you would – for it to be useful or sensible to have masks, you'd have to be wearing – if you were just going to put on a mask and hope that it would prevent spread, you'd have to wear a mask for prolonged periods of time. A lot of the masks that are out there we don't think would do anything to prevent the spread. It would have to be particularly fit, tested masks, which takes some time, has to fit well on your face.

It makes complete sense and it would be irresponsible not to have those for healthcare workers in hospitals. They have to have them. But for everyone to walk around for months wearing masks in a community - first of all, the mask-makers in the world –

HEALY: Well, I don't think we're saying that.

INGLESBY: They don't have them. We don't have those kinds of -

HEALY: But I think we have to focus it.

INGLESBY: Like for a day or two –

HEALY: I mean, you know, on the other side of Washington we just heard that, you know, someone has come down with a transmissible form of H5N1. I mean, think about what Dr. Low said on our second panel. What did he say? It was barrier that made a difference.

INGLESBY: In the hospital, but community-wide use of masks, I think there's a lot of debate about whether it's been proven to be useful anywhere. I think some people –

HEALY: Although people were wearing them on the trains and – what do you think, Dr. Kellermann?

KELLERMAN: I think that, as was said earlier, anything that can slow down virus spread may be of some use. But it's interesting you brought up the issue of Toronto. One of the key sparks that started the SARS epidemic was a second index case - came into an emergency department that was crowded, spent the night with a patient parked on their right, a patient parked on their left and staff moving in between, with what was thought to be community-acquired pneumonia. They infected both patients, who subsequently died, multiple members of the medical staff, and sparked that epidemic.

So masks matter, but so does having a healthcare system that can take people in the door, get them into isolation, handle the most sick appropriately, and provide effective care, and we don't have that level of resources today.

HEALY: Do you think people in emergency rooms would tolerate if we were getting closer to a major communicable disease outbreak, whether it's this or something else, to anybody who goes into a hospital having a mask put on them, because part of the issue is –

KELLERMANN: Sure, absolutely, and we do that all the time. We certainly did that during the SARS outbreak and we would do that in flu season.

ATKINSON: I think people come to hospitals with the assumption you're going to do what's best for them, and we hope that happens more frequently than not, but I think people are usually pretty reasonable about the advice they're given in that setting, and if not, you just have to deal with it in an enforceable way that's reasonable for the circumstances.

KELLERMAN: In fact, one strategy that I think there's some discussion about we have to work more on is helping people to know when not to come to the hospital, when not to come to the ER. Obviously if and when we have a major outbreak of influenza or another infectious disease, people who are getting symptoms and worried, the first thing they want to do is run to the doctor's office or run to the ER, but if they're not infected, they could leave that waiting room infected. So we need to give people access to Web resources, call lines, maybe even drive-by clinics where you can screen people and say, you need to come in to the hospital; you can go home with home care, and, again, try to keep people apart as much as possible so you don't inadvertently pass the disease from one to another.

ATKINSON: In fact, in the all-hazards approach that I think we're taking to disaster preparation around the nation, the concept is not necessarily to see the hospital as a destination at all for someone who may have something they perceive as minor. I think we think about anthrax and you look at the Senate building and other buildings when there's a microscopic level of presence, but we shut down entire buildings for long periods of time, appropriately so. The last thing you want to do is take someone that's been exposed to an agent like anthrax and introduce them to an emergency department and shut down a major hospital if there are alternative sites – if you realize it's not an injury and you can move them in that location. If we were dealing with a pandemic, alternative care sites, exactly like happened in 1918 - however we would do that - need to be one of the things we think about and plan for, and the separation of those patients that have the symptomatology of the pandemic from those that have other items because, as we know, in all disaster situations, the routine emergencies and acute needs continue also. People are going to have heart attacks, they're going to have strokes, they're going to have other things that need to be treated, and you just don't stop doing one emergency because other ones come along.

HEALY: I'd like to get back to something that – again, we're looking about preparing, in a very practical way, in the trenches, for what might happen six months from now, two years from now. And you mentioned meningitis on college campuses, and certainly that is something that is – in fact, you can go on the website of some of the university associations and they'll have plans for what you do if there's meningitis on a campus and it informs family members what to do and students what to do. Actually, I even saw one on SARS and how you deal with that in students coming from abroad.

Now, tell me, what about college campuses? We have, what, more than a million students on residential campuses. They're almost like they're in the military. They're all close together. Again, mentioning what I said earlier, they may be uniquely vulnerable to something like smallpox because they haven't been vaccinated, at least anybody under 40, or perhaps biologically sensitive to H5N1 – at least there's a hint of that. All right, when you do come up with a plan for college campuses?

BENJAMIN: Now. (Chuckles.) You know, the problem with college –

HEALY: Oh, we don't have it yet?

BENJAMIN: I know. The problem with college campuses of course is that, yes, they're living in the conjugal setting, but for those of us who can still remember – and although every year it's getting a little more tough, they share, they eat after each other, they drink after each other, and they share lots of things. And so college campuses are a real potential problem, particularly if you have a disease which preferentially strikes people at that age group. So it is a problem. And then you have people who you can't send them home. You have people here who are from in and out of state, and if there's transportation limitations – you have people here from other countries – you have a whole range of things that have to happen. And then of course you have the parents who have now decided that they're going to come to the campus and either stay with their child because they want to help take care of them, or leave campus with their child in a scenario in which you've said they can't leave campus because health authorities have said they can't leave campus, or parents can't come in. So you're going to have to figure all of those rules out. It is a big deal on a college campus.

HEALY: Now, I've heard it said from some people in the leadership of universities and colleges that, well, we'll just shut them down and send all the kids home.

INGLESBY: I think as a practical measure that would happen in a lot of places right now because the idea of trying to keep people in dorms I think would become indefensible pretty quickly. If there were actually a couple of cases in a dorm at University X downtown, I don't think the leaders of the university could keep going for some time. It may in the end not be useful in the event that the people who are going to get sick are going to get sick at some point in the next year anyway – we don't know that yet - but it might slow it down, it might give us more time to develop a vaccine, as Art was saying before.

So I think there would be a lot of closures, but your point to what is the standard operating procedure and what are the triggers for closure, and how do we communicate with parents and students about what's sensible is well taken, and probably not as well done as we should have done by now.

HEALY: Do you have a plan for that at Emory?

KELLERMAN: We actually do. Again, we've spent a lot of time in the last three or four months discussing this, and a campus like Emory that has a major medical center, lots of laboratories, lots of professional and graduate students, as well as international students, yeah, a lot of kids will go home. They'll want to go home, their parents are going to call them to go home, and to that degree you can shut the campus down, but you really can't shut the campus down. You have cell culture lines to maintain, a hospital to operate, clinics to run, and lot of students, like Georges said, who are from Europe or Africa or Asia, there's no way they can go home. And so we have to have plans in place to meet the medical needs of those kids, make sure their food service is maintained, make sure that campus security is there. You've got to do very, very substantial contingency planning now.

Now, if you do that for pandemic flu, then it will work for lots of other issues as well. So it's time and energy well spent. Our university has even made the commitment that even if there is a major disruption on the campus they're going to pay their personnel. We're going to take care of our own. We're going to make sure that the community stays together because otherwise the whole place will fall apart.

ATKINSON: I would agree. I mean, I think you have to – for any location, public or private, that involves large numbers of people, you have to have plans that are prepared to shelter in place all the way to send someone home, and to have that and to understand what that plan is – not to create a plan and put it on the shelf and never look at it but to understand it and understand the dynamics and to make sure that the rank and file officers of that organization understand it, because the "person in charge," quote, may not be there at 3 in the morning – most likely won't be – or they're on a weekend. And it has to be something that the people who can make a decision are in place to make that decision. They need to know the options. And I think it's always going to come down to the leaders, the defined leaders in that community, making a call when the situation is approaching, if you have pre-warning, or after it happens to make that call.

And the best example I can think of, certainly in the South – it may not apply to all parts of our country, but in the South is whether the superintendent makes a decision when it snows whether our kids are going to school or not and whether you're going to put buses on the road and whether it's too dangerous on the road to endanger kids from automobile accidents. I mean, that's what that's about. And that call is made at some time in the morning before the school day, and it's going to have to be the same scenario to decide what's best at the time, but whatever your answer is going to be, to have a plan to implement that, whether to shelter in place or to move those students or faculty or others to another location – quite frankly, the whole community. And there is no better example than what we saw in New Orleans, and what happens when you've got a bad situation and lots of people are trying to make decisions. You can see the hesitation.

HEALY: Now, from a public health point of view, suppose there is an outbreak on the campus. Can you send other students home? They're getting on airplanes and they're going all over the country.

BENJAMIN: Well, you know, public health authorities are going to make some decisions about whether people can leave or not. I mean, they'll do, obviously, a disease investigation.

One of the challenges we will have on a campus that large, at least early on, is trying to do some contact tracing, although that's going to go away pretty quickly. I'm not even sure contact tracing is actually going to happen in a pandemic situation, or even early on. There may not be very much of it. But it may turn out that the public health authorities have to shut down the campus but decide who can leave and who cannot leave, and they may have to put people either in isolation who are sick and who are quarantined in some kind of situation - and as Art said, someone is going to have to figure out how to take care of them.

HEALY: All right, now – okay, our young – our 22-year-old or 21-year-old is on a campus. They've had an episode of pandemic flu - you know, small cluster, one dormitory. Do you put all the other students and faculty and everyone on Tamiflu?

INGLESBY: If this is the first case in the country –

HEALY: No, no, no, we don't know yet.

INGLESBY: We don't know yet.

HEALY: You have to make a decision.

INGLESBY: So this is the suspected first case in the country?

HEALY: Yes. We called the CDC or we called Dr. Kellerman and he said, well, you know, the CDC is worried there may be one or two other outbreaks; we're not sure.

INGLESBY: On the books I think the policy right now is to use Tamiflu and antivirals for people who are sick, but I think if you actually had that singular circumstance where you thought you had the first one or two people identified, I think the policy would be to surround them with as much Tamiflu and try and prevent the spread.

I don't think most public health experts think that's the likely way for it to happen. I think we will discover it in our midst, more likely, but I think – if it was your scenario I think it's possible we would try and stamp it out. That's certainly one of the plans for Southeast Asia – we find some localized areas of person-to-person spread and millions of Tamiflu doses will be flown into the area.

HEALY: Dr. Kellerman, in the emergency room?

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KELLERMAN: If you have it, or if you can get it, and if it's effective, none of which any university or system knows today. I mean, we're all struggling with do you rely, as you said, on the government to send a push-pack? Maybe you don't. Do you try to order it on your own – thank you very much, will ship in two years when we get around to your order. Two years from now is it actually going to be effective or is this virus going to be resistant to it? It's a very, very tough bet. As Walt Orenstein, a former head of the National Immunization Program at CDC said, there is only one right answer to this epidemic: Do nothing and have nothing happen. That's not acceptable to most planners. So we're going to make our best guess and do the best we can and hope it's good enough.

INGLESBY: What did he mean by that?

KELLERMAN: Oh, he just meant the only way a politician can escape this situation would be to not spend any resources and have no catastrophe occur. If you spend a lot of money - many in this room will remember the political fiasco of swine flu. I still believe that people made the right decision at the right time, faced with an equally devastating prospect, and they got crucified for it because swine flu did not turn out to be the next global pandemic. So they paid a dear price for doing the right thing. If you don't take action and a terrible epidemic happens, then, boy, are you really in trouble then. So the only way you could get out of it if you were a federal official would be to get real lucky. But I for one don't want to rely on a faith-based initiative and pray that nothing happens. [Laughter.] I think we have to be ready.

HEALY: If you remember swine flu, which is a very interesting thing to bring up, you had Doctors Salk and Sabin, who were on the committee. They both told President Ford, this has got to be a presidential initiative; you have got to lead; we have got to get the public vaccinated. They went into production, they had the vaccine, and of course the side effects of the vaccine, the Gulliain-Barr&#eactue; and the neurological cases, made that backfire, in addition to the fact that the swine flu did not materialize.

Now, the person who really got the heat, which is what you said, is President Gerald Ford. In retrospect, was he right or was he wrong?

ATKINSON: You know, before I give you a quick answer on that one –

HEALY: It has to be short.

ATKINSON: – I think you've got to have courage to lead when people are second-guessing what you do. And whether you're an elected official, whether you're a health official, every day you make choices and those choices might seem bureaucratic but the reality is they –

HEALY: You've got to answer the question.

ATKINSON: Yeah.

HEALY: We're talking about President Ford, right or wrong. Was it the right decision, the wrong decision or should he –

ATKINSON: Right decision.

HEALY: What about –

BENJAMIN: Right initial decision, but the problem was they didn't monitor the situation and make a mid-course correction, which would have prevented them, probably, from going down that path.

KELLERMAN: Right decision. Jim Senser made the right decision as well.

HEALY: All right.

INGLESBY: I think the right decision. I think the extent to which they actually used the vaccine – to make enough – to make a swine flu vaccine on a crash course like that was the absolutely right decision. Whether to vaccinate to the extent they did, you know, that's kind of at the margins.

HEALY: All right, now, then let's get back to Tamiflu, and there is a broad issue that I want to raise here. If we look at – we heard the secretary this morning talk about Tamiflu and the stockpiling that the federal government is doing – HHS. Now, the reported numbers for Tamiflu – if you look at Europe, Western Europe, you will see that the numbers for stockpiling Tamiflu are in the range of 40 to 50 percent of the population. I think Switzerland, France, even Great Britain, they are pushing those numbers.

The United States right now, we're roughly at about 5 percent. By the way, many of those countries have already achieved that level of stockpiling. Now you can grant that, you know, Switzerland is small; it's not quite as big a deal, but 40 to 50 percent, here we're at about 5 percent. We heard this morning by the end of the year, the end of '06 we'll be at a – still under 10 percent. I think that would be 25,000 or 26,000 units, and by the end of '07 we would be up to 25 percent and we will level off there. Now, that's with the recognition, whether you're in Europe or whether you're here, that we don't know whether or not this is going to work, but at least the evidence – the WHO, the CDC, they're all saying it's sort of the best we have.

All right, now, does this say something about our country being more willing to accept risk? Is it that Switzerland and France and – they're less willing – that they're more security oriented, less – you know, they don't want to take risk to their population whereas we're a little more willing to take risk. Why the 5 percent/50 percent?

KELLERMAN: I think it's because we were more worried about bioterrorism than we were about pandemic flu. I think that's where we were putting our money and our time and our resources.

Mother Nature is one heck of a bioterrorist. Just look at natural history and look at biology. Western Europe focused on a different kind of threat. We focused on our threat. You know, who guessed right? Time will tell.

INGLESBY: Yeah, can I just respectfully disagree with Art? I understand the frustration. It may seem from a distance that that's the choice, that it's either pandemic threats that are natural or bioterrorist threats. I think that's the wrong choice. We're spending – the Wall Street Journal last year said – last week reported that the United States government is spending $1.3 trillion on new weapons systems in the next five years, and in the last two months, the inflation adjustment on that purchase went up by $40 billion.

The United States should be able to prepare for bioterrorism since we had an anthrax 2001 and pandemic flu at the same time. And the problem is that the people who are charged with doing in this in the government are very few. It's a new program. If you compare it to what the DOD program is for any particular – for fixed-winged aircraft or for bio-programs, they are completely off in orders of magnitude. We should be able to get a pandemic vaccine at the same that we are looking for an anthrax vaccine.

HEALY: Are we –

BENJAMIN: Let me agree with Tom on that.

HEALY: Okay.

BENJAMIN: We clearly we have to balance our portfolio. This nation spends money on what it wants to spend money on.

HEALY: I want to make it practical. Let's go back to Tamiflu. Should we be at 5 percent, 10 percent, 25 percent right now or by the end of the year. I mean, is that – if it's all we have for a while until the vaccines come in, what do you think?

BENJAMIN: I wish we were higher, but I think we – I think we don't want to give ourselves a false security about Tamiflu. Tamiflu isn't preparedness, whether you have 5 percent or –

HEALY: No, no, no, we are not saying – we are not saying that. But we are just saying there is such a disconnect between 5 percent and 25 and 50 percent.

BENJAMIN: Well, I think there is a disconnect that many of the other countries are pinning a core of their strategy around Tamiflu and I think we are pinning this core of our strategy around vaccine. We are spending a fair amount of money on the vaccines.

HEALY: But they are not either/or are they because Tamiflu might be preventive before you get your vaccine?

BENJAMIN: Well, they are not either/or, but the vaccine is central. A vaccine that is current and easily used totally changes the ballgame here, totally changes the whole event if you have an effective vaccine. So it really is the center of trying to respond to a pandemic.

HEALY: But we are talking about the surge, right, before the vaccine.

BENJAMIN: Well, that is true and all of it is about timing. If it was – if the disease occurred some place else and we were able to delay it and give ourselves six months, we know this thing comes in waves, we'll be able to do something about it, but it is truly about getting a vaccine, and we have – I think we have build our strategy around that more so than Tamiflu. You have got to remember also there is a huge risk of it being, the organism being resistant to Tamiflu.

HEALY: All right, now that –

KELLERMAN: Dr. –

HEALY: Yeah.

KELLERMAN: I just – I do want to point out, the title of this panel is "Preparing for the Next Disaster." And I do want to emphasize –

HEALY: Today, preparing today.

KELLERMAN: While we have spent a lot of time talking about pandemic flu and Tamiflu, et cetera, the next disaster might be an earthquake in San Francisco. It might be a Madrid-style transit bombing of multiple targets in Boston. It might be another hurricane in the Gulf Coast. And so I think that the all-hazards approach is absolutely fundamental, and you have got to have a healthcare system that can stabilized, absorb, and manage large numbers of casualties whether they are due to trauma, infectious disease, chemical exposure, or whatever, and that requires and infrastructure that works every day so it will work in an extraordinary circumstance.

That is not currently the case. That is well within our capacity as a people at the local level and at the national level and we'll benefit across the board; we will benefit for the next wreck involving your teenage child. We will benefit with the next heart attack involving a member of this room. We will also be better prepared for any disaster that comes down the pike if we take that kind of approach.

INGLESBY: Can I just completely second what Art just said, and in addition, say that as an indicator of how far out the inner circles of preparedness, the healthcare system is, of the $3.5 billion or so that was appropriated by Congress last year for pandemic flu preparedness, there is really no indication yet of any particular monies going to the healthcare system to prepare for pandemic flu, even though that is where all people would go for healthcare. So far it's basically off the radar screen as one indicator of hospitals not being at the center of preparedness.

HEALY: Which may be one reason why we might talk about it. Yes. Okay, we have some questions.

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Q: I am Jane Bourbon, and I have two observations/questions. The first one is that I haven't heard any reference here today to tapping into the resources of organized labor, not withstanding the fact that a lot of the first responders in New York were union members. They tend to be – unions tend to be fairly hierarchical and command-and-control oriented; they are really good with phone trees and stuff. And I don't know if reaching out will happen on the federal level, but perhaps on the state level something like that can happen. Unions have county labor councils and state federations and I think you would find them receptive to folks in medical care.

And then the other thing is I kind of get anxious when I hear a lot about individual responsibility because I start to think about guns. I think a big difference between now and 19 – between now and 1918 is how many folks are at home with firearms. I don't know if – words went around in California earlier this year that homeland security officials were having meetings with bank managers and the managers were being told that in the event of a national emergency, people would not be allowed to remove firearms and precious metals from their security boxes. I don't know if that is true; it's just what I heard and I'm a reporter by training.

I personally fear that in case of a big emergency, folks would go home and start drinking and cleaning their guns and then say –

HEALY: I don't think that is on our list. Why don't we –

Q: Well, Dr. Kellerman, what happens in the emergency room?

KELLERMAN: One of the most important groups that we have to make sure that we provide personal protective equipment to, anti-virals if necessary, vaccination, is our security personnel. I mean, working in the ER is a dangerous occupation. The key for any disaster is engaging and informing the public and doing our very best to prevent panic Purposeful, directed activity yes; panic no.