By definition, a pandemic affects a vast geographic area and a huge number of people. Avian flu would spread fast and easily from person to person (especially in buses and other confined public spaces), since it is contagious before symptoms develop. By the time the first victims appeared, epidemiologists would have to presume that the flu had already spread far and wide.
Every community in America would go on red alert. At that point, the federal government "can't come in and take over," Libbey said. "The math alone just doesn't work." The federal role in such a pandemic would be largely policy-oriented and advisory, Libbey and local health officials explain. The Centers for Disease Control and Prevention would issue technical advice to health care workers, such as what symptoms to watch for in the population, how to administer a vaccine or an antiviral, and which groups of patients should receive treatment first.
The government would also distribute the vaccine -- although one doesn't yet exist for the H5N1 strain of bird flu that would likely show up here -- and would provide extra emergency medical supplies, when possible. The Health and Human Services Department, for instance, would undoubtedly tap its emergency stockpiles of medical supplies that are pre-positioned in secret locations across the United States.
But beyond all that, the federal government can't provide much tactical help. "It's every community for itself," says Gary Oxman, the health officer for Multnomah County, Ore., which includes Portland. This comes as no surprise to local officials. Ever since the 9/11 attacks and the October 2001 anthrax mailings, communities have been gearing up for a bioterrorist attack, the effects of which could mirror a flu pandemic. In the process, they've taken a hard look at their own limits.
The Portland metro area has about 3,500 hospital beds, Oxman says. Officials have been planning for an emergency surge of 1,000 to 5,000 patients. Public health workers can provide "first-class care" to 1,000 people, he says. If 5,000 people got sick, they would still get care, but in a more rudimentary fashion. School gymnasiums might be converted into patient wards; "lower-intensity" treatments, such as delivering fluids and urgent care, would replace more sophisticated and individualized regimens, he says.
The modern public health system has dealt with disease outbreaks only on a localized level, says Dr. Georges Benjamin, the executive director of the American Public Health Association. The country has seen "pockets" of anthrax or monkey pox, and health agencies have responded to large food-borne outbreaks of hepatitis A, he says. But a flu pandemic would stretch the public health system to its breaking point, and probably beyond. "A pandemic's going to be a catastrophic nightmare. What we're going to be doing is trying to make it less of a nightmare," Benjamin says.
The federal government could mitigate the severity of a pandemic by setting standards for pandemic care, and by helping local officials understand the circumstances under which they should take dramatic action. For instance, when should a hospital cancel all elective surgeries, or move less-infirm patients out, in order to free up space? "We need federal standards for care," says Dr. Howard Backer, the interim state public health officer for California. Today, states and localities "have gaps in all our major areas of response," he says.
Few local hospitals have the "surge capacity" to take in thousands of extra patients; and even if they did, no stockpiles of flu vaccine exist, and supplies of antiviral treatments are inadequate, Backer says. While state and local officials have been taking what steps they can to prepare for avian flu, they've been eagerly anticipating a national preparedness plan to tell them how to seal up those gaps.
But plans get you only so far. "Now the challenge is, how do we make a policy plan into an actionable plan," Libbey says. "And that's the role that the local [government] ultimately plays."
He contends, "Local public health will indeed respond, and it will probably respond better, based on its experience of the past [few] years." But, Libbey adds, the public health system generally is anemic, and hasn't yet ramped up to the level of readiness a bird-flu pandemic demands. If the flu arrives in the very near future, "we're looking at a potential scale that will outstrip [the system's] capacity."