H1N1: How did things go, and what’s in store?
The initial mobilization for the novel H1N1 virus has transitioned into a longer-term, lower-profile — but ongoing — process. Many emergency operations centers (EOCs) or similar incident management tools have demobilized, downgraded or completely shifted the focus of their operations.
Is it over? Pretty likely it’s just the beginning, and we have no idea what or when the end is. We’ve learned a lot, though, and several of the lessons are not new:
• Plans, not just planning, can be useful.
• Plans are as good as the assumptions on which they’re based.
• When people feel threatened, they seek clear guidance from trusted sources.
• People will use just about any event, including a disease outbreak, to advance their particular agenda.
• The media’s collective breathlessness threshold is remarkably low, a reminder that the goal of providing a functional, consistent message is ongoing (see preceding two points).
• Photos of a toddler kissing a pig might be cute at first view, but get really old well before the 20th. (Those pictures, however, circle the globe even faster than the most contagious virus.)
After Katrina, the most popular aphorisms typically quoted military leaders past and present on the worthlessness of plans (plus or minus recognizing the value of planning). In some critical ways, the H1N1 outbreak was the anti-Katrina, in that a lot of agencies at all levels of government had developed plans – and proceeded to use them.
There’s no question that the planning process can be at least as useful as the product, but realistic plans do serve a purpose. Organizations that implemented their pandemic plans certainly found rough spots and surprises, and likely generated good-sized to-do lists for follow-up, but they also found that they didn’t have to make up everything as they went along. That’s one of the most important functions of a plan.
In short, a lot more things went well than poorly. Our partners in public health have a much better idea of what works and what doesn’t. Our school districts have a better appreciation of the need to coordinate with other agencies, and those agencies that didn’t already realize it have had a potent demonstration of how important it is to include schools in the planning and response process. Our population has a much greater appreciation of just how disruptive an unforeseen school closure can be.
Most of our pandemic plans assumed that the virus that generated the next pandemic would be avian in origin and would originate in eastern Asia. With that model, the world could be at WHO Level 6, a full-blown pandemic, before North America started seeing a high volume of cases. Plans would be implemented before a high caseload appeared within the U.S., and decisions on school closures and other non-pharmaceutical interventions would have a better chance of being implemented uniformly, or at least with clear, consistent guidelines and thresholds.
The North American origin gave us somewhat of a head start over that common model; we were aware that something was going far earlier in the progression than most plans assumed.
The downsides were that it led to the need for a lot of decisions in the absence of much actual disease information, and the media caught wind of it and held on earlier than they might have otherwise done, which led to a lot of anxiety.
On the other hand, if this outbreak had started in Asia, we may not have seen the level of infection that we did (as of May 24, well over 90% of the confirmed cases were in North America), and thus may have lacked the impetus to activate plans and ops centers to the degree we did.
Another assumption, or at least a concept, that took a hit was that of early containment. Even with a North American outbreak and rapid response, any confidence in limiting spread went out the window early. It’s certainly worth trying, but no one should count on it as part of their planning.
That did not stop some governments from quarantining Mexican nationals, or some U.S. pundits from proclaiming this a border security issue, the product of the assumption that the U.S. can “seal” its borders. It also left a lot of employers, healthcare providers, and school districts trying to make the best decisions they could in the face of public pressure, and without a lot to go on.
There’s no question that we saw a vastly improved level of coordination between the different governmental levels of public health, compared to the benchmark of the 2001 anthrax attacks. The right people were doing the talking, the messages were more consistent, and scientists did a much better job discussing uncertainty than has been done in the past.
Here in Oregon, a regional medical coordination center that had previously existed only on paper and in exercises stood up for real. A county EOC activated to support a public health emergency for the first time outside of exercises, and the state health department parlayed exercise and disaster experience (and, yes, a plan) into a leading role.
There is still room for improvement, however. As noted risk-communication guru Peter Sandman and others have pointed out, people can handle the truth even if it’s unpleasant, and we need to do a better job of being direct. Extensive research has demonstrated that people do not perceive risks in a linear, statistical manner, and that simply quoting statistics or repeating the same guidance on personal hygiene, even if the content is completely accurate, is not an effective long-term strategy.
The events of the past few weeks (yes, it really hasn’t been that long) have advanced significant portions of our state, regional and local preparedness, and not just in public health. An extended activation that everyone believes is “real” tests systems, plans and people in ways that cannot be done by training and exercises alone. Processes have moved forward at a far greater pace than they otherwise would have, and there is far more motivation, really a sense of opportunity, to follow up on what has been learned.