Quarantine

The age-old response could be all that's left when the vaccines run out.

Facing the continuing threat of an influenza pandemic, a new hurricane season less than a year after Hurricane Katrina and the ever-looming possibility of bioterrorism, federal agencies are spending too little money and time devising nonmedical strategies for containing and responding to disaster, many experts say. For all the stock put in vaccines and other drugs-many of which are in short supply or have yet to be developed-government at all levels has focused comparatively little attention on enlisting citizens in responding to disease outbreaks and other public health catastrophes. These efforts, public health officials say, are an important supplement to medical therapies and, in cases where medicine is exhausted or unavailable, the only hope of containing an outbreak or other calamity. Without them, the risk is not just complacency, but a public response that exacerbates the spread and reach of a crisis.

"A great deal of attention, particularly by the federal government and certainly the lion's share of federal funding, is devoted to vaccine development and antiviral stock-piling," says Dr. Art Kellerman, professor and chairman of emergency medicine at Emory University's School of Medicine. "Nonmedical countermeasures . . . [are] not likely to stop a pandemic, but it can slow it down, and slowing it down may be crucial to keeping disease at a level manageable for a system already severely stressed."

Nonmedical strategies have proved crucial in wiping out disease. For example, in the 1970s, Donald A. "DA" Henderson arrived in Africa with a relatively small team and budget on a campaign to combat endemic smallpox. Henderson, now credited with leading the successful smallpox eradication worldwide, discovered an unexpected ally in his efforts to find and inoculate all those carrying the disease, one nearly as helpful as reports from the local hospitals: children. "What was truly remarkable was how much 9- to 12-year-olds knew what's going on in the community and are willing to tell you about it whether they were supposed to or not," Henderson said at a recent public health conference.

It wasn't just the children. Two-person teams sent to each village enlisted the help of the local religious leader, school principal and head villager in organizing the inoculation drive, and trained citizens to deliver the vaccines themselves. Despite an annual budget of only $2.5 million, Henderson's team in 1977 made smallpox the first disease to be wiped out.

The smallpox victory demonstrated that vaccines are not the only important element in reining in disease outbreaks. Science can only go so far. Then, defenses against infectious disease, bioterror agents and other public health catastrophes reach the threshold of human behavior, where nonmedical strategies, such as communication, psychology and citizen engagement, take over. For Henderson's team, involving the public was crucial.

Partnering With the Public

In the last four years, the Health and Human Services Department has spent more than $1 billion on vaccines and other therapies. The anthrax attacks of 2001 were followed in 2003 by Project BioShield, a $5.6 billion program of incentives meant to entice pharmaceutical companies to develop drugs to treat bioterror agents. Since then, HHS has awarded more than 10 contracts for vaccines and other therapies, and Congress and industry have criticized the department for not buying more.

There's no question that medical countermeasures are necessary and play a significant role in biodefense and emergency preparedness. Smallpox, for example, couldn't be stopped without a vaccine, says Henderson, professor of public health and medicine at the University of Pittsburgh Medical Center and former director of the HHS Office of Public Health Emergency Preparedness. And technology that aids early recognition of outbreaks can slow their spread. But public health experts say medical counter-measures are not the silver bullet they are sometimes portrayed to be.

Even if the U.S. vaccine industry was not ailing, as many observers contend it is, such products frequently take years to develop. For example, a California firm that was awarded a nearly $1 billion contract for anthrax vaccine in late 2004 announced in May that new delays will push back the delivery date to 2008 or 2009. And even if all 75 million of those doses are delivered, the government still would not have enough for widespread prophylactic use. What's more, many pathogens have vaccines of unknown effectiveness or no vaccine at all. In the case of a flu pandemic, the strain of influenza would not be known until the outbreak was recognized, which could mean limited or no vaccine availability during the initial months of the crisis.

Add in widespread worry that hospital emergency units are already at capacity and lack the ability to respond to a mass casualty event-in the words of a two-year Institute of Medicine study released in June-and you start to see the problem."For all the paperwork and all the documents and all the speeches, I haven't heard anyone in the federal government out of Health and Human Services or Homeland Security confronting the fact that we don't have enough [emergency room] capacity," Kellerman says. "It defies imagination spending money on sniffer stations and smallpox vaccination programs, but we're not doing anything [about hospital capacity]. . . . We can't handle a bad night of 911 calls in the United States today, much less a pandemic."

The Bush administration has floated military-enforced quarantine as an option in the case of a pandemic, although parts of the influenza plan the White House released in May acknowledged that the usefulness of such a measure is limited. Many health experts agree. Flu is contagious before symptoms appear, so a quarantine-which isolates individuals who have been exposed to infection but are not yet ill-would not stop an outbreak, only slow it, they say. "Quarantine is a concept perhaps 50 years out of date," Henderson says. "This is something we can happily set aside."

Instead, health experts recommend a variety of measures that fall under the umbrella term "social distancing"-strategies that limit how often or how closely citizens come into contact with each other. The White House influenza plan mentions some, such as closing schools and other meeting places; using face masks and other personal hygiene methods; widespread telecommuting; and "snow days," on which individuals or families simply stay home. But many public health experts say there has been little thought about how to implement these measures successfully. The devil, they say, is in the details.

"It's the law of unintended consequences," says Michael J. Hopmeier, a former adviser to the surgeon general and president of the consulting firm Unconventional Concepts Inc. with offices in Arlington, Va. He cites day care as an example. If schools are closed, parents who can't afford to miss work might turn to ad hoc day care in the neighborhood. "[They've] now taken [children] out of the organized, relatively structured and monitored, licensed and effective day-care centers," Hopmeier says.

He rattles off a list of nonmedical actions that could help slow the spread of a pandemic enough to ensure that the health care system can still provide for those who need it: wearing surgical masks; enforcing hand-washing and other hygiene guidelines in the same way smoking regulations are enforced; using more disposable items, more automatic doors and more automated sinks and hand-dryers in public bathrooms; keeping supermarkets open longer and holding discount sales at off hours to reduce the number of people in stores simultaneously; and increasing ventilation in public buildings.

Kellerman says hospitals have to take steps to ease emergency room overcrowding. One of the people most responsible for triggering the outbreak of Severe Acute Respiratory Syndrome in Toronto in 2003, Kellerman says, spent the night in an overcrowded ER and infected those seated next to him. "Yet we're still parking our patients shoulder to shoulder, ear to ear in America," Kellerman says. "They're still doing it in Toronto. That's crazy."

Public health experts and others insist these measures must be thought out in advance of a crisis and communicated effectively to the public. Lengthy government reports don't suffice, they say. "It's not good enough to post a plan on a Web site," said Elaine Chatigny, director general for communications at the Public Health Agency of Canada. "People don't [pay attention] in noncrisis times. That's normal. People have busy lives."

Chatigny was one of dozens of public health professionals attending the May conference in Washington where Henderson spoke. Organized by the Center for Biosecurity at the University of Pittsburgh Medical Center, where Henderson is a professor, the gathering focused on a broad form of nonmedical strategy: engaging the public directly as partners in emergency preparation.

"To grossly generalize, prior to the 9/11 attacks and the anthrax letter attacks, it was my sense that the public was typically represented in very stereotypical or monolithic terms," says Monica Schoch-Spana, a senior associate at the Center for Biosecurity. "They were the problem that needed to be managed, the crowds that needed to be controlled, the worried well that would wander into the hospital, that would get in the way of health professionals trying to do their jobs." After 9/11, citizens helped in relief efforts. Now many experts say leveraging the public is vital for fighting health crises.

The list of tasks that people with no medical training can do is long: visiting homes to make sure residents have evacuated; helping with debris removal; staffing mobilization centers, call centers and hot lines, to name a few.

Involving them is important not just to build up the capacity for emergency assistance, but to ensure buy-in. A pandemic or other large-scale crisis could force agonizing and morally complex decisions-how to distribute limited vaccines, ventilators or medical care among an excess of patients, for example-that are more likely to meet widespread acceptance if they were developed beforehand, with public debate, rather than on the fly in the midst of a crisis. "We don't make those decisions today," says Kellerman.

Success Stories

The news is not all discouraging in this realm of public health. Many experts say the issues are being discussed more than in the past. The Center for Biosecurity's May conference will serve as fodder for guidelines issued later this year by a working group chaired by Schoch-Spana. In June, HHS announced $1.2 billion in funding for states and localities to improve medical surge capacity and other aspects of public health preparedness. The Centers for Disease Control and Prevention last year tested citizen engagement, asking volunteers how they would allocate limited influenza vaccine and to whom during the initial months of a pandemic. The agency has funding to conduct a similar, national-level exercise on social distancing later this year.

And there is Citizen Corps, a Homeland Security Department entity that aims to coordinate local volunteers in crises. Citizens convene with businesses, nongovernmental organizations and emergency responders through city- or county-level Citizen Corps Councils, which encompass about 72 percent of the country. One of the Corps' biggest successes came last year after Hurricane Katrina, when the council in Harris County, Texas, produced 60,000 volunteers to set up a mini-city at the Houston Astrodome, where 65,000 Gulf Coast evacuees lived for three weeks. "What Citizen Corps gave them was a ready-made Rolodex . . . of people they could call upon very quickly to drill down into the community," says Liz DiGregorio, acting director of the Office of Commu-nity Preparedness in DHS' Office of Grants and Training.

That Rolodex produced more than 8,000 volunteers the first day buses began to arrive from the Gulf Coast, says Mark Sloan, who handles homeland security special projects for Harris County Judge Robert Eckels, chairman of the local and state Citizen Corps Councils. The group had a Web database of 20,000 volunteers whom Sloan e-mailed after learning that evacuees would be coming to Houston. Even he was surprised at the response, which he said was about 1,000 e-mails an hour. "The disaster was so far to the east of us, people still had lives going on," he says. "We didn't know who would show up."

More than 60,000 did. Those with proper training-including Citizen Corps members from other states-were put in key positions, such as supporting incident command, while others were happy to carry water, pick up trash, deliver food and listen to evacuees. In all, about 70 percent of the workers at the stadium were volunteers. "It pulls at your heartstrings when you see what citizens can actually do," Sloan says. "To watch people show up and wait three hours for an assignment and not complain."

Citizen preparedness is being integrated into more funding streams for states and localities and will be mentioned more prominently in the revised version of DHS' National Preparedness Goal, said Karen Marsh, Citizen Corps program director, at the biosecurity conference.

But public health professionals say such endeavors must be more top of mind.

DHS' 2003 instructions for families to seal a room with duct tape and plastic sheeting in the event of a chemical or biological attack were derided as evidence of an outdated federal mind-set. Critics called the approach reminiscent of the "duck and cover" nuclear bomb drills of the Cold War era, now considered to have been useless for those within range of a detonation. "I am concerned that the social science research that is generally being utilized for disaster planning is 50 years old," Rep. Bart Gordon, D-Tenn., wrote in a December 2005 letter to HHS Secretary Michael O. Leavitt.

A DHS report released in June found that most state and local emergency response plans insufficiently addressed mass medical care questions and other issues. Meanwhile, HHS funding for bioterrorism and emergency preparedness has dropped in recent years, and remains below what many public health experts say is necessary. The budget of Citizen Corps has dropped from $40 million in fiscal 2004 to $15 million in fiscal 2005, then bumped up to $19.8 million in fiscal 2006 (the White House request was $50 million). The Bush administration requested $35 million for fiscal 2007, but Marsh said at the Washington conference that Citizen Corps was "zeroed out" in the new House spending bill for DHS. "Regrettably, because we are new, we're competing with a lot of other programs on the Hill," DiGregorio says diplomatically. "Congress has not been so kind to us."

The funding news seemed to shock many at the conference. Proponents say the public health system has been ignored and allowed to deteriorate for far too long, creating a critical deficiency in the nation's ability to prepare for and respond to large-scale emergencies. "I believe that there's a strong reason for trying to develop our public health infrastructure so we're prepared to deal with any number of problems," Henderson says. "As evidenced in Katrina, we're not well equipped to do that."