Martial Law And Quarantine?

by DemFromCT

One of the problems with being late to the table with pandemic flu planning (as well as allowing the public health infrastructure to deteriorate, so that survelliance, vaccination and other aspects of public health are not as routine as they used to be - when's the last time you got a tetanus booster?) is that the fixes for the problem become more drastic the later they are implemented.

Take using the military for enforcement of quarantine, for example. Unlike recruiting them for logistics and delivery of goods, at which they are very good, Bush's call for using the military to enforce quarantine skips steps A-Z and goes right to omega. There's been pushback to that from a variety of quarters, incuding this excellent op-ed in the Boston Globe today by George Annas from the Boston School of Public Health, who is an expert on quarantine law.

WHENEVER THE world is not to his liking, President Bush has a tendency to turn to the military to make it better. The most prominent example is the country's response to 9/11, complete with wars in Afghanistan and Iraq. After Hurricane Katrina, Bush belatedly called on the military to assist in securing New Orleans, and has since suggested that Congress should consider empowering the military to be the ''first responders" in any national disaster.

On Tuesday, the president suggested that the United States should confront the risk of a bird flu pandemic by giving him the power to use the US military to quarantine ''part[s] of the country" experiencing an ''outbreak." So we have moved quickly in the past month, at least metaphorically, from the global war on terror to a proposed war on hurricanes, to a proposed war on the bird flu.

Of all these proposals, the use of the military to attempt to contain a flu pandemic on US soil is the most dangerous. Bush says he got the idea by reading John Barry's excellent account of the 1918 Spanish flu pandemic, ''The Great Influenza." Although quarantine was used successfully in that pandemic, on the island of American Samoa, Barry in his afterword suggests (sensibly) that we need a national plan to deal with a future influenza pandemic. He said last week that his other suggestions were the only ones he hoped public health officials and ethicists would consider, but they read like policy recommendations to me and apparently the president. Barry writes, for example, ''if there is any chance to limit the geographical spread of the disease, officials must have in place the legal power to take extreme quarantine measures." This recommendation comes shortly after his praise for countries that ''moved rapidly and ruthlessly to quarantine and isolate anyone with or exposed to" SARS.

Planning makes sense. But planning for ''brutal" or ''extreme" quarantine of large numbers or areas of the United States would create many more problems than it could solve.

For anyone with knowledge of the 1918 pandemic, much of the initial response was dictated by the need to boost 'morale' in the midst of WWI. Wilson's administration refused to heed the advice of public health professionals and quarantire the large boot camps designed to train and ship soldiers overseas for the Great War. In one famous incident, a war bonds rally was not cancelled in Philadelphia despite the dire warnings of the  local public health officials that large gatherings would make things worse. But to cancel the big parade would simply be bad for morale.

Later, the bodies were buried in a mass grave using a steam shovel. True story. So when Annas writes:

What has not changed in the past century, however, is the fact that national flu policy will be determined by national politics. In World War I, as [John] Barry [The Great Influenza] recounts, this policy demanded that there be no public criticism of the federal government.

That policy was a disaster, and did prevent many potentially effective public health actions. Today's presidential substitution of a military quarantine solution for credible public health planning will also be counterproductive and ineffective in the event of a real pandemic. It would leave US citizens sick with the flu to wonder -- like the citizens of New Orleans told to go to the Convention Center and the Superdome for help -- why the federal government had abandoned them.

Public health in the 21st century should be federally directed, but effective public health policy must be based on trust, not fear of the public.

it really is a good idea to listen. That's especially so when the leaked CDC pandemic flu plan not only shows we're not ready, it includes what the NY Times describes:

If such an outbreak occurred, hospitals would become overwhelmed, riots would engulf vaccination clinics, and even power and food would be in short supply, according to the plan, which was obtained by The New York Times.

Hmm. Sounds like they've been reading Flu Wiki.

 

Comments

[DemFromCT]

Sounds like they've been reading Flu Wiki.

And if they have, they know planning goes well beyond just using the military. we have yet to see the published flu plan, and it needs to drill down to local and state officials to plan for a doubling of hospital beds, and plans to recruit and indentify those who survive the flu as emergency health workers. This is in addition to rebuilding the public health infrastructure. This is in addition to antiviral stockpiling and rebuilding the vaccination capacity, both manufacturing and implementation.

Neglected health care reform is going to come back and haunt us.

[DemFromCT]

P.S. Peter Daou wrote about the triangle, whereby blogs influence media which influences the politicians.

Check out:

Can flu guru do the job? Critics question his credentials.

[Tim]

Their plan is the same plan they've always used. In case of a pandemic, take care of their friends and use PR for everyone else. A military quarantine, while ineffective for public health, would be just what the doctor ordered to keep the rich and the powerful safe from the proles.
I'm going to guess that every Republican congressman spent the last week taking phone calls from every corporate lobbyist expressing the desire for Tamiflu priority and military protection for their upper levels in the event of a pandemic.

[emptywheel]

I've been contemplating a post today trying to really spell out the scandalous degree to which some tactical military movements in the first days of the Iraq were had everything to do with the fight between Pentagon and State, and nothing to do with military necessity, US interest, or Iraqi interest. And, on top of that, because of the way the Pentagon is riddled with influence peddlers, it was child's play for an Iranian double agent name Chalabi, a Filipino named Aragoncillo, and a US traitor named Franklin to interject the influence of forgeign governments into our military strategy.

Which is why it's all the more disconcerting that the only hammer they seem to have is the military. Honestly, if the military were still the fairly apolitical entity it used to be, military involvement might not be such a bad idea. But as it is, it's just a recipe for disaster.

[RonK, Seattle]

On NPR this morning, Daniel Schorr said something to the effect that Leavitt says they're getting an effective vaccine into production. Not sure where in the chain the misunderstanding sets in, but at this rate it's spreading faster than any human-adapted variant of the virus.

[DemFromCT]

The regular seasonal flu vaccine is done with production, so the companies are switching over to the experimental high dose avian flu vaccine previously reported on. Is it the right strain? Even if not, the Feds are counting on some partial protection. Within 6 months, there'll be enough for 10 million Americans (2 doses per person one month apart).

That leaves... let's see... 290 million people in this country unprotected.

[emptypockets]

Third most-emailed article at nytimes.com is about bird flu. People are paying attention. It feels like a sea change from a month ago, DemFromCT. Predictions? Will public interest increase, decrease, or stay the same in the next 6 months?

[DemFromCT]

Will public interest increase, decrease, or stay the same in the next 6 months?

well, we're discussing martial law, posse comitatus, a multi-billion dollar Federal effort, Bush's need to look strong and pre-emptive disaster-wise, a developing epidemic in SE Asia and a new relationship with the vaccine makers, not to mention insuffucuent vaccine and anti-virals.

I think it'll stay a hot topic. This isn't "summer of sharks". And since the pandemic isn't imminent (of major concern, but not imminent), there's plenty of time to keep talking about it.

[Mimikatz]

I also noted that in the latest Homeland Security bill they cut money for first responders. Funding first responders was something that would have made sense over the last 4 years for a variety of reasons, but those folks all belong to public employee unions, so we can't have that. Attack them instead of funding them, like Schwarzenegger does. Maybe prayer will be touted as the answer, just like it was in 1348.

And where are the intelligent design advocaters to explain how bird flu evolving into H2H transmission is going to be beneficial? Oh, I forgot. There is no evolution. If it wasn't there in that form yesterday, I guess it means it will never be so don't have to worry!

It is simply unbelievable how ideology trumps intelligence in dealing with public policy issues.

[DemFromCT]

it's core public health functions (surveillance, vital records, maternal and child health, substance abuse, communicable disease, immunization, etc., etc.) that have been shafted and need to be built up. First responders are part of that.

[emptypockets]

I have a few minutes to jot down some notes from a lecture yesterday by Robert Webster. Webster is a professor at St. Jude's Children's Research Hospital in Memphis. He is also the director of the WHO Collaborating Center for Studies on the Ecology of Influenza in Animals and Birds (what, birds aren't animals anymore?) and generally an eminence grise in influenza circles, I understand.

The title of his talk was, "H5N1 Influenza: Will it Achieve Pandemic Status?"

Overall, readers of fluwiki & DemFromCT's posts should feel they are well-informed. There was little material presented here that DemFromCT & collaborators have not made available on-line. Personally, I was surprised at how little molecular or mechanistic information there was. How does flu make us sick? Why is some flu worse than others, at the cellular level?Either Webster is not interested in those questions, or the answers are simply not available yet.

As I said, there was little new information presented, or I would write a nicer summary and try to contribute it in some way to fluwiki. As it is, there are just a few points and I think reprinting them as comments here is enough:

Webster outlined, essentially, three modes of prevention and treatment: agricultural (here I include quarantine), antiviral and vaccine.

Agricultural methods, he said, have been shown to work by Hong Kong. In 1998 Hong Kong banned ducks and geese from markets; in 2000 they instituted a single "clean day" each month when all markets would simultaneously be cleaned; and in 2001 they extended the market ban to quail. They now vaccinate poultry on all farms, and have had no recent outbreaks of H5N1. So, agricultural methods can control the virus.

Antivirals (drugs that inhibit virus spread) are of limited use, but better than nothing. He mentioned specifically oseltamivir, a neuraminidase inhibitor (neuraminidase being the "N" in "H5N1"). H5N1 remains sensitive to oseltamivir, unlike other antivirals, but only somewhat so -- it takes a longer treatment course to prevent death than it would with other viruses.

Vaccines are tricky because there is no natural nonpathogenic H5-type viruses one could use. To get around this problem, an artifical virus has been engineered using the hemagglutinin and neuraminidase genes (again, the "H" and "N" in "H5N1") from H5N1 and genetically engineering them into a nonpathogenic virus commonly used for vaccine production. This vaccine gives protection from H5N1 and also cross-protection from the Vietnamese variant of H5N1. (Possibly DemFromCT can help me with some of the nomenclature here.)

He specifically spoke about the policy question of whether to stockpile this virus. On one hand, the virus will drift and this vaccine will no longer give us immunity to it. But his reasoning was that we should stockpile it anyway, because it will at least give vaccine recipients a baseline immunity to the H5 antigen, which none of us have, that would likely mitigate the effects of infection even if it could not block infection altogether.

This was an important distinction I got out of the talk. A virus treatment can block death but not block symptoms. Likewise, a virus treatment can block symptoms but not block "shedding," or virus spread. In fact, the latter is exactly the case with a lot of the cheap poultry vaccines that are causing a lot of trouble in third world countries and may be a major reason why Indonesia is experiencing an increase in H5N1 outbreaks even while places like Hong Kong, which share the same migratory bird paths, get it under control: in Indonesia, and elsewhere, they are buying cheap vaccine that is ineffective -- in some cases it's enough to stop the symptoms and death of the livestock but not the virus spread. The result is that the farmers' ducks all seem fine and healthy, but when they come in contact with a chicken population you get a sudden huge outbreak.

There was quite a bit of other information I'd be glad to go through if anyone's interested, but the above are the highlights. Some of the rest includes information on the 1918 flu (I haven't been reading sites this week or I'd have known that the original 1918 virus has just been reconstructed in the lab); what makes H5N1 so different from other viruses (empirically, not molecularly); and what hangover cure to avoid when in southeast Asia.

[Melanie]

Emptypockets,

We do not, in fact, know how influenza makes us sick or even how the virus replicates. There are a lot of unknowns about this disease.

[DemFromCT]

Some of the highpoints of emptypockets' post can be found on Flu Wiki. For example, on the main page 'tip of the week' is a profile of Webster, who is very well known.

Nomenclature is found here. The thing about tamiflu and other meds is that it does not stop infection, it only helps with symptoms. Someone taking tamiflu is still infectious; hopefully they don't die (which is the point of taking it when you've got 55% mortality).

Also, vaccines may mean asymptomatic or mild infections with viral shedding still present. if you don't know which fowl are infected, it makes it that much harder to control. H5N1 may well be more common than WHO reports in Indonesia, for example, because mild cases don't get noticed.

[DemFromCT]

emptypockets, I take that as a compliment if you feel after listening to Webster that we've covered the basics correctly.

[YK]

It occurs to me that this quarantine stuff isn't a good thing from the military's point of view, either. It's definitely a more challenging mission than New Orleans was, because of the risk of contagion, and also because people aren't going to be happy when they're quarantined. Most soldiers aren't trained for police duty, which increases the chance of violence if people resist the quarantine. In some ways, this is almost a peacekeeping mission. It's nowhere near as hard as Iraq, but considering everything that's happened in Iraq, that doesn't give me much comfort.

[DemFromCT]

from the above link:

Robert Webster is currently in his mid-seventies, and much of that life has been spent battling and studying influenza. With all he’s seen, it’s significant that he’s made the following comments regarding H5N1:

This is the worst flu virus I have ever seen or worked with or read about. We have to prepare as if we were going to war—and the public needs to understand that clearly. This virus is playing its role as a natural bioterrorist. The politicians are going to say Chicken Little is at it again. And, if I’m wrong, then thank God. But if it does happen, and I fully expect that it will, there will be no place for any of us to hide. Not in the United States or in Europe or in a bunker somewhere. The virus is a very promiscuous and efficient killer.

[DemFromCT]

YK, quarantine may only set up the military to become ill itself. Taking tamiflu prophylacticly won't stop viral shedding and I'm not sure there'll be enough vaccine for the entire military.

That assumes drug runners, illegals and other under the table movements of people don't break the quarantine anyway.

[emptypockets]

Someone taking tamiflu is still infectious

From what Webster said, the one trick H5N1 hasn't picked up yet is the ability to transmit from (in the case of experiments) pig to pig and (presumably) person to person. My own understanding is that it becomes much more of a "doomsday scenario" if it picks up that ability -- and presumably that's what all this quarantine discussion is assuming, and that was the case in 1918. In terms of the virus we have now though, my understanding is that that isn't a problem (although antivirals that block death but not shedding are a damn fine way to select for just such a superbug.)

[Webster says:] This is the worst flu virus I have ever seen or worked with or read about

More on that sentiment, with data not just rhetoric, from Webster: this virus causes hind leg paralysis and death in ferret, their regular model system for testing viruses on mammals. Webster says he has NEVER seen this in a virus before -- EVERY OTHER influenza he's EVER looked at causes respiratory illness only.

This virus is also unique in his experience in that it kills its native host -- usually viruses only kill when they get into organisms they don't usually infect. That this virus kills chickens is not as alarming as that it kills ducks and geese, the aquatic waterfowl that would be considered its normal hosts.

I take that as a compliment if you feel after listening to Webster that we've covered the basics correctly.

Good, it was meant as one! :)

[4jkb4ia]

St. Louis vs. Houston on Yom Kippur?