On what to expect when you are expecting a Pandemic

The Covid-19 Coronavirus was a predictable catastrophe. A novel viral pandemic is likely to inflict significant damage on human society. Individual immunity is unpredictable. That means that every person who randomly contracts the virus might randomly survive or perish. According to Michael Osterholm, in a pandemic, over the course of the year, up to 50 percent of affected populations could become ill and as many as five percent could die. How we deal with that is Osterholm's main concern in Preparing for the Next Pandemic, published in Foreign Affairs in 2005. Osterholm raises issues that have not yet made it into our minds. While we worry about hand sanitizer and try to avoid touching our faces (all of which are categorically imperative to reduce the spread of the virus), there are big questions that would serve us well to ask ourselves.

Should we provide medical supplies and equipment to patients on a priority basis? If five percent will die but the society has the choice of who lives, should society make that choice? Osterholm suggests we should decide in advance how that triage would look.

The World Health Organization addresses this question very gently in its Influenza Risk Management Guidance:

Preparedness planning for an influenza pandemic involves balancing potentially conflicting individual and community interests. In emergency situations, individual human rights and civil liberties may have to be limited in the public interest. However, efforts to protect individual rights should be part of any policy. Measures that limit individual rights and civil liberties must be necessary, reasonable, proportional, equitable, non-discriminatory and in full compliance with national and international laws.

Ethics do not provide a prescribed set of policies; rather, ethical considerations will be shaped by the local context and cultural values. The principles of equity, utility/efficiency, liberty, reciprocity and solidarity are especially helpful in the context of influenza pandemic preparedness planning.

For example, the principle of utility suggests that resources should be used to provide the maximum possible health benefits, often understood as “saving most lives”.

If we would intend to save a young mother of four and let die an old man with dementia, we ought to understand what we are doing before this hits. Among other resources there are four areas of concern:

1. Antiviral medications and vaccines - both will be in short supply; a vaccine may not be available for up to 18 months.

2. Antibiotics - While Covid-19 is a virus, it is the secondary bacterial infections which often kill patients.

3. Ventilators - If supplied a mechanical ventilator many patients will eventually recover. Ventilators are expensive and society cannot afford to keep enough on hand to manage a surge in demand.

4. Doctors and Nurses - medical professionals will suffer N increased risk of infection due to their high-volume exposure to infected persons. They will die at a greater rate than the general population.

The population explosion in China and other Asian countries has created an incredible mixing vessel for the virus. Consider this sobering information: the most recent influenza pandemic, of 1968-69, emerged in China, when its population was 790 million; today it is 1.3 billion. In 1968, the number of pigs in China was 5.2 million; today it is 508 million. The number of poultry in China in 1968 was 12.3 million; today it is 13 billion. Changes in other Asian countries are similar. Given these developments, as well as the exponential growth in foreign travel over the past 50 years, an influenza pandemic could be more devastating than ever before.

A random distribution of the scarce resources above will likely cause us to lose individuals who we would choose to keep like the mother of four. Likewise, a highest bidder approach, that would favor the wealthy at the expense of the useful is inefficient. Given the possibility to choose who takes priority of treatment society has for now abdicated the responsibility of choice. Sadly, as Rush so eloquently put it, if you choose not to decide you still have made a choice. For now, it looks like a first come first served random distribution. I asked a doctor what he thought we should do. He said no politician would have the courage to identify priorities. The politician would be afraid of liability. Instead the social choice is outsourced to the individual physician. Society says, "treat who you can" and the doctors will interpret that mandate as best as they can.

About doctors, Osterholm also explores the possible response to a surge demand for treatment. He suggests that the hospitals will be insufficient for the need. High school gymnasiums, arenas and other public assets may become field hospitals. As for the medical workers, he suggests there will not be enough of them to treat the patients. "Volunteers who are naturally immune as a result of having survived influenza infection would thus have to be found and employed. That means that the medical community's strong resistance to using lay volunteers, which is grounded in both liability concerns and professional hubris, would need to be addressed."

Finally, the question of handling the bodies. If New York City suffers 100,000 more Covid-19 deaths in a short span, our approach to death, mourning and burial will be impractical. This fundamental aspect of grieving may be lost, hardening our collective heart just a little more.

I encourage you to find this article and read it. If you are one with influence in your city, state or company, share it with others. We need original thinking now more than ever.

I will leave you with this lyric by Eugene Hutz: "you are the only light there is, for yourself, my friend."