H1N1: Why we are unprepared

We just published a paper in PLoS Currents: Influenza estimating what our ICUs can expect this flu season in the US due to the H1N1 pandemic. The picture is not pretty: about 300,000 extra patients needing assisted breathing from ventilators, and some of them requiring advanced modes of ventilation available only in specialized centers! Herein lies the paradox of this flu: by and large it does not cause a particularly severe disease, save in a small proportion of its victims. However, its contagion potential is high, and large numbers of the US population are likely to be affected (about 46 million by our estimates), accompanied by a large number of critically ill, thus potentially overwhelming the ICUs.

Here is how it fits into the overall picture of critical care in the US. ICU beds are perennially occupied, personnel numbers are shrinking and the volume of the sickest of the sick is growing at a clip 6 times that of all hospitalizations. Not to mention that 1/3 of all hospitals are financially in the red, and ~1/2 of all EDs are on diversion at some point (and, by the way, in the majority of these situations the reason for diversion is lack of ICU bed availability). Given that there are about 1 million patients on ventilators in the US annually, we are talking about a 33% surge likely compressed into a few months of the flu season! So what do you think is going to happen?

My friends on the ground tell me that we are not ready. Jeremy Kahn, MD, MS, Assistant Professor of Medicine and Epidemiology at the University of Pennsylvania School of Medicine and Senior Scholar in the Leonard Davis Institute of Health Economics, who happens to be one of the foremost experts on ICU capacity and regionalization in the US, told me that "we are woefully under prepared" for this pandemic. He is very concerned that critical care bed and ventilator supply will be outstripped by demand. But what concerns him even more is that "most municipalities do not have resource allocation or disaster preparedness plans in place". What this means is that we do not have plans in place to use the available resources optimally.

There are other ways in which we are unprepared. One is manifesting itself in our current national discourse on healthcare reform. The level of immaturity and selfishness in this "debate" makes me worry that we are not prepared as a population to make the tough decisions that have to be made during a disaster, which is what this pandemic is promising to be. Canadian Critical Care investigators came up with a protocol for their ICU resource allocation in case of a mass casualty event. This is an explicit scheme spelling out how prioritization is to take place. (Oh, yes, there will be prioritization). In a Society of Critical Care Medicine's podcast Dr. Randy S. Wax, a co-author of the Canadian protocol to triage ICU care during a pandemic, talks about this scheme. He uses the phrase "distributive justice". What this boils down to is that in the face of a public health disaster a bedside doc is responsible to the society at large even more so than to an individual patient. It is critical to have an explicit and transparent prioritization protocol, developed and put into place with full participation of community members. This is necessary as much for clarity and community buy-in as it is for protection from liability. The Canadian scheme has been available for 3 years -- have we heeded the call? Clearly not. And what is the Society of Critical Care Medicine doing? Well, to be fair, they have offered some disaster management courses. Now, at the 11th hour, they are advertising a web cast on September 17 at a cost of $65.00 for individual non-members!

So, where does all this leave us? As I said before, with our pants down! Is this sad state of affairs another reminder why we need a healthcare system devoid of the profit motive? A few days ago I reviewed a paper in the New England Journal of Medicine comparing Israeli preparedness scheme to ours. Some of the pivotal differences between our two systems are the centralized nature of planing and enforcement functions (they have it, we don't), competition between centers (they don't have it, we do), and the profit motive (they don't have it, we do).

Since it is too late for this pandemic to benefit from a philosophical and infrastructural overhaul, we need to have a realistic national plan. We have to do as much as we can to put plans into place that optimize the use of currently available resources. At the same time, prevention is clearly going to be the cornerstone of this effort. I believe that we need to be exceedingly aggressive with preventive efforts, including school and business closures, travel restrictions and the like. In fact, this may be a great opportunity to test to its fullest our communications web. It is possible that if we handle this potential catastrophe with some measure of common sense, we may gain useful insights not only into who we are as a community, but how our vast technological resources can make us into a more compassionate and efficient work force.

A narrowing window of opportunity

Catching up on last week’s journals, two seemingly unrelated pieces caught my eye: one in JAMA and the other in the New England Journal of Medicine. The one in JAMA talked about how the Israeli health system deals with mass casualty-related surge capacity, and the one in the NEJM focused on how growth of corporate medicine can benefit healthcare in the US. Juxtaposing these two papers made for an interesting exercise in gap analysis.

In their JAMA Commentary, Peleg and Kellermann point to evidence from studies by the Government Accountability Office, the Institute of Medicine and the House Committee on Oversight and Government Reform, that the US hospitals lack infrastructure and resources in case of a mass casualty event. The authors then offer a formalized schema used by the Israeli health authorities to address their contingencies for disasters. Their planning, testing and enforcement functions are centralized: a government body is not only held accountable for developing and testing the systems, but also is imbued with authority to demand compliance from the participating institutions. In the US, on the other hand, the responsibility for disaster planning is divided between the CDC, Homeland Security and the department of Health and Human Services, and none of these bodies monitors preparedness and surge capacity on the ground, leaving the hospitals themselves to take them on individually and voluntarily.

Turning now to the NEJM Perspectives piece by David Cutler, a grim, albeit not unfamiliar, picture of the US hospitals emerges: ¼ of all US hospitals operate in the red, with another 11% making a less than 2% annual profit margin. In the current financial situation Medicare and Medicaid increases don’t have a snowball’s chance in hell, and private third-party payers are steadily negotiating lower reimbursements. Of direct relevance to disaster planning, emergency departments are seeing 30% more visits than they did two decades ago, and among urban centers, those most likely to be affected by a mass casualty event, two-thirds operate at or over capacity. How does one prepare in this context?

Back to Israel. Three points are critical in the Israeli preparedness plan. First, they have a concrete blueprint for de-clogging the EDs, the central point for efficient and effective management of the sick. Do we? Second, Peleg and Kellermann also remind us that centralized coordination, so well designed and executed in Israel, is possible there partly because of universal access to healthcare: hospitals do not have the incentive to see insured clients over engaging in potentially less lucrative mass casualty care. Not so here. Finally, communication and collaboration between healthcare institutions are key to the success of preparedness efforts. In the US competition precludes such collaboration.

Let’s add the threat of H1N1 to this mix. Now, I am not a catastrophist, and I do not want to be perceived as Chicken Little of the 2009 flu season. I recognize that so far this flu seems by and large to cause less severe disease than its seasonal counterpart. What I am also appreciating is that this flu is highly contagious, so, despite a relatively low frequency of complications, their volume may be vast. These predictions are based on what we know so far, and, while they may not come true, we need to be moving as if they were certainty. If we do not, and they come true, we will be caught with our pants down and suffer more than just a red face. Yet no one is at the wheel coordinating a response to this likely event. If the EDs are operating at or over capacity and have no contingency plans, how do we expect them to provide adequate care this fall? If hospitals are having to let go of essential personnel due to financial difficulties, how can we expect them to care for 30-60% more patients coming through their doors with the flu? Although the Federal Government has allocated funding for institutional preparedness, no one has overseen its implementation and the math is not adding up.

The situation poses an obvious conflict between our collective need to be prepared and our societal fear of centralization, exacerbated by the healthcare system’s financial ruin. Further, our culture of individualism is driving absurdly self-centered discussions without any regard to the reality or application of wisdom to the upcoming potential disaster: not everyone will get everything. In fact, even if we had the will to implement a preparedness schema akin to Israel’s getting all of our ducks in a row, rationing during a pandemic would be mandatory. What will things be like when tough choices have to be made under the pressure of a chaotic situation, choices that we as a society are ignoring now, when there is time to approach them rationally? Why are we engaging in hysterical lies about government-sanctioned euthanasia instead of discussing this challenging and rapidly approaching reality?

Today in New Hampshire Obama appealed to our civility and common sense as a nation in our discourse on healthcare reform. We need to heed this message, turn away from demagoguery and focus on developing a roadmap for realistic scenarios of 5 patients competing for one ICU bed, of our EDs clogged with a relentless influx of casualties from H1N1, and of having to make end-of-life choices for our critically ill grandma because asking her about her preferences when she was well would have amounted to a Nazi execution.

Both, the JAMA and the NEJM papers offer solutions to the US problem of healthcare capacity and preparedness. These solutions require time and a culture shift. But time is short, and culture change before the fall is unlikely. Yet this is a teachable moment in which we need leadership. Mainstream media should lead this conversation without attention to their ratings and in more than sound bites. Treat us, the citizens, like intelligent adults, and we will rise to the challenge; treat us like spoiled children, and we will miss this narrowing window of opportunity.

Medical ethics in the era of H1N1: A need for a national conversation

In the UK the H1N1 pandemic is bringing to the forefront the public's concerns for healthcare rationing. In a recent article for the BBC news, Daniel Sokol, a medical ethicist, discusses the issue with frightening lucidity. He cites several probable scenarios and asks how they should be handled. For example, when 5 critically ill patients are "competing" for a single ICU bed, how should the allocation decision be made? Should it be on the basis of viability? Age? Value to society (that is, should a healthcare worker take precedence over another patient?) While he argues for transparency in such choices, he acknowledges the uncertainties inherent in our understanding of disease. Thus, a patient who is 99% likely to die may still surprise us 1% of the time and survive.

These are very thorny issues that we very well may get confronted with in this coming flu season. How will we handle them? The Brits at least appear to have the emotional maturity to start the discussion in explicit terms, so that they can wrestle with some of these issues before the 11th hour. Are we? In the US we cannot even seem to get beyond the demagoguery of grandma killings at this most important healthcare juncture. What will we do when we are actually confronted with having to make these very real and concrete choices? The culture of "me-me-me" will only impede us from electing the rational path.

The time to think through these conundrums is now because come fall and winter it will be too late. Revolts have been fomented over lesser issues; do we really want to leave this to the last minute? As a nation we need to take a deep breath, arm ourselves with courage and open our eyes and ears. Not everyone will be pleased with everything, but at least we will have a clearer idea of what we can expect and, perhaps, in turn this clarity will allow for better personal and societal choices. The press needs to help lead this discussion in a measured non-sensationalized way. This is our opportunity to grow up as a nation. If we do not take it now, the results may be more devastating than we can imagine.

Swift-boating the healthcare reform in the month of August*

Do you know the kids' book "Officer Buckle and Gloria" by Peggy Rathmann? It is a story of a police officer and his dog Gloria, who, as a team, go around the local schools giving such useful safety tips as "do not stand on a swivel chair". They are a big hit: they teach and make kids laugh, and their popularity soars to the point where a news team films one of their presentations. Watching it that evening on TV, officer Buckle has an epiphany about the etiology of their popularity: it is Gloria's charming antics, acting out his tips while standing behind him on the stage! Naturally, officer Buckle feels like a fool and slips into a depression and refuses further engagements, but it's OK, because Gloria is the real attraction, and she is still invited to talk, and she fails miserably without her buddy to the point that both she and her audience are depicted in the auditorium in a peaceful slumber. Z-z-z-z-z...

This is how I am beginning to feel about this whole healthcare "debate": z-z-z-z-z. The public is bogged down with worsening economy, the press are colluding with the Republicans in spreading mis-information, a la the Swift Boat gate. Members of Congress are day-dreaming about their summer recess, and the President is busy chugging Bud light at a teachable summit. So, among these doldrums, in walks Paul Krugman with his Nobel Prize in economics, and in a few computer strokes says as much as Tolstoy could say in a novel, and just as eloquently: Get your facts straight, you anti-government conspiracy-theory bile-spewing idiots! You owe whatever small amount of success exists in our current healthcare debacle to government regulation. Between Medicare and Medicaid, caring for the elderly and the indigent, respectively, and tax incentives for employers to cover their employees, while taking away their ability to cherry pick the healthy ones and rescind those with "pre-existing conditions", the government is already responsible for the parts that work.

This over-$2-trillion behemoth, and many of those feeding at its trough and promoting inefficiency, inequity and overuse, needs to be reined in! With the economy in the slump, and the US index of production, the GDP, continuing its nose-dive, our healthcare spending is continuing to increase, and I would not be surprised if it came in around 25-30% of the total GDP by the end of 2009. This would be a good investment, if the health of the population was improving. But with the rates of obesity on the rise, the threat of a tough flu season ahead that we are ill-prepared for, and fully 40% of the population carrying a chronic disease diagnosis, this does not appear likely.

So, let me reiterate a few points. If you worry about reduced incentives for innovation, don't: manufacturers' own risk-averse attitudes in response to market pressures have already squelched innovation. If you worry about the government getting into your affairs, don't: the role of the government will be well defined and limited to providing the funding and the tools necessary to make rational care decisions. If you worry about rationing, don't: we have a long way to go in cutting away the fat of unnecessary care before we get to the lean mass of what is useful and effective. And please, do not confuse "rational" with "rationing". Rational is what you will get if comparative effectiveness research is allowed to do its job. Rationing is what you are getting now from the suits in the boardroom who refuse to pay for your care.

So, as any doldrums, these too will pass. In the "Officer Buckle and Gloria", as you can imagine, officer Buckle sees the light and understands that he and Gloria are a team, and without him the schtick does not work. So, in the all's-well-that-ends-well fashion of children's books, the two friends get back together to the delight of their fans. Will our reality end well? I do not know, but what I do know is that without our involvement this healthcare schtick will not work. So, during the August recess we need to resist the slumber of summer and continue to pressure our elected officials to do the right thing: bring us quality equitable healthcare that will not bankrupt our children's future.

*I cannot take credit for this "Swift-boating" terminology, which I have respectfully borrowed from the Chairman of the DCCC, Chris Van Hollen