Ready for the Worst? A Case Study of the Pandemic FluPolicy Recommendations Prepared by

SCUSA 66: Plagues, Peoples, and Power Roundtable

Humanity has a tendency to focus on the most terrifying, rather than the most realistic scenarios. As a result, the most threatening and plausible situations are often overlooked. Pandemic disease has the potential to decimate populations to a degree even higher than human conflict. The 1918 influenza pandemic alone killed approximately 50 million individuals, including nearly 675,000 Americans, and claiming over 30 million more victims than the First World War.1 While globalization has brought about a new era of prosperity and interdependence, increased interconnectedness presents new dangers for the spread of disease; an outbreak would have ramifications beyond loss of life. Considering pandemics, the worst case is simple: a deadly, infectious disease with the potential to devastate not only lives, but economic, political and social structures.

In order to prepare for a worst case scenario, parameters must be defined. A severe infectious disease has the potential to cause both disability and death in a population. Influenza, with a wide degree of mutability, can easily produce a new strain to which all populations are vulnerable. The ease of influenza transmission may exacerbate its lethality, leading to its spread across wide geographic areas. Using influenza as an example of pandemic disease with a strong likelihood of lethal mutation and a high degree of transmissibility, it is critical to analyze domestic and global ramifications and establish a policy response for disease crises in the United States.

Why Influenza?Likelihood & Lethality

The influenza virus is zoonotic, meaning its reservoir is in animal populations. Because of this, the virus will always remain present near human populations, even if it is not infecting people within the host population.2 Specifically in the case of avian flu (H5N1), the movement of poultry farms closer to the wild bird reservoir has drastically increased the likelihood the diseases will move and mutate into the human population.

Furthermore, countries that would be likely hosts to the origin of a pandemic flu, such as avian flu, have economic incentives to not prepare for the disease. Epidemiologist Sophal Ear suggested that countries in Southeast Asia like Vietnam, Thailand, and Cambodia would not vaccinate poultry for avian flu because it would target the agricultural lifestyle of low-income families. Instead, the governments rely on culling the populations because vaccinating poultry would be too costly and eliminate possible export due to health standards. As Ear noted, culling is not nearly as effective as vaccination.3 Globalization has become a modern phenomenon that

1 "Pandemic Flu History," Flu.gov, accessed November 14, 2014, http://www.flu.gov/pandemic/history/. 2 David Quammen, Spillover: Animal Infections and the Next Human Pandemic (New York, NY: W.W. Norton & Company, n.d.), 130.

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adds new dimensions to the virus transfer likelihood and speed; for example, diseased poultry can be traded across Asia, infecting humans around the world and starting a pandemic.

Additionally, international migration caused by poverty, overcrowding, repression, and economic failure has increased in recent times, expanding the probability for airborne virus transfer.4 Malnutrition, overcrowding, poor water and health standards, and large-scale migrations increase chances for virus transfer. Moreover, globalization has extended the interaction between groups with disparate health and sanitation conditions.

Annually, influenza kills as many as one and a half million people globally; past events have shown that this number can fluctuate drastically depending on the flu season.5 The most deadly pandemic in history was in 1918, when one fifth of the world was infected and over 50 million people died. The life expectancy dropped 10 years because many of those who survived the First World War were killed by the flu.6 While this H1N1 flu only had a 2.5% mortality rate, other strains such as avian flu, H5N1, can have a mortality rate of up to 60%.7 8 The flu is spread through respiratory droplets transmitted person to person through close or direct contact.Contact can occur by direct bodily contact (such as kissing) or touching something with virus on it (such as shaking hands with someone who has the flu) and then touching your mouth, nose or eyes. In 1918, 20% of the world was infected with Spanish Flu.9 Even with the advent of modern medicine, it is estimated that 25% of people were infected with the flu in 2009.10 In most cases, the flu impacts children and the elderly. However, influenza can also cause an autoimmune reaction in which those with stronger immunity see higher mortality rates.Burden of Disease

The burden of disease is a quantifiable measure for assessing the relative impact from a given disease. The World Health Organization provides one metric, the Disability-Adjusted Life Year (DALY)11 for quantifying the burden of disease from mortality and morbidity. A DALY is defined as the loss of one year of a healthy life. The cumulation of a populations’ DALYs therefore measures the total loss of life arising from a given disease. The equation provides the basic formula for measuring the DALY, where YLL is the sum of Years of Life Lost due to

3 Sophal Ear, "Avian Influenza: The Political Economy of Disease Control in Cambodia," Politics and the Life Sciences 30, no. 2 (Fall 2011): 7.4 Forum on Microbial Threats, ed., The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities.5 Jeffery Taubenberger and David Morens, "1918 Influenza: The Mother of All Pandemics," Emerging Infectious Diseases 12, no. 1 (January 2006), accessed November 14, 2014, http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article. 6 Billings, "The Influenza Pandemic of 1918."7 Taubenberger and Morens, "1918 Influenza: The Mother of All Pandemics.”8 Robert Roos, "Study Puts Global 2009 Pandemic H1N1 Infection Rate at 24%," CIDRAP: Center for Infectious Disease Research, last modified January 24, 2013, accessed November 14, 2014, http://www.cidrap.umn.edu/news-perspective/2013/01/study-puts-global-2009-pandemic-h1n1-infection-rate-24. 9 Roos, "Study Puts Global 2009," CIDRAP: Center for Infectious Disease Research.10 Molly Billings, "The Influenza Pandemic of 1918," Stanford University, last modified June 1997, accessed November 14, 2014, https://virus.stanford.edu/uda/. 11 "Metrics: Disability-Adjusted Life Year (DALY)," Health Statistics and Information Systems, accessed November 14, 2014, http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/.

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premature mortality arising from the disease and YLD the lives lost due due disability arising from living with the disease.

A pandemic such as influenza poses great burden on economical, political, social and environmental aspects of the Unites States. The following section will discuss these burden further and analyze what would “break” in this worst case scenario.

The Case Study: SCUSA Flu The case begins during the month of June in Mumbai, India. A poultry worker contracts

the SCUSA flu (a deadly strain of influenza named after several high profile deaths of SCUSA conference delegates) from a poultry market and spreads the virus to the public, including American servicemen participating in a joint military exercise with the Indian military.

Among the US military personnel is Case A, a Special Operations serviceman who proceeds to spread the virus to other personnel. Given that the incubation period of the SCUSA virus is 3-5 days, symptoms do not manifest themselves immediately, allowing the SCUSA virus to spread undetected. The symptoms of the SCUSA flu are similar to those of a normal flu; however the consequences are far more deadly. Those infected often do not seek medical treatment until it is too late.

Week 1: The service members return to the United States and disperse to densely populated cities such as San Francisco, New York and Dallas. Pockets of SCUSA flu cases begin to appear across the US, with infected individuals typically spreading the disease to 2-3 others. The mortality rate stands at about 25%, a devastating statistic similar to that of the 2009 swine flu outbreak.12 Included among the infectious are “super spreaders,” individuals who are highly efficient at spreading the virus without being symptomatic themselves. By the end of Week 1, there are approximately 50 reported cases in the United States. Because the Centers for Disease Control and Prevention (CDC) only provides influenza surveillance from October to May, they do not identify a pattern and insufficient data is collected.

Week Two: Healthcare institutions and workers are overwhelmed with a rise of cases of what they believe to be seasonal flu.

Week Three: There are now 450 people who have been infected, 100 of which have died. By the time CDC’s Epidemic Intelligence Officers recognize the crisis, SCUSA flu has spread to more than a dozen major US cities. The DOW industrial index has dropped significantly, and continues to drop throughout this crisis, creating a major economic downturn. Further contributing to the economic downturn is the mass panic created by inaccurate reporting by new media and sensationalist accounts on social media.

Weeks Four and Five: There are 2,000 reported cases, nearly 500 of which have resulted in death. Local and state governments begin to limit access to large gathering places including movie theaters, public schools, and restaurants as means of slowing the spread of the SCUSA flu. There are also strong measures to isolate the infected and quarantine exposed persons. Public transportation such as busses, subways and trains cease to run.

12 Roos, "Study Puts Global 2009," CIDRAP: Center for Infectious Disease Research.

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Week Six: Local, state, and federal governments continues to isolate and quarantine those infected and exposed to the SCUSA flu, and travel restrictions are implemented across the country. Maintenance of infrastructure such as highway repair and waste management have almost completely ceased. Ten percent of health care workers are infected, and hospitals are over-worked with both actual cases and potential cases. Temporary morgues become overwhelmed by the high death rate, and high school gymnasiums are set up as makeshift hospitals and quarantine centers.

Weeks Six-Twelve: Despite government and civilian efforts, at the end of two months there are 16,000 reported cases. The President and state governors declare martial law and curfews in selected locations, with interstate travel limited to emergency and military vehicles only. Riots over food shortage, pharmaceuticals, and other resources such as flu masks prompt a crackdown on civil liberties to maintain order.

Month Four: Two million cases are reported, equivalent to the population of Houston, Texas. The death toll is nearly 450,000. Vaccine development, largely outside of the United States, is in the final stages, with an estimated completion date in the following month. The SCUSA flu is continues to outpace vaccine development. Around the globe, the number of reported cases rises, with a death toll over one million. Affected cities include Hong Kong, Beijing, London, Johannesburg, Rio de Janeiro, Cairo, Dubai, Dhaka, and other highly populated cities.

Months Five-Six: Even though the vaccine is developed and delivered, the number of cases and deaths continues to rise in the US due to delays in prioritization and distribution.

End of Year 1: The SCUSA flu has killed over 30 million people.The global effort to combat the flu continues in full force, and the US and others are preparing for the next wave of the virus.

Impacts of Pandemic InfluenzaThis section will discuss the impacts of the SCUSA influenza pandemic. The economic,

population, infrastructure, and political ramifications of the outbreak will be analyzed through individual, domestic, regional, and global lenses. The impacts explored result from the worst case scenario and justify the necessity to establish a new policy approach for combating pandemic flu in the United States.Economic Impact

The economic impacts of the SCUSA influenza pandemic would have serious implications on a global, domestic, and individual level. At the global level, the closing of borders and the slowing of international transportation due to increased levels paranoia would threaten the world’s economy. From a security standpoint, checkpoints would be implemented at border crossings as a result of heightened border patrol activity. Governments could issue travel bans both to and from heavily infected regions. International trade would sharply decrease, as travel and transportation bans would prohibit the exchange of goods. This could ultimately lead to a global depression more serious than the Great Depression of the 1930’s.

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There would be a drastic decrease in productivity as the disease becomes more widespread and infects more of the working population. The American public would face shortages of both essential and nonessential goods. Lack of productivity translates into a smaller supply of products such as food and medical supplies. This would place a strain on society, and patterns of looting and hoarding would emerge as the demand for goods quickly outpaces the diminishing supply. The US will begin to redirect funds originally marked for international aid for its own use in acquiring these essential goods and maintaining order. The burden placed on the healthcare industry would be greatly increased due to exponentially rising case numbers. As a result, the government would need to provide financial assistance to this sector.

On an individual level, infected people will suffer loss of income for time they must take off work, which could cause financial instability and an inability to provide for their families. For those who do not have healthcare, this could also result in an inability to pay for any medical treatments they might need as a result of the pandemic. Even individuals who are not sick may choose to stay home from work and isolate themselves and their families to avoid any potential exposure. This Influenza outbreak will prevent individuals from working, and this will lead to the downward spiral of the global economy. Population Impact The SCUSA Flu outbreak also has the potential to have devastating ramifications on populations, from the individual to global scales. On the individual level, familial units will be heavily impacted as fathers, mothers, and children fall victim to the disease. The disintegration of families not only affects individuals on an emotional level, but leads to increased numbers of orphans; an increase in children without parents would heavily strain social services in physical and economical capacities. Individuals may also transition into survivalist mentalities, hoarding food, water, and weapons, leading to potential lawlessness and unrest. Similarly, in the face of crisis, individuals tend to engage in social distancing; for example, individuals stop attending football games and engaging in their communities to avoid contracting the feared disease. Domestically, civil unrest and crime rates are likely to increase as fear and panic set into populations across the nation. This situation is exacerbated by the media, which, in efforts to increase viewers, often emphasizes worst-case scenarios. For example, primarily reporting the most devastating and unlikely instances of disease. This, therefore, greatly increases widespread panic throughout the population. On a regional and global level, widespread pandemic influenza may lead to increased emigration and immigration between nations. Some states may run the risk of healthy citizens fleeing to nations suffering less heavily from the pandemic. Alternatively, individuals may seek to immigrate to nations with higher quality healthcare; this would not only spread the disease further, but would further strain health care systems that would likely already be overwhelmed.Infrastructure Impact

Apart from economic and social ramifications of pandemic disease, pre-existing institutional faults will deteriorate worsening conditions in both the United States and globally. Citizens lack of access to institutions which should provide relief, will instead cause further disengagement from the same organizations. The current United States healthcare apparatus,

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with an increasing focus on chronic illness as well as decreasing costs, will be unable to satisfy the quick increase in demand. Shortages of medical resources, including manpower, will overwhelm the health care system at all levels of care, from first responders to all levels of hospitals. Lack of human capital will effectively cripple other state institutions, most importantly, transportation. The inability of providing ambulances, firefighters and other first responders will aggravate an already stressed healthcare system. In turn, the difficulty in transferring supplies from one part of the nation to another will create greater disconnection between the individual and the state. Furthermore, availability of key resources such as energy and safe water will be strained by the absence of employees and reduction of productivity in these sectors.

Internationally, the possible infrastructural dilemmas will exist to the same or even greater degree. In nations with already weakened healthcare systems, the capacity to respond to pandemic disease will be sufficiently poorer. The assistance of non-governmental aid organizations will be overwhelmed by the increased need for funds and care. Aid response for those in need across the globe may be limited by reallocation of resources from nations facing their own institutional burdens. Political Impact

As a result of the flu pandemic individuals within the American population might feel disillusioned by lack of political effectiveness and disengage from political institutions. By disengaging politically, the individual risks falling into alienation from political bodies, extremism along political lines or complete lack of involvement in the political system. As the nation gets sicker, the reaction to the distribution of vaccines and the priority given to people groups who receive them first will raise concern and disagreement among the public. There are two ways this could be exacerbated. One, if the United States distributes vaccines to another nation but does not provide enough for their entire population, politically there could be negative ramifications like the breakdown of relationships between leaders or increased anti-American sentiments. Or two, if vaccines are shipped abroad to other nations before the entire U.S. population is vaccinated, the American public reaction will be negative. These political decisions will place tension on the individual as he considers participating in the political system. The role the federal government plays, not only in the allocation of vaccines, but their control over the decisions of the individual will be tested. On the one hand, the federal government has the option to enforce Martial Law and force individuals to take the vaccine. The federal government may face backlash from the state and local governments on the violation of civil liberty.

Between Canada, Mexico, and the Caribbean there will a breakdown of trust and communication, thus further isolating the United States from the rest of its neighbors. Countries will move to immediately close their borders to the movement of peoples both in regard to trade and travel. Globally, the political scene will be chaotic, seen with strained relationships between nations and political leaders. As political parties lose their population base, non-state actors will come to fill these gaps. The number of failed states will rise as infrastructures fail and populations drop. Violence between nations will increase as people push their state leaders to take action against those nations who do not share vaccines or threaten their states’ security.

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Lastly, foreign aid will be almost completely cut as countries seek to help their own citizens in the wake of such a large pandemic.

Policy Recommendations and Conclusion Domestic Policy

We suggest introducing incentives and increasing grant programs in order to (1) augment emergency hospital capacity, (2) develop state and local capacity to respond to natural disasters, (3) increase domestic vaccine development and production and (4) incentivize the creation of a strong critical supply transportation system.

(1) Emergency Hospital Capacity: Currently the CDC has eighteen to fifteen field medical response stations with a two hundred fifty bed capacity per unit.13 These stations are at various levels of readiness. We suggest augmenting the supply of field medical stations to five per one hundred thousand people in major urban centers. (2) State and Local Disaster Response: We propose bolstering existing communications

systems to establish a more structured chain of command as well as training first responders to work in this structure during natural disasters. We would like to see greater communication and coordinated responses between local, state, and federal governments. (3) Domestic Vaccine Production: We would like to promote American production of vaccines both as a means of returning business to the US, as well as hastening vaccine delivery time. Furthermore, we would like to provide grants to institutions researching faster vaccine development strategies. Additionally, we would provide incentives for companies who maintain production lines of emergency vaccines and pharmaceuticals.(4) Critical Supply Transportation System: In order to ensure efficient distribution of critical supplies such as food, water, and medication during an emergency, we suggest incentivizing private industry to invest in transportation systems. Such systems should deliver critical supplies to civilian homes to reduce the need to visit highly populated commercial areas (often hotspots for disease transmission). Additionally, we propose implementing higher bio-security standards at the nation’s meat

production and processing facilities. Given that the majority of diseases capable of producing a pandemic are zoonotic, it is crucial that we prevent spillover from wild reservoirs into the country’s beef, pork, and poultry production.14 This can be accomplished through mandating a larger distance between farms and wild areas, and providing better farm security, fencing, and sterilization procedures around animal pens.

Thirdly, we believe the creation of a reserve Health Corps will be crucial to the national pandemic relief infrastructure. The members of the Health Corps would be trained in disease prevention and detection, as well as the dissemination of pertinent disease information during crises. These reserve units will help mitigate sensationalist news in traditional and social media because they will be comprised of trusted local community members. International Policy 13 Lewis Chosewood, interview by the author, West Point, NY, November 14, 2014.14 Lewis Chosewood, interview by the author, West Point, NY, November 14, 2014.

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We propose strengthening multilateral partnerships with US allies for year-round disease surveillance. The cornerstone will be geo-sentinels, which are systems of selected health institutions that provide continued coverage of disease occurrence throughout the world.15 The program should also utilize big data such as real-time internet and point-of-sales purchases for better predictive powers.

Secondly, we would like to enhance regional emergency infectious disease response by enacting joint response exercises in North America. These joint exercises should address border security procedures in case of a pandemic. They should also establish zones for monitoring potential refugees before they can move into more permanent camps or local communities.

Lastly, we suggest early identification of regional disease hotspots to facilitate infection containment. As a part of this strategy, a proportional amount of vaccine (relative to the number of global cases) should be given to affected regions, with the philosophy that containing a disease before it can become a pandemic is beneficial to both US and international interests.

ConclusionThe threat of pandemic influenza poses the greatest threat to public health due to its high

levels of likelihood and lethality. The economic, population, infrastructure, and political ramifications of SCUSA flu would be devastating; in order to avoid these negative effects, we propose the implementation of the aforementioned domestic and international policy revisions. While our proposals will not completely eliminate the threat posed by influenza and other diseases, our approach provides a comprehensive framework for advancing public health and national security needs during a period of heightened risk posed by globalization.

Roundtable Members: CPOC Sean McQuade, Fernanda Andre, Cadet Don Stanley Dalisay, Sandra Kurylonek, Sarah Kader, Kimberly Bosse, Andrew Musco, Zachary Grieb, Allison Jeffery, Drew Ferraro, Derek Frank, Cadet Collin McCloy, Kimvy Ngo, Katheryn Scott, Katherine Telford, Joseph Dunne, Charlotte Lathrop, Michelle Serozynski, Stanton Skerjanec, and Cadet Allison Zablocky. Co-Chairs: Dr. Lewis Chosewood and Dr. Moise Desvarieux

Bibliography

15 "Public Health-Related Activities," Public Health Related Activities, accessed November 15, 2014, http://aspe.hhs.gov.

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Billings, Molly. "The Influenza Pandemic of 1918." Stanford University. Last modified June 1997. Accessed November 14, 2014. https://virus.stanford.edu/uda/. Chosewood, Lewis. Interview by the author. West Point, NY. November 14, 2014. Ear, Sophal. "Avian Influenza: The Political Economy of Disease Control in Cambodia." Politics and the Life Sciences 30, no. 2 (Fall 2011): 2-19. Forum on Microbial Threats, ed. The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities. Quammen, David. Spillover: Animal Infections and the Next Human Pandemic. New York, NY: W.W. Norton & Company, n.d. Roos, Robert. "Study Puts Global 2009 Pandemic H1N1 Infection Rate at 24%." CIDRAP: Center for Infectious Disease Research. Last modified January 24, 2013. Accessed November 14, 2014. http://www.cidrap.umn.edu/news-perspective/2013/01/study-puts-global-2009-pandemic-h1n1-infection-rate-24. Taubenberger, Jeffery, and David Morens. "1918 Influenza: The Mother of All Pandemics." Emerging Infectious Diseases 12, no. 1 (January 2006). Accessed November 14, 2014. http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article. U.S. Department of Health and Human Services. "Pandemic Flu History." Flu.gov. Accessed November 14, 2014. http://www.flu.gov/pandemic/history/. ———. "Public Health-Related Activities." Public Health Related Activities. Accessed November 15, 2014. http://aspe.hhs.gov. World Health Organization. "Metrics: Disability-Adjusted Life Year (DALY)." Health Statistics and Information Systems. Accessed November 14, 2014. http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/.

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