A tsunami of sick people has swamped hospitals in many parts of the country in recent weeks as a severe flu season has taken hold. In Rhode Island, hospitals diverted ambulances for a period because they were overcome with patients. In San Diego, a hospital erected a tent outside its emergency room to manage an influx of people with flu symptoms.
Wait times at scores of hospitals have gotten longer.
But if something as foreseeable as a flu season — albeit one that is pretty severe — is stretching health care to its limits, what does that tell us about the ability of hospitals to handle the next flu pandemic?
That question worries experts in the field of emergency preparedness, who warn that funding cuts for programs that help hospitals and public health departments plan for outbreaks and other large-scale events have eroded the very infrastructure society will need to help it weather these types of crises.
“There’s nothing really that can impact on a national level — or for that matter on an international level — more quickly than influenza,” warned Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota.
A dozen years ago or so, government officials placed pandemic influenza preparedness efforts on the front burner because of fears that a dangerous bird flu strain — spreading quickly across Asia at the time — might trigger a catastrophic pandemic.
Those worries were focused on H5N1, a poultry flu virus that infects few people but kills more than half of those confirmed to have been infected.
Then in 2009, the first flu pandemic in four decades did hit. But instead of bird flu, it was a swine flu virus called H1N1. There were not mass casualties. In fact, the global death toll was estimated at just over 200,000 — fewer people than the World Health Organization says die from seasonal influenza most years.
Pandemic influenza lost its big, bad bogeyman status. And in the years since, budgets for preparedness work have suffered.
“It’s true to some degree that we’re even more vulnerable now than we were at the time when H1N1 hit,” said Dr. Jeffrey Duchin, head of infectious diseases for the Seattle & King County public health department.
“We did learn a lot during the H1N1 outbreak about how to do things better,” Duchin noted. “But we haven’t invested in turning those learnings into action and better preparedness. … After H1N1, it’s pretty much fallen off the radar.”
Hospital and public health preparedness programs have sustained cuts in the order of about 30 percent in recent years, said Dr. Oscar Alleyne, a senior adviser with the National Association of County and City Health Officials, adding: “The level of funding is a concern to us.”
In the aftermath of the 9/11 attacks, Congress freed up money to help hospitals plan for and respond to mass casualty events, said Dr. Tom Inglesby, director of the Center for Health Security at Johns Hopkins University.
That has helped institutions respond to contained events — incidents like the Boston Marathon bombing or last year’s Las Vegas shooting, Inglesby noted. “But when you start scaling up beyond that and you introduce the variable of contagious disease, hospitals are pretty brittle,” he warned.
A modeling program called FluSurge developed by the Centers for Disease Control and Prevention to help hospitals plan generates some pretty sobering scenarios, he noted. In a bad pandemic, hospitals might have four times more people in need of a ventilator than they have ventilators, and far too few intensive care beds for the seriously ill.
“So there would be a big mismatch between demand for care, lifesaving care, and the ability to provide it,” Inglesby said. “We would have a huge problem in this country.”
The problem with influenza relates to the way it attacks, sickening large numbers of people in a relatively short period of time.
A hospital can plan for how much cancer care it will need to deliver based on the size of the nearby population and estimates of rates of various cancers. Affected people will seek care over the course of any given year.
But with flu, most of the severe illness happens in the space of a few weeks in any one location. The pressure that puts on a health system is exacerbated by the fact that some of the people needed to care for the sick fall ill themselves.
Getting help from elsewhere — as a community will often do in the case of a major medical disaster — isn’t really an option during flu epidemics, because other places are either dealing with their own or steeling themselves for a wave that’s about to hit. In the first week of this month, the entire continental United States was reporting widespread flu activity.
Osterholm noted that in the time since the 2009 pandemic, health care systems have been operating on ever-tighter margins, leaving them pressed to respond even to what are ordinary system stressors.
“Even before flu season struck here, our hospitals were struggling to cope,” Duchin agreed. “We have hospitals that have large numbers of patients living in the hallways routinely. … Flu season comes and it all gets worse.”
“These should be wake-up calls to us,” Osterholm said of severe flu seasons like this one.
But the inability to predict the intervals between flu pandemics makes it easy for officials to shift preparedness efforts into the “should do” instead of the “must do” column.
There were nearly 40 years between the 1918 and 1957 pandemics; then the 1968 pandemic hit 11 years later. And then there was a 41-year interval before 2009. There is virtually no way to tell when the next will occur.
If anyone knew for sure that the next pandemic was coming soon, then society would begin planning aggressively, Inglesby said. “But since we have uncertainty about the timing and severity of the next pandemic, we’re kind of in this relatively modest national effort to prepare hospitals, which is doing what it can with the resources available.”