This article was originally published in Maclean's Magazine on May 18, 2009
Canada's Pandemic Influenza Plan
Canada's official "Pandemic INFLUENZA Plan" is 550 pages long, including glossary and acknowledgements. The few devoted readers who make it to page 371 - "Guidelines for the Management of Mass Fatalities" - will encounter a brief but blunt discussion about this nightmare scenario: if every funeral parlour in town is filled to capacity, what happens to the overflow of flu-infected corpses?
The local hockey arena (as long as it's chillier than eight degrees Celsius) could double as a makeshift morgue, the report says. So could a curling rink. But of all the possible storage solutions, the federal government's PANDEMIC playbook endorses one option above all others. "Refrigerated trucks can generally hold 25-30 bodies without additional shelving," the document declares. "To increase storage capacity, temporary wooden shelves can be constructed of sufficient strength to hold the bodies. Shelves should be constructed in such a way that allows for safe movement and removal of bodies (i.e. storage of bodies above waist height is not recommended)."
The "temporary morgues" write-up includes one other helpful suggestion: "To reduce any liability for business losses, municipalities should avoid using trucks with markings of a supermarket chain or other companies, as the use of such trucks for the storage of corpses may result in negative implications for businesses." In other words, even the worst pandemic will eventually pass - but a Loblaws rig rammed with body bags is the sort of image that never quite goes away.
Two months after surfacing in Mexico, the world's newest strain of swine flu is showing no signs of going away, either. At last count, the never-before-seen virus (officially known as Influenza A/H1N1) has killed 31 people and infected 1,500 others in 21 different countries - including 142 people in Canada. The global case count is climbing so rapidly that by the time you read this sentence, those figures will have doubled, if not tripled. Most infectious DISEASE experts now predict that it's only a matter of days before the World Health Organization concedes the obvious and declares a full-blown, "Phase Six" pandemic.
The Canadian government - to its credit - is prepared for the absolute worst. When senior health officials assure us that they have been anticipating this moment "for years," they are not exaggerating. Our country's pandemic road map - all 550 pages - is an exhaustive, methodical collection of what-ifs and what-to-dos that tries to imagine every conceivable scenario and answer every possible question. No detail, no matter how minute or how morbid, is left to chance.
Should people wear surgical masks in public? (No. They are "of limited effectiveness and may provide a false sense of security.") Should hospital volunteers be asked to provide a criminal records check? (Yes. And they should register with the provincial workers' compensation board, just in case they twist an ankle - or fall victim to "accidental dismemberment.") Should schools and daycare centres be closed? (Perhaps. But remember, "alternate arrangements will need to be made for child care, which may lead to 'gatherings' of children outside of the school setting thus contradicting the intended benefit of the school closure.") What about other types of indoor gatherings? Should theatres and subway trains be shut down? (Not recommended. "This type of measure may be feasible but compliance and sustainability might be difficult, especially because effectiveness is unproven. This is particularly true for gatherings and activities that are considered 'essential' and would cause significant societal disruption should they be discontinued.")
And what if there aren't enough temperature-controlled trucks for all those corpses? "Mass burials or mass cremations," the report says, "would only be considered in the most extreme circumstances."
Thankfully, we're not there yet. Not even close. In fact, as ominous as it sounds - Phase Six Pandemic! - the term itself is more about geography than severity. The WHO designation simply confirms that there is sustained human-to-human transmission in two regions of the world (North America and Asia, for example). It doesn't mean that millions of people will inevitably perish, as in 1918. Scientists are not even sure if this latest strain is any more potent than your everyday flu.
But it's that fear of the unknown that has the public so petrified. Because this virus is so new, and because humans have no natural immunity, it's entirely possible that it will mutate into something far nastier than anything the labs have ever seen. And according to estimates contained in Ottawa's master plan, a pandemic of "mild to moderate" severity could sicken 10.6 million Canadians, send 138,000 to hospital, and kill up to 58,000. Left unchecked, a "severe" pandemic would be catastrophic, killing up to two per cent of the population (more than 700,000 people). As the authors put it - in typical deadpan fashion - the country's health care system would be placed "under extreme stress."
Sticking to the blueprint, the first thing Canada would do at the onset of a pandemic is "scale back" its surveillance. That may sound counterproductive, but once the new flu virus has spread into the community with relative ease, it is futile for authorities to try to keep track of every single patient - not to mention every single person who came into contact with that patient. "Once a pandemic has been declared, you would be fooling yourself attempting to contain it," says Dr. Gerald Evans, an infectious disease expert at Queen's University and a member of the pandemic-planning committee. "It now becomes a matter of mitigation. It's here, let's do everything we can to reduce the levels of transmission, and start devoting our resources and our time to treating people who are afflicted."
That is easier said than done. During an especially harsh outbreak, Canadian hospitals would endure an unprecedented surge in visitor traffic, forcing them to cancel non-emergency procedures (hip replacements, for example) in order to free up all available resources. Some overloaded emergency wards may have to ship patients to temporary facilities, such as a hotel or a church. (Again, the report recommends selecting such sites well in advance). Adding to the chaos is the inevitable fact that up to one-quarter of all health-care workers could be home sick at some point during the pandemic. According to the plan, health departments should anticipate that shortfall and aggressively recruit reinforcements - from med students to veterinarians to pharmacists. "Retired and foreign-trained personnel may be asked to step in."
Patients who step into a waiting room will notice something else: no magazines or toys. Such items are notorious for spreading infection. (If this is your copy of Maclean's - and not the one in your doctor's office - it still wouldn't hurt to wash your hands.)
Though excruciatingly thorough, the bulk of the federal pandemic plan is the stuff of common sense. Antiviral medication has been stockpiled, with up to 55 million doses of Tamiflu available for distribution. Hospitals in "bordering jurisdictions" should co-ordinate their action plans to "avoid migration to centres of perceived enhanced services." And if you're sick and sneezy, stay home.
The report also cautions against the kind of knee-jerk reactions that do absolutely nothing to protect public health (i.e. the Mexican army distributing blue masks on the streets of Cancun). In times like these, many cities rush to install extra soap dispensers in public places in the hopes of encouraging hand washing. Though commendable, such measures are expensive and unsustainable, and "may give people a false sense of security." Same goes for bolstering the number of cleaners at an office building. Unless a janitor is wiping a door handle - or the elevator buttons - after every single touch, hiring more staff is not worth the effort or the cost.
Travel restrictions and border closures are equally pointless, especially once a pandemic is declared. Governments have every right to urge citizens to avoid non-essential travel to a certain country, but an all-out ban does little else but stoke public anxiety and hammer local economies. Besides, many people will decide on their own whether to go ahead with their vacation plans or postpone that business trip. If anything, your flight will be cancelled because so few people bought a ticket - not because the government said so. "I'm going to Argentina next week, and I have absolutely no worries about it," says Dr. Andrew Potter, an expert in vaccine development at the University of Saskatchewan. "But one never knows if Air Canada is going to be flying there next week."
Indeed. As our influenza playbook accurately points out, "pandemic plans need to be flexible in order to be useful," and "it is not feasible to completely plan for every possible pandemic scenario." There are just so many unknown factors that are impossible to predict. Could the stock markets weather a full-fledged pandemic? Will standard services - from garbage collection to Internet connection - grind to a halt as droves of people call in sick to work? Will your neighbourhood grocery store have enough food to go around?
Or will the fleet of delivery trucks be needed somewhere else?
Maclean's May 18, 2009