Now vs. 1918: Looking beyond the obvious
December 28, 2006
A couple of days ago, I noted that some people believe we're much better equipped to deal with a pandemic today than we were in 1918. Some even think a severe 1918-scale pandemic is not possible. I think it's dangerous to make that blanket statement. In fact, some of today's conditions may put us at a disadvantage.
Those who think a severe pandemic can't happen again happily note that we have much better medical knowledge and resources than in 1918. It's been pointed out, however, that it doesn't matter if we have modern medical tools, if we can't deliver enough of them when and where needed. A pandemic will cause a surge in the need for health care. But our "surge capacity" is limited.
As I wrote last month, sickness-related issues - like avoiding sickness, treating the sick, and coping with an overloaded health care system - deal with the most direct consequences of a pandemic. We don't want to make the mistake of just thinking about the direct effects of a pandemic - those which are more readily visible. Rather, we need to look downstream at the relatively hidden indirect effects - the ripples, the domino effects.
In this post and the next, I'll address some of these secondary impacts, to wit:
- Today, supply chains are long and fine-tuned, depending on a just-in-time flow of goods.
- The delicate balance of modern medicine. It provides life-giving care to people who have various medical conditions. But to do so, it depends upon an ongoing flow of medical products and services.
- The ripple effects of a modern pandemic on commerce and daily life.
- Demographic differences between 1918 and now.
These impacts show that the pandemic risk is more complicated than it might seem at first.
We can't see the future; but we can see H5N1 in birds
The extent to which these added issues would matter depends upon how severe any pandemic might be. This cannot be known in advance. However, with influenza A (H5N1), we know we're dealing with a historically virulent disease, at least as it exists in wild birds and domestic poultry. (NOTE: We do not know whether H5N1 will develop a pandemic-causing human strain.) And we know that the U.S. government's pandemic plan assumes 20% of working adults will get sick during a community outbreak. (An estimated 30% of the overall population is predicted to get sick.)
As a result, governments and businesses worldwide are making contingency plans concerning:
- How to maintain operations in the face of potentially high employee absenteeism.
- How to bolster the reliability of their supply chains and transportation systems during a pandemic.
The supply chain vulnerability
Why are there concerns that supply chains might get disrupted during a pandemic?
First, we live in a time (compared to 1918, for example) when commerce is more complicated. We use modern technologies, materials, and processes to design complex products. Then we source the needed materials and divide the manufacture of components among different companies, taking advantage of their specialized skills and equipment and reliable transportation services. As a result, supply chains can be very long and involve many companies. Much of the production is global. Companies routinely use "lean manufacturing" techniques - such as just-in-time (JIT) delivery schedules - to reduce the amount of money tied up in inventories, to accelerate throughput, and to improve flexibility and customer responsiveness.
As you can imagine, the more complex the system, the more places it can break. And the thinner the inventory, the less cushion against fluctuating customer demand. In sum, modern manufacturing and distribution is efficient, but vulnerable.
Second - and this is very important to understand - an infectious disease affects an organization's people, not its infrastructure. By definition, a pandemic flu spreads much more readily than does seasonal flu. So employee absenteeism may be high during a pandemic. The problem of a worker shortage may be exacerbated if employees with specialized skills are sidelined. In any case, if people can't work, their company's output slows down. The company can't send goods to other companies "downstream." Those companies then lack the parts, materials, ingredients, and sub-assemblies they need. So their output starts to lag. That domino effect continues down the production chain.
In a pandemic, a supply chain may have more than one "weak link." Think about a baker who can't get enough flour ... OR yeast ... OR plastic bags in which to wrap bread. Even if all of his employees are healthy and at work, they may be limited in how much work they can do.
Transporting goods down the supply chain
At different points in the supply chain, one of the most critical pinch points might be transportation. What if 10-20% of the long-haul truck drivers are sidelined by a pandemic? (The United States already has a driver shortage.)
During a pandemic, what if some countries restrict incoming commercial shipments (road/air/rail/sea) from areas where the flu is widespread? Will that process - checking for country-of-origin - delay commercial transportation, in general? What if, in an effort to control the spread of infection, some countries temporarily close their borders?
Certainly, it will be in everyone's best interests not to impede the flow of goods. Governments, manufacturers, and transportation companies will try to reduce any pandemic-driven hinderances to commerce. But they'll also be trying to stop the spread of a highly-infectious disease.
The delicate balance of modern medicine
The continued timely production and delivery of products would be critically important to people receiving medical treatment.
Since 1920, 20+ years has been added to the average life expectancy in the United States. Much of that beneficial change, of course, results from advances in medical science.
But for many medical conditions, the improvements have a contingency clause: today's medical products and tools must be available day-in and day-out. There are millions of people whose lives are made possible (or whose health is stabilized) thanks to ongoing medical treatments, including daily prescription drugs. As a nurse wrote on another bird flu blog, "In 1918, there were no long-time survivors of end stage renal and liver disease, cancer patients, transplant patients, [or people with] severe heart and lung disease surviving with the use of home oxygen machines..." The medical resources used to treat such conditions weren't available in 1918. So these medically vulnerable populations didn't exist. That's why average life expectancy was 55-60.
Think about how many people today need:
- outpatient services such as:
- dialysis treatment
- chemotherapy to fight cancer
- prescription medicines for:
- heart conditions
- diabetes
- high blood pressure
- hormone replacement therapy
- mental conditions
- HIV
- chronic pain
- etc.
People benefiting from such care - care which wasn't available in 1918 - are vulnerable in a pandemic in two ways - one direct and one indirect. First, given their less-than-ideal health, their bodies might not endure the flu. Secondly, if medical supply chains are interrupted, these people may lose access to the medicines which keep them alive. So even if they don't catch the flu, they could worsen or die from lack of needed medicines and treatments.
I'm not sure the pandemic naysayers think about this. Since they can't imagine a serious pandemic with 20% worker absenteeism even occurring, they can't imagine disruptions in long, specialized, just-in-time supply chains and transportation systems. And they have no idea how many of their prescription drugs and other medical supplies are manufactured in another country. Not a clue. They just don't think that deeply about it.
Other people do think about it.
Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, told USA Today (2-1-06):
"Today we have a just-in-time delivery system for masks, syringes, for IV bags," he says. "Most people don't realize that 80% of the drugs we use in this country come from offshore. Right now, the two manufacturers of N95 masks in this country are operating on 100% capacity. They have no surge capacity. We will run out quickly of all these things. And at that time, we'll be dealing with the equivalent of a 1918 health care system."
The Wall Street Journal (1-12-06) also discussed the critical role of supply chains in delivering health care:
In the event of a pandemic flu outbreak, that chain is almost certain to break. Thousands of drug-company workers in the U.S. and elsewhere could be sickened, prompting factories to close. Truck routes could be blocked and borders may be closed, particularly perilous at a time when 80 percent of raw materials for U.S. drugs come from abroad. The likely result: shortages of important medicines - such as insulin, blood products or the anesthetics used in surgery - quite apart from any shortages of medicine to treat the flu itself.The very rules of capitalism that make the U.S. an ultra-efficient marketplace also make it exceptionally vulnerable in a pandemic. Near-empty warehouses are a sign of strong inventory management. Production of drugs takes place offshore because that's cheaper. The federal government doesn't intervene as a guaranteed buyer of flu drugs, as it does with weapons. Investors and tax rules conspire to eliminate redundancy and reserves. Antitrust rules prevent private companies from collaborating to speed development of new drugs.
Most fundamentally, the widely embraced "just-in-time" business practice - which attempts to cut costs and improve quality by reducing inventory stockpiles and delivering products as needed - is at odds with the logic of "just in case" that promotes stockpiling drugs, government intervention and overall preparedness.
What all of this means: our ordinary way of life isn't made for such an extraordinary event as a pandemic.
Tomorrow, I'll step away from the medical themes and illustrate how pandemic planning is NOT just a matter of not getting sick.
RELATED POST:
Fighting a flu pandemic from 1918-era supply shelves
This post is part of a series: