Vintage Big Med – D Newman | Chronicle of a bio-attack: London 1664-1665 – 2001

Chronicle of a Bio-Attack: London 1664-65 by David A H Newman [from a 2001 column]

Introduction

Daniel Defoe was 5 during the 1664-65 London Plague. He wrote his ‘Journal’ (available as a Dover Thrift Edition reprint 2001) in 1722, drawing upon parish records, civic documents, and the memories of the living.

The Plague epidemic started slowly in September 1664, peaked terribly in the summer and fall of 1665 and then suddenly faded out. Official records suggest that one in four died. The true proportion was much greater: many people left town at the first hint of trouble.

Defoe describes a society caught up in a nightmare: not knowing what to do or where to turn. His “Journal” is presented haphazard. There are no chapter or section headings. It starts, moves on more or less chronologically, and ends. He repeats himself and is not always consistent. But he offers insights that could serve us well today. I have reorganized and compressed his material: my apologies to his Shade, but I hope I have been true to his purpose.

London, 1665

London at the time of the Plague was by no means in the dark ages. It had a population of close to 500,000. It was an age of exploration and discovery. Science had become ‘popular.’ The Royal Society had recently been founded. Many scientists were also physicians: Gilbert (magnetism) and Harvey (anatomy) of particular note. Other illustrious names of the time: Newton, Hooke, Halley, and Boyle.

There were many more: it wasn’t unusual to find a group of them drinking together at say one of the better known coffee houses and talking about navigation, the structure of the universe, the state of naval architecture, and just about anything else. But when the plague came, what they knew was not enough.

Limited Early Warning

There were no newspapers, wire services, or TV journalists in 1664 “to spread rumors and reports of things, and to ‘improve’ on them.” The word came from abroad by letter from one merchant to another, and locally by word of mouth. This took time.

“But it seems the Government had a true account (of what was happening abroad) and several councils were held about ways to prevent its coming over; but all was kept very private.”

Description of Symptoms

There are three forms of Plague: bubonic, septicemic, and pneumonic. From Defoe’s descriptions, it appears the 1664-65 epidemic included bubonic and septicemic, and possibly pneumonic as well.

“The plague operated in a different manner on differing constitutions: some were immediately overwhelmed with it, and it came to violent fevers, vomitings, insufferable headaches, pains in the back, and on up to ravings and ragings with those pains, dying in dreadful manner.”

The Bubonic

“Others with swellings and tumors in the neck or groin or armpits … The swellings when they grew hard and would not break, grew so painful that it was equal to the most exquisite torture; and some, not able to bear the torment threw themselves out of windows or shot themselves. Others, vented their pain by such loud and lamentable cries to be heard as we walked along the streets that would pierce the very heart to think of, especially when it was to be considered that the same dreadful scourge might be expected every moment to seize upon ourselves.” “These were the worst visited, yet they frequently recovered, especially if the swellings could be brought to a head, and to break and run.”

Septicemic?

“Others, who did not develop these swellings died suddenly” “nor could physicians know certainly how it was with them till they (autopsied) them.” “Many that had the plague upon them knew nothing till the inward gangrene had affected their vitals, and they died in a few moments. This caused that many died in that manner in the streets suddenly, without warning.”

“Many persons never perceived they were infected until perhaps several days later, the ‘tokens’ came out on them: mortified or gangrened flesh in small knobs as broad as a little silver penny and hard as a piece of callus or horn. At that point they were beyond curing.”

THE FIRST CASES

Version One

“The first death occurred around Dec 20, 1664 in or about Long Acre; whence the first person that had the infection was generally said to (have caught it) from a parcel of silk imported from Holland, and first opened in that house. But after this, we heard no more of the plague until the 9th of February 1665 and then one more was buried out of the same house.”

Version Two

At the end of November 1664, two visitors from France died of the plague. The families tried to conceal the cause of death (fearing reactions of neighbors) but word spread. The authorities sent “two physicians and a surgeon” to inspect the house and they reported it was the plague. This was printed up in the weekly “Bill of Mortality” by the parish clerk, in the “usual manner: Plague: 2. Parishes infected: 1.”

In December, a third man died of plague in the same house. People all over town grew nervous. But there were no further deaths for six weeks, and everyone assumed it had been an isolated occurrence.

But on the 12th of February 1665, a fourth man died — this time in another house but in the same parish. The weekly mortality reports began to show increases beyond the norm, and rumors spread that there had been many more cases of plague than the authorities were admitting. But the numbers, though on the increase, were still low, and confined to one part of town.

Lack of Trend, at first

“It is true it was a very cold winter and a long frost which continued three months, and perhaps the disease was’ frozen up.’ But the principal recess of this infection was from February to April — after the frost had broken and the weather mild and warm.” “The numbers waxed, but then waned; and people were eager to assume all was well.”

The weather turned warmer, and there were reports of deaths from two other parishes — yet the total deaths were but 54 for the whole city, and when in the next week the numbers dropped, there was a collective sigh of relief that the worst was over.

Then it became evident that the plague had in fact spread “beyond all hopes of abatement.” The official numbers were too obviously fabricated: the true death toll was many times higher than was reported, and everyone knew this.

“Perhaps it was that the disease was there, but in small numbers, and households could better conceal the truth about cause of death from the official rolls — until the numbers grew so high that no concealment was possible.”

It was a hot summer, and “the infection spread in a dreadful manner…the bills rose high; the articles of the fever, spotted fever, and teeth began to swell.”

By mid-July, the plague was progressing through the town. It kept mainly to the more crowded, poorer, sections, but perceptibly, was moving on the more affluent.

“The question is this: Where lay the seeds of the infection all this while? How came it to stop so long, and not stop any longer?”

DEFENSIVE MEASURES

Concealment

All that could conceal their illness did so: “to prevent their neighbors cutting them off, and also to prevent the authorities from sealing their homes: this was not yet practiced, but was threatened, and people were terrified at the thought of being sealed in and isolated to die.”

Flight

The wealthier people removed themselves from town in large numbers. “For some weeks that there was no getting at the Lord Mayor’s door without exceeding difficulty: to get passes and certificates of health, for without these there was no way to being admitted to pass through the towns upon the road, or to lodge in any inn.”

This exodus continued through May and June, spurred by rumor that the Government was about to establish barricades on the roads to prevent people from London passing — for fear they would bring the infection with them. It was not a good time to fall ill; if you complained, it was assumed you had the plague.

“It was thought that there were not less than 10,000 houses abandoned by their occupants, besides the numbers of lodgers and particular members who were fled out of other families, so that in all it was computed that about 200,000 people were fled and gone.”

Some (who left later on) “perished in the street or fields for mere want, or dropped down by the raging violence of the fever upon them. Others wandered into the country, and went forward any way, as their desperation guided them, till not getting any relief, the houses and villages on the road refusing to admit them whether infected or no, they perished by the roadside or in barns — none daring to come to them or to relieve them, though perhaps not infected, for no one would believe them.”

Many of the poor — being destroyed not only by the infection but as much by the consequences of it (lack of employment) — in desperation, fled the city, but only found death on the road; “and they served for no better than the messengers of death, for some carried the infection with them into the country.”

The country folk did what they could: carrying out food and placing it at a distance. When the wanderers died, the country folk would dig a hole at a distance from them to windward, and then, with long poles and hooks, drag the bodies into these pits and cover them. Those that so died, and others unknown, are not included in the statistics.

“The face of London was now strangely altered. Sorrow and sadness sat upon every face. Everyone looked on himself and his family as in the utmost danger. The shrieks of women and children at the windows and doors of their houses, where their dearest relations were perhaps dying, or just dead, were so frequent to be heard as we passed the streets.”

Portents and Superstitions

A comet appeared several months before the plague came, and another just before ‘The Fire’ (1666). In hindsight, “these things had a more than ordinary influence upon the minds of the common people.” Prophecies, astrological conjurations, dreams, and old wives’ tales took hold. Would-be preachers ran through the streets with apocalyptic shouts and further alarmed the populace.” There were instances of crowds caught up in “mysterious visions.”

“This folly presently made the town swarm with a wicked generation of pretenders. Purveyors of nostrums had a field day: ‘Infallible preventive pills against the plague’; ‘Sovereign cordials against the corruption of the air’ ‘Anti-pestilential pills’.” [We in our day are also bombarded with such claims].

Supposedly eminent healers from abroad [the gurus and miracle workers always hail from far away] set up shop and touted their prowess: “newly come over from where he resided during all the time of the great plague last year, and cured multitudes of people.”

“But there was still another madness beyond all this, which may serve to give an idea of the distracted humor of the poor people at that time: in wearing charms, philters, exorcisms, amulets, and I know not what preparations, to fortify against the plague…that it was to be kept off with crossings, signs of the zodiac, papers tied up with so many knots, and certain words or figures written on them, as particularly the word Abracadabra, formed in triangle or pyramid.”

But these charms did not help, and all too many poor souls were “carried away in the dead carts and thrown into the common graves of every parish with these hellish charms and trumpery hanging about their necks.”

By the end, all the predictors, astrologers, fortune-tellers, and what they called cunning-men, conjurers and the like “were gone and vanished: not one of them was to be found. Many went to their long home, not able to foretell their own fate.”

Who to Turn To in Extremity?

As the plague spread, the populace gave up their trust in the quacks, but then, not knowing what to do, or who to turn to, they ran frantically around: calling on God, and asking one another “What shall we do?”

Many “turned to prayers, fasting, and ‘humiliation’, and imploring the mercy of God. But “neither can I acquit those ministers that in their sermons rather sank than lifted up the hearts of their hearers.”

With imminent death looming, many, especially the dying, repented of past actions. “But none durst come near to comfort them.” “Some of the ministers did visit the sick at first, but it would have been present death to have gone into some houses. The very buriers of the dead, who were the hardenest creatures in town, were sometimes so terrified that they durst not go into houses where the whole families were swept away together — but time inured them to it all.”

Actions by the Authorities

“At the start, the Lord Mayor and the sheriffs, the Court of Aldermen, and a certain number of the Common Council men, or their deputies, came to a certain resolution, and published it: that they would not quit the city themselves, but that they would be always at hand for the preserving good order in every place, as also for the distributing the public charity: for doing the duty and discharging the trust reposed in them by the citizens to the utmost of their power. And they were in fact continually in the streets and at places of the greatest danger. [We have witnessed similar courage and leadership, by many in our own time; and ‘sauve qui peut’ cowardice from a few].

The finances of the City were in good shape, and used generously to sustain the poor. (many were unemployed now because Trade was ‘stopped’, and also, the city was largely depopulated or closed up). Few ships ventured up the river, and none were allowed to leave. Every family retrenched their living as much as possible. The Royal Court contributed considerably (but kept their physical distance). Many of the wealthy who had left town gave generously for relief of the poor.

Bread and Provisioning

Thanks to the authorities, even at the height of the epidemic, provisions were always to be had in full plenty, and the prices not raised much.

“Neither was there any want of bakers or ovens kept open to supply the people. The Master of the Bakers’ Company, was, with his court of assistants, directed to see the orders of my Lord Mayor for their regulation put in execution: the due assize of weekly bread observed; all the bakers obliged to keep their oven going constantly.”

Pest-Houses

There were only two ‘pest-houses’ to house the sick. “If there had been, and if a person, as soon as he fell sick, could have been removed there, the number of fatalities would have been greatly reduced.” “Very good physicians were appointed, so that many people did in fact come out of them well again: in all the time of the visitation, there were but 300 buried from the two houses, in total.”

The lack of hospitals meant shutting up the well with the sick at home. This was a powerful inducement for the others to escape — to further transmit the sickness.

Quarantines

There was a necessity in this extremity to look to law and order, and it was done.

Starting in June, the authorities established emergency regulations. Houses in some parishes were “shut up” — guarding against entry or exit. The dead were taken and buried immediately. The plague ceased in those streets: early vigilance is an essential weapon in the struggle.

This shutting up of people in their own houses was first used in the London plague of 1603 under “An Act for the charitable Relief and Ordering of Persons infected with the Plague.” Anyone found to be sick with the plague was to be immediately sequestered in the same house, and even if he recovered, “the house shall remain shut up for a month.”

*To quarantine the infection, “the sickroom beddings and apparel, etc. must be well aired with fire and “such perfumes as are requisite within the infected house.”

*Any person who visits a person known to be infected or who entered willingly into a known infected house, “his house too is to be shut up.”

*No one can be removed from the house where he fell sick except to the “pest-house or a tent” or to a house where the owner/occupier accepts full responsibility. If a person owns two houses, he may send either his sound or his infected people to the second house: the second house also being shut up then for a week, in case of undetected cases.

*Every house visited by the plague is to be marked with a large red cross.

*Searchers, Chirurgeons, Keepers, and Buriers are to hold a red rod of three feet in length, open and evident; they are to abstain from company, and must not enter any home except their own or to where they are officially sent.

*Hackney-Coachmen [Taxis] must air their coach and place it in quarantine for 5 days after carrying an infected person.

The shutting up of houses was at first looked on as very cruel and ‘unchristian.’ “But it was a public good that justified the private mischief.” “But it was not to be depended on. It served to make those confined desperate, and they resorted to extremities, including assault upon the watch, and even murder to break out.”

From those shut up “we heard the most dismal shrieks and outcries of the poor people, terrified by the sight of the condition of their dearest, and by the terror of being imprisoned as they were.” For, if one member of a household fell ill with the plague, and the rest of the household were ‘shut up’ with the sick person, it was almost certain that all would die. Some are on record as actually dying of fright; many were traumatized to the point of going mad; and some lost their memory of those events.

Self-Quarantine

On the other hand, many families, warned that the plague was coming, put up provisions and shut themselves in; not being seen or heard of until the epidemic was over: “keeping their houses like little garrisons: suffering none to go in or come near them.”

In the beginning of August, the plague grew ‘very violent’, and ‘my doctor friend’ coming to visit me, and finding that I ventured so often out into the streets, earnestly persuaded me to lock myself up and my family; to keep all our windows fast; shutters and curtains close; and never to open them.”

“People walked in the middle of the street, so they would not mingle with anyone that came out of houses, or meet with smells and scent from houses that might be infected.”

Inspections

The master of any house, as soon as anyone in his household complained of “blotch or purple or swelling in any part of the body or who fell dangerously sick “without apparent cause of some other disease,” had to notify the Examiner of Health within two hours.

Examiners made sweeps of neighborhoods to list “what persons be sick, and of what diseases, and upon doubt, to command restraint of access until it appear what the disease shall prove.” Every infected house was to be under watch day and night.

Women Searchers, “of the highest and most honest repute”, were appointed to inspect the dead to make sure of cause of death. “No Searcher during this time of visitation was permitted to use any public work or employment, or keep any shop or stall, or be employed in any common employment whatsoever.”

Any “Nurse-Keeper” who removed herself out of an infected house before 28 days after the decease of any person dying of the infection, both she and the house to which she removed herself was also quarantined for a further 28 days.

Disposal of the Dead

Thanks to the authorities, even at the height of the epidemic, no dead bodies lay unburied or uncovered: *The dead are to be buried before sunrise or after sunset. No neighbors or friends are allowed to attend. *No corpse dead of infection is to be buried or remain in any church at a time of common prayer etc. (where others are present for services). *Children are not allowed to come near the corpse, coffin, or grave.

*All graves are to be at least six feet deep. “They dug several great and deep pits into which they put 50 bodies each; then they made larger holes wherein they buried all that the dead-carts (in that parish) brought in a week.” At the beginning of September the numbers of bodies to be disposed of was increasing: “people that were infected and near their end, and delirious also, would run to those pits, wrapt in blankets or rugs, and throw themselves in, and expired there.” (At the height of the epidemic, the numbers to be buried across the city ran to 10,000 a week, concentrated in a few parishes!)

There were problems excavating large and deeper pits: the water table was encountered at twenty feet depth.

Sanitation

[These regulations are all sensible; more so in a time when they had no clear idea of what the Plague was, or how it was spread].

*No clothes, stuff, bedding, or garments can be removed from infected houses. (Dealers and trade in second hand clothing and goods were ordered closed down). Some turned to fumigation and fire to purge infected houses and goods: burning brimstone, sulfur, pitch, and even gunpowder!

In 1666, the Great Fire did indeed destroy remaining traces of infection in much of the City. But not in all. Defoe asks: “How has it been that the plague has not come back in all those great parishes where the fire never came, and where the plague raged with the greatest violence?”

*The streets are to be swept clean: every householder must do so daily before his door. *The sweepings and filth of houses is to be carried away daily.

*No poor quality produce or fish or meats is to be sold. Breweries and drinking establishments are to be inspected for “musty and unwholesome casks.”

*No hogs, dogs, cats, tame pigeons, or conies, are to be kept in any part of the city (see below under “How the Plague was Spread”).

Restraints on Public Gatherings and Converse

*No wandering beggars. *“No plays, bear-baitings, games, singing of ballads, or such-like causes of assemblies of people. No public feasting till further order. *A Curfew on taverns, ale-houses, and coffee-houses.

THE EPIDEMIC RAGES

The Medical Profession

Physicians were appointed “for relief of the poor.” The College of Physicians was asked to publish recipes for cheap and effective remedies: this helped at least to turn the populace away from the quacks, their nostrums, and the use of outright poisons.

But “the violence of the distemper, when it came to its extremity, was like the fire the next year. The fire, which consumed what the plague could not touch, defied all the application of remedies; the fire-engines were broken, the buckets thrown away, and the power of man was baffled and brought to an end. So the plague defied all medicines, the very physicians were seized with it, with their preservatives in their mouths, and men went about prescribing to others and telling them what to do till the tokens were upon them, and they dropped down dead. Many of the most eminent died of the infection.
Abundance of quacks too died, who had the folly to trust to their own medicines.”

“Not that it is any derogation from the labor or application of the physicians to say they fell in the common calamity; it is rather to their praise that they ventured their lives so far in the service of others. Doubtless they helped many by their skill, and their prudence. But they could not cure those that had the tokens upon them, or who were mortally infected before the physicians were sent for.”

How the Plague was Spread

There were many theories about how the plague was spread. The more enlightened assumed an ‘infection’ transmitted by some unknown agency — possibly airborne. Others considered it a punishment from Heaven and therefore without agency.

“The plague is carried from house to house in the clothes.” It first broke out in a house where goods from the Levant by way of Holland had been carried. It spread from there carried by those made sick to those with whom they had conversation.

“The best physic against the plague is to run away from it.” “Consider separating the people into smaller bodies, and removing them (before the plague comes) farther from one another, and let not such a contagion as this, which is indeed chiefly dangerous to collected bodies of people, find a million of people in a body together. The plague, like a great fire, if a few houses only are contiguous where it happens, can only burn a few houses. But if it begins in a close-built town or city, and gets a head, there its fury increases; it rages over the whole place, and consumes all it can reach.”

Infection generally came into a house because members of the household went out to shop — for food and other necessaries, and in so doing, came into proximity with others on the street and in shops, etc.

“Nothing was more fatal to the inhabitants of the city than the supine negligence of the people themselves, who, during the long notice of warning, made no provision for it by laying in store of provisions, or of other necessaries, by means of which they might have lived retired and within their own houses: those who did were in great measure preserved by that caution.”

“However, the poor could not lay up provisions, and must go to market to buy; this brought abundance of ‘unsound’ people to the markets, and a great many went thither sound brought death home with them.”

At the height of the plague, The Lord Mayor caused country people who brought provisions to sell in the city to be stopped at the outskirts (in informal markets) where they sold what they brought and then went away. This precaution encouraged country folk to bring the food to the city that the people needed.

“We were ordered to kill all the dogs and cats; for they are apt to run from house to house and from street to street, and are capable of carrying the infection in their fur. All possible endeavors were used also to destroy the mice and rats — especially the latter, by laying poisons for them, and a prodigious multitude of them were destroyed.”

Crime

There were many robberies and “wicked practices”. “The power of avarice was so strong in some that they would run any hazard to steal and to plunder, and particularly in houses where all the inhabitants have been dead and carried out, and without regard to infection take even the clothes off the dead bodies and the bed-clothes.”

At the Height of the Plague

From the middle of August to the middle of October, the official records show thirty to forty thousand died of plague. Another ten thousand were recorded as dying of other causes — but most of those were probably due to one or other form of plague, or its consequences.

But it was impossible to know the real totals: clerks, administrators, and those on the ‘front line’ were overwrought simply trying to gather and bury the dead. The true toll probably reached two thousand a day at the height. There were likely at least 100,000 victims of the plague in 1665 alone. “There was not a town within ten or twenty miles of the City but that was more or less infected.”

“Whole families and indeed whole streets of families, were swept away together. It was frequent for neighbors to call to the bellman to go to such-and-such houses, and fetch out the people, for that they were all dead. By then, the work of removing the dead bodies had grown extremely dangerous; innumerable of the bearers died of the infection. Yet there was such need of employment that others of the poor were always ready to take on the work. So, not withstanding the great numbers dying and sick, the bodies were always cleared away and carried off every night, so it was never to be said of London that the living were not able to bury the dead.”

With those died, and those who had left town, there were not one-third as many people in town during August and September as there had been in January and February.

“After funerals became so many that people could not toll the bell, mourn or weep, or wear black for one another; nor so much as make coffins for those who died; so after the fury of the infection appeared to be so increased, in short, they shut up no houses at all. It seemed enough that all the remedies had been used until they were found fruitless.”

“People began to give themselves up to their fears and to think that all regulations and methods were in vain. I do not mean a religious despair, or a despair of their eternal state, but I mean a despair of their being able to escape the infection or to outlive the plague, which they saw was so raging and so irresistible in its force.”

“People in this despair turned bold and venturous: they were no more shy of each other, or restrained indoors, but went anywhere and everywhere, and began to converse: ‘tis no matter who is all sick or who is sound.’ As it brought people into public company, so it brought them in large numbers into the churches. ‘A near view of death soon reconciles men of good will to one another, and bring us to see with differing eyes than those with which we looked on things with before.’ But as the terror abated, those things all returned again to their less desirable state.”

THE END OF THE EPIDEMIC

“It was even at the height of this general despair that the plague began to slacken, surprisingly, even as it had come.”

In September, the plague abated in the west and north-west parishes (so dreadfully visited at the first), but raged elsewhere in the city through the beginning of October. Then, as October wore on, the plague diminished both in numbers infected and in its intensity so that the proportion of deaths among those infected dropped. People grew careless, and for a time the numbers increased again. But the contagion was ‘exhausted,’ and winter weather came: the air was cold and clear, with sharp frosts. Most of those fallen sick recovered.

Not withstanding the violence of the plague in London, it was never on board the fleet.

In the absence of gravitas: crapola

HalProfile2009Mar22by Hal Newman

The latest in a countless series of grave warnings sent by email with an ever-changing list of signatories, this one was supposedly from a PhD MD RN MSc and opened with this phrase:

“No one should take the swine flu vaccine-it is one of the most dangerous vaccines ever devised”

In the absence of intense myth-busting information communicated by credible leaders, this kind of crapola propagates. Several times a day I find myself being called upon to explain why I believe it’s essential that we all get vax’d against H1.

Here’s my response:

For me, it has become a very serious risk v benefit model.

And understand, Di and I sweat each and every time we get the kids inoculated against something. We wonder – just a little bit – about the safety of the vax. There’s that moment of dread that lasts from the time the needle breaks skin to the time it takes for us to be convinced of no evil and debilitating sequelae.

And then there’s H1N1.

There’s nothing abstract about this – it’s not like the concept that I might be hit by a truck. Might. Maybe. Likely never happen.

H1N1 is a real threat. It has replaced the seasonal flu virus as the dominant flu bug crisscrossing the globe. Just think about that fact for a moment. Wow. H1N1 is the king of the microbe heap and it’s only been in circulation since April.

H1N1 has a disproportionately awful impact on the very young, on pregnant women, and on people with underlying medical conditions. How many asthmatic kids do you know? My own daughter is still prone to croup at age 11 – when she was younger she weathered some critical moments in ERs and ambulances. How many young people are medically fragile? How many adults are medically fragile? The answer will blow you away when you realize just how high the percentage of the population are considered at risk.

From the CDC briefing on Oct 16

“There are now a total of 86 children under 18 who died from this H1N1 influenza virus, the 2009 H1N1 influenza virus. We had 11 more influenza pediatric deaths reported in week 40, which is the week that ends October 10. Ten of those are confirmed to be due to the new strain, the 2009 H1N1 strain and the 11th is probably due to that but the typing hasn’t been completed. About half of the deaths that we’ve seen in children since September 1st have been occurring in teens between the ages of 12 and 17. These are very sobering statistics, unfortunately, they are likely to increase.”

From the CDC briefing on Oct 20

“More than half of the hospitalizations are occurring in young people under the age of 25. We are seeing 53% in people under 25 years of age. 39% of hospitalizations are in people 25 to 64 years of age. And only 7% of hospitalizations are occurring in the elderly. Almost a quarter of deaths are occurring in young people under the age of 25. Specifically, 23.6% of the deaths are in that age group. About 65% of the deaths are in people 25 to 64 years of age… With seasonal flu 90% of fatalities occur in people 65 and over. Nearly 60% of fatalities are occurring under age of 65.”

Bottom-line: Get the shot.

. . .

I understand why it’s probably a good idea to prevent access to some websites from within the hallowed halls of hospitals, however can anyone explain to me why the IT department of a major academic/pediatric hospital would block access to the government’s H1N1 pandemic information website?

In the absence of gravitas: crapola.

Tachycardia with a hint of all-out gallop

HalProfile2009Mar22by Hal Newman

For whatever reason, the national media haven’t quite zero-zeroed in on the realities associated with H1N1, the vax, and high-risk groups. Certainly, the tone of local and regional coverage has shifted from cautionary optimism to creeping negativity.

Life-Saving H1N1 Drug Unavailable to Most
CBS News
OR, the currently fast-tracked H1N1 vaccine has received much of a legitimate trial period to verify efficacy and safety! Yet, the H1N1 vaccine has been
See all stories on this topic

H1N1 Vaccine Shortage Stalls Clinics
WBAL TV
BALTIMORE — Maryland is facing a flu vaccine shortage as the numbers of H1N1 hospitalizations and deaths continue to rise. Many local health departments
See all stories on this topic
H1N1 vaccine shortage, East Texas officials react
KLTV
A shortage of the vaccine has some doctors wondering when they will receive the shots. Marlo Bitter is back at work, but less than a week ago,
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No flu shots available
Palestine Herald Press
The problem of seasonal flu vaccine shortage has been reported all across East Texas. The shortages are not just with DSHS, but also with pharmacies.
See all stories on this topic

Whether the media gets it right or wrong at this point is unlikely to make a dent in the public perception of being at the heart of something wicked this way comes.

If you were to take a pulse of America right now, I believe you’d find it in tachycardia with a hint of all-out gallop as intense fear rides on the cusp of all-out panic.

The indicators for me arrive on the hour in the form of email queries from healthcare professionals, community leaders, and emergency management colleagues wanting to compare notes on what personal steps they can take to protect themselves and their loved ones from H1.

To further confuse and confound, there are mixed messages being sent by federal, state and county health officials to the public they serve, e.g. 1020 State officials understand and share frustration associated with H1N1 vax shortages [Massachusetts].

If you ever wonder how rumor generators get primed, read this piece out of North Dakota and imagine the news being transmitted on a national game of broken telephone: 1020 DoH recommends revax of some individuals against H1N1 [North Dakota].

With so many people with functional limitations [the vulnerable at the moment] mixed into the at-risk groups, this ongoing crisis represents a significant challenge for us all. How do we ensure a fully-inclusive response?

When I’ve tried discussing H1N1 with some of my colleagues, there has been tremendous pushback with an accusation of my ‘having given in to the hype.’ The claims of hype tend to fade as more people we know are affected by a nasty bit of influenza that has a habit of going hard after the very young.

Does H1N1 represent the perfect storm with an even more devastating legacy than that of Katrina? Katrina struck the Gulf Coast and still managed to impact an entire generation, create its own diaspora and continues to have a lingering effect on millions of people. Katrina had a beginning and is still looking for an end.

H1N1 is an ongoing evolving global crisis with nothing to link it to the episodic view we have for emergency management. And unlike all those other crises occurring out there – famine, civil war, genocide, malaria, HIV/AIDS – this one is affecting us right here in our homes. So H1N1 has our rapt attention and even with all eyes on the ‘prize’ we’re still unable to manage this ongoing emergency.

Sometimes it feels as if the professionals would rather not disturb the peace with discussions focused on what happens when the victims of emergencies or the emergencies themselves don’t act in ways predicted by the plan.

Were it only so easy if disasters had neither victims nor responders but only featured rulemakers who could wear funny hats.

Standing with Serge

by Hal Newman

I’ve been looking at medical surge as a series of ever-larger waves crashing ashore in that they continue picking up more and more debris and carrying that further inland until finally they begin to ebb.

All the surge plans I’ve seen are based on the notion that the emergency healthcare system will need to handle more and more patients until finally the peak flow is reached.

There is a fair bit of ‘resurrection medicine’ built into these plans – the need to reach into death’s door and pull the victims back into the land of the living.

Shouldn’t we be looking at creating critical care field triage levels that would prevent the surge waves from carrying patients requiring resurrection-medicine from reaching the ERs? Isn’t it about time we took a hard look at plans that would include field-based palliative care units?

Any idea on the total number of mechanical ventilators and respiratory techs there are in any given major jurisdiction in the United States or Canada? Anyone have a breakdown on that number per hospital – just the major centers?

So now that we’re seeing a strong run on tickets for a possible Kick Your Ass tour for A/H1N1 in the fall, does anyone have any idea what we can anticipate in terms of both clinical attack and absentee rates when it comes to the respiratory techs themselves? Has anyone got any ideas about who to train and how to train them in Ventilation for the Uninitiated?

Does anyone have numbers for pediatric vents and resp techs at pediatric centers? It seems that the vast majority of hospitalizations in a more virulent return of H1N1 would be among children below the age of 15. Unless I’ve missed something, we just do not have the collective pediatric resources to provide care on that scale.

The estimates I’ve heard sure don’t give me any peace of mind – and the fact that the actual numbers seem to be so closely guarded also gives me pause. Certainly don’t get the vibe there are overwhelming numbers of either ventilators or the human beings required to make them effective lifesaving tools.

As my friend Roy says, “It has been nearly five years since the discussion of vent shortages in the United States began with SARS as the stimulus. So, in five years the US has apparently done little to increase the number of ventilators available for pandemic flu surge and train a much-enhanced healthcare cadre to manage ventilator systems in compromised patients.”

The problem is, as Roy so aptly quips, “Vents are not particularly sexy or worthy of discussion in a healthcare system barely able to manage a bad season of colds and flu.”

My educated guess would be that roughly 85 percent of the available mechanical ventilators in Montreal hospitals are currently in use. Combine that with an average ER occupancy rate in the 90-something percent range and we’re not talking surge – we’re talking about a damned near bankruptcy of the emergency healthcare system.

Roy’s educated guess is that the same percentage of current daily use holds true for the 100,000 or so ventilators available across the United States at any given moment.

“Disaster preparedness typically includes plans that address the need for surge capacity to manage mass-casualty events. A major concern of disaster preparedness in respiratory therapy focuses on responding to a sudden increase in the volume of patients who require mechanical ventilation.” – Mechanical ventilation in mass casualty scenarios. Augmenting staff: project XTREME, Hanley ME, Bogdan GM. 1: Respir Care. 2008 Feb;53(2):176-88; discussion 189

While I recognize the wonderful work done by major trauma centers that kick themselves into overdrive to deal with 20-30 seriously injured patients from a single incident, I believe it’s time to take a real-world look at what happens when there are 100 or 200 or 300 or maybe 1,000 people who are sick or injured?

Or when there are tens of thousands of people concerned about their children who are presenting with the signs and symptoms of pandemic flu.

And perhaps it’s not a one-time event.

I live in Montreal where the EMS system runs on a Basic Life Support platform and where firefighter-first responders have been limited to a SSU [sticky side down] approach when it comes to providing care for patients prior to an ambulance crew’s arrival.

The idea that somehow the combined Fire/EMS system would be able to successfully triage, then transport more than 100 critically ill patients from a single incident without completely outstripping available resources is pretty well pure science fiction.

The EMS system is constantly short of ambulances and crews. There are a finite number of firefighter first responders. And that’s when the going is relatively good. Throw in an icy night and a few multi-patient car crashes and maybe simultaneous multi-alarm fires [definitely not unheard of in a major metropolitan area].

And we don’t need to be talking pandemics or terrorism. We could be talking about an ethyl-methyl-bad-stuff incident at one of the multiple chemical facilities that are smack dab in the middle of a heavily populated center. All that’s required to tip the balance between feasible and outright chaos is a higher percentage of critically ill patients.

If the walking wounded aren’t – then we’ve got a serious problem on our hands. It’s not as if we’re going to tell the populace to get a pick-up truck and an air mattress and take their neighbors to the ER on their own. One major incident doesn’t come with permission to suspend operations for the rest of the population. Just standing with Serge and talking with Roy watching the waves crash on Tundra Beach.

Be well. Practice big medicine.

Not so private musings

by Hal Newman

Despite the recent rah-rah session aka the Flu Summit in DC and all the good tidings that flowed forth from that ‘rather vacuous’ gathering, I have serious concerns about what awaits us as H1N1 circles the globe and comes streaming back towards us as a virulent mo-fo capable of creating the tipping point that sends healthcare systems well over the edge and into semi-permanent surge status.

WHO has recently recommended that all nations should immunize their healthcare providers as a screaming priority in order to protect the health infrastructure. Remember, folks, that’s the same health infrastructure that’s currently operating well beyond normal capacity on an ongoing basis despite the fact real life has been in the fat dumb and happy zone in between natural disasters and man-made catastrophes for years.

There are problems with the production of a workable flu vax [perhaps as far down the road as 10+ months] and there are rationing schemes afoot with country-specific customizations on order of priority of the following groups: pregnant women; those aged above 6 months with one of several chronic medical conditions; healthy young adults of 15 to 49 years of age; healthy children; healthy adults of 50 to 64 years of age; and healthy adults of 65 years of age and above.

And so, as my pal Roy says, even mid-2010 does not mean global coverage, just those that can afford it or have special arrangements. Perhaps it’s time we considered home schooling..

Do not take the mainstream media’s inability to deal with its own Attention Deficit Disorder lightly. While it’s somehow amusing to watch CNN’s Situation Room monitors flicker with images ranging from Jocko’s funeral services to the uprising in the streets of Tehran, keep in mind these are the times we need to be looking at our emergency services’ capabilities with the eyes of a malevolent red team because the wicked things that are inbound will surely stretch the anticipated limits and then some.

There are challenging times ahead. Just my two vicious bits.

Be well. Practice big medicine.