Vintage Big Med – D Newman | The London Plague of 1664-1665: Summary – 2006

The London Plague of 1664-65: Summary [from a 2006 columnn] by David A H Newman

Foreword

The following account is based on Daniel Defoe’s famous “A Journal of the Plague Year.” He wrote it in 1722 — the result of interviews with survivors and extensive research into parish records, brought together by a remarkable novelist and investigative reporter (in the true sense).
The Arrival of the Plague

The plague had visited 60 years before, and a few times each century for centuries before that, but with the exception of the terrible “Black Plague” of the 13th century, each visitation was no worse than those of the other scourges – flu, smallpox, and starvation.
There was no reason to expect anything different.

When the plague reached London it wasn’t a surprise; it had been reported in Amsterdam and elsewhere on the Continent. It moved slowly from town to town.

There were 3 plague deaths from late December 1664 through January 1665; they were all in the same house where visitors from the ‘Continent’ were staying. A fourth death was registered in early February: this time in another house in the same parish.

The winter was long and bitter cold and this seemed to inhibit the infection. Then it turned warmer: more cases were reported, but not in epidemic proportions, and confined to one part of town. But the reports were incomplete and it soon became evident that the plague had spread “beyond all hopes of abatement.”

When do you know that you face an epidemic: at the first death? when the trend is clear? And when do you know for sure what illness people are dying from?

London had a population of 500,000 in 1664. It was home to many illustrious scientists and physicians. But when the plague came what was known was not enough. “Where lay the seeds of the infection? How come it emerged when and where it did?” Why did the plague never again return in such a virulent form?

The plague came in bubonic, septicemic, and pneumonic variants. Symptoms were not always evident: many didn’t know they were infected for several days; they continued to move freely and spread the disease “till the inward gangrene affected their vitals and they died in a few moments” nor could the cause of death be known for certain until an autopsy was performed.

When should ‘The Authorities’ let the public know? To declare an emergency might cause panic and disruption; not to speak out might doom many who might heed the warnings and take precautions.

Fear and rumour compounded the risks. Quacks came from all parts to sell their nostrums at exorbitant prices. None of them worked; by the end the quacks had fled or were dead.

It seemed all regulations, precautions and remedies were useless. Abandoning hope, many went out and gathered freely, as if there was no infection. The plague spread faster.

The plague killed nearly everyone there was to kill in the infected parishes. At least 100,000 died. “Whole streets of families were swept away together.” It finally self-destructed like a fire that had consumed all its fuel.

WHAT YOU CAN DO WHEN YOU DON’T KNOW ENOUGH

Decentralize your “Assets”

“Let not such a contagion as this, which is 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, and gets a head, there its fury increases: it rages over the whole place.”

Run for your Life

Get out of town early. The wealthy and those who could afford it left town. This exodus continued through May and June; spurred by rumors that the government was about to set up barricades on the roads. Without a Pass and a Certificate of Health “there was no way to being admitted to pass through the towns upon the road, or to lodge in any inn.”

Many of the poor, out of work and desperate, fled to the countryside. Many were not sick, but having no place to go, were forced to wander until they died of exposure and malnutrition, or from the disease.

“Country folk would carry out food and place it at a distance. When the wanderers died, the people would dig a hole to windward, and drag the bodies into these pits with long poles, and cover them.”

The Lord Mayor and other officials stayed at their posts. They used the City treasury to help sustain the poor. By order of the Lord Mayor, even at the height of the plague, bread and other basics were made readily available and price-gouging was forbidden. .

Avoid Contact

To quote an old maxim: “Shun it as if it were The Plague!”

Some families stockpiled food and other essentials and shut themselves in for the duration: keeping their houses “like little garrisons and suffering none to go in or come near them.” [Reminiscent of the early 1960’s nuclear attack panic — bomb shelters in backyards, taking to the back woods, gun in hand to fend off neighbors.]

But in many households, someone had to venture forth to shop for food and other necessities, and inevitably came into proximity with others on the street and in shops, and brought the infection back into the home.

[Conventional disaster planning suggests keeping 72 hours of food and water on hand. In the event of a pandemic, 6 months of supplies would be a minimum!]

Destroy the (presumed) Carriers of the Infection

Not knowing by what agency the plague was communicated, they did what seemed reasonable: “We were ordered to kill all the dogs, cats, mice, and rats: for they are apt to run from house to house and might carry the infection in their fur.” [With Avian Flu, should we slay all the birds too?]

[The irony of killing off the cats and dogs was that they were the main anti-rat weapon, and it was the virus carried by the fleas on brown rats that carried the plague; but no one knew that at the time. Still, fleas do transfer to other carriers, and cats and dogs might have carried the disease that way.]

Get the Facts: Inspect and Verify

If anyone in a house had plague symptoms or fell dangerously ill without apparent cause of some other disease, the head of the household had to notify the authorities within two hours. But given what would happen to one’s household if one did report (see below), few would want to.

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.” If you fell ill it was assumed you had the plague and you were quarantined at home until it proved otherwise.

Inspecting and verifying works when there are just a few cases. But when entire streets and neighbourhoods are stricken, few will dare go there.

Quarantine the Sick and Anyone or Anything in Contact with the Illness

The rules were first promulgated by James I during an outbreak in 1603: “Anyone found to be sick with the plague is to be shut up in the same house, and the house is to be quarantined for a month,” marked prominently and placed under watch day and night so no one leaves or enters.

Officials charged with visiting, examining, or nursing the sick, or with carrying away the dead, were ordered not to engage in any ‘social’ contacts. They had to carry signs warning others to keep clear [like a leper’s proverbial ten-foot pole with a bell on it.]

Sickroom beddings and apparel had to be fumigated or burned. Nothing could be removed from infected houses. The entire trade in second hand clothing and goods was shut down.

But when the plague spread the law became meaningless. Those under house arrest in close quarters with the plague knew they would die miserably if they stayed; so many tried desperately to escape. Those charged with standing guard had an incentive to accept hefty bribes to look the other way, or to desert (because duty and death marched together).

Plays, bear-baiting, games, singing, ballads, such-like causes of assemblies of people, and public feastings were banned. There was a curfew on taverns, ale-houses, and coffee-houses. Few ships ventured in and none were allowed to leave.

Have Enough Hospitals, Staff, Supplies, and Transportation ready Before “It” Happens

To be shut in at home with the plague meant death. Being treated at one of the two hospitals meant a chance of recovery. More hospitals and more physicians and nurses to staff them would have significantly reduced the mortality rate, would have provided a much more effective quarantine of the sick, and the general population would have been better protected [as was the case in Toronto during the SARS outbreak.]

The system could cope with small numbers of victims but could not handle the scale of the emergency: an epidemic can overwhelm resources and facilities — more so if the infection runs its course through a victim in a matter of hours or just a few days..

At the start, there were many courageous doctors and nurses who valiantly did what they could, but they caught the infection and died: so by the time the epidemic reached its peak, the resources available to fight it had been reduced to a minimum.

Dispose of the Dead

The numbers to be buried at the peak (10,000 a week) almost overwhelmed the authorities. Only the most desperate and destitute, (and a few saintly souls), could be persuaded to take on the task of collecting and burying the dead (and the near-dead!). But “not withstanding the great numbers of 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.”

Prevent Crime

Greed, desperation, and an attitude that anything goes, led to break-ins of houses from which all the residents had been carried out dead. Some even stole the clothes and boots from the corpses of plague victims.

Do what is Necessary

Hippocrates said: “Desperate Circumstances may need Desperate [Creative] Responses.”

Vintage Big Med – D Newman | Pandemic flu planning: A flow is a quantification of assumptions – Dec 2006

Pandemic Flu Planning: “A Flow is a Quantification of Assumptions” by David A H Newman

[Dec 6 06]

References. I have made use of three references: 1] Government of Ontario Flu Pandemic Plan, Chapter 17 Acute Care Services & 17a: Tools; 2] Shoppers Drug Mart Healthwatch Pamphlet: Flu; and 3] Government of Ontario Pamphlet, “What you should know about a flu pandemic.”  April 2006.

My own comments are enclosed in brackets [like so].

Flu and Pandemic Flu Facts

FLU

Flu is caused by influenza A and B viruses.

It is spread mainly by virus in the air.

It finds a comfortable home in your airways. It starts to be contagious 1 day before you first experience symptoms and remains contagious for at least 5 days after symptoms start.

Flu can lead to serious complications: pneumonia, bronchitis, sinus infections, ear infections, dehydration, and in very serious situations, death.

Ordinary flu happens every year: usually from November to April – and then stops.

Pandemic flu usually comes in two or three waves several months apart. Each wave lasts 2 -3 months.

5%-20% of the population may get the flu in any given year.

A yearly flu shot reduces risk of catching flu by 70-90%.

PANDEMIC FLU

A pandemic is distinguished by its scope: it is a worldwide epidemic.

A pandemic flu strain often develops when an animal or bird virus mixes with a human virus to form a new virus. Because people have little or no immunity, the disease can spread faster than with an ordinary flu.

The symptoms are the same as with an ordinary flu but can be much more severe.

There were three flu pandemics in the 20th century: the most deadly, the “Spanish Flu” in 1918-19 killed 20,000,000.The death rate was highest among healthy adults in their 20’s and 30’s. [The Median Age of Ontarians is 37].

A flu pandemic could happen any time.

We can’t predict just how society will be affected until we learn how strong the virus is.

There is no existing vaccine for pandemic flu. It will take 4-5 months after the start of the pandemic to develop a vaccine.

Drugs used to treat ordinary flu may also help people with pandemic flu but we may not have a large enough supply, and we won’t know how effective they are until the virus is identified.

ASSUMPTIONS

[“A ‘FLOW’ IS A QUANTIFICATION OF ASSUMPTIONS”]

Based on CDC’s U.S. FluSurge Forecasting model and an assumed 35% Influenza Attack Rate —

Over an eight week pandemic:  [there might be 3 such waves in a pandemic year]

Admissions:

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
3675 6125 9188 11638 11638 9188 6125 3675

Peak admissions/day: 1814

Deaths:

Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8
726 1209 1814 2298 2298 1814 1209 726

 

If you live in Ontario: during the first wave —

You have 1 chance in 3 of catching the pandemic flu

If you catch it, you have 1 chance in 2 of needing to visit your family doctor

and 1 chance in 70 of needing to be hospitalized

If you need to be hospitalized, you have 1 chance in 5 of dying there.

An unknown proportion of the population will develop health complications.

These levels are at least six times greater than typical hospitalizations for influenza and pneumonia during inter-pandemic periods.

[If you don’t get the pandemic flu in the first wave, your odds improve greatly:

*improved natural immunity from the 1st wave experience

*probable availability of a pandemic flu vaccine

*much better understanding of how to deal with the virus]

Resources needed by Hospitalized Influenza Patients:

100% using an acute bed for 5 days

15% using ICU beds for 10 days

7.5% using ventilator support for 10 days

If the Assumptions hold:

At the peak of the pandemic, influenza patients will use:

52% of all Acute Care Beds

170% of ICU Beds

117% of Ventilator-supported Beds

Current Demand for hospital services is already high: ICU Beds are utilized 90% daily.

The FluSurge model does not take into account Health Care Worker absenteeism but the Plan assumes that staff will contract influenza at the same rate as the general population in their communities. [History suggests staff will come down with pandemic flu at a much higher rate, and fatalities will be disproportionately high — especially in the first weeks. If so, the net effect will be to seriously reduce availability of trained staff as the pandemic goes on: the impact will be particularly grave should a second wave and then a third wave hit]

[The Model does not consider how patients will be moved to and from hospitals: Ontario is a big province with a population of 12 million (5 million households). However, Ontario is 80% urban, and most live in the so-called “Golden Horseshoe – from Oshawa to Niagara, including the Greater Toronto Region].

DEVELOPING HOSPITAL SURGE CAPACITY

There has to be a Phased Approach:

*Deferring non-influenza care

*Dynamic use of influenza Triage

*Dynamic Use of Admission/Discharge Criteria

These will vary according to available and needed local hospital resources.

Specifically —

*Defer Services for Non-Life-Threatening patients.

*Discharge ALC (Alternative Level of Care) patients to Long-Term Care.

*Discharge acute patients and inpatients to home care.

*Create “flex-beds” from reserved or recently closed beds.

*Deploy freed-up beds for influenza patients.

*Use Ventilator Capacity anywhere sufficient oxygen is available:

ER, post-anesthetic care units.

*Cohort infectious and non-infectious patients.

Re-deploy staff.

*Defer holidays and leaves of absence.

*Establish 12 hour shifts.

*Train non-clinical staff to handle support services: meals, personal care, patient movement, cleaning, etc. and support for health care workers and families (child care, pet care, etc)

*Coordinate with other hospitals.

*Encourage participation of public in Home Health Care courses before the pandemic.

*Cross-train clinical staff.

[Wait until the Pandemic strikes. Then count backward 1 year, and initiate training].

MASS EMERGENCY CARE DECLARATION

AND CRITICAL CARE TRIAGE

With the assumed 35% Attack Rate the phased development of Surge Capacity will not be enough to meet the Peak Demand. Accordingly, a Mass Emergency Care condition will have to be declared: this will have “substantial legal, regulatory, and logistical implications.”

The type of Triage contemplated is only justifiable in an Overwhelming Crisis i.e. when all resources are in danger of being exhausted.

Principles

*All patients will be cared for – one way or another. [True, but not very comforting.]

*Triage is a practical application of Ethics [Everything is.]

*Fairness and Justice will prevail. [How about Compassion?]

*Based on Clear and Transparent Criteria.

Timely Accurate Information is vital

Health Care providers will need real-time data about patient outcomes during a disaster; in order to modify criteria and prevent over- or under-triage. The Protocol will evolve with time and use.

Triage Models

No Triage systems have been developed yet for use in critical care or medical illnesses but there are models available to draw on:

Illness Severity Scoring Systems: “cumbersome and impractical during a disaster when human resources are scarce.”

Military Triage Systems: “devised specifically for Trauma and not for medical conditions or biological events.”

SEIRV Triage System: “developed for use in Bio-Terrorism attacks.”

Categorizes patients but does not address Resource Allocation.

Uses ‘Inclusion’, ‘Exclusion’, and ‘Minimum Qualifications for Survival (MQS)’, to guide triage decisions – “which should be part of all Critical Care Triage Systems.”

Sequential Organ Failure Assessment Score (SOFA): “may be useful as a component of a Triage System.” It uses general physiologic parameters applicable in a wide variety of conditions.

Inclusion Criteria

Identifies patients who may benefit from admission to critical care: focusing primarily on respiratory failure.

Exclusion Criteria

Identifies those needing a level of resources which cannot be met in a pandemic, and even if ICU resources were found they would have a very poor chance of survival (SOFA Score of > 11 i.e. mortality rate of > 90% even with full critical care). For example —

*Severe burns

*Cardiac Arrest not responding to prompt defibrillation or cardiac pacing .

*Needing large blood transfusions

*Underlying “significant and advanced” illnesses with poor prognosis and high short-term mortality (as in advanced cancer and end-stage organ failure)

MQS — Minimum Qualifications for Survival

Principles

*Place a ceiling on the amount of resources that will be allocated to any one individual.

*Early identification of patients who are not improving and are likely to have a poor outcome.

In other words — find a ‘balance’ between those who are sick enough to need the resource and will do poorly if they don’t get it, but are not so sick that they are unlikely to recover even if they do receive intensive care. In other words, every patient who is admitted to critical care should survive. [And those not admitted will surely die? Self-fulfilling prophecy.]

OPERATIONALIZING CRITICAL CARE TRIAGE

“Effective Triage depends on an established, skilled, and practiced infrastructure.”

CENTRAL TRIAGE COMMITTEE

This is a Multi-disciplinary Team:

*Making clear and transparent decisions with support from ethical and legal experts.

*Using consistent Criteria flexible enough to allow local responses.

*Primarily responsible for:

— Modifying the Protocol as the pandemic evolves – based on analysis of

[as it happens] data

— Command and Control over the critical care resources in the field.

— The key decision – when to activate the Protocol.

“These issues are too important to be decided by the individual Triage Officers in the field.”

TRIAGE OFFICERS

“The best triage decisions are made by senior physicians with training in triage and significant clinical experience.”

They must be given proper training beforehand, as well as on-going support during a pandemic.

COMMUNICATIONS

The quality of decisions by the Committee and by Triage Officers depends on the availability of accurate [up-to-date and sufficient] information. There has to be a reliable two-way Communications Network between the Field and the Committee.

[Given the current lack of effective communications and a near-total absence of reporting of system-critical information in all aspects of health care, it’s hard to believe that the Plan – which results from considerable research, intellect, and experience – will work as stated: but it is a very good start.]

POST-SCRIPT

On Tuesday, November 21, 2006, The Hamilton Spectator headline read:

“No pandemic care for elderly” as the page 1 lead-in to an article by Joanna Frketich.

On page 8 of the same issue, an article by Peter Van Harten was headed”

“Pandemic rules hard to swallow?” with the sub-head “MD predicts major ethical debate.”

I’m amazed there weren’t more such headlines, but it takes a certain amount of effort to locate and then read such things as pandemic plans, and supreme court decisions.

Does one have to be able to read as a criterion for attending journalism school? Evidently the Spectator people can, and do. I wonder about some of the others.

The debate over ethics will surely take place – if not before the pandemic, then after. As with all disasters — natural and non-natural – the political propensity to re-hash will once again raise its very ugly head.

One element (among many) in the Draft Triage Protocol Exclusion from Admission criteria set is Age > 85. So Seniors might be well advised to hide their birth certificates and lie about their age.

Triage is never easy. If a pandemic comes upon us the hard choices could become very hard. “Tennis anyone?”

Be well.

Vintage Big Med – D Newman | Ethics and Triage: A Nasty Scenario – Dec 2006

Ethics and Triage: A Nasty Scenario by David A H Newman

[Dec 12 06]

If only the rich could pay the poor to die instead of them, Then the poor would make a very good living. (Ancient Yiddish Joke)

A Flu Pandemic has begun. The hospitals are crowded. Staff is overworked: many have come down with the flu – one sort or another. The ‘normal’ flu doesn’t vanish just because of a pandemic. Even before the flu’s came, the usual ailments and conditions have just about taxed the limits of the system’s capacities; and the pandemic is a long way from peaking.

It’s bitter cold outside. People, old and young, are dragging themselves, or loved ones, or neighbors, to Family Practice offices, and to hospital Emergencies. Taxis refuse to take them – this stuff is dangerous! – public transit is barely operating: drivers are sick, or calling in sick and maintenance is non-existent. Who would want to ride the bus and breathe in undiluted virus? So people drive, or walk, or stumble, or are wheeled to their local version of purgatory.The paramedics and first-response people, like many doctors, nurses, and orderlies, have, in some cases, literally worked themselves to death. Others are genuinely seriously ill at home. In any case, hospitals won’t allow ambulances to unload: the situation has become too serious for ambulances: they are irrelevant against the scale of the emergency. This puts the First Responders in a Catch-22 bind: what are they supposed to do with the living, the dying, and the corpses? The fire-paramedic and police stations have become hospital wards, and mortuaries.

Family Practice offices are crowded; there weren’t enough to begin with, and now more and more are closed – the doctors and nurse practitioners have strived valiantly for weeks, working round the clock; but many have succumbed to the illness and are too sick to carry on. Some have already died. The sufferers keep arriving – and are told to go to “Emergency.”

The Emergency is so crowded it’s impossible to move: too few staff, too few Triage Officers’, too many forms and too few to fill them in. More tests needed? – long waits; supplies dwindling.

It’s not just in “Emergency” – the corridors are lined with sick and dying. The ‘lucky’ ones have beds; others are wrapped in blankets on the floor. The sound of coughing, hacking, groans rasps and rattles adds to the background. The place doesn’t smell- it reeks.

The only ones around to help are family and volunteers; but they too are a dying breed.
The kitchens have shut down. The Tim Hortons a few blocks away is the main source of hot soup and beverages.

The chaos extends outside the hospital. Every few minutes a car pulls up to the curb and someone terribly sick is pushed out or loaded into a wheelchair; and then abandoned. People are desperate. People don’t want to watch loved ones die. They want to get them to where help is available, but there is no more room at the inn.

There’s no room and the authorities have instituted a quarantine. There are fierce barriers to admission – -even to approaching the hospital. Police and Military, guns evident, are supposed to enforce the ban, but they didn’t sign up to turn away the sick and dying to perish of exposure on the street; at the very gates of supposed aid and comfort. They try to keep a semblance of order: lining up the wheelchairs – many with their frozen dead occupants — in neat rows. Some are in tears; none will ever be free again in their minds. This is not a job: this is hell.

Worse yet are the ones who have lost it, watching their loved ones going downhill with no access and no hope. Some arrive in a rage, screaming threats, demanding access — armed and very dangerous. Are they to be gunned down on the spot? Is there time, patience, and skills to talk them into calm? Can it be done?

Pharmacists (legitimately part of the Front Line) are also besieged as people line up to request, demand, and plead for something – anything – to help their loved ones. They are worked off their feet doing what they can, but they are hampered by government irresolution in deciding what powers pharmacists should have. It would have been an enormous assist to everyone if government had given them emergency powers to prescribe and dispense on the spot; and if government had also picked up the tab for all pandemic-related drugs. Some go ahead and prescribe anyhow; but supplies are dwindling.

As in all pandemics, even in our supposedly enlightened age, the miracle-workers with trumped up testimonials from the crowned heads of Europe, quacks with nostrums, and ‘end is nigh’ callers to repentance all have their moments of glory — and riches: its remarkable how expensive the goods and services are which these selfless folks ‘freely’ offer. Human nature is eternal in its often excellent ways — and in its folly.

At the other end of the chain, the mortality rate among those admitted to hospital is much higher than predicted: in part because the virus is especially virulent; in part because the system has broken down; and in part because all attempts to establish interior quarantines (cohorting) have been defeated by increasingly over-worked staff, and a shared air-circulation system. The usual crop of hospital-specific infections is proliferating.

There are no more resources left and little chance of getting any anytime soon: suppliers and distributors are at their limits and manufacturers are forced to ration dwindling output.

The hospital mortuaries are full. Autopsies will have to come later — much later; if at all. Meanwhile, bodies, neatly toe-tagged, are stacked like firewood in a more-or-less exterior courtyard. The weather is cold enough: they will wait there quietly. Anyhow, morticians have closed up shop for the duration. Those with the courage and strength retrieve their dead and go to join the long lines at the crematoria.

The death rate is also high among the thousands cleared out from the hospitals to make room for the pandemic flu sufferers: sent home, or to long-term care facilities, or otherwise moved out of sight and out of mind. They live, or die, or will be debilitated for the rest of their lives.

Scalpers are thriving: they don’t mind the cold as they wait patiently on the streets around the hospitals for new arrivals. The going rate for an admission for one is $25,000 (up front in cash). There are enough takers to make the middle-men wealthy, and to handsomely reward the good folks inside who are ready to pocket the bribes. Being a triage officer, or a key person in the paperwork chain, is a license to print money.

Anyhow, a disproportionate number of highly placed bureaucrats and politicians, and their friends, family, and lovers, seem to get rooms and beds and ventilators, and the world’s gone mad around you, so why not get some benefit? After all, you’re one of the few still on the job, taking the big risk with your life, so why not?

There are still some who are trying hard to stay ethical – to do the right thing because it’s in their nature. But it is hard; because so much has gone wrong and it’s not a matter of pointing blame. It doesn’t mean the Plan was flawed. It doesn’t mean that society, and the system, were at fault. There may have been flaws and errors, but that’s only because we are human and frail and mortal and come with the full set of emotions. This emergency is overwhelming – like a millennium storm it has surged through our cities and buried our best plans and hopes in an abyss of tragedy. (It happens).

PostScript

Worst Case scenarios seldom happen: by definition, they are unlikely. But when they do happen, they tend to be much worse than anyone could imagine.

I wrote this scenario to try to answer a lurking question: are Ethics and Triage at all compatible? Worst Case scenarios test the limits and when I think about what could happen at the limit, I don’t at this point see any room for Ethics (or Morality) in a Triage situation — unless, and this may be key – the Ethics are built in to the Triage Design.

However, stating a set of lofty humanitarian principles up front is not the same as ensuring they are followed in the field. With the best will in the world, Triage has to be based on other principles – such as making the most effective use of limited resources, and the greatest good for the most.

Fairness is a worthy test of a system – in the sense that Triage and what follows must not be arbitrary, and should be equitable (without fear or favor). In the main, that is feasible – though there will always be queue-jumpers. But Fairness has little to do with Compassion.

Hard choices — sometimes the trade-offs are wrenching, at best.

I’ll try to work some more with these issues. Your views, in the light of your own experiences, would help.

Be well.

Vintage Big Med – D Newman | Danger Pay – Aug 2007

Danger Pay by David A H Newman [Aug 27 07]

Back when SARS threatened Toronto, the Ontario government of the day introduced strict quarantine measures reminiscent of the often drastic quarantine laws applied in times of plague — [as in London 1664-65].

Quarantines are difficult to enforce, but the quarantine worked for Toronto and SARS was contained. But, as can happen when something new attacks in epidemic proportions, people died and some of them were healthcare workers.

They died in part because we didn’t know enough — we never do — and in part because people wore the wrong masks, or they weren’t properly fitted, and because the hospital culture took a while to get over an under-estimation of the dangers. We will be ready for SARS next time, but next time it won’t be SARS, and there will be casualties. One outcome of the re-hash of the SARS experience is a call for danger pay — looking ahead to an anticipated pandemic. Undoubtedly healthcare workers will face risks and uncertainties; some will be casualties and some will die. It’s not enough to say that it goes with the territory and the Hippocratic Oath — I’m not sure it does when it comes to the crunch.

In the exceptionally virulent plague outbreak in London [1664-65], many of the best doctors and nurses died in the first weeks, as they worked valiantly and desperately to help the sufferers. This was not the dark ages; London was a capitol of enlightenment, home to many men and women of science and medicine. But when the plague came, in a particularly horrific form, they didn’t know enough. Regardless of how advanced we think we are today, the same truth holds — we never know enough, and too often, the best among us die trying to stem the tide.

Danger pay or compensation or insurance may well be justified. But think about it: pandemic is just one form of disaster affecting the many, and the response to disaster involves the many. There are many unsung heroes. There are many who suffer, and too many who die. Pandemics, like disasters in general, do not differentiate between the professionals and the rest of us. Doctors and nurses, and orderlies, and many other healthcare workers, are on the firing line. But so too are the paramedics, firefighter first responders and a host of others including volunteers. And then there are the collectors of the dead, and the ones who dig the pits and dispose of the corpses. How about the folks trying to maintain law and order while the world around panics and goes ballistic? And finally, there is the largest category of them all: you, me, and everyone else; the patients and the potential victims. We are all in it together, so where does danger ‘pay’ begin and end, and with whom?

A few callous souls have argued that if ‘we’ don’t get danger pay ‘we’ will simply down tools and refuse to show up at work; the ‘we’ variously referring to doctors and other healthcare workers. It’s an interesting argument. Fortunately, there is a precedent —

A few years ago, emergency room doctors in Winnipeg walked out. They claimed, likely justifiably, that they were overloaded, the system was breaking down, and no one cared. So they downed tools and the entire emergency system shut down. I think the walkout lasted for two weeks or thereabouts. The mortality rate in Winnipeg dropped alarmingly; of the order of 30 percent. In due course, the emergency people returned to work.

But one seems to have absorbed the underlying issue: if there were no healthcare system, would we be worse off or better off? What would happen if all the patients downed tools and walked out? How would the politicians cope with a pandemic of angry voters? Let them try to quarantine that!

Remember Bob: “You have the power.” So vote as you like, but vote often.