The only thing that was missing was whiskey.
Six weeks' worth.
Everything else was taken care of: food, water, medical supplies, and enough toilet paper to last a month or more. We had piled the stuff—$360 worth of dry goods, nonperishables, canned foods, and paper supplies—onto a flatbed cart with a broken wheel and wheeled it around the South Seattle Cash and Carry, debating endlessly: Do we really need four giant cans of Chef Boyardee? How much water should we really have on hand? Does it make sense to buy a bag of rice if the power's going to be off anyway?
Our shopping spree was inspired by avian influenza, a disease that had a brief moment in the media spotlight back in 2005. Since then, flu has largely disappeared from the stage in favor of climate change, hurricanes, and Paris Hilton.
But it hasn't gone away.
It's still mutating, jumping from species to species, and killing more people every year—four in 2003, 32 in 2004, 43 in 2005, 79 in 2006, and 33 so far in 2007, according to the latest information from the World Health Organization. Most of the dying is going on in places most of us don't think about very often: Indonesia, Cambodia, Laos, Vietnam. But when this flu mutates, as flus routinely do, into a kind of flu that's easily caught by humans, it will be too late to confine it to poor nations in Southeast Asia. Indeed, by the time you hear the first news report, it will be too late to do anything to stop it.
Every single person I spoke to for this article—epidemiologists, emergency health-care specialists, pandemic preparedness experts, and politicians—said the same thing: The question isn't whether pandemic flu is coming, but when. "Pandemics have happened throughout history," says Meredith Li-Vollmer, a risk communications specialist for King County. "There's no question that it's going to happen. What we can't tell is when and how bad it's going to be."
Back at the Cash and Carry, we finished loading up our cart, our debates settled, and headed for the checkout lanes. Then we loaded all the stuff into the Flexcar, drove it home, and lugged it down the stairs into the basement.
We're ready for the pandemic—how about you?
All flus begin as bird viruses. Birds, particularly waterfowl, are the natural reservoir for every strain of influenza. The virus that currently has public-health officials worried, known as H5N1, is a particularly nasty, virulent flu strain that has been circulating in poultry in Asia since 2003.
So far, the virus has mostly limited itself to people who come in frequent, direct contact with infected birds—poultry workers and people in isolated rural areas. Right now, it's bad, but it won't be really bad until the flu starts to move from person to person.
The current bird-to-human form of the virus kills an astonishing number of those it infects; according to the World Health Organization, more than half of those who have contracted the virus from birds have died. Its impact is greatest among the young; in a study of more than 200 confirmed human avian flu cases conducted in early 2006, WHO found that just over half of all cases were in people under 20, and that the median age of those who caught the flu was 18. Of the youngest victims, the majority died; the majority of those older than 50 survived.
"People my age just get sick and get better," says King County Executive Ron Sims, 58, the local public official most responsible for making bird flu a top health priority. "This is a disease that attacks the young."
Right now, people can only catch bird flu from infected birds; however, the virus mutates constantly, making it highly likely that it will eventually learn to transmit itself easily from person to person. Once that happens, a pandemic will occur. The likelihood of pandemic is currently high, which is why WHO took the unusual step of increasing the world pandemic alert level from a 2 to a 3 (pandemic is declared at the highest level, a 6) in 2005. The organization predicts that the world is now closer to a flu pandemic than at any time since 1968, when the last of the 20th century's three pandemics began. The others were in 1957 and 1918.
The 1918 pandemic killed between 40 million and 50 million people around the world. The 1957 and 1968 pandemics were milder, in part because they were hybrid human-flu viruses, to which people have some immunity; they killed one million and two million, respectively. The current bird-flu virus worries scientists because it's similar to the one that led to the 1918 pandemic.
In one of WHO's "more conservative scenarios," according to its strategic action plan for pandemic flu, there will be as many as 233 million outpatient visits, 5.2 million hospital admissions, and 7.4 million deaths worldwide. The U.S. Centers for Disease Control and Prevention predicts that as much as 30 percent of the population of the U.S. could be infected; in King County, officials predict that as many as 540,000 people could be infected, with as many as 18,000 deaths, according to Sims.
"This is something that will kill millions," says Barb Graff, head of emergency preparedness for the Seattle Police Department. "There will be no natural immunity. There will be no vaccine." And because the disease can take weeks to kill its victims, it will spread very easily from person to person.
King County, thanks in large part to the vigilant efforts of County Executive Sims, is perhaps the best-prepared county in the nation. Unfortunately, that doesn't mean we're actually prepared. If a severe pandemic hit tomorrow, King County would be in serious trouble. Hospitals, which have almost no excess capacity, would overflow immediately; the movement of goods through the port and freight rail systems would slow to a crawl; medicine supplies would run out; the mortuaries would fill up; and many basic functions of government would cease.
"Ebola," which struck in Africa in the mid-1990s, "kills people by the hundreds and ends because it kills them quickly," says Sims, who's so obsessed with bird flu that he puts Purell alcohol gel on his phone, keyboard, and doorknobs every morning. "This virus isn't like that. It's a mean virus," and death comes slowly. "You die with your lungs full of water."
Think about all the people you come into contact with in a day.
Simple acts like using an ATM, riding the bus, boarding a plane—all put us in contact with the fingerprints, bodily fluids, and germs of hundreds, sometimes thousands, of people. Flu can survive on nonporous surfaces, like steel and plastic, for up to 48 hours, and on paper and cloth for up to 12 hours. That means that when you touch the plastic bin at the airport, the germs of everyone who's touched it before you for the last two days are now yours. Touch your eyes, rub your nose, eat a sandwich without washing your hands, and you're infected.
The last time I flew, from Sea-Tac to Austin, I used an American Airlines e-ticket machine that had been touched by hundreds of people over the last 48 hours. Then I lugged my suitcase into a long line behind a family of six, a couple of whom were sniffling. I gave my luggage to the airline representative, touching the steel counter and setting my plastic ID on top of it. I waited through the security line—handing my ID and ticket to yet another airport worker—and put my carry-on, laptop, and shoes in a plastic bin where someone else's luggage and shoes had been before.
I walked through the line, put my shoes back on, and made my way to the crowded gate. There I sat in close proximity to other passengers, many of them making connections from other places, before boarding. On the plane, I was squeezed in between a man and a woman; a crying child squirmed and coughed behind me. Several hundred of us shared the same tiny space, the same recirculated air, for nearly five hours. I probably came into contact with a thousand people on my trip, all without talking to anyone or shaking a single hand.
Our lives are a microbiological disaster waiting to happen.
Previous pandemics took six to nine months to travel around the world; today, thanks to globalization and air travel, a flu pandemic is expected to reach all parts of the world within just three months.
"Once a pandemic begins, it's not feasible to think that it can be stopped," says Michael Loehr, head of the preparedness program at King County. "We're acting under the assumption that once things start spreading from human to human, it's going to happen here."
Flu spreads the same way as all viral infections—through respiratory secretions, droplets released into the air when people cough or sneeze. The closer people are to one another, the more likely they are to catch the flu. The most effective tool for slowing flu transmission—far more effective than quarantine and isolation of infected patients, which only work during the first days of a pandemic—is to keep people from getting together.
Officially, this strategy is called "social distancing"—using police power to prevent people from gathering in large groups. If a pandemic hits, and if the flu is virulent and severe, Sims says the county will impose social distancing as soon as it confirms five cases. That means no school, no church, no concerts, no professional sports.
Children, notes Jeff Duchin, head of King County's communicable disease program, are "very effective carriers" of viruses, so closing down all the schools will be an important step in limiting the flu's spread. Closing down the schools, in turn, will mean a big hit to the local economy, as businesses lose workers who have to stay home to take care of their kids (to say nothing of the quarter to one-third of all workers who are expected to fall ill). Although Duchin says social distancing "doesn't mean we're going to encourage people to close down restaurants" and other small businesses, he adds, "we wouldn't encourage" keeping them open, either.
Sims goes further, suggesting that he might invoke police power to shut businesses down.
If the worst happens—if people stop going to work, if businesses are shut down, if the power and water get disrupted—the city of Seattle will look much different. The normal bustle of small-business operations—people walking in and out of restaurants, cars driving into gas stations for beer and cigarettes, workers lining up at Starbucks—will cease. If there's no power, Seattle will be a dark spot on the map. If there's no water, there will be raids on grocery stores—by people wearing masks because they fear being infected by the other looters, not because they fear being identified by the police.
As unlikely as that scenario seems, that's exactly what happened after Hurricane Katrina, as the realization dawned on people that no one—not the federal government, not the state—was going to help them. They had to help themselves. That can happen just as easily here in 2007 as in New Orleans in 2005.
County health officials seem convinced that voluntary compliance with social distancing measures will be high—that is, people will stay home willingly to avoid getting sick. Li-Vollmer, the King County risk communications specialist, says that at a flu preparedness forum the county put on with the CDC earlier this year, "the vast majority of people said they would be willing to support" measures to keep people from congregating.
However, she acknowledges that those were "people who were willing to come to a forum on pan flu, a self-selecting group of people who are already interested in the subject." Among the general population, officials' optimism seems excessive: People are creatures of habit, and if you tell them not to go to church, or to cancel travel plans, or that they can't have a funeral for a loved one, they're likely to rebel. When that happens, people will get sick.
When they do, even the most optimistic officials predict that the existing health-care system will be overwhelmed almost immediately.
"If we were to have a severe pandemic tomorrow, our [health-care] planning would not be complete," says Dorothy Teeter, the chief of health operations for King County. King County has between 3,500 and 4,000 hospital beds; on any given day, 90 percent of them are full. If more than a few of the 540,000 sick people in King County need to go to the hospital (and they will), they'll quickly find they don't have anywhere to go.
"There's going to be a run on every hospital around here," Sims says. "We can discharge people to free up capacity, but we'll never have enough." Ventilators, drugs, even things as simple as hospital bedsheets, will be in short supply. "If we have anything more than a moderate pan flu, we won't have enough hospital beds," Teeter says. "In any health-care emergency, we're outstripped."
Hospitals, overwhelmed by the influx of patients, will have to discharge patients who aren't critically ill, cancel all elective surgeries, and send many sick people to so-called "alternate care facilities," large public places like gyms and community centers that have been recommissioned to serve as makeshift hospitals. Teeter expects that there will be three such alternate care facilities in the region; however, none have yet been identified.
There's also the question of inequality of care: What happens to people who have the misfortune to get sick in a poor part of town, or while homeless? "You can't have one hospital having a surplus and everyone else having nothing," Loehr says. To that end, the county has put together a health-care coalition—an organization that will coordinate flu response efforts between all the health-care entities and hospitals in the region. "The health-care system is very fractured, competitive, and independent. It's important that the system work as a system," Loehr says. Aspects of the health-care coalition were put into effect during last December's windstorm, enabling health-care workers, for example, to get people in nursing homes without power to places that still had electricity.
Mortuaries will also be overrun with bodies; estimates range between 12,000 and 18,000 deaths in a six-week period for a county that usually sees 13,000 deaths in a year. The state and federal governments will be unable to provide disaster relief, because people will be sick everywhere at once. Many health-care workers will be sick, putting more strain on a system that's stretched thin already. Nationwide, there's already a shortage of 100,000 nurses; the system can't afford to lose a third of its already meager work force. Medications, likewise, are in short supply; most hospitals have only enough inventory for a few days, and the sudden spike in demand during a pandemic would correspond exactly with a period of limited supply.
"Everyone thinks hospitals have drugs on site. Well, they do for that day, but they don't have any backlog," Sims says. "The more you think about how daunting it is, the more it starts to overwhelm you."
Seattle City Council member and health board member Tom Rasmussen, who has been an advocate for the elderly and disabled on the council, says that when people with mental-health problems and other disabilities can't get their medication, "that is a huge problem. I met a woman recently who has bipolar depression. Without her meds, she would be on the street screaming at people."
King County and other health agencies recommend that people keep a few weeks' supply of extra medication on hand; however, most insurance companies will only dole out a month's worth at a time, making that option unrealistic for those who can't buy extra medication at full price. The county is also stockpiling enough of the antiviral drug Tamiflu to treat 25 percent of the population, the goal of local governments nationwide; however, those doses will be targeted at health-care workers and others on the front lines of the pandemic, not the general population.
And there's no guarantee Tamiflu will work against pandemic flu anyway. In a best-case scenario, Tamiflu might lessen the severity of illness in the very sick, but only if they manage to take it on time—within 24 hours of infection. (Meanwhile, there's no vaccine, because the flu has to break out before a vaccine can be developed, a process that takes between four and six months.)
While all that is going on, businesses and government agencies will be hard hit, losing as many as 30 percent of their work force on any given day. Health officials suggest that businesses cross-train workers to do other people's jobs, a strategy that may work in government and at places like Boeing but that's likely to be tough for small businesses to swallow. "The larger businesses take it very seriously, but smaller businesses don't have a lot of extra resources lying around," Loehr says. The Stranger, which has about 70 employees, does not have a specific plan for pandemic flu.
If—when—the pandemic hits, Li-Vollmer says staying home is the best protection.
"If you're at home," she says, "you're not circulating among people who have the virus."
Health officials all agree that you should have a stockpile of food, water, and medication. What they don't agree on is how big that stockpile should be. King County's current preparedness campaign recommends that people prepare for "three days, three ways"—make a plan, build a three-day emergency kit, and get involved in your community. However, although virtually every official I talked to for this story had their own stockpile (see sidebar, "What's in Their Stockpiles," page 23), they all agreed that three days won't cover it when the flu hits Seattle.
Here's what's in my personal stockpile: One 20-pound bag of rice; one gallon jar of pickles; four 40-ounce cans of Chef Boyardee ravioli (a childhood indulgence I would never allow myself to have in "real" life); two weeks' worth of bottled water, allocating one gallon per person per day; several assorted cans of beans; several large cans of soup; a large box of crackers; a half-gallon jar of peanut butter; canned vegetables, including corn and green beans; several pounds of pasta and jars of pasta sauce; a half-dozen aseptically packaged boxes of broth and soup; cereal; vitamins; toilet paper; tea; and a bunch of other stuff I can't remember.
Most of my coworkers think I'm an overprepared nut. According to the state department of health's checklist, though, I'm actually underprepared. I still need medication, a digital thermometer, cold packs, extra toothpaste and soap, games, cash, and large trash bags. Assuming I don't get sick, I could "survive in place" for two weeks or longer—staying at home while the flu rages outside—assuming the boredom wouldn't kill me first.
"Seventy-two hours works in an earthquake or a tsunami," says Sims, referring to "Three Days, Three Ways." "[But a] pandemic is a rule changer. You cannot prepare for it. You buy two weeks of supplies, and in two weeks you're going to have to go out and buy more."
Some advocate solving that problem by simply building a bigger stockpile. "I recommend highly that you take all the information you've ever been given about earthquake preparedness and multiply it by six," SPD emergency preparedness director Graff says. "The way I put it is, get ready to go urban camping. Three days of supplies isn't nearly adequate." For those who don't have the resources or the storage space to do that (aka apartment dwellers), the health department recommends relying on family, friends, and neighbors—a hard sell in a city where most of us don't know the people in the apartment next door.
Think city living is impersonal and isolating now? When the flu hits, you're really going to be on your own.
Let's say—it's possible—that none of this comes true. No flu, no panicked raids on grocery stores by the less prepared, no corpses stacking up in temporary morgues while I hole up in my house and wait it out.
My stockpile, now augmented by whiskey, won't go to waste. If a year goes by without a disaster, I'm having a disaster party and using up everything that won't keep.
But then I'm going out and buying more.