As U.S. Secretary of Health and Human Services Secretary Leavitt has noted, states and local jurisdictions will be in the vanguard of the battle that has 5,000 fronts. According to the secretary, "A lot is going to be expected of us. Fortunately, a great deal of the preparation activities laid out below have already become part of our awareness and skill set as a result of some of the terrorism and emergency response planning that public health has recently experienced" (Fabian, 2006, p. 47). In sharp contrast to the secretary's assertions concerning the country's level of preparedness for such an epidemic, many experts are warning that more needs to be done today before it becomes too late to do anything. In fact, it is not out unreasonable to assume that many public health officials would become involved in the administering of medications and caring for the sick based on the anticipated shortages of health care workers and the potential need for warehouse hospitals; the community also needs to consider ways in which it can help sustain and care for the health care workforce (Fabian, 2006). Employees of local health departments could easily become involved in providing assistance on this healthcare front (Fabian, 2006).

Another environmental health director told this author that a number of communities have many households in which children are taken care of by a single parent or even by elderly relatives or friends. Some monitoring of these households would be in order to assure that the children are still being cared for, especially if the care provider becomes ill or dies. Therefore, the following issues remain unresolved:

Techniques for securing food, water, and supplies to quarantined populations need to be figured out and implemented; government officials need to work with grocers to ensure that food supplies are maintained and that people have access to them.

Public-education campaigns, which only public health professionals can devise, need to be developed to educate the public concerning everything from cough etiquette to carrying alcohol hand wipes to remembering to limit hand-to-face patterns.

It is likely that environmental health professionals will also become involved -- if only to a limited extent -- in some of the state pandemic-flu planning now taking place.

There will be a critical need for reliable communications; public health authorities will need to be able to keep in touch with the public and to communicate accurate, reliable, and helpful information about everything from health resources to the state of the pandemic to basic risk assessment to measures by which people can take care of themselves. Such public communication programs will have an enormous impact on how a crisis will play out. The public will look for information that answers their questions. Providing that information will help maintain community order and confidence in the government. Such programs also provide an opportunity to dispel misperceptions. Success or failure on this one function can tip the scales between peace in the streets and public panic and disorder (Fabian, 2006).

It is easy to envision environmental health professionals working with various components of the community's infrastructure so that essential and even normal services can be maintained; therefore, it is also critical that public utilities, particularly power and water utilities, receive the assistance they require in order to maintain their workplaces as safe as possible and to have redundant systems in place so that they can continue to operate (Fabian, 2006). In the event that an influenza epidemic began, the American workplace would be changed into a home-based operation; in this environment, Fabian emphasizes that the requirement for operational utilities would be one of the most important concerns. According to this author, "It is not too early to be looking at how outdated quarantine laws and protocols can be revised. Health departments will likely be involved in determining when to close schools and when public gatherings, social events, or both will need to be cancelled" (Fabian, 2006, p. 47). In addition, public health authorities may be required to provide basic consultation services for their communities; for instance, public health departments would be a natural place for businesses to turn to for advice and assistance on measures they could take to limit the impact of the influenza outbreak (Fabian, 2006).

Because we're talking about a crisis that could develop before we have enough supplies and resources to treat it, tough resource allocation decisions are going to have to be made by governors, mayors, and...

Decisions about how to allocate masks, gloves, antivirals, vaccines, palliative drugs, and the like will be difficult" (Fabian, 2006, p. 47). More tough decisions will also need to be made about makeshift or warehouse hospitals in hotels, schools, and stadiums. Decisions might even be necessary for food supplies for quarantined populations. All of these decisions have the potential to involve members of our profession simply because environmental health professionals are also public health professionals (Fabian, 2006).
As Secretary Leavitt noted, "We're looking at a minimum of three to five years before we get to where we need to be. The President's plan calls for the ability to produce 600 million doses of a vaccine by 2013 -- seven long years from now. Our public health ethic would seem clear on the answer to this key question" (quoted in Fabian, 2006 at p. 47). These federal authorities have concluded that the country needs to be better prepared for just such an eventuality, and it would just seem to make good sense to begin preparation sooner than later. In fact, Secretary Leavitt was adamant about the need for more preparedness today: "If this thing ever breaks loose," he adds, "I am convinced that we will need every preparation, every resource, and every body that we have to manage it in a way that minimizes its impact. It would be an irresponsible and unforgivable dereliction of our professional duty to delay our preparations until a pandemic is actually under way" (quoted in Fabian, 2006 at p. 47).

The foregoing considerations have caused many observers to question whether the United States is adequately prepared for such a threat, and whether there are any efficacious drugs available for its treatment should such an epidemic occur. The research to date indicates that two of the popular antiviral drugs, amantadine (Symmetrel) and rimantadine (Flumadine), are not effective against H5N1; however, researchers have identified two others, oseltamavir (Tamiflu) and zanamavir (Relenza), that might be effective but more research is required (Ford, 2006). To this end, the National Institute of Allergy and Infectious Diseases (an agency of the U.S. National Institutes of Health) sponsored the production and clinical testing of an investigational vaccine based on the H5N1 virus, and in August 2005 the agency announced that preliminary testing of the vaccine had been successful (Ford, 2006). Nevertheless, even after it became available to the public, the vaccine will still require significant time to produce, and a vaccine made for the H5N1 subtype might not provide immunity to a mutated strain (Ford, 2006). According to an epidemiologist at the Harvard School of Public Health, there has been a dearth of preparation for an H5N1 pandemic around the world in general, and cautioned that if such an influenza pandemic affected the United States, the country would be able to manufacture enough vaccine for only about 25% of its population and enough Tamiflu for less than one percent (Ford, 2006).

In response to these shortcomings in preparedness, President George W. Bush outlined a $7.1 billion plan to provide funding for the early detection and containment of any pandemic flu outbreaks both in the United States and in other countries in 2005, including improved methods for creating flu vaccines, and the stockpiling of flu vaccines and antiviral drugs (Ford, 2006). Not surprisingly, there appears to be a more pronounced sense of urgency throughout Southeast Asia compared to the United States in dealing with the potential threat represented by avian influenza; in fact, taxis in some Asian country have installed signs that warn passengers that feel ill to go straight to a hospital (Ford, 2006). Indeed, the influenza pandemics of 1957 and 1968 killed millions of people each, and the great influenza pandemic of 1918 likewise was responsible for the death of tens of millions; clearly, another influenza pandemic is a possibility, but preparing for the threat is a serious and difficult problem (Ford, 2006).

Disciplines, Perspectives, Evidence, Insights

Logic, Reasons for Order of Presentation of Disciplines Used.

Biological Perspective. There are some profound biological issues involved in planning for a potential pandemic of avian influenza that will adversely affect the ability of public health officials to respond. In his essay, "The Growing Challenge of Avian Influenza," Imperato (2005) reports that avian influenza viruses typically infect a specific range of bird species; subtypes of influenza A, the various strains of these avian viruses can be classified…