THE THIN WHITE LINE: the history of a future avian influenza pandemic

Chapter 2: State of Emergency

Chain of infection

    Several days before October 26, Dr. Susan Anderson, Alberta’s Provincial Chief Medical Officer, couldn’t believe the numbers coming out of Sentinel Influenza Surveillance, Alberta Viral Watch, FluWatch and the Canadian Integrated Outbreak Surveillance Center Respiratory Alert Program. Calgary, Edmonton, Vancouver, Toronto and Montreal all showed an abnormal surge in doctor visits, flu tests, hospitalizations and deaths. Calgary, in particular, suffered a significant epidemic. Anderson’s phone rang almost continually as the Capital, Calgary and Palliser Regional Health Authorities (RHAs) reported outbreaks of a flu that closely matched the WHO case definition of Avian Flu.
    As the epidemic developed, she contacted the Health Minister of Alberta and advocated that the government declare a province-wide public health emergency so that the health system could launch a coordinated, managed response to the crisis.
    Public health emergencies are legal events. They can be declared by individual RHAs or by the government, specifically the Lieutenant Governor in Council, upon the advice of the Provincial Chief Medical Officer. The Lieutenant Governor is The Queen’s representative and CEO of a province. It’s an apolitical position; for example, the Lieutenant Governor gives royal assent to bills passed by the Assembly and signs proclamations and other official documents. “The Lieutenant Governor in Council” simply means the provincial Cabinet makes a decision that is approved by the Lieutenant Governor. Public health emergencies grant government strong powers and diminish individual rights, and are therefore not taken lightly.
    On October 29, three days after the NML confirmed Avian Flu as the pathogen responsible for the growing epidemic, Alberta claimed these powers. Other provinces, managing their own developing outbreaks, followed suit within days.
    The Public Health Act specifically gives medical officers the authority to prohibit people from attending school, engaging in their occupation and having contact with other people. These are actually sweeping powers, enabling a ban on public gatherings, restrictions on travel, and the shutdown of non-essential businesses.
    Within days of the declaration of public health emergency, medical officers announced the scheduled shutdown of schools and large public venues such as theaters, stadiums and community centers. The severe public backlash that followed, coupled with scientific uncertainty, sapped the political will to take further measures.(28)
    Most people were aware of the threat of Avian Flu, but other than the government closings it had not touched them personally yet. At the time, a growing number of people knew somebody who had gotten sick and were home in bed with flu, but relatively few knew anybody who’d died or even had to go to the hospital. A poll conducted by a major national newspaper on October 26 found that 28 percent believed the government was exaggerating the threat, with 52 percent saying they weren’t sure. At the time, only 20 percent of Canadians agreed with the government’s response.
    On October 31, parents took their children out for Halloween, as they always did.

    With an R0 value of >2, the Avian Flu spread exponentially among the Canadian population. Dr. Anderson says government basically had two strategies they could use to intervene and reduce the rate of transmission of disease from one person to the next: non-pharmaceutical and pharmaceutical interventions.
    “Pharmaceutical interventions include antivirals drugs and vaccines,” she says. “These were our most important life-savers. But we had limited antivirals and a vaccine wouldn’t be ready for months——until essentially the first wave had ended. That left the non-pharmaceutical interventions such as public education and social distancing.”
    The goal: Get people to stay away from each other to keep them from passing the disease around, and observe good hygiene to prevent becoming infected, and thereby contain the virus’ spread by effectively reducing its R0 value to <1.
   In the first weeks of the epidemic, prior to any interventions, an estimated 30 percent of disease transmission occurred in the home, while 33 percent occurred in schools and workplaces. This is only natural: Disease transmission mostly occurs where people tend to spend a lot of time in close proximity to each other.
    With a new virus, since the immunity level is so low, basically either everybody gets it or the chain of infection is broken. In the early days of the epidemic, the flu spread like wildfire through the school system and public places; an infected man coughs in a crowded movie theater, and everybody around him can easily become infected. Just as bad, an estimated one-third of the flu cases were asymptomatic——people walking around feeling fine but still spreading the flu as a carrier.
    “If we could prevent people from having contact with each other, at least in large groups, we could slow its spread and reduce pressure on the health system even if we couldn’t stop it,” Anderson explains. “Since one-third of disease transmission occurred in schools, workplaces and large public venues, then ideally we could stop people from congregating in those places. It was easiest to close schools and large public facilities.”
    She points out that these strategies, however, were only partially effective when instituted by themselves. They had to be combined and layered in the community to have a significant impact. And they had to be introduced early enough to make this impact.
    “Unfortunately, we were always one step behind the epidemic in our decision-making,” she adds. “By the time we had good information and then made a decision, we were usually too late to have the kind of impact we wanted.”
    Another 30 percent of disease transmissions are believed to have occurred in the home. Anderson says the government had three options to reduce spread. First, they promoted good hygiene to keep people from becoming infected; all provincial governments during the epidemic launched major public service announcement campaigns promoting hand washing and homecare.
    Keep your distance when out, wash your hands when in, they told citizens. If there is somebody sick in your home, stay at home yourself.
    One PSA encouraged, “Say hi, and wave goodbye.”(29)
    Second, government encouraged people to stay at home if a family member was sick and being cared for at home, a practice called self-quarantining. Government never took the third and most drastic step——closing all non-essential businesses and declaring a general home quarantine for all citizens for the duration of the epidemic.
    “Disease is often compared to fire,” Anderson says. “If you deny it something to burn, it will become extinguished. A home quarantine could have accomplished this; we simply don’t know. The consequences of this strategy, however, were unpredictable and potentially too severe. How would we have enforced such an order? Even if everyone complied, they would say to us: Okay, we’ll stay at home if you take care of our basic needs——food, medicine, rent. But we didn’t have the resources to take care of everyone.”
    So government stuck to enforcing social distancing outside the home. But even this proved difficult. Humans are social animals and in cities, survival and economic activity requires social contact. Social distancing could only be accomplished by severely limiting individual freedoms Canadians take for granted.
    Normally, within the public health system, clinical ethical principles, which concern the rights and interests of the individual, are balanced with public health ethical principles, which concern the rights and interests of the public.
    In other words, it’s in the group’s interest to be comprised of healthy individuals, just as it’s in the individual’s interest to be part of a healthy group. The most significant values are justice and respect for the individual and his or her freedom.
    When a single individual is affected by a health risk, balance shifts in favor of clinical ethics. When the health risk is shared by the public, however, then balance shifts in favor of public health ethics. As a result, during the Pandemic, collective interests temporarily trumped individual interests and individual freedom.
    “If you are sick and spread it, you put everybody at risk, and therefore it is our duty to limit your ability to spread it, even if that means we must curtail your rights,” Anderson explains. “Government’s rules, however, must be enforceable to be effective, and they must be obeyed. During the epidemic, many people didn’t obey, and we didn’t have the resources to force them.”