With all the media coverage of the emerging influenza pandemic I thought to visit the archives of the Crozet Annals of Medicine for some perspective on preparing for a global influenza pandemic. This is an article I wrote in October 2007 [pdf]:
I took a sick day this week. A communist convinced me it was right thing to do. When I returned to work the Journal of the American Medical Association (JAMA) waiting on my desk confirmed it scientifically. Sick days save lives.
I was interviewing an émigré from the former Soviet Union last week regarding the differences in health care delivery between the U.S. and Russia. As expected, there were some significant differences, but what struck me the most was the attitude toward going to work sick. Vladimir explained to me that the notion of taking “powerful medicines” for every illness did not resonate with most Russians. Rather, in Russia the common cold triggered a leave from work of a week or more. Maternity leave ran to years instead of weeks. Vladimir did acknowledge that this had as much to do with the lack of incentive to work under a socialist regime as with health care beliefs. But he pointed out that, in his opinion, it did produce a healthier population.
I guess this was in the back of my capitalist head somewhat this week when I picked up some bug, no doubt from one of my sick co-workers or maybe from one of my patients whose only motivation to seek medical care was to convince a boss that he should take off from work. Having no life or death duties compelling me to go in to the office, I simply stayed home. I caught up on some Law and Order reruns and recovered uneventfully.
When I came back into the office, a thick packet of information from the Virginia Department of Health was on my desk urging me to be prepared for the possibility of a global flu pandemic. The most likely source will be a mutation from an avian (“bird-flu”) strain. Most of the instruction boiled down to this: stay home. For a long time.
There were three influenza A pandemics in the last century, with the 1918 pandemic being the most deadly. Labeled the Spanish flu, it actually originated in the U.S., almost certainly as a mutation from an avian source. The mortality was shocking, with estimates as high as 50 to 100 million people killed worldwide. There was no vaccine and no antivirals, but there were effective non-pharmaceutical interventions. A group of medical historians and Center for Disease Control epidemiologists recently studied the public health records from 90 years ago and reported some interesting findings in the August  issue of JAMA. They looked at 43 cities and their responses to the 1918 flu pandemic. Cities that cancelled school and public gatherings early in the pandemic and kept them cancelled for long periods of time had half the mortality of cities that waited till the flu was already upon them wholesale. Staying home saved lives.
Not much has changed since 1918 in our vulnerability to pan-flu. A sudden mutation would preclude a vaccine in the first several months of attack and antivirals will be in short supply, if effective at all. We will have to go old school, pun intended and cancel school. We call it “social distancing” now, and it is intended to reduce what is known as social density. Preschools are the most crowded social environments with 35 square feet per student, followed by elementary schools at 49 square feet and high schools at 60 square feet per person. Bad news for teachers for sure, but hospitals are not far behind in social density, so I am right there, too. Home is the least dense environment at 734 square feet per person. Perhaps that is why we feel so happy and healthy there.
All of this is a good reminder that mid- to late-October is time to get your flu shot. No, it won’t save you from pan flu, but it will protect you from the inevitable yearly influenza outbreak. And if you do get sick, for goodness sake think like a communist and stay home. Your co-workers or classmates will thank you. Vladimir will thank you. Nostrovia!*
* Russian toast “to good health”
Update: The source patient for the new swine flu was a little boy living near a large pig farm in Mexico owned by Virginia-based Smithfield Corporation. Pork industry representatives have lobbied vigorously to rename the disease something other than swine flu and I think they have a valid point. While this strain of influenza A (H1N1) does reside in pigs, the pigs got it originally in 1918 from us. We got it from chickens, so why not chicken flu?