Maintain infrastructure in flu pandemic

Emphasis on maintaining basic supply lines

In a new study, for which Nancy Kass, ScD, of the Johns Hopkins Berman Institute of Bioethics is the lead author, she and others outline their vision of an ethical response to a severe influenza pandemic: Keep society functioning.

That goal of maintaining such basic necessities as Internet, cable, gas and electricity is critical in an already stressful situation, and scarce resources should be considered for those workers who keep basic utilities functioning.

"Where I think we differ is that most response plans that were written in the past, although I think this is changing, most of the response plans that were written in the past privileged health care providers, vaccine manufacturers, and what I will call traditional first responders – and very often, rarely mentioned anybody else," Kass tells Medical Ethics Advisor.

But in the study, Kass and her co-authors suggest that "the secondary consequences of severe pandemic influenza could be greater than deaths and illness from influenza itself. Response plans, then, must consider threats to societal as well as medical infrastructures."1

One of the primary threats to continued societal function likely would be absenteeism, they write: "Rationing strategies will need to be considered not only for ventilators and medical countermeasures but also for potentially threatened resources, such as food, water, and gasoline."

The study suggests that during a severe pandemic, absenteeism estimates are as high as 40%, which could be due to illness, other family members who are ill and require care, or self-isolation due to fear of contracting the flu from others.

That, the study says, could lead to "significant interruption of usual services across multiple sectors."

"Indeed, if individuals, at the extreme, found themselves with no functioning toilets or clean water, no electricity or heat, no radio or cell phone or Internet, and extremely limited access to gasoline or food, there could be widespread social chaos, significant outbreaks of other infectious diseases, and severe anxiety, with the possibility of social degeneration, looting, or even violence as people try to secure needed supplies," the authors write.

Public mental health in such a scenario also could be severely impacted.

What is the ethical approach?

The authors suggest that an ethical response plan should focus on these essential functions. But how should that be implemented?

In addition to vaccine makers, first responders, and health care providers designated to receive scarce medical resources, an ethical response plan should also consider "privileging, for example, some utility workers, key communications personnel, and truck drivers who can deliver food or fuel to communities in need," the study says.

While Kass emphasizes that she is "not trying to suggest that a truck drivers is more important than an ICU doctor by any means," a response plan designed to keep society functioning must be "sensible about all the different players it takes to keep those functioning."

Essential personnel might also include people "willing to remove infectious waste and run laboratory facilities at every functioning hospital."

Three-pronged response strategy

The suggested response from the authors includes three components:

  • state-organized public-private coordination;
  • industry/organizational preparedness;
  • individual/household preparedness.

In the preparedness stage, local governments will be called upon to carry out the lion's share of the response plan.

"As part of the dialogue, state and local health departments should ask each critical sector and business whether it plans to stockpile antiviral drugs, protective equipment and perhaps emergency supplies of food and water, and how the state can facilitate intersector cooperation and assistance," the authors write.

Individual and family preparedness is also key, the authors write.

"Federal, state and local governments must identify additional ways to convince individuals that they should prepare emotionally and practically for a pandemic and to give them the confidence and practical tools to be increasingly self-sufficient," they write.


  1. Kass, Nancy et al. "Ethics and Severe Pandemic Influenza: Maintaining Essential Functions Through a Fair and Considered Response." Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 6; 3:227-236.


For more information, contact:

  • Nancy E. Kass, ScD, Deputy Director, Berman Institute of Bioethcis and Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Balitmore, MD. E-mail: nkass@jhsph.ed.