Five people you need to know during a pandemic

Groups represent essential public health, clinical roles

A recent bestselling novel centers around five pivotal people the main character meets in the afterlife. But ethics researchers at The Hastings Center say there are five pivotal people that public health leaders are going to want to meet now, to prepare and protect them before an influenza pandemic.

International public health experts agree that a new flu pandemic is inevitable, and in response to this threat and to a federal mandate, all states in 2007 submitted pandemic influenza preparedness plans to the Centers for Disease Control and Prevention (CDC). But while all plans note that rationing of supplies, devices, and manpower is inevitable in a pandemic, few address how they would make ethical decisions on rationing.

Nancy Berlinger, PhD, deputy director and research associate at New York's The Hastings Center bioethics research center, is co-author of an ethics backgrounder, "The Five People You Meet in a Pandemic — and What They Need from You Today," published in December 2007.1 In the report, Berlinger and co-author Jacob Moses describe five key people — actually, five groups of people — who community and health leaders should identify and prepare in order to make fair decisions under the pressure of a sustained public health crisis.

A recent survey of states' pandemic influenza preparedness plans revealed that ethical decisions that must be made in preparing for and dealing with a pandemic were mostly left out of plans, or given only cursory mention.2

"Ethical challenges — how a community will make fair decisions about using scarce resources, protecting public health, and keeping basic services running — must be discussed before pandemic hits," the authors write. Berlinger says in meetings on pandemic preparedness, it became evident to her that pushback to rationing plans on the clinical level was the result of health care workers not perceiving the guides as based on ethically sound plans.

"We realized the level to discuss this was really the interface between clinical medicine and public health," Berlinger says. Thus, the five key groups of first responders to see a community through a public health crisis posed by a flu pandemic include clinicians, non-clinical service providers, and individuals who straddle the clinical and public health boundaries.

Where public, clinical ethics meet

Preparation for a pandemic includes making sure everyone involved in planning understands ethics the same way, Berlinger says.

"When public health officials talk to clinical ethicists and ask how to get ethics into the plan, if the ethicist hasn't had a lot of public health exposure, they quickly see that clinical ethics and public health ethics aren't the same thing," says Berlinger.

Specifically, whereas clinical ethics emphasizes the values and preferences of the individual patient, "in a public health crisis, you can't ask each individual about their values and preferences," she says.

To devise a tool that public health officers can use to bring together clinicians, administrators, business, media, clergy, and elected officials to speak in the same language about ethical decisions in a pandemic, the Providence Center for Health Care Ethics and The Hastings Center partnered to convene a meeting of public health officials, experts on public health ethics and clinical ethics, and clinicians to discuss the challenge of building pandemic plans on an ethically sound framework. From that meeting, the "Five People" model was developed.

"The plan has anticipated five groups — some in health care, some outside, some rules makers, some rules followers," Berlinger continues. "No matter the size of the community, you will have all these people in your community. This is a way of working through and saying, 'What does [our plan] look like through the eyes of the person with the least power?'"

The five groups of people, as identified by the authors, are:

  • The truck driver: Represents community members responsible for essential non-medical tasks in a public health emergency;
  • The gatekeeper, the triage officer, and the janitor: Represent groups working inside hospitals, responsible for a variety of essential tasks and decisions;
  • The public health official: Represents local, state, and federal authorities responsible for making or carrying out the rules — laws, regulations, emergency triggers, policies — that communities will follow during an emergency and that will help them recover after an emergency.

Besides identifying the five groups, community public health leaders must then make sure those five are trained to act under emergency conditions in ways that might not come naturally. Hand in hand with that is making sure the groups know they are prepared and that they will be protected; the essential nature of their roles makes them high priority groups for receiving vaccine in the event of rationing.

"The temptation is there to say, 'They'll know what to do; they're trained for triage.' But we're going to be asking them to think and act differently. We can't also be asking them to think on the spot how to do it ethically," Berlinger explains. "That's where the planner comes in — to create the rules that say, 'If you follow these rules, you're acting ethically even though you're acting differently than you normally would, you're doing things differently, and the hospital is different."

Five groups to train and protect

Truck Driver. The truck driver represents the first responders who produce, deliver, or ensure delivery of essential supplies that cannot be stockpiled or that have run out. This includes those who ensure supplies of food, medical supplies, fuel, and clean water, as well as essential personnel who unload and load the trucks; public safety officers who make sure the truck drivers can get through; and factory workers who meet demands for vaccines.

The Gatekeeper. The gatekeeper's role is to ration access to public health facilities. Hospital emergency department personnel will be overrun with influenza patients, on top of the regular emergencies that come to the hospital under normal conditions. Berlinger says the gatekeeper's role can be played by clinical personnel; chaplains, administrators, and social workers who help turn people away if they're not ill enough to be admitted under the emergency rules triggered by the pandemic; and security staff, who will be charged with protecting hospital staff and patients.

The Triage Officer. In an influenza pandemic, intensive care for the most severely ill will be in high demand, and hospitals with inadequate staffing or beds may have to restrict access to only the sickest patients. In those cases, the authors suggest, pandemic plans have to anticipate a shortage of ventilators — some ventilators will already be in use, and influenza is a respiratory illness. Berlinger says planning in concrete, actionable, ethically sound terms will give gatekeepers the tools to say who gets access to available ventilators and under what conditions.

The triage officer is a gatekeeper with very specific duties, focused on ventilators. The triage officer should be supported by clinical ethicists who can apply clear, consistent rules that acknowledge the rights of individual patients while also acknowledging that, for the duration of the emergency, the need to be fair to all patients may trump individual claims, the authors state.

The Janitor. Though non-clinical, the janitor — like the truck driver — is an essential component to a pandemic preparedness plan. Because the janitor — which includes housekeeping, laundry services, orderlies, food service staff — works in the hospital, the risk of exposure to infection is high. Planners for this group must determine the priority to assign the janitor when it comes to rationing vaccine, weighing supply against the effects of not having the janitors at their posts during and after the pandemic.

The Public Health Official. Public health officials include not only those in traditional public health roles, but government officials who can make good decisions — or, as Berlinger says, "boneheaded decisions" — that affect public health during an emergency.

"People are already talking about who will show up at work, and who is ready to do things that need to be done," she says. "The unilateral decisions, however — like closing routes that prevent doctors from getting from their homes in the suburbs to their hospitals in the city — need to be thought through, to be sure that they're good decisions."

Planning for public health officials also needs to clearly address secondary effects of a pandemic, including disruption of hospitals' cash flow from Medicare and insurance, and fears of negligence liability on the part of clinicians (as seen following Hurricane Katrina), the authors point out.

Plan, then make plan transparent

Berlinger says that the effectiveness and success of any pandemic preparedness plan hinges on the public being able to understand it and have questions about it answered.

"Planners need to encourage the media to be a vector of public information and education, and not incite panic," she says. "Putting things on a factual basis helps people understand the reasoning behind ethical rationing decisions."

Even though the idea of scarcity is an unfamiliar one to most Americans — true unavailability of vaccine or access to care is something few Americans have had to face, Berlinger says — to assume that the public won't follow rules or adhere to rationing rules would be to "break faith" with the public interest before a plan even has a chance to be tested.

"In Toronto [during the SARS outbreaks], 25,000 citizens were quarantined, so it is possible in major North American cities to do this," she points out. One way to help accomplish a greater level of compliance is to create a system that can't be "worked."

"You don't want to set up a system that people can work around. You don't want people to think they won't have to worry about rules, because that makes thing very hard," says Berlinger.

Source/Resources

For more information, contact:

  1. Berlinger N, Moses J. Bioethics Backgrounder. The Five People You Meet in a Pandemic — and What They Need from You Today. November 2007. Available for free download at www.providence.org.
  2. Thomas JC, Dasgupta N, Martinot A. Ethics in a pandemic: A survey of the state pandemic influenza plans. Am J Public Health2007; 97:S26-S31.