All emergencies are local ...

		A woman and child wear masks to protect against the SARS virus as they wait in a queue to enter Beijing's West Railway Station in this May 13, 2003 file photo.
		By Greg Baker, AP

No one can say when a pandemic will begin or how severe it will be ... ... but the SARS outbreak in 2003 showed us how quickly a new disease can spread ... ... the 2004 flu vaccine shortage prompted panic and long lines at clinics... ... and the aftermath of Hurricane Katrina brought home the alarming reality of American citizens stranded at a time of need.

A severe flu pandemic would combine elements of all those crises, and more. And, even worse, it could persist over a period of months, health experts say.

Planning for a pandemic is well underway at the mile-high level of the Department of Health and Human Services, which has produced a hefty Pandemic Influenza Plan and a website, www.pandemicflu.gov, along with handy "to do" checklists. But it's at the one-foot level, in homes, neighborhoods and communities, that planning is most crucial. (Related story: How prepared are you?)

"All emergencies are local and it doesn't matter what the federal stockpile is, if it doesn't get out locally it doesn't matter," says Arnold Monto of the University of Michigan. "And it's the local health departments that have to get it out."

State and local health agencies, perpetually understaffed and short of cash, are struggling to prepare.

Officials of these agencies say they need help, not only in the form of money to pay for training, staff and supplies but also guidance to make sure each of the approximately 5,000 state and local health departments is working from the same set of assumptions so that there is a degree of uniformity. If not, there could be chaos: One county could close schools and ban sporting events to restrict the spread, while a neighboring county goes about business as usual. One state could designate police and firefighters as "essential workers" and give them anti-virals and vaccines, while the next state designates snowplow drivers and grocery store managers as essential. "We can't afford to have 100 flowers blooming," says Maine state epidemiologist Kathleen Gensheimer. "We need minimum standards."

There hasn't been a flu pandemic since 1968, but concern about another one has been growing since a strain of bird flu, called A (H5N1), began to cause serious illness in people in Hong Kong in 1997, killing six of the 18 infected. Authorities ordered the slaughter of all the chickens in the city, and world health experts breathed a sigh of relief, believing the pandemic had been averted.

The strain re-emerged in early 2003 in a Hong Kong family that had visited China's Fujian Province, then seemed to disappear again. But at the end of that year, poultry outbreaks were reported in South Korea, quickly followed by outbreaks in Vietnam, Japan, Thailand and across Asia into Europe.

This month, it turned up in wild birds in Azerbaijan, Bulgaria, Greece, Italy, Slovenia, Iraq, Iran, Austria, Germany and France. It has spread into India, Egypt and Nigeria, raising fears it could race through Africa. And it has killed more than 90 of at least 170 people known to have come down with it. World Health Organization officials say, with a couple of exceptions, people caught the virus directly from infected chickens. It has not yet been able to spread easily from person to person, but if that happens, the disease could be in every corner of the world in a short time.

It's good to have a national stockpile of drugs and supplies, but there has to be a plan to get the drugs or vaccines to the people who need them, and the staff, facilities and supplies to carry it out, experts say.

"When a pandemic strikes, the entire country will be only as strong as the weakest link in the chain," says Jeff Levi, director of Trust for America's Health, a health advocacy group. "We hear from (Health and Human Services) that it's all going to have to be worked out at the state and local level, and that's true, but there is a federal responsibility to make sure everyone is following the same guidance and has a minimum level of capacity to implement that guidance."

Dorothy Teeter, director of public health in Seattle and King County, Wash., says state and local health departments don't have the money to stockpile everything that will be needed in the first weeks of a serious pandemic.

"Our hospitals and our public health system are funded for normal levels of operation, which include some degree of seasonal variation, but have always relied on the federal government should we have need for more ventilators, for example, in the event of an earthquake or other mass-fatality event," she says in an e-mail.

What the federal planners are not getting, she says, is that in a pandemic, every community will be asking for ventilators from the national stockpile at the same time.

Public health experts praise the efforts of HHS to stockpile antiviral drugs and speed development of a pandemic flu vaccine. They welcome the $100 million that HHS says it will release to the states for preparedness, part of the $350 million emergency appropriation passed by Congress in December.

But they fear it will be a one-shot windfall, when what is needed is a steady stream of funds for pandemic-flu planning. That would strengthen the states' ability to respond to all kinds of emergencies, says Frank Welch of the Louisiana Department of Health and Hospitals. "There's a lot that would be the same in any disaster, and if we had sustained funding to do pandemic flu ... we could get planning down to the local level in a more effective way than any one-year program is going to do."

There are "at least 50 versions of planning going on now," says Penny Hitchcock, a senior fellow at the University of Pittsburgh's Center for Biosecurity. "When you listen to someone from New York City or Seattle, you get the feeling they're working hard on it and it's moving along, but when you listen to people on hospital preparedness, you get a sense of enormous gaps."

What that will mean for the average person is that "it's unclear where they're going to go for help, whether for a vaccine, if one's available, or for treatment," she says.

Clearly, some localities are better prepared than others. In Louisiana, "a lot of what we do, we do very well," Welch says, "but we're one of the poorest states in the country." The state's public health office and state lab, which were in New Orleans, were destroyed in the floods after Hurricane Katrina, and while the state has a flu pandemic plan, says Welch, "it's very difficult to try and have people focused on (pandemic planning) while our state is trying to recover from one of the worst natural disasters our country has ever seen."

Public health agencies in Seattle and New York City, among the best prepared in the nation, have had plans in place for months. Still, health officials in both cities say a pandemic could quickly overwhelm hospitals and resources.

"We're not contemplating opening Madison Square Garden at this point" for hospital beds, said Isaac Weisfuse, deputy commissioner of New York City's Department of Health and Mental Hygiene, speaking at a meeting earlier this month in Washington, D.C. But shortages of intensive-care beds, ventilators and respiratory therapists and other health staff are expected.

Health officials also are struggling to prepare to provide services to homeless people, non-English-speaking immigrants, disabled people, the elderly and other vulnerable populations. "The lessons of Katrina are reverberating through every health department in the U.S.," Weisfuse says.

Says Teeter: "You have to imagine all the things that would happen. If you don't do that, you don't make the right connections with the right people." One hundred languages are spoken in King County, Wash., and 39 cities within county limits. Preparedness means coordinating with businesses, hospitals, jails, schools and universities. "It doesn't mean it's impossible. It just means it takes time, people and problem-solving skills."

How long we have before a pandemic is anybody's guess, but infectious-disease specialist Brian Currie of Montefiore Medical Center in the Bronx, N.Y., says the further off it is, the more ready communities will be.

"Time and geography are buying us a year, probably," he says. "But we'd better be ready then. We'd better make good use of our time."