Saint Louis University community health professor Greg Evans has a diagnosis for what ails local disaster planning: preparedness paralysis. Speaking at a symposium sponsored by the Center for Health Law Studies at Saint Louis University's School of Law on March 5, Evans said the problem starts at the federal level and trickles down to state and local governments.

Photo by Nancy Fowler Larson

Greg Evans addresses the disaster preparedness symposium at Saint Louis University.

Many decisions, big and small, must be made in the face of a pandemic, bioterrorism attack or natural disaster. In a situation, such as the recent H1N1 pandemic, those judgments include how much antiviral medicine to stockpile, who should be vaccinated first, and if and when people should be banned from public places.

Laws governing federal disaster money made after 9/11 allow federal officials to offer guidelines but no firm rules. Those are left to state and local authorities. Problem is, it's hard to find someone on the local level who wants to be the decider, said Evans, the director of the Institute for Biosecurity at SLU.

"Authorities do not make decisions because they are afraid of making a mistake and they're afraid that will lead to an undesirable political consequence," Evans said. "The result is, if local planners address these issues at all, they do so indirectly and sidestep the actual decision, leaving it to whoever must make it in the midst of an actual disaster."

FLAWED OR FLEXIBLE?

Keeping decision-making at the local level is good policy, said Margaret Donnelly, the director of Missouri's Department of Health and Senior Services, during a question-and-answer session of "Pandemic Preparedness: Lessons Learned and Future Challenges." When Congress was determining how post-9/11 disaster preparation funds should be spent, state and local governments rallied against federal control. Local decision-making allows for flexibility, such as divvying up vaccines among those with the highest risk, for example, pregnant women.

"A small county with three obstetricians will have very different needs than St. Louis with Barnes-Jewish Hospital when it comes to prioritizing who gets the vaccine," Donnelly (right) said..

Mandatory vaccination can only be imposed at the state level. Governors make that call but only after declaring a state of emergency. The pandemic that began last summer fizzled before vaccination requirements were even considered in Missouri. Overall, compulsory inoculation is a situation that most authorities want to avoid.

"We don't ever want to get to the point where we tie people down on a gurney and inject them," said symposium speaker Dan Stier (right), with the Centers for Disease Control in Atlanta. "But once you have mandatory vaccination, then [you can enforce it by saying], 'If you're not getting your child vaccinated, they don't get into school.'"

Carrying out mandatory vaccination in those beyond school age poses a bigger dilemma.

"It's easier to enforce things in schools, but how do you enforce it with adults?" Evans said in an interview. "It would really be the last-case scenario because we realize it's almost impossible."

Closing schools is another important consideration during a pandemic, one that's determined by each school district. It's also a situation in which no one wants to be wrong. Overreacting is a better policy than under-reacting, according to Evans (right), but it may not be the popular choice.

"If you close schools and this had been a really lethal pandemic, then you would have been a hero for saving lives and not exposing children," Evans said. "If you close schools and it turns out to be nothing, then everyone says, 'You wasted money, our kids didn't get to school, I had to take off work.' In public health we believe you have to err on the side of protecting the public as much as you can."