Dead Serious 

The diary entry penned by Dorman Kent of Montpelier on September 29, 1918, offers only a glimpse of the horror enveloping Vermont. “Terrible times,” Kent wrote, underlining his words three times. “Nine died over Sunday and four today. It’s awful, awful! The sickness is increasing hourly.”

Three days later, a partial survey of the state capital found 1237 people sick in bed, another 1876 either ill or recovered, and eight dead. In Montpelier, 59 people died in 12 days; in Barre, 40 died in three days.

The culprit: Spanish Influenza, a previously unknown and particularly virulent strain of the flu, which struck Vermont in the fall of 1918. The illness quickly swept the state, felling not only the very young and the very old but also strong, hearty Vermonters, including hundreds of workers in the state’s granite sheds.

In addition to the usual flu symptoms — severe headaches, high fevers, nausea and swollen joints — victims suffered intense pain and hemorrhaging from their eyes, ears and noses. Many suffocated as their lungs filled with fluid. Whole families died, children were orphaned, and in some places, bodies were left unattended.

Vermont’s remoteness offered little protection. Within weeks, 6000 cases were reported statewide. Public officials did what little they could to stem the tide of death, banning all public assemblies and imposing travel restrictions, but they were overwhelmed. Many doctors and nurses were overseas as part of the war effort.

By the time the pandemic subsided in February of the following year, 43,735 cases had been reported in Vermont — though the actual number probably surpassed 50,000. At least 12 percent of Vermonters contracted the illness; more than 2100 died.

Kent’s diary entries and other eyewitness reports are included in Michael Sherman’s 2004 monograph Spanish Influenza in Vermont, 1918-19, one of the few in-depth accounts of Vermont’s horrendous pandemic experience.

Ninety years later, the state’s worst-ever outbreak — which claimed many more Vermont lives than did World War I — has been virtually forgotten. Yet, as history reminds us, pandemic flu is one of the few natural disasters that occurs with reliable frequency.

“Over the last 300 years, there have been many well-documented pandemics, and they occur about three times per century,” says Dr. Christopher Grace, director of Infectious Disease at Fletcher Allen Health Care. “The longest time period in the last 300 years between pandemics is 42 years. Our last pandemic was 40 years ago. You do the math.”

Grace and his fellow emergency planners at the Vermont Department of Health, Vermont Emergency Management and 14 community hospitals work under the assumption that it’s not a question of if another pandemic will strike, but when. And they’re all gearing up for the next Big One.

They’re not alone. Most large businesses and organizations that run Vermont’s critical infrastructure — the electricity grid, water and wastewater plants, transportation and telecom systems — have “continuity of operations” plans in place to get them through a pandemic, which could last anywhere from six weeks to six months.

But what about the rest of society? Vermonters rely on thousands of other agencies and organizations that don’t fall under the traditional rubric of “essential services” but nonetheless are vital to our day-to-day lives: banks, supermarkets, restaurants, pharmacies, fuel distributors, childcare centers, mental-health facilities, food shelves and homeless shelters, to name a few.

Many of these goods and services are provided by small, family-owned businesses or nonprofits that struggle even in good times. For many of them, emergency planning goes no further than keeping up with their insurance premiums. But consider the consequences for these companies if 30 to 40 percent of the population were to contract a potentially deadly disease, and the health department advised everyone to avoid public places. How many could stay afloat if one-third of their employees were too sick to work, or stayed home to care for loved ones or bury their dead?

These aren’t just worst-case scenarios, experts say. Vermont’s professionals who plan for such eventualities offer a blunt assessment: If a major pandemic strikes, the public should not expect federal, state or local governments to provide everyone with food, water, medicine and other essentials. (Think Hurricane Katrina.) The health department and other agencies would disseminate timely information and advice, depending on the pandemic’s severity. But ultimately, most people would be told to “shelter in place” in their homes for a period of days and perhaps weeks. And if individuals and businesses wait until the pandemic strikes to start preparing for such a scenario, it’ll be too late.

“In the end, it all boils down to community readiness and individual preparations,” says Dr. Wendy Davis, commissioner of the Vermont Department of Health (VDH). “We’re talking about an illness that has a high likelihood of killing many, many people . . . I don’t want to send people into a panic in the streets. But I want them to be prepared.”

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When health officials talk about pandemic flu, they’re not referring to the seasonal flu that hits each winter and is generally preventable with a flu shot. Although seasonal flu is dangerous to a small percentage of the population, such as infants, the elderly and people with compromised immune systems, most people who contract it recover within two weeks with no lasting effects.

Pandemic flu is different. The U.S. Centers for Disease Control and Prevention (CDC) define pandemic influenza, or “pan flu,” as a new and previously unknown strain of the influenza virus for which humans have no natural immunity. Pan flu would spread easily from person to person, move rapidly around the globe, and cause serious illness and death. Because of the speed with which this flu would emerge, it’s unlikely a vaccine could be developed, manufactured and distributed in time to halt its spread.

The last pandemic, the Hong Kong flu of 1968, was relatively mild, claiming about 700,000 lives worldwide, including more than 34,000 in the United States, according to CDC figures. The previous Asian flu pandemic of 1957 was more severe, killing 1 to 2 million people, including more than 70,000 in the U.S. The 1918 Spanish Influenza, or “Great Pandemic,” hit in three waves starting in 1918 and claimed 20 to 50 million lives worldwide. An estimated 675,000 Americans died of the disease.

Dr. Grace, who also chairs Fletcher Allen’s subcommittee on biological preparedness, says even a moderate pandemic — say, one with a mortality rate comparable to the Asian or Hong Kong flu — would afflict 30 to 40 percent of the population and kill 0.1 to 0.5 percent of those who caught it. In Vermont, that’s as many as a quarter-million people ill and more than 1200 dead.

And even in a mild-to-moderate pandemic, Vermont’s health-care system could easily be overwhelmed. Though hospitals routinely plan for and rehearse mass-casualty incidents — Fletcher Allen’s most recent “surge” drill was last spring — no other disaster would tax their resources like this one.

Under Fletcher Allen’s pandemic plan, Grace says, flu patients wouldn’t even be treated at the main hospital in Burlington, since its heating and ventilation system would quickly spread an airborne virus to other patients. (During a pandemic, people still wreck their cars, give birth, have heart attacks and need dialysis.) Patients most likely would be screened in the field first, either at walk-up clinics or over the phone. Those with flu symptoms would be kept away from the emergency department and sent to the Fanny Allen campus in Colchester or, more likely, sent home unless they were gravely ill.

“The last place you want to come to is a crowded area,” Grace says. “If there’s a big line outside the E.D., you could catch flu when you don’t even have it.”

Should the pandemic become severe — say, with a mortality rate of 2 percent or more, like that of 1918 — health-care providers would face some tough ethical decisions, notably, how to allocate scarce resources such as antibiotics and ventilators. Vermont’s medical professionals are already wrestling with ways of deciding who gets treated, based on such factors as the patient’s age, severity of illness and chances of survival.

“If we have a bad pandemic like we did in 1918, it’s going to get real ugly no matter what we do,” Grace admits. At the state level, plans exist to bring in refrigerated mortuary trucks if necessary. Vermont could also experience a shortage of coffins, as happened in 1918. There have even been “loose discussions” with the University of Vermont to use its ice rink to store bodies. “I don’t think that will happen here,” Grace adds, “but it won’t be pretty.”

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At the onset of a pandemic — officials expect they’ll get no more than a few weeks’ warning from CDC and World Health Organization representatives overseas — Vermont Emergency Management (VEM) would swing into action and open its emergency operations center, in coordination with the health department and other state agencies. Ross Nagy, VEM’s deputy director for preparedness and planning, says that a pandemic would present “the most difficult continuity-of-operations challenge we’ve ever faced.”

Pandemics aren’t like other disasters. They know no geographic boundaries and, unlike blackouts, blizzards and terrorist attacks, are measured in months rather than days. More crucially, emergency-service personnel aren’t immune to the flu’s effects and couldn’t rely on mutual aid from neighboring jurisdictions.

Nagy works under the assumption that a pandemic would reduce his own staff by 30 to 40 percent for 12 weeks. Recognizing that bringing people together in an emergency command center could hasten the virus’ spread, VEM has invested in web-based software so its employees can operate remotely via laptops and cellphones. Their efforts would focus primarily on keeping critical infrastructure operating and providing support and coordination where needed. Fortunately, most of these organizations already have pandemic plans in place.

For instance, the Champlain Water District, Vermont’s largest water supplier, developed an emergency response plan several years ago and is currently updating it with a new chapter for pandemic readiness, says Dick Pratt, CWD’s assistant manager and chief engineer.

“Something this severe really raises our ears, because we have to operate 24 hours per day,” he says. In a pandemic, nonessential work would probably fall by the wayside. However, even a brief interruption in the trucking of essential supplies from out of state, such as chemical disinfectants, could cause problems.

“Worst-case scenario, if we were not able to get disinfectant chemicals, we may go to a do-not-drink notification,” Pratt adds. But he sounds confident when he says that, even if his staff were reduced by 40 percent over three months, CWD could “pull in enough resources and keep the water flowing.”

Similar plans are also in place, or in the works, at Central Vermont Public Service, Burlington Electric and Vermont Yankee. But VEM’s Nagy admits that, while the state has done some outreach to the private sector to encourage pandemic planning, “I’d be leading you down the wrong path if I were to tell you that we’ve done a lot of coordination with them.”

In fact, phone queries made by Seven Days in recent weeks indicate that the level of preparedness in Vermont’s business community varies dramatically, from extensive to virtually nonexistent. Several businesses contacted, including those in construction, waste management, retail and, surprisingly, the funeral industry, were taken off-guard by the question. Other company reps downplayed the likelihood that such an event would ever occur, or suggested we check with the health department instead.

“All of the companies I deal with have emergency plans if the power goes out or the computers don’t work,” says Craig Fuller of Keller and Fuller, Inc., a health-care consulting firm in Burlington. “But what happens if people don’t come to work because their kids can’t go to school? We have entire risk-management departments that have never even considered that.”

Kelly Devine, executive director of the Burlington Business Association, says many of her members have never given a moment’s thought to pandemic planning.

“We have a lot of small businesses here in Burlington, and their focus is the day-to-day operations of making money and paying their employees,” she says. “That’s our goal at this point, to get our people thinking about this, because right now, it’s not on their radar screen.”

Not surprisingly, the state’s biggest employers have devoted considerably more time and resources to the issue. IBM, Vermont’s largest private employer, has had a pandemic-response plan in place since 2005 for all its facilities worldwide, according to spokesman Fred McNeese. Although the details are confidential, McNeese says Big Blue has “a very broad and comprehensive pandemic response plan” that includes contingencies for global travel restrictions, supply constraints, employee health monitoring and limiting access to critical facilities, where necessary.

Chittenden Bank, Vermont’s largest financial employer, also has a “multidisciplinary team” in place to assess and prepare for a pandemic. In fact, all federally insured banks and credit unions are now required by law to have a “business resumption plan” that includes pan-flu preparedness, according to Thomas Candon, deputy commissioner of Vermont’s banking division at the Banking, Insurance and Securities and Health Care Administration (BISHCA).

Food and drug distribution poses unique challenges for Vermont, according to VEM’s Nagy, because the state is “sort of at the end of the supply line for a lot of things.” Shaw’s, Vermont’s largest supermarket chain with 18 stores and 1800 employees statewide, has had a pandemic flu plan in place for about three years, according to Scott Sanderson, the company’s senior manager for business continuity planning.

Like other private employers, Sanderson won’t reveal the details of that plan. However, he insists that Shaw’s has an “extensive” emergency infrastructure — satellite dishes on every store rooftop, video feeds to each store, backup generators strategically placed around the country — as well as “local emergency-response teams” that can respond to a variety of natural disasters.

“We work off the assumption that people will eventually have to venture out, even if they’re nervous to, and they’re going to go to what they perceive to be the safest place to do that,” says Sanderson, himself a 12-year veteran of FEMA. “So a lot of our work is about compensating for that fear factor, not only with customers, but also our own associates, who might be nervous about coming into contact with other people.”

One problem that’s bound to arise in a pandemic is coordination, especially among private-sector companies that may be reluctant to reveal their weak links. “Obviously, we don’t have any food if it’s not brought to our distribution centers,” Sanderson adds, noting that Shaw’s suppliers, trucking firms and other business partners “are probably no more forthcoming than we are with opening up their back rooms and showing us all their trade secrets.”

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A number of other large Vermont institutions are also gearing up. Vermont’s colleges and universities, including UVM, Champlain and Middlebury, have invested significant time in pandemic planning.

Al Turgeon chairs UVM’s emergency-management planning working group. He says the university first began to explore this issue two years ago at the request of the president and provost. Since then, UVM has set up teams to focus on various tasks, such as keeping classes and research functioning and protecting the health and safety of faculty, students and staff. If a pandemic were to hit Vermont, UVM would most likely suspend classes and send students home to wait it out.

“We can’t have 13,000 students on campus in the middle of a high-severity pandemic,” Turgeon says. “We will not be able to care for them.”

While many of UVM’s plans are still wending their way through the approval process, they include such proposals as teaching classes remotely via email, websites or podcasts. But that presupposes that Vermont’s telecommunications network will be up to the task of supporting thousands, perhaps even tens of thousands, more people who are telecommuting and conducting their business online rather than in person.

Turgeon notes that his biggest challenge right now — apart from the daunting organizational task of planning a temporary closure of UVM — is skepticism from some people at the university who say officials shouldn’t be wasting their time on this process.

“I would describe their reaction as sort of like the grieving process,” Turgeon says. “They start off completely angry that we’re doing this, or that anything like this could happen to them. Then they start to accept it and begin to figure out what their role would be to mitigate it.”

Distance learning, remote worksites and e-business may help alleviate the effects of a pandemic on some employers, such as colleges, banks, software developers and news outlets. But what about those organizations and agencies whose work can’t be performed without large congregations of people?

Rob Hofmann, commissioner of the Vermont Department of Corrections, doesn’t have to imagine that scenario; he’s dealing with one right now. The Southern State Correctional Facility in Springfield is in the midst of a strep outbreak, with about 30 cases diagnosed among 500 inmates. Last year, a similar outbreak infected nearly 100 prisoners.

Hofmann says he’s trying to be proactive and plan for something far more serious, but he’s limited by his budget, an aging infrastructure and the realities of the correctional system.

“If there were a statewide epidemic, we would be expected to treat in place,” Hofmann says. “That would present an extraordinary challenge for us, but we’d have to live with the fact that the rest of society would be challenged as well.”

For now, a pandemic’s potential impact on Vermont’s criminal-justice system is “a huge unknown,” he adds. No one knows whether the prisons would see more new inmates, owing to an increase in crime, or fewer arrivals, as the courts suspend their activities and police are diverted to the most pressing tasks.

With 1150 employees spread over nine facilities, Vermont’s correctional system does have the advantage of non-concentration: “Having your eggs in nine small baskets is better than having them all in one big one,” says Hofmann. But other questions remain unanswered, such as the fate of Vermont’s inmates housed out of state. Transporting unaffected inmates in a pandemic could not just spread the infection but also raise the specter of escape, especially if the corrections staff is diminished by a third.

Finally, while Vermont’s prisons are preparing and rehearsing for other disasters, such as power outages, chemical spills and riots, the department has stockpiled only a few basic emergency supplies, such as surgical masks. Thus far, no correctional facilities are storing enough food or water to last two weeks, as the health department recommends.

“It’s daunting, just the potentialities of something like this,” Hofmann admits. “There are no easy answers.”

Another organization that would be particularly stressed in a pandemic is the Vermont Foodbank. Disaster planning is “a pet subject of mine,” says Chief Operating Officer Ed Fox: The Foodbank breaks ground this month on a new generator for its Barre operations to keep the phones, freezers and computers running. Still, the agency has yet to determine how it would cope with a pandemic.

“This is huge, because we have 65,000 Vermonters we serve,” Fox says. “In the best of times they have difficulty keeping food on their shelves for a day.”

One idea that’s been tossed around, Fox continues, is something called the “Joseph Project.” Named after the biblical character who foresaw seven years of plenty followed by seven years of famine, the idea is to store a six-month supply of food, then distribute it into the Foodbank’s network of 270 agencies and replace it with another six-month supply. Needless to say, this would be an enormously expensive undertaking.

“We’re thinking about it, and we have some plans in place,” Fox says. “But there’s still a long way to go.”

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The news isn’t all dire. For one thing, Burlington is one of seven cities nationwide participating in a pilot project with the U.S. Department of Health and Human Services to coordinate its pandemic flu planning. Called “Taking the Lead,” this test project is enlisting a broad cross-section of the community, including civic leaders, businesses and religious groups, to help individuals and organizations develop their own pandemic plans.

And, although no one can prevent the next pandemic, Vermont’s emergency planners all say we have several advantages. For one, Vermont is small, and most of its upper-level health and safety people know one another or have worked together before.

Second, many point to Vermonters’ independent spirit and experience with survival in isolation, even for long intervals, as during blizzards. Nearly all the emergency planners interviewed for this story mentioned the great ice storm of January 1998, which knocked out power for thousands of people and left many to fend for themselves for as long as a week.

A pandemic would be on a different order of magnitude, notes Health Commissioner Davis, but many of the preparations would be the same: Vermonters should keep at least a two-week supply of food, water, medications and other daily essentials on hand.

State officials are unlikely to order a mandatory quarantine even in a severe pandemic — Vermont doesn’t have the resources to enforce one. Instead, the health department would refer the public to so-called “non-pharmaceutical interventions” (NPIs) designed to limit the pandemic’s spread and reduce sickness, suffering and death. NPI is a fancy term for common sense. In general, it means isolation of people with confirmed cases, voluntary home quarantines, dismissal of students from school and employees from the workplace, and other “social distancing” measures.

In the absence of a suitable vaccine, the health department would strongly encourage other basic hygiene practices, including reducing or eliminating interpersonal physical contact (such as hugs and handshakes), washing hands more often, wearing masks and, of course, covering one’s mouth when coughing or sneezing. In short, the grandmotherly advice we hear every time seasonal flu comes around.

“Epidemics are as old as history and have often changed the outcomes of events as well as people’s lives. It creates confusion, fright and blame,” writes Michael Sherman in his 2004 monograph. “But epidemics can also create moments for discovery and opportunities for change,” he adds, referring to improvements in public health and disaster relief systems.

No one can predict when the next pandemic will strike or whether it will be as “terrible” as the times chronicled by Dorman Kent in 1918. But one thing’s for certain: The old Scout motto applies here. Be prepared.