HHS's assistant secretary for preparedness and response talks about how we all have a role to play in getting ready for pandemics and disasters.
Rear Admiral W. Craig Vanderwagen, MD, is the first person to serve as the Department of Health and Human Services assistant secretary for preparedness and response.
HP: What drew you to health care and public service?
Vanderwagen: I got into public service rather naturally. My great grandparents were missionaries at the Zuni Pueblo in New Mexico and my dad's family stayed and raised five generations there. My great grandmother was a nurse who provided care to the Zuni people during epidemics of smallpox and tuberculosis. My grandmother was a school teacher there for 40 years. My uncle was a pediatrician in Indian country for 30 years. So the most natural thing in the world was for me to become a doctor there. I spent 25 years of my career serving American Indians and Alaskan natives.
Eight or nine years ago, I got involved in disaster response. I was involved in providing care to Kosovar refugees during the Balkans conflict. I also helped out in Honduras after Hurricane Mitch in 1998. Then there was Sept. 11 at the World Trade Center, Iraq in 2003-2004, Indonesia in 2005 after the tsunami, and then Hurricanes Katrina and Rita. Each of these events taught me many things about the strength of spirit that arises in such circumstances.
In brief, I would say that my family heritage has taught me to serve the community, especially in times of need. This started me down a pathway that was reinforced by the lessons taught to me by many good mentors from many cultures.
HP: What do you see are among the biggest challenges in preparing for pandemics and disasters?
Vanderwagen: I think one of challenges is that we really don't know when a pandemic might strike. But we can be sure of two things: everything we do before a pandemic will seem alarmist, and everything we do after a pandemic will seem inadequate.
This is the dilemma we face, but it should not stop us from doing what we can to prepare. As my boss, HHS Secretary Mike Leavitt, has said many times, we need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.
We probably can't prevent a pandemic, but we can minimize its impact. A well-prepared response can delay the onset of a pandemic. It can also lessen the severity of a pandemic's peak.
Another challenge in preparing for pandemics and other public health emergencies is recognizing and meeting the needs of special populations, including the elderly. Through the Pandemic Influenza State Summits, as well as through guidance the CDC gives for states using pandemic flu grant dollars, we have urged states to consider and plan alternative care sites, such as home care. We have also asked states to take into account the special needs of the elderly when developing their vaccine and antiviral distribution plans.
It will be essential that local and state plans take into account how the chronic medical conditions of the elderly will be managed during a pandemic or other public health emergency. We are working with our colleagues at the Centers for Medicare & Medicaid Services to allow supplementary refills of medication during a pandemic, as they have done in prior public health emergencies.
HP: When you talk to health care leaders, what are among their biggest worries when it comes to pandemic and disaster preparedness?
Vanderwagen: Pandemic flu competes with many other issues that health care providers need to communicate to their patients in very limited amounts of time. While research shows that the general public and health care providers have a good understanding of pandemic flu and its potential impact on society, most do not consider it an imminent crisis. This makes it difficult to take the time to counsel patients on the need to prepare for pandemic flu and other disasters. In recognition of the limited time that providers have with patients, I would ask providers to help us validate the threat of pandemic flu with their patients by helping us distribute informational materials.
Health care providers are particularly concerned about reaching populations that will be most vulnerable in the event of a pandemic. To help reach underserved populations, we are partnering with many organizations that reach such populations across the country, including faith-based organizations and community groups. Catholic health care providers can play a critical role in reaching the underserved before and during a pandemic event.
HP: Panic exacerbates the challenges of dealing with pandemics and disasters. What can health care providers do to assuage people's fears in the communities where they serve?
Vanderwagen: Actually, there is little evidence that large proportions of the population "panic" during disasters. During Sept. 11, for example, people followed instructions on how to leave the city, helped each other to evacuate the buildings and dangerous areas, and generally behaved in more heroic than panicky types of behavior. That said, I understand we are talking about frightening situations where people may rightly feel very afraid. We need to be careful not to confuse being afraid, which is a rational and appropriate response, with panicking, which is a less rational and less appropriate response.
There are many things that health care providers can do to help people cope with and manage their fear, while encouraging a productive and protective response. It helps to keep in mind what most people want and need during public health emergencies, such as protecting themselves and their loved ones, getting the facts they want and need to protect themselves, being able to make choices and informed decisions, being involved in the response somehow and stabilizing and normalizing their lives.
Health care providers can offer much to help their patients and communities achieve these objectives. For example, the simple act of acknowledging how scary a situation is helps people cope with their feelings and enables them to take protective steps. Giving people permission to be afraid helps mitigate another reaction to crisis, denial. If people realize that it is acceptable to be scared, they have less of a need to deny the problem. Another effective tool is to give people important things to do. Taking action helps people cope with fear and crisis situations. But we need to help our patients and our communities by taking appropriate actions; actions that protect their wellbeing. Therefore, it is imperative that health care providers become well informed about pandemics so they can provide accurate and useful information to their patients.
HP: What lessons from past pandemics and disasters can we apply to preparation efforts today?
Vanderwagen: America has experienced three influenza pandemics in the past century that have provided us with important lessons as we prepare for future events.
History shows that influenza pandemics can occur at any time and vary in severity. Every year, annual seasonal flu causes the deaths of about 36,000 Americans. In the U.S. the influenza pandemic of 1957 caused up to 69,800 deaths and the pandemic of 1968 caused up to 33,800 deaths. The 1918 pandemic, however, was much more severe, killing between 20 and 40 million people worldwide and approximately 500,000 in the U.S.
In order to minimize the impact of an influenza pandemic, we must understand that humans will not have the same level of immunity as they have for the regular annual flu. In addition, while the single most effective step to respond to a pandemic would be to develop a safe and effective vaccine, a vaccine for a new flu virus will take months to develop. Therefore, we cannot rely solely on vaccines to keep Americans safe. We need to take other steps to prepare.
We've also learned from the past that decisive action to help communities limit transmission between individuals will save lives. During the pandemic of 1918, different cities took different actions, resulting in very different outcomes for their citizens. The pandemic of 1918 affected just about every city in the nation. Some urban areas fared well, effectively minimizing rates of infection and mortality. Some, on the other hand, fared quite poorly.
For example, death records indicate that Philadelphia fared much worse than St. Louis, and we can trace the outcomes for both cities to how local community leaders responded when the pandemic arrived. Philadelphia officials did not take the outbreak seriously, and by the time the city initiated its response — 16 days after the first local cases were diagnosed — it was too late. St. Louis, by contrast, took action just two days after the first cases were identified and limited the risk of transmission.
We can draw a fundamental lesson from these case studies. If leaders don't take action to help communities limit transmission at the individual level, then the battle is lost. Closing schools on day 10 will produce a much different result than closing schools on day one. Closing schools on day one will help communities interrupt the backbone of local transmission. Cough etiquette and the importance of hand washing, social distancing, and vaccination are also important mitigation strategies. Individually, each of these measures will produce a limited health benefit. But collectively, they can make a significant difference.
The past has also taught us that individual preparedness will make a difference in a pandemic, as well as other disasters. Understanding the risks and preparing for them ahead of time is a proven method of mitigating the effects of disasters, including pandemics. The lessons of St. Louis and Philadelphia I just mentioned show us that if individuals understand the potential impact of a pandemic and follow simple advice to limit exposure and practice proper hygiene, the impact of a pandemic can be greatly limited.
Although is it important for federal, state, and local governments, and the private sector, to prepare for and respond to disasters, it is imperative for individuals to also take steps at home to prepare. For example, having supplies and a shelter in place, or an evacuation plan in place prior to major storms, tornadoes, or earthquakes is needed for families to withstand the impact of a disaster before community and government responders can assist.
While the impact of a pandemic is different from that of natural disasters, the steps to prepare can be beneficial for both. Stocking up on at least two weeks-worth of food and understanding how to stay home for an extended period of time will serve individuals well for a variety of events. And practicing good hygiene and understanding how illnesses can be spread can help mitigate the effects of infectious diseases.
HP: What are some new initiatives at HHS in the area of pandemic and disaster preparedness?
Vanderwagen: Nearly two years ago, President Bush mobilized the nation to prepare for a pandemic. Since then, the federal government has made great progress in building up the nation's defenses and planning for the future. We have licensed the first H5N1 vaccine for humans and stockpiled enough antiviral medicine to treat 40 million Americans. We have committed more than $1 billion to expand cell-based influenza vaccine production over the next five years. This investment will make possible a more flexible alternative to egg-based production. We have awarded $161 million in grants to help expand surveillance programs and bolster clinical research. We have also invested $180 million to help high-risk countries strengthen their surveillance systems.
We held 50 flu summits around the country. And we have launched a government-wide web site (pandemicflu.gov) and produced and aired a series of television and radio ads, and other materials to educate people about pandemic flu and encourage them to prepare. We recently completed a series of "listening sessions" to hear concerned groups' ideas and suggestions for meeting the needs of at-risk and special needs populations before and during a pandemic.
We held our first "blog summit" on pandemic preparedness, which attracted tens of thousands of visitors from 67 countries to a lively online discussion on matters related to preparing for a pandemic. Many of our efforts related to public education and preparedness are focused on involving others in pandemic preparedness.
Pandemics aren't like hurricanes. Hurricanes strike in one place, do their damage, and then the recovery begins. The whole nation can focus its resources on helping the stricken area out of the disaster. We saw that after Hurricane Katrina. Pandemics don't strike just one area. They strike everywhere. Areas hit first can't depend on relief from elsewhere because the entire country will be affected. Areas that haven't been hit yet will be preparing their own defenses.
Local preparedness must be the foundation of our national response. Communities that fail to prepare, expecting the federal government to come to the rescue, will be tragically mistaken.
Local leadership is the key. There needs to be preparedness at every level. There is a part for everyone in preparing for a pandemic; from stockpiling necessities to adopting good public health habits. Every county, every business, every school, every church, every household needs a plan. But people won't plan unless urged repeatedly by leaders they know and respect. HHS is now working with local leaders to engage them, and provide resources for them, to encourage others in their communities to prepare.
Many of the things we do to prepare for a pandemic will make us a safer and healthier nation. The new vaccine technologies we are developing will make it possible for every American to have an annual flu shot. The surge capacity we develop in hospitals and communities could be critical in other emergencies. And the lessons we learn about the distribution of medication could save lives in a bioterrorism attack.
HP: What contribution do you see Catholic health care making in addressing pandemics and disasters?
Vanderwagen: Encouraging and helping individuals and families to prepare for pandemic influenza requires leadership from individuals who are trusted and respected as information gate-keepers and key influencers of opinion in their communities. We know patients look to health care providers for information on pandemic influenza. According to a recent CDC study, the majority of the general public believe health care providers have a major responsibility for preparing for an influenza pandemic.
Catholic health care providers can play a powerful role by raising awareness about the real threat of a pandemic, and that Americans can and should take steps to protect themselves and their families by learning safe and simple ways to practice good hygiene (like hand washing, cough and sneeze etiquette, etc.), and by stocking up on critical supplies to help them stay home during a pandemic. For the first time in our nation's history, we have the opportunity to prepare in advance for a pandemic, and the time for leadership in this area among Catholic health care providers is now.
Rear Admiral W. Craig Vanderwagen, MD
Rear Admiral W. Craig Vanderwagen, MD, was confirmed by the U.S. Senate and sworn into office as the first Department of Health and Human Services Assistant Secretary for Preparedness and Response on March 23, 2007. He is Secretary Michael Leavitt's principal advisor on matters related to bioterrorism and other public health emergencies.
Vanderwagen has significant public health emergency and disaster response experience. Most recently, he was the deputy secretary's special assistant for preparedness and led the teams that implemented changes at HHS recommended in the White House report "The Federal Response to Hurricane Katrina: Lessons Learned." Additionally, he led the U.S. public health team to Indonesia to assist in the 2005 tsunami recovery; served as the chief of public health for the Coalition Provisional Authority and the Ministry of Health in Iraq, and directed a portion of health care provided to Kosovar refugees during the 1999 Balkans conflict.
His federal career began as a U.S. Public Health Service general medical officer at the Zuni Indian Hospital in Zuni, N.M. He later served as the director of the Indian Health Service Office of Clinical and Preventive Services. He was responsible for the full scope of clinical health care programs, including quality assurance and preventive programs for 49 hospitals and hundreds of clinics and health stations.
Vanderwagen is a board-certified family physician. He is published in several medical journals covering family practice. He and his wife have three grown sons.
This interview was conducted on September 25, 2007.
Copyright © 2007 by the Catholic Health Association of the United States
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