Pandemic avian influenza (PAI), or “bird flu,” is a serious health and social threat. Because it attacks the inside of the lungs, it has the potential to incapacitate or kill its victims. As of today, the virus affects birds and humans in close contact with infected birds. At press time, it had not mutated into a form that jumps from human to human. The World Health Organization and U.S. Centers for Disease Control and Prevention monitor the advance of this virus every day on a worldwide basis.
A human vaccine against PAI could be produced only after the virus mutates into a form that spreads from human to human. Similarly, control procedures, such as quarantine, can be implemented only once active cases are suspected or discovered. However, it is imperative that response planning occur now. Mental health and substance use services are essential components of that response planning.
One Potential Scenario
The following scenario is hypothetical and is intended to motivate action rather than frighten.
Today, PAI mutates in one of the large cities of the Far East, an outbreak occurs among the city's residents, and returning air travelers bring it to New York City three days later. The CDC immediately begins screening and quarantine procedures for these air travelers, but these procedures are not fully effective, and the virus escapes into the population of New York City.
Within a few days, New York City hospitals are overwhelmed with PAI cases. Inoculations with standard flu vaccine begin almost immediately, but there is insufficient vaccine for all residents of New York City. Shortly thereafter, New York City schools are closed to prevent the spread of the virus, and many workers stop going to work to avoid exposure on the subway system, in their offices, and in restaurants. Essential police, fire, and infrastructure services, such as electric power and telephone, are very difficult to maintain because personnel elect not to come to work because they are caring for ill family members, are themselves too ill to come to work, or are frightened. Help from other cities and states is very difficult to mobilize because they too are confronted with the same problems. Society, as we know it, quickly begins to disintegrate.
So how do we prevent this scenario from ever occurring? Immediate planning is necessary. A complete description of all the components that will be required for this planning is far beyond the scope of this short commentary. However, some essential steps can be outlined for mental health and substance use services.
The Field's Role
Both mental health and substance use services will be essential parts of the response to any pandemic. First, ongoing services to current clients must be maintained, particularly for those who have case managers and who are prescribed psychotropic medications. Second, many new cases of bereavement, depression, post-traumatic stress disorder, and substance use are very likely when family members, neighbors, and friends become seriously ill or die, or when people are unable to cope with the effects of social chaos. Third, professionals from these fields will be asked to play important roles in mitigating panic. For example, they will be asked to work with the broadcast, print, and Internet media to craft effective messages and to gauge responses.
Mental health and substance use services, however, are likely to suffer with the same types of infrastructure problems as other essential services. Workers will be unable or unwilling to come to their clinics, and help will not be available from elsewhere because the pandemic is likely to be national in scope.
Planning must begin immediately if we are to mitigate the consequences outlined above. Thankfully, some of this planning already has begun, but planning should remain continuous to take into account changing variables. Key features of this planning include the following:
The federal government will need to plan for financial resource reallocation for emergency mental health and substance use services, mobilization of human resources to work in urban areas that are hardest hit, and appropriate technical assistance to states and cities. Legal and regulatory reform may be required now so that these essential tasks can be accomplished when needed.
State and local governments will need their own response plans. The federal government should help develop these plans. An essential feature of these plans will be to assure continuity of operations and to designate backup personnel for those who occupy essential mental health and substance use service delivery positions.
States and localities also will need to work with employers so that each business has its own response plan. Designation of backup personnel for critical infrastructure roles is a high priority.
At all levels, work with the broadcast, print, and Internet media should be undertaken now. Messages need to be crafted and tested for different audience segments, including different demographic groups, those receiving mental health and substance use services, and others. The goal of this work will be to communicate effectively while mitigating panic reactions in the population.
Behavioral health agencies should be preparing plans to cope with PAI and should discuss them regularly with staff, payers, regulatory organizations, and with clients, if appropriate.
Looking to the Future
Hopefully, we will never be required to implement these plans. The virus may not mutate in the short term. Also, the longer the interval we have to prepare for the next pandemic, the more direct prevention and treatment strategies will improve.