Exactly what would happen if the Waikato was hit by a killer flu virus?
At the stroke of a pen, Anita Bell could become the dictator of the Waikato. She would be able to override the Bill of Rights, effectively ordering unlimited detention without trial and compulsory treatment. She would be able to order anything to close or any event not to happen. The police and army are authorised to do her bidding, confiscating any kind of property at will for purposes she decides, including the disposal of bodies.
The good doctor makes it very clear that kind of thing is a long way down the track. Such actions would happen only if a pandemic started in New Zealand. She has an enormous preference for educating and making suggestions, anyway ("We have a very nasty flu that is killing 50 per cent of the people who get it, so is it really a good idea to have that school disco right now?"), rather than shutting it down with an order that would be enforced by police or troops at gunpoint. But as one of Waikato DHB's four Medical Officers of Health (MOH), her powers currently exist in reserve under the Epidemic Preparedness Act and can be brought into reality within hours.
The law authorising God-like power for the MOH passed with a unanimous vote in our Parliament. Recognising that a pandemic in New Zealand would constitute a national emergency, threatening our cohesion as a society, it was seen as a wise precaution. And now, with the outbreak of a new, deadly strain of flu in China, everyone involved in pandemic planning in New Zealand is quietly dusting off the briefing notes and thinking about what might have to be done next.
The new strain of flu, called H7N9, emerged in China the week before last. At this writing, it has killed nine people. Its extent and danger became clear only last weekend, but by Monday morning, Bell had started taking action.
"We sent out an information sheet within the hospital and to GPs. It said that there's no evidence of human-to-human transmission, though that might change and that the current drugs seem effective in treating it."
People who turn up with a bad flu or serious respiratory complaints are tested as a matter of course, to see what they have got. Bell told the doctors to be even more on their toes.
"We told them to be on heightened alert if someone with a respiratory illness comes in, who has recently travelled from China or come in contact with someone who has. There is no evidence H7N9 can travel human to human, but it may adapt. We told them to be thinking of that, treat them as an infectious case, talk to us and let's get their samples into the lab."
If there is a case found here, the Ministry of Health would track down and monitor everyone the person had been in contact with. An information campaign would begin to get people to take precautions. This is mainly what they should be doing during the impending flu season anyway.
If it's starting to spread and there are a number of linked cases, the Ministry of Health will attempt what it calls cluster control, trying to contain the virus within an area.
"We may know that you can't stop it spreading in the end, " says Bell, "but it's trying to give you time to assess the situation or discover what happens next, or maybe to stop it spreading before a vaccine is developed."
She says that the sort of scenario where, for instance, Raglan is sealed off and cars going in and out are hosed down by people in chemical suits is fanciful and the stuff of Hollywood. Probably. During the 1918 flu epidemic, the Coromandel banned visitors from Auckland, with good results.
"I think some of those measures would be a step too far, " says Bell, "but it depends what the disease is."
If it spreads widely to become a pandemic the Ministry of Health stays the lead agency, but every part of Government - from the GCSB to the IRD, Fire Service and Social Development - has a pandemic plan and a part to play. Large food producers, such as Fonterra, have also been involved in the planning and will have a role, too. The country would almost shut down. Treasury estimated in 2009 that a bad pandemic would cost us about $24 billion, with even a lesser outbreak, such as happened in 1957 and 1968, tipping us into a downturn. The exercises run by Government assume a worst case: We would get the same level of infection and fatalities as the 1918 flu that killed an estimated 100 million worldwide.
It's assumed 1.6 million people would get sick here and the emergency would last for eight weeks. Thirty-three thousand people would die in New Zealand, with the peak of 10,000 dead a week reached in the fourth week of the outbreak.
With a deadly flu outbreak under way, the Ministry of Health would set up community-based assessment centres. David Robson, Hamilton City Council's crisis manager, says all the council's resources, such as the Claudelands Arena, Waikato Stadium, the theatres and Seddon Park, would be made available to the ministry. All public facilities, including parks and reserves, would probably be closed. The council is currently looking at its pandemic plan, made in the light of a 2007 exercise with Waikato DHB that worked through an outbreak scenario. Robson says the city has a plan in place to keep essential council services running, even after almost all staff are sent home.
Trevor Ecclestone, who co-ordinates WDHB's emergency management planning, says he and his staff have run through what has to happen in a pandemic. Exercises have identified GP practices as the likely community-based assessment centres, supplying treatment and vaccines if available and topped up by staff from the hospital if they become overrun. Ecclestone says the exercises showed GPs should be able to cope in a crisis, with only two needing extra staff supplied during the last practice held.
Bell says the community-based assessment centres would probably supply more than just testing and treatment, also delivering food and welfare services to those who need them. The satellite centres would be useful in keeping the central hospital running, she says.
People will still be getting sick from other things, having accidents and injuring themselves. "You may want to protect some of your health care resources, keeping some free of infectious cases."
As of now, all eyes are on Environmental Science & Research's (ESR) National Influenza Centre in Upper Hutt, where director Susan Huang is a little worried by H7N9 for a couple of reasons.
"One tricky thing about this virus is that it's not like the H5N1 virus that killed birds infected with it. So you knew when it was in the bird population. This one is causing a silent kind of infection."
The birds just get sick, the people die.
"We didn't know about it until it somehow managed to infect humans. What pathway and which mode of transmission it uses, we're not absolutely sure. We think it is mainly contact: You touch the bird and rub your nose or mouth."
The other thing is that, at this early stage, it seems to be extremely dangerous. Huang says when the H1N1 "Swine Flu" outbreak began in Mexico in 2009, scientists were very worried because its early mortality rates were running at 8 per cent. "The picture is still evolving, but there are 33 people known to have been infected with H7N9, and nine have died. That is a 27 per cent mortality rate."
Just hours before the centre received the assay of H7N9 from the World Health Organisation (WHO). This is a description of the virus and will be sent to all the flu- testing labs, including the one at Hamilton Hospital. It means if the new flu turns up here, it can be immediately identified for what it is. The WHO got the assay from the Peoples Republic of China. It was quick work, given that the virus was discovered only nine days ago. In late 2002, an outbreak of another virus in China, known as severe acute respiratory syndrome (Sars), was covered up and went on to kill more than 750 people around the world.
But, echoing what seems to be the global consensus, Huang says China has lifted its game. "They are much more transparent than they were with Sars. In 2002, I think they didn't want to tell the global community what was going on. But since then, I have been there several times and visited their labs. They have put a lot of funding into the public health infrastructure and they have proper public health surveillance now. The response now is quite open and they are doing all the right things."
She says we're in good shape, too, with our response to the 2009 swine flu praised as "best in class". Though we had a bit of luck.
"In 2009, a group of children came back from Mexico carrying the virus. The fact that they got in on a Saturday and didn't go to school was a lucky break. It bought us about six weeks of time without sustained transmission in the community."
Buying time is what the response to a virus essentially comes down to. The United States Centres for Disease Control and Prevention (CDC) is already working on a vaccine. But the pandemic exercises assume that it will take six months to get here, by which time the epidemic may have run its course. The Tamiflu vaccine and others are effective, at the moment, in treating H7N9. But there is not enough for everyone in Government stocks. More is coming, but it will be down to ESR to total up numbers and find out what groups have the highest risk - usually thought to be the very young and old, people already unwell and Maori and Polynesian people - and set Government priorities for vaccination.
The Ministry of Primary Industries (MPI) Biosecurity units tested more than 1400 samples from mallard ducks (a known carrier) last year and found no evidence of a dangerous virus. Staff surveyed industrial poultry after avian influenza was made a notifiable disease back in 2005 and found nothing significant there, either. MPI says the virus has never been found in migratory birds. Smuggled animal products are a greater threat, but the real problem is people and aircraft. Huang says she used to think New Zealand was at the very end of the Earth.
"Swine flu changed my mind. I didn't think it would get here. But with air travel, we have the same risk as anywhere." As soon as human-to-human contagion is confirmed anywhere in the world, health authorities everywhere now assume the genie is out of the bottle and step up their preparations.
Huang isn't sure if there will be a virus we can't handle. Birds and animals, especially pigs, are mixing bowls for disease, making new kinds of flu all the time.
"That's the scary thing. It's constantly changing and evolving. Animal surveillance really needs to be enhanced at a global level - including here."
Official Chinese sources are blaming the outbreak there on intensive agriculture and dense populations of birds - factory farming. Here, MPI says it is continuing to monitor the situation and it would be foolish to speculate, but there "are considerable differences between Chinese and New Zealand poultry farming methods and husbandry".
Huang says we need to get on top of what kind of new viruses animals are cooking up for us. "We're doing a good job of human surveillance, but we need a greater capacity to predict what might happen. We're kind of chasing our tail at the moment."
Back in Hamilton, Bell can't say enough about how reluctant she would be to use her potential powers. For those powers to come into full effect, the prime minister would have to believe an outbreak of a defined quarantinable disease was under way and likely to significantly disrupt essential governmental and business activity. He would then issue an epidemic notice, with the consent of the minister of health. It would remain in force for three months and would be subject to parliamentary scrutiny. "Usually people are very easy to deal with and quick to do what they can to stop the spread to other people, " says Bell. "It really is a last resort."
H7N9 may not be the one that triggers her responsibilities, but it could happen.
"There may be one that we can't beat, even if it is for certain amount of time. Viruses are very good at adapting and changing."
The 2009 response to swine flu in New Zealand was made fun of in some circles, because no pandemic resulted. Bell makes no apologies.
"You have to be very, very careful and be monitoring very carefully and put in very restrictive measures at the beginning, because you don't know how it's going to progress. It may turn out to not be very severe or not spreading, but it's only once you know those things that you can back off. You can't know that until you have been able to watch it for a while."
H7N9 responds to an existing treatment and isn't spreading human to human. So the current scare must be a useful, unplanned exercise?
"It's not an exercise, " says Bell.