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outbreak. Plans to ensure access to other critical logistics and infrastructure— including clean water, electricity, data and telecommunications, and waste management and other sanitation services—during a severe pandemic need to be made.
: What Would the 1918 Influenza Pandemic Look Like Today? In the worst pandemic in recorded history, the 1918 influenza pandemic, the novel virus infected approximately one-third of the global population over a period of 2 years, ultimately leading to 50 to 100 million deaths worldwide. One might imagine that the death rate would be lower today due to the advent of modern medical equipment and procedures that did not exist in 1918, but the global population is now approximately 4 times greater than in 1918. This growth, however, is disproportionately higher in low- and middle-income countries, often the ones with developing health systems. Many—predominantly in Africa, Southeast Asia, Latin America, and the Middle East—have experienced population growths of 1,000% or more since 1918. Crowded urban areas provide prime conditions for the spread of respiratory diseases, and urbanization is increasing globally, including the emergence of 47 “mega-cities” (populations over 10 million). By comparison, London was the world’s largest city in 1918, at approximately 5 million people. Additionally, global travel has increased by orders of magnitude compared to 1918. Even then, shipping and population movement (including World War I) played an important role in global spread of the disease, but today, humans can fly anywhere in the world in less than 1 incubation period, meaning that global transmission can be expected to be even faster. In 1918, the global case fatality ratio is estimated to have been 2.5%, but it was considerably greater in low- and middle-income countries, with some estimates exceeding 10%. Today, some high-income countries would be expected to fare much better because of modern health care, but the case fatality in countries with limited access to healthcare could be as bad as or worse than 1918. Simple arithmetic would suggest the possibility of 100 to 400 million deaths if a 1918-like pandemic were to occur today, but unprepared or under-resourced health systems could further exacerbate disease transmission through nosocomial spread and an inability to promptly diagnose and render care, a particular concern for developing health systems. During the 2003 SARS epidemic, 72% and 55% of presumed and confirmed cases in Toronto and Taiwan, respectively, occurred as a result of healthcare transmission. A similar nosocomial outbreak in which healthcare facilities became amplifiers of the epidemic, this time of MERS, happened in South Korea in 2015. Community Engagement Community engagement entails the collaboration of affected and at-risk populations with policymakers and practitioners in the generation, implementation, and evaluation of measures to safeguard public health and safety.98 When genuinely operating within a community engagement framework, authorities see themselves as working with, rather than on behalf of potentially endangered people, and they accord community members both respect and responsibility as actors who have influence over their own well-being.46,99 Community engagement—comprised of dialogue, power sharing, collaborative decision making, and combined actions among a community, its providers, and its leaders—can strengthen readiness, response, and recovery in the case of a potential high-impact respiratory pathogen outbreak.100 Once fully engaged in larger systems of disease outbreak planning and consequence management, for instance, community members can offer ideas and insights that enable public health interventions and clinical care to be more culturally competent, attuned to local conditions, and socially acceptable.46 In addition to their intellectual contributions, the community offers the power of many hands—for example, backfilling depleted responder workforces, complementing care in the formal health sector with care in the home, and standing up mutual aid networks for ill and/or confined people and their families.100 Lastly, beyond the community’s practical offerings are its moral and ethical ones: Leaders faced with extreme conditions and stark choices can elicit community values and views on—and thus secure broader support for—for 48 instance, the allocation of scarce life-saving resources, the alteration of burial practices to accommodate mass casualties, and the appropriateness of research on novel countermeasures in emergency conditions.101 Treatment of community engagement in the high-level reviews and reports cited earlier ranges from specific mention as a core capacity in health security to silence on the topic altogether. Some recent health security reports and reviews strongly advocate community engagement as a “core function when managing a health emergency.”4,44,46-48 Helping prompt such a stance is recognition that “community engagement ultimately made the difference” in the countries most affected by the H1N1 and H5N1 outbreaks,47 and that greater efforts to understand, and to earn the cooperation of wary villagers who resisted care and containment measures, could have reduced the impacts of the West Africa Ebola outbreak. For previously unaware audiences, the West Africa Ebola outbreak concretized the benefits of community engagement when practiced—and the adverse effects when neglected. The West Africa Ebola outbreak experiences—including community rejection of public health interventions and the deaths of several health workers and journalists in Guinea in September 2014—brought an immediacy and urgency to the importance of having the trust and help of affected communities during a high-impact infectious disease outbreak.18,42,44,47 As discerned through Ebola successes and failures, the positive effects of community engagement include creating bridges, open dialogue, and mutual understanding among clinical trial participants, communities, and investigators, thus furthering research;102 achieving collective behavior change, such as alterations in burial practices,