That scenario, an emergency exercise developed by the federal government, was known as Crimson Contagion, and played out from winter to late summer 2019, with Chicago serving as host.
At the federal level, the sobering results of the war game revealed in an October draft report published by the New York Times "drove home just how underfunded, underprepared and uncoordinated the federal government would be for a life-or-death battle with a virus for which no treatment existed," the Times reported. The exercise laid bare some of the issues playing out today, including that officials could not "quickly manufacture more essential medical equipment, supplies or medicines, including antiviral medications, needles, syringes, N95 respirators and ventilators."
But for local officials, the trial run was immeasurably valuable in identifying gaps the city could address before a real crisis hit.
"It's amazing that we truly exercised something like this less than a year ago and it's rolling out as our plan is written," says Christopher Shields, assistant commissioner for emergency preparedness and response at the Chicago Department of Public Health. The Crimson Contagion series included both a tabletop simulation in April 2019, a federal interagency seminar in May and a weeklong drill in August.
With just a single simulated case and a couple of exposures, in early spring the city walked through its existing pandemic influenza methodology, or "panflu" for short. What would containment mode look like? How would the city give guidance to clinical providers? How should health officials report their epidemiological data "to make sure we're operating off the same sheet of music in the hymnal?" Shields says.
The April exercise "allowed us realistically to tear our plan apart and rebuild it so it was more operationally functional," he says. Rather than a series of if-then scenarios, officials created a hierarchy of decisions to offer potential courses of action. "It gave us the opportunity to play in real time," to attack a pandemic with high infection rates and high mortality, akin to the 1918 flu, Shields says.
Health officials point out they conduct regular emergency preparedness exercises and are on guard for major incidents throughout the year. Big events like Lollapalooza and regular vaccination programs let health officials flex their muscles and tinker with systems.
Dr. Julie Morita, former commissioner of the Department of Public Health, left the department before the August exercise, but she says she was surprised how helpful incident command structures turned out to be. "Years ago when we first started doing this, I thought, 'Oh my gosh, it's like we're in the military!' " Morita says, but "in the time of a crisis, the last thing you want to be doing is figuring out who is responsible for what."
Crimson Contagion—which helped the city build on the knowledge gleaned from not only the 1918 flu pandemic but Ebola, Zika, H1N1 and 9/11—was especially helpful. It allowed officials to plan the impact of school closures, supply delivery routes and morgue demands.
"We are using those plans. We're so glad that we had decided to make that our focus last year," CDPH Commissioner Dr. Allison Arwady told reporters March 24.
Dr. Ngozi Ezike, the state's director of public health, testified before Congress this month that the state had built a "remarkable emergency response network" in the aftermath of 9/11 thanks to federal terrorism and emergency preparedness funding. "A true reflection of our preparedness is found in the containment efforts at Chicago's O'Hare airport and contact tracing of potentially exposed citizens; Illinois has demonstrated that its public health infrastructure is strong and prepared," but she warned then the state could run short on personal protective equipment, or PPE, and space to house quarantined and isolated patients.
Where the federal government has fallen short, city and state officials say they've stepped up.
Gov. J.B. Pritzker announced March 23 that two local trade groups would help match factories that can shift production to items like masks and ventilators with medical providers that need them. The city is paying hotels to host quarantined patients, reducing the burden on hospitals caring for acute patients.
The exercise wasn't without a hitch—health officials can always improve on communication, collaboration and IT issues. But at its foundation, Morita says Chicago benefits not only from a strong network of hospitals that are used to working together in crisis, but also a deep bench of epidemiologists at CDPH. "The exercises are incredibly valuable and worthwhile. Even if federal support is lacking, the health department staff and partners learned a lot from it; it informed activities happening now."