When an outbreak of the Spanish flu spread worldwide in 1918, a doctor in Newark advised his patients that they could cure their illness with red onions and coffee. In Atlantic City, the authorities closed amusement parks and theaters indefinitely. And in upstate New York, public health officials distributed a poster warning people against “careless spitting, coughing, sneezing.”

Those precautions had mixed results, and an estimated 675,000 Americans died during that outbreak, according to the Centers for Disease Control and Prevention in Atlanta.Today, New Jersey, Connecticut and New York are much more prepared than they were 90 years ago in the event that an influenza outbreak turns into a pandemic. But five years after an avian flu outbreak in Asia made pandemic flu planning a priority, some experts are concerned that states have not been equally vigilant about preparing, and as attention and federal financing begin to decrease, they fear that preparedness efforts will slacken.

“There is a worry that there was a lot more attention to the issue two or three years ago,” said Richard Hamburg, government relations director for Trust for America’s Health, a Washington-based nonprofit health watchdog. “The fact is that it’s still spreading. There are still cases throughout the world.

Preparedness is not a one-shot deal. You don’t know if this will hit this year, next year, five years, 10 years from now.”

Federal officials are tracking the flu worldwide, but it is up to cities and states to prepare their own public health plans. So in 2002, when fears of a new pandemic began to escalate, the federal government agreed to send the states billions of dollars to prepare for a pandemic. The health and human services secretary, Michael O. Leavitt, warned states in 2005 that if they expected the federal government to bail them out when a pandemic hit, they would be “tragically wrong.”

Trust for America’s Health released a report late last year examining how states were preparing for public health emergencies. The report graded the states on their efforts to protect against a pandemic. Over half of the states received a score of 5 or less for their health emergency preparedness capabilities, with 10 being the highest score.

In this region, Connecticut received a score of 8; the state lost points for failing to buy enough antivirals and failing to use a disease surveillance system that is compatible with the federal system to track the progress of an outbreak as it moves across the country. New York scored a 9 — for failing to increase public health financing as quickly as inflation, though state officials said financing has since risen — and New Jersey received a 10.

Pandemics occur when the flu virus mutates into a more deadly form and begins to spread easily from person to person. Health officials are worried about pandemic flu now because they fear the avian flu that has spread to Asia and Europe could mutate into a more deadly and transmissible form.

During the 1918 flu pandemic, which killed about 50 million worldwide, the federal government did not ask states to report their flu tallies until weeks or months after the disease had begun to spread. This time around, the government has been tracking the flu for years.

And in 1918, scientists were unable to make an effective vaccine; in an outbreak today, a vaccine could most likely be created within six months.

Connecticut, New Jersey and New York expect to use two basic methods to keep the flu under control before the vaccine is ready: antiviral drugs and a kind of mass crowd control. The federal government has bought 50 million courses of antiviral drugs that federal officials said could limit the severity of flu infections and possibly serve to protect uninfected people from the disease.

The Department of Health and Human Services has urged states to buy antivirals through a discount program that offers a federal subsidy, cutting the cost of a course of drugs (enough for one person) to $20 from $80, said Dr. William F. Raub, science adviser to Secretary Leavitt. The eventual goal is to have enough antiviral medication to cover at least one-fourth of the population.

In the region, the states have taken different approaches to stockpiling antivirals. Connecticut decided not to buy its full share of antivirals, though it has bought about 11,000 courses with federal money and sent a letter to the federal government indicating it wants to buy 8,465 more. Even after including the 520,000 courses in the federal stockpile designated for Connecticut, the state would still have only enough antivirals for about one-sixth of its population.

William Gerrish, a spokesman for the Connecticut Department of Public Health, said state officials haven’t put as much emphasis or money into antivirals as other states because they have “limited utility and limited shelf life.”

Indeed, federal officials are uncertain just how effective antivirals would be in the event of a pandemic and whether they could serve some prophylactic purpose. And because antivirals currently have a five-year shelf life, states are spending millions of dollars on medicine they may have to throw away in the next few years. But other state officials said they weren’t willing to take chances.

“If you had a novel strain causing a pandemic that was responsive to antivirals and your state had no stockpile, I could predict that the public would be pretty upset,” said Dr. Eddy Bresnitz, the state epidemiologist in New Jersey, which has bought 850,000 of the 900,000 courses available under the federal cost-sharing program. He acknowledged, however, that if the antivirals expire, “that’s a lot of dollars flushed down the drain.”

Similarly, New York has gone so far as to buy supplies of antiviral medications that were initially designated for other states that decided not to buy them.

The bulk of the planning, however, has focused on other methods to keep people from getting sick during a pandemic, ranging from surveillance to shutting down public gatherings and schools to quarantining people who are exposed to the flu and isolating those who have it.

The states have held drills for public health and safety workers to determine what to do when the flu hits, and they have developed increasingly sophisticated reporting systems that make doctors pick up the telephone immediately after seeing signs of certain diseases.

New Jersey has been particularly diligent: the state compiles analyses of school absenteeism and flu diagnoses each week and links to its pandemic flu plans from the top of its Web site. The challenge, state officials say, is keeping their plans current and local officials up to date on flu preparedness.

Meanwhile, state officials said they have received less money for outreach to local communities that they have done in the past. Congress turned down the president’s request for $870 million in this year’s budget for flu preparedness, and state officials said they expected future grants to be much more competitive.

“It means the system is a little bit thinner,” said Dr. Gus Birkhead, New York’s deputy commissioner for public health.

By Anthony Carey, MA, CSCS, CES About the Author: Mr. Carey, CEO of Function First, holds a master’s degree in bio-mechanics and athletic training and is a certified stretch and conditioning specialist and a certified clinical exercise specialist.

If exercise is good medicine, how is it that the medical and fitness communities have not yet come together to develop a system to help people in desperate need of exercise? If fitness professionals are out there every day helping people exercise — a proven benefit to health — then physicians must not be directing their patients to community resources well developed to provide this therapy … Not necessarily.

If you hear the words “fitness professional” and the images of a steroid-enhanced muscle head, entertainer-turned-expert, or a cosmetically enhanced role model come to mind, I wouldn’t blame you. Why would you trust a patient’s health to someone like this? Because of these unfortunate stereotypes, the fitness industry is struggling to establish itself as part of the legitimate healthcare community.

As an exercise physiologist who takes my education, training, and my role with my clients as seriously as any physician does, let me clarify the role and qualifications of the serious exercise professional so that you can feel comfortable providing the appropriate direction for your patients’ long-term success.Many people call themselves “personal trainers.” One may hold a graduate degree in biomechanics; another may have just finished his online course for $49.99 the night before.

How do you know the difference? The qualifications of the fitness professional continue to improve year after year. Several organizations that certify exercise professionals are now using third-party accreditation. These organizations use the National Commission for Certifying Agencies (NCCA), which is the accrediting body of the National Organization for Competency Assurance (NOCA). These include the American Council on Exercise, the National Strength and Conditioning Association, the National Council of Strength and Fitness Professionals, the National Federation of Professional Trainers and the National Academy of Sports Medicine.

Within the realm of the fitness professional are advanced certifications that require supervised internships and advanced knowledge of special populations. These include the clinical exercise specialist through the American Council on Exercise; the medical exercise specialist through the American Academy of Health, Fitness, and Rehabilitation Professionals; and the ACSM exercise specialist® and the ACSM registered clinical exercise physiologist® through the American College of Sports Medicine. Fitness professionals provide a service along a wide continuum of health needs. The entry-level trainer should have a certification from one of the organizations with NCCA accreditation. This individual is prepared to work with apparently healthy individuals seeking to improve their levels of fitness.

On the other end of this continuum is the fitness professional with advanced degrees in the fields of exercise science, multiple certifications, and clinical experience. Most of what we do looks nothing like a preconceived gym workout. Because of the health complexities of the types of clients these professionals see, they typically work with specific populations. For example, our clientele at Function First consists of individuals with musculoskeletal challenges. If we received a referral for a person with diabetes needing help controlling their insulin levels with exercise, we would recommend to their physician an exercise physiologist who excels with these types of clients.

We have worked successfully with physician referrals for exercise programs for more than ten years. During that time, we have observed characteristics in the physicians that refer their patients to exercise programs and have those patients follow through:

We have also observed the type of physicians who are not successful getting their patients to get on a much-needed exercise program:

As a physician, you are guided by an obligation to provide responsible direction to your patients for their health choices. This should include exercise.

You wouldn’t recommend a diagnostic test as an afterthought at the end of a patient’s appointment and leave it to the patient to negotiate on his or her own. Instead, you would write the prescription, making a specific referral along with a follow-up visit to review the results. That same degree of influence and direction would have enormous impact on your patients’ initiating and adhering to an exercise program.

All of these challenges faced by physicians who find it difficult to convince patients to exercise can easily be resolved by developing relationships with qualified fitness professionals. It is our job to stay abreast of the current literature on exercise science.With knowledge of your goals for your patient, we can work to further your directives and assist in maintaining exercise compliance. As managed care and sedentary lifestyles change the landscape and as baby boomers age, relationships between the primary medical providers and the supporting players in the fitness environment are inevitable.