Homeland Security Watch

News and analysis of critical issues in homeland security

April 27, 2009

Our role in the swine flu situation

Filed under: General Homeland Security — by Philip J. Palin on April 27, 2009

Homeland Security Watch does not aspire to be a breaking news resource.  Despite this, over the last two weeks we have sometimes behaved as such.  In regard to both the controversial intelligence product on so-called right-wing extremism and the swine flu epidemic this blog has been on the cutting edge.  Some have said our inputs over the weekend even influenced the risk communications effort that was deployed (see Friday, Saturday and Sunday posts).

As we move into what promises to be a  busy week in regard to swine flu, this blog might play a helpfully differentiated role by focusing on the intersection of policy and practice that is exposed as we engage the emerging threat.  Some readers have already begun to wrestle with questions such as,

  • What does this situation tell us about the legal and doctrinal frameworks that were developed over recent years specifically for this kind of event?  Are they being given attention?  Are they working?  Why or why not?
  • What does this situation tell us about our threat surveillance capabilities?
  • What does this situation tell us about our communications and information-sharing capabilities?
  • What does this situation tell us about our collaboration and coordination protocols, especially between federal agencies, between the Feds and the States, and between the public and private sectors?
  • What does this situation tell us about our current state of preparedness for preventing, mitigating, and responding to a potentially catastrophic threat?

Others have better resources to gather and report fast-breaking information.  Based on my first few weeks of contributing to this blog, I perceive our readers have the knowledge, perspective, and judgment to articulate the policy and strategy implications of the unfolding situation. This could have value far beyond the cacophony of coverage that is almost certain to dominate the news for several days.

Chris Bellavita and I will be otherwise engaged this week in a way that will limit our contributions.  I will, however, intend to start each day with a policy/strategy question that, I hope, you will take under serious consideration.   Many of you have used private email to share valuable insights with me.  I suggest this is the right time to share your thoughtful inputs with others.

How about if we begin by identifying questions beyond the five listed above on which we might focus?

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9 Comments »

Comment by William R. Cumming

April 27, 2009 @ 7:40 am

This is a very helpful post with which I fully agree. Don’t try to be cutting edge on breaking news ever. Usually that info in the arena of Homeland Security is as likely to be misleading or even false as revealed by the passage of time. I like the notion that perhaps even months or years down the road some will be able to learn from some of the posts and comments.

As to supplementing the questions [all of which are excellent areas to post posts IMO]I think that definition of the processes and systems utilized by DHS and other pertinent organizations, including the White House, are completely relevant to HOMELAND SECURITY.
To some degree my expertise and interest is two-fold in this blog! First to provide lessons learned from a 34 year career as a federal lawyer and Army Officer that might be applicable, with particular attention to civil-military relationships including their impacts on civil crisis managment in the domestic arena where federalism must be involved as a matter of Constitutional necessity. Second, how do decisionmakers with respect to policy and administrative action incorporate technical information (including scientific, technical (legal and medical, e.g.)into their decisionmaking. And of course what are the systems and processes used if any to incorporate that information. In that of course is how policy differences are adjudicated and resolved to enhance the protection of the public.
Clearly these are not questions although they relate to the concerns expressed in the posts. Occassionaly the subtext of some of my comments are even facetious but all are designed to try and expand on the notion that as the oldest and richest democracy (republic) we can do HOMELAND SECURITY in a manner that helps all nation-states that must deal with the same issues and policy formulation and even international organizations. I give one small example of how long term analysis of the type on this post can impact for the better systems and processes. For years the World Bank refused to consider natural disasters as a major factor on development in the third world. Finally in the early 90’s they could no longer ignore the impacts and started a program that involved the researching, funding and implementation of programs concerning natural hazards, the preparedness and mitigation of those hazards to promote development goals. I had a very small part but helped as did many others. There can be change although sometimes slow. Bureacrats tend to do what they can do (are funded to do) and that they can do over and over thereby negating creativity and new approaches. They (bureacrats) are brilliant at arguing why they cannot do something–e.g. blaming the lawyers, Congress, or history (we just don’t do that sort of thing even though none can explain why not). So for younger people who may read this blog and comments hope to provide some ray of hope (no matter how small) that things can change and that learning organizations can learn to do them better. Congress and the Executive Branch create political solutions, not always in fact seldom the most efficient and effective. So perhaps an element of disclosure on this blog (the King really does NOT have any clothes) can be of some help.
I certainly write these comments with those objectives in mine and can only hope to sometimes succeed.

Comment by Peter J. Brown

April 27, 2009 @ 7:57 am

What does this situation tell us about the legal and doctrinal frameworks that were developed over recent years specifically for this kind of event? Are they being given attention? Are they working? Why or why not?

It is still too early to discuss impact of legal and doctrinal frameworks from the standpoint of implementation and effectiveness unless everything in this realm post-Katrina constitutes doctrine today.

What does this situation tell us about our threat surveillance capabilities?

Threat surveillance in this instance seems a bit disjointed as Asian media started to display photos of remote sensing / thermal imaging devices widely in use over the weekend suggesting that in many major Asian ports of entry this activity is well underway whereas in the US, ICE/CPB has simply started to ask inbound people questions — no thermal imaging or other remote scanning of passengers mentioned.

What does this situation tell us about our communications and information-sharing capabilities?

Washington Post story yesterday was not very positive at least in terms of its evaluation of early activity.

See “U.S. Slow to Learn of Mexico Flu —
Canadian Officials Knew of Rare Strain Before Americans Did”
By David Brown, Sunday, April 26, 2009

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/25/AR2009042501335.html?nav=hcmodule

“U.S. public health officials did not know about a growing outbreak of swine flu in Mexico until nearly a week after that country started invoking protective measures, and didn’t learn that the deaths were caused by a rare strain of the influenza until after Canadian officials did.

“The delayed communication occurred as epidemiologists in Southern California were investigating milder cases of the illness that turned out to be caused by the same strain of swine flu as the one in Mexico.

“In the wake of the 2001 terrorist attacks, the outbreak of severe acute respiratory syndrome (SARS) in 2003 and the more recent emergence of H5N1 bird flu in Asia, national and local health authorities have done extensive planning for disease outbreaks that could lead to global epidemics, or pandemics. Open and frequent communication between countries and agencies has been a hallmark of that work.
?
“Whether delayed communication among the countries has had a practical consequence is unknown. However, it seems that U.S. public health officials are still largely in the dark about what’s happening in Mexico two weeks after the outbreak was recognized…”

What does this situation tell us about our collaboration and coordination protocols, especially between federal agencies, between the Feds and the States, and between the public and private sectors?

Also, too early to tell, but the area of concern for me in terms of collaboration and coordination will involve the rapid deployments of regional surge components – when and if activated — and the overall ability of health care workers / hospital personnel to sustain response especially if their ranks are somehow depleted etc, ie, have the lessons learned from the SARS episode been translated effectively into a sustainable and well-balanced game plan.

What does this situation tell us about our current state of preparedness for preventing, mitigating, and responding to a potentially catastrophic threat?

Really too early to tell, but transparency / media outreach aspect of response thus considerably up tempo over last 48 hours with news of outbreak clusters being shared quickly — no doubt driven or at least encouraged by the aggressive news reporting in the field including from Mexico City. And everyone seems to be keeping up the pace. Missed presence of HHS ASPR and DHS CMO at news event yesterday.

Comment by Peter J. Brown

April 27, 2009 @ 8:42 am

I forgot to mention that one of the biggest transitions in this post SARS response environment involves the implementation of NIMS, along with Hospital ICS or HICS and the entire online dimension of these guidelines.

Given that there was a decision quite a while ago to back off from the online training component of NIMS, it will be interesting to see what online lessons learned result from this whole episode as well as the final grades on the interoperability scorecard.

Comment by Peter J. Brown

April 27, 2009 @ 10:08 am

Last June, GAO issued a timely update.

“EMERGENCY PREPAREDNESS States Are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scarce Medical Resources” June 2008 — GAO-08-668

GAO was asked to examine
(1) what assistance the federal government has provided to help states prepare for medical surge,
(2) what states have done to prepare for medical surge, and
(3) concerns states have identified related to medical surge.

GAO identified four key components of preparing for medical surge:
(1) increasing hospital capacity,
(2) identifying alternate care sites,
(3) registering medical volunteers, and
4) planning for altering established standards of care.

The Results in Brief —

Following a mass casualty event that could involve thousands, or even tens of thousands, of injured or ill victims, health care systems would need the ability to “surge,” that is, to adequately care for a large number of patients or patients with unusual medical needs. The federal government has provided funding, guidance, and other assistance to help states prepare for medical surge in a mass casualty event. From fiscal years 2002 to 2007, the federal government awarded the states about $2.2 billion through the Office of the Assistant Secretary for Preparedness and Response’s Hospital Preparedness Program (ASPR / HPP) to support activities to meet their preparedness priorities and goals, including medical surge. Further, the federal government provided guidance for states to use when preparing for medical surge, including Reopening Shuttered Hospitals to Expand Surge Capacity, which contains a checklist that states can use to identify entities that could provide more resources during a medical surge.

Based on a review of state emergency preparedness documents and interviews with 20 state emergency preparedness officials, GAO found that many states had made efforts related to three of the key components of medical surge, but fewer have implemented the fourth. More than half of the 50 states had met or were close to meeting the criteria for the five medical surge-related sentinel indicators for hospital capacity reported in the Hospital Preparedness Program’s 2006 midyear progress reports. For example, 37 states reported that they could add 500 beds per million population within 24 hours of a mass casualty event.

In a 20-state review, GAO found that —
• all 20 were developing bed reporting systems and most were coordinating with military and veterans hospitals to expand hospital capacity,
• 18 were selecting various facilities for alternate care sites,
• 15 had begun electronic registering of medical volunteers, and
• fewer of the states—7 of the 20—were planning for altered standards of medical care to be used in response to a mass casualty event.

State officials in GAO’s 20-state review reported that they faced challenges relating to all four key components in preparing for medical surge. For example, some states reported concerns related to maintaining adequate staffing levels to increase hospital capacity, and some reported concerns about reimbursement for medical services provided at alternate care sites. According to some state officials, volunteers were concerned that if state registries became part of a national database they might be required to provide services outside their own state. Some states reported that they had not begun work on or completed altered standards of care guidelines due to the difficulty of addressing the medical, ethical, and legal issues involved in making life-or-death decisions about which patients would get access to scarce resources. While most of the states that had adopted or were drafting altered standards of care guidelines reported using federal guidance as they developed these guidelines, some states also reported that they needed additional assistance.

Comment by Peter J. Brown

April 27, 2009 @ 11:04 am

As some readers may wonder about the role of DHS in a situation such as this, I include both an excerpt from last September’s CRS report on DHS FY2009 Appropriations, and an excerpt from recommendations made by the HSAC Emergency Response Senior Advisory Committee (ERSAC) in January 2008 involving HSPD-* and HSPD-21 below.

CRS report –“Office of Health Affairs (p. 80)

The Office of Health Affairs (OHA) coordinates public health and medical
programs throughout DHS, and administers several of them, including the BioWatch program, the National Biosurveillance Integration System (NBIS), certain functions of Project BioShield, and the department’s occupational health and safety programs.

Dr. Jeffrey Runge was confirmed as the first DHS Assistant Secretary
for Health Affairs in December 2007. (Note- he also served as Chief Medical Officer at DHS).

Office of Health Affairs Issues for Congress.

The upcoming presidential transition may prove challenging for OHA, which is in the midst of rapid growth. It began as the Office of the Chief Medical Officer (CMO) in 2005, and was funded at $2 million in FY2006. As OHA, it grew to a funding level of $117 million in FY2008. Of that amount, $100 million was in existing programs transferred from elsewhere in the department, principally the BioWatch program, which was transferred from the Science and Technology Directorate.

OHA uses contractors to meet some of the workforce needs associated with its rapid growth, particularly in support of BioWatch. It also requested additional FY2009 funding for new staff positions, partly to strengthen its administrative functions, such as contracting, budget formulation, budget execution, and internal controls.

In prior appropriations, Congress has been interested in the effectiveness of
OHA programs. In FY2008, Congress provided funding for the National Academy of Sciences (NAS) to study the effectiveness of BioWatch. In the Implementing Recommendations of the 9/11 Commission Act of 2007 (P.L. 110-53), Congress called on the Comptroller General to evaluate implementation of NBIS. These reviews are pending. In its FY2009 recommendation, the House Committee provided BioWatch funding substantially below the request, and expressed concern about
OHA’s plans to deploy new versions of BioWatch sensing systems.

The Committee said that until the NAS review is completed, the funding provided would maintain current operations and continued testing of new sensing systems, but that the Committee was to be notified prior to any future BioWatch deployments in new locations.

The Senate Committee did not discuss BioWatch in its report.

Additional concerns mentioned by the House Committee include, among others, basing DHS’s pandemic influenza planning activities in OHA rather than elsewhere in DHS, and expanding OHA’s activities to monitor environmental exposures among disaster victims. The Senate Committee expressed concern about the level of national preparedness for a nuclear incident, and provided that $10 million (the amount that the Committee provided above the request) be used to expand OHA’s efforts to plan for this threat.

Both the House and Senate Committees expressed concerns about problems with medical care in ICE detention facilities, and the status of OHA’s responsibility to evaluate health and medical policies across the
department. Both committees also directed OHA and FEMA to coordinate their
efforts in managing the Metropolitan Medical Response System (MMRS) grants to cities.”

In January 2008, the Emergency Response Senior Advisory Committee (ERSAC) recommended to the Homeland Security Advisory Council, “for consideration and further submission to the Secretary.”

A. Medical Surge Capacity Findings & Recommendations: The requirements found within the National Preparedness, Homeland Security Presidential Directive Eight (HSPD-8) and Public Health and Medical Preparedness, Homeland Security Presidential Directive Twenty One (HSPD- 21) call for medical preparedness, including the surge capacity for Emergency Medical Technician (EMT) first responders and hospital treatment facilities. Responsibility for ensuring this capability rests with the Department of Homeland Security (DHS) and the Federal Emergency Management Agency (FEMA), but different elements of the response and management of required resources are spread among various federal agencies including Health and Human Services (HHS), the Center for Disease Control (CDC) and the Department of Defense (DOD).

There continues to be strong evidence that Emergency Medical Service (EMS) response operations and hospitals are largely forgotten sectors in homeland security preparedness efforts. This unfortunate and precarious situation is not a secret. The neglect of addressing capacity woes for EMS responders and hospitals must be addressed in a sustainable, meaningful and coherent manner. DHS and FEMA should be the lead federal organization in ensuring there is sufficient medical surge capacity in the Nation.

Among other things, these specific recommendations were made —

Recommendation #3: DHSIFEMA should fully support and require testing by evaluations and ongoing exercise(s) of the EMS and hospital care capabilities for maximum surge based on the existing planning scenarios. The scenarios include the full range of responder personal protection, decontamination and hospital bed (treatment) capability including isolation, decontamination and burn care. Such exercises should be as inclusive as possible and community-based to reflect the true impact of an incident. The findings from such exercises should be promptly addressed by the best and most efficient means to bring the Nation’s capability to the required standard.

Recommendation #5: DHS I FEMA should require field testing, demonstration and training of the existing planned Strategic National Stockpile distribution system for this response.

Finally, with respect to the Emergency Support Function #8 — Health and Medical Services Annex– ERSAC recommended that, “consideration should be given for creating a separate (additional) ESF or an explicitly defined group within the National Response Framework that specifically addresses EMS response and critical care medicine support and related coordination issues. The promulgation of this new ESF or defined sub-group, with one federal agency tasked for this responsibility, will also clarify the issue of “who is in charge” of providing support and coordination for this area within the federal government.

Recommendation #7: The Secretary should require the explicit assignment of the EMS function within ESF#8 to a specific federal agency.

“B. Response Capabilities — Findings & Recommendations —

“Finding #8: The National Preparedness Guidelines final version released in September 2007 is only a listing of “best practices” and does not meet existing requirements. The National Preparedness, Homeland Security Presidential Directive Eight (HSPD-8), the Post Katrina Emergency Management Reorganization Act of 2006, as well as the Implementation of the 911 1 Commission Recommendations Act of 2007, which call for a single document to be used to define and measure “Preparedness” across all levels of government.

“These directives specify that this document must be “risk based”, tied to national standards and guidelines, and detailed enough to measure capabilities at the local, state, regional and federal levels. FEMA Preparedness and DHS Policy have together developed a suggested new approach to the HSPD-8 Target Capabilities List (TCL) that seeks to meet this requirement.

“The new TCL attempts to clearly define specific capabilities and assess shortfalls based essentially upon clearly understood and relevant criteria, such as a jurisdiction’s population, population density, or the presence of significant and relevant critical infrastructure. This new TCL is currently in the pilot development stage and has the potential to describe and define measurable “Preparedness” at all levels. While the new version of the TCL is promising in its relative clarity and overall structure, it should be recognized that this initiative comes on the heels of several recent attempts to assess “readiness” or preparedness at the state and local level. Before any general roll out of the new TCL is attempted, the pilot initiatives should be completed. The current approach for the several pilots is to build consensus and then build the program out to implementation. Use of web-based technology will allow each location to build their own TCL with meaningful roll-up capabilities and metrics to report on each capability. The TCL update is scheduled to be a three year process.

“Recommendation #8: The Secretary should fully support and expedite the rewrite and pilot implementation of the HSPD-8, Target Capabilities List (new TCL) by FEMA Preparedness and DHS Policy. The new TCL program pilots for several locations should also be expedited to ascertain the value of the TCL to local and state jurisdictions and the level of effort required to complete the assessment.”

Comment by Peter J. Brown

April 27, 2009 @ 7:04 pm

As #4 comes up on the WHO dial, who exactly constitutes the top 10 currently missing from the federal government’s pandemic response team due to the somewhat slower than expected nominee process at DoD, DHS and HHS?

Well, based on the designation “No Action Taken” on the Washington Post federal appointee web site today, my slightly biased, priority-based key missing personnel file includes —

1) the Assistant Secretary for Preparedness and Response (ASPR) at HHS
2) the Assistant Secretary for Health Affairs and Chief Medical Officer (CMO) at DHS

3) the Assistant Secretary for Health Affairs at DoD

4) the Secretary of the Army

5) the Under Secretary of Defense for Personnel and Readiness
6) the Assistant Secretary for Homeland Defense

7) the Assistant Secretary for Reserve Affairs

the Assistant Secretary of the Air Force for Manpower and Reserve Affairs

9) the Assistant Secretary of the Navy for Manpower and Reserve Affairs

10) the Principal Deputy Under Secretary for Personnel and Readiness

We certainly could use at least 5 in place immediately out of these top 10.

Comment by Arnold

April 27, 2009 @ 7:54 pm

“due to the somewhat slower than expected nominee process at DoD, DHS and HHS.”

It is my understanding that vetting/taxes/political theater delays aside, this administration is still ahead or equal of pace of any since and including Reagan.

Not saying that is a good situation to be in, but they have not been particularly slow in getting people in place. In fact, I’d wager that DoD, due to Gates carrying over, has less than normal vacant positions in comparison to previous new administrations.

And at least the Medical Director in DHS was “acting” for months during the Bush administration. So the official in place there hasn’t just been warming the seat for a month or two, but has been in place almost a year.

I guess I’m wondering that below the cabinet rank, if the “acting” seat warmer has been in place for months (and most likely the deputy before that) how much of an operational impact does it really have?

Comment by Arnold

April 27, 2009 @ 8:25 pm

My last post made me think a little bit more.

Right now, in terms of responding to this unfolding crisis and below Cabinet rank, could “acting” officials possibly be better suited operationally than newly confirmed or appointed ones?

If one were to assume that many, if not most, of those with “acting” in their titles have been in their respective departments/offices for at least some time, they should (hopefully) have some level of awareness with the pandemic planning that occurred during the last administration.

New officials would most likely have to get quickly up to speed with their new charges’ roles, authorities, etc.

I can imagine there could be difficulties when temporary heads have to either make hard choices within their departments or coordinate with confirmed/newly appointments in other departments. A deficit of power.

But is it possible that knowledge of roles and responsibilities could trump that–at least in the short term?

Comment by William R. Cumming

April 28, 2009 @ 8:25 am

These are great post comments by Arnold and Peter ( if first names okay with you guys?)!

Hopefully confirmation by Senate of HHS Secretary even possible today Tuesday the 28th.

As to Arnold’s comment on “actors” that seems to depend on the personality (I would also argue competence) of the Actor (Acting.)

What typically happens on a percentage basis is that no matter how competent the Actors are seldom promoted and in fact if the position is civil service even in the SES the Actor can serve only 120 days before rotation to another. If a PAS appointment the Actor can act for up to 210 days in the first year of a new Administration. So no VACANCY ACT issues yet in large part and GAO has statutory role to police this statute. The real problem in my mind and in fact the basis of the entire system is that there will be political leadership lawfully appointed and in place. This transition period is about to be fully documented as a “disaster” for Obama because of the key vacancies in the positions potentially in the civil domestic management system and processes for a Pandemic and a chain of command that works. Really too late now so will have to manage by those who can and will! This may not include “Actors”.

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