Homeland Security Watch

News and analysis of critical issues in homeland security

October 30, 2014

No Ebola sitrep yet

Filed under: Biosecurity,Public Health & Medical Care — by Philip J. Palin on October 30, 2014

As of early Wednesday morning the WHO had not released updated data on the Ebola transmission rate in West Africa.  Given the rest of my life, I have to pound out a post before 0900 on October 29 if I am to get you anything on October 30. There are related reports that I might share, but it is probably more helpful to minimize my contribution to the noise level until some meaningful signal is available.

UPDATE

Late on Wednesday afternoon WHO released an update.  Here it is.  Received too late for my further analysis.

By the way, trying to seriously follow major trends and events in order to have something to write to you each Thursday is a very helpful intellectual and temporal discipline.  I would not know half what I know about Ebola if I was not trying to fulfill my relationship with you.  Thank you.

October 26, 2014

Embracing diversity

Filed under: Biosecurity,Border Security,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on October 26, 2014

obama pham(Official White House Photo by Pete Souza)

None of us much like what we perceive as mixed messages.  But many of us seek out diverse sources of information.

I am — as regular readers know too well — a big fan of diversity.  It is an intellectual and aesthetic preference, almost certainly a personality predisposition.

Diversity is also a key characteristic of resilience.  The more diverse a system the less prone it is to catastrophic collapse, the more creative combinations that exist the more likely the system (or sub-system) is to resist and, if necessary, rebound from challenges.

I am personally skeptical of most efforts to reduce variance, increase consistency, and especially any tendency to reserve decisions for some centralized authority.  I am aware such approaches can generate benefits.  But there are also trade-offs and I perceive we too often accept the trade-offs without recognizing what we are giving away.

Since Thursday I’ve been in Newark and New York.  The confirmation of Ebola in a physician who returned to New York after treating patients in West Africa has caused concern.  On Friday Governors Christie and Cuomo, acting more on their political instincts for advancing the common good than expert medical advice, announced a strict quarantine requirement for health care workers returning to JFK and Newark International airports.  This exceeds federal requirements. (Illinois soon followed for those arriving from West Africa into O’Hare.)

I was busy, but as I watched the local news a bit and read the reports I was pleased to see this diversity emerge.  I like it when state and local leaders exercise their best judgment and authority.  I respect political judgment, especially when it relates more to how human social systems actually operate and less about the next election.  I found the non-partisan, reasoned rhetoric of the Governors and Mayor de Blasio mostly helpful.  Medical therapies and social therapies can diverge.

At just about the same time, or at least during the same news cycle, President Obama was purposefully — and a bit awkwardly to my eyes — hugging nurse Nina Pham (above) who has recovered from the Ebola she contracted at her hospital in Dallas.  The intended message was, I hope, clear enough.  For the more literal minded, the President followed up explicitly in his weekly media message.

Meanwhile… Kaci Hickox a nurse arriving at Newark from Sierra Leone, asymptomatic, and according to a preliminary test virus-free, is nonetheless being kept in a 21-day quarantine against her will.  She writes in the Saturday Dallas Morning News:

I am a nurse who has just returned to the U.S. after working with Doctors Without Borders in Sierra Leone – an Ebola-affected country. I have been quarantined in New Jersey. This is not a situation I would wish on anyone, and I am scared for those who will follow me.

I am scared about how health care workers will be treated at airports when they declare that they have been fighting Ebola in West Africa. I am scared that, like me, they will arrive and see a frenzy of disorganization, fear and, most frightening, quarantine… (The nurse continues with a rather horrific story of her welcome to the United States.  You should read it.)

The epidemic continues to ravage West Africa. Recently, the World Health Organization announced that as many as 15,000 people have died from Ebola. We need more health care workers to help fight the epidemic in West Africa.  The U.S. must treat returning health care workers with dignity and humanity.

The ACLU has announced it will take action challenging the New Jersey quarantine order.

Then as if to put into even sharper contrast the different angles on reality alive in Trenton, Albany, and Washington DC, on Sunday morning I read our UN Ambassador Samantha Power is in West Africa.  She has already visited the Ebola wards.  Should she be quarantined in isolation on her return?  Or in deference to separation of powers, will a sanitary cordon of the Ambassador’s residence at the Waldorf be sufficient?

Thursday and Friday I was mostly impressed with how New York local-media was handling the story. Saturday I was too otherwise engaged to notice. Now early on Sunday morning there is a nearly palpable urgency to take sides… or, if one does not feel confident/competent to choose sides, to bitterly complain regarding the incompetence of the “authorities” who should have had this sort of risk fully thought-through.  ”It’s not tight”, the President himself has complained.

In my experience reality is seldom tight. At a certain point working to make it tight strips the threads and even breaks the head.  Can we learn to engage diversity affirmatively, creatively, even systematically, as a potentially positive — in any case, persistent — aspect of reality?  In dealing with complex risks, I have found this to be an especially productive option.

MONDAY UPDATE:

According to several news sources, New York will “loosen” its screening protocols.  Here’s a bit of the AP report:

Gov. Cuomo back peddled Sunday on his insistence that medical workers returning to New York from Ebola-stricken countries would have to undergo a mandatory 21-day quarantine at a government-regulated facility

The governor, in a joint news conference with Mayor Bill de Blasio, said health care workers and citizens who have had exposure to Ebola patients in West Africa will be asked to stay in their homes for the 21-day quarantine.

During the 21 days, the quarantined person will be checked on twice a day by health care professionals to take their temperature and evaluate their condition, Cuomo said.

Here’s the official statement from the Governor’s office.

Constant change in response to feedback, adapting to new information (new expressions of reality) is another feature of diverse and resilient systems.  And just to be clear: in the most resilient systems while change is constant a core-coherence persists.  Which highlights the big difference between consistent and coherent, between control and collaboration…

SECOND UPDATE:

According to NJ.com and other news outlets, Nurse Kaci Hickox will now be allowed to quarantine at home in the state of Maine. The New Jersey Governor’s office released a transcript and video to provide context for this shift.

October 23, 2014

Ebola source sitrep 2

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on October 23, 2014

This is the second in an irregular update on efforts to slow and eventually stop the rate of Ebola virus transmission in west Africa.  The risk of transmission in the United States is a function of the rate of transmission at the source.

It is important to acknowledge issues with data quality.  Over the weekend a piece in Science magazine noted, “… it’s widely known that the real situation is much worse than the numbers show because many cases don’t make it into the official statistics. Underreporting occurs in every disease outbreak anywhere, but keeping track of Ebola in Guinea, Liberia, and Sierra Leone has been particularly difficult. And (as) the epidemic unfolds, underreporting appears to be getting worse.”

Still the data that is collected can help us understand some broad dynamics of transmission.

Yesterday afternoon — October 22 — the World Health Organization released a progress report on their response roadmap.  It provides details through the end of last week for all known cases of Ebola, but focuses primarily on the situation in Guinea, Sierra Leone, and Liberia.  Following is a timetable for transmission of the virus in Liberia and metropolitan Monrovia. Similar charts are available for Guinea and Sierra Leone in the online report.  The report also provides updates on treatment centers and other interventions underway.

WHO_liberiaClicking on the image will generate a larger version

CITYA.M., the City of London business publication, has produced a helpful visual analysis of the Ebola outbreak in Liberia, so far the hardest hit of the the three nations at the epicenter of the outbreak.  These maps communicate the crucial role that population density plays in transmission. They also suggest how the virus moved along human networks from the index case in southeastern Guinea into Lofa County and quickly to the economic/social/political center of metropolitan Monrovia.

Liberia density and number

Liberia per 100,000

MORE from CITYA.M.

While US media focus on early indications that transmission has been contained in the Dallas case, at least as important is the news that the Nigerian public health system has successfully contained an initial set of transmissions in densely urban Lagos.  Fundamental to this Nigerian success was a well-organized existing public health infrastructure and network of human expertise. An effective anti-polio process was essentially repurposed to rapidly contain a new infectious threat. Strategically it is important to recognize this was the adaptation of an existing capacity, not an ad-hoc insertion of a special or reserve capability.

According to the Associated Press, in Nigeria “Health workers tracked down nearly 100 percent of those who had contact with the infected, paying 18,500 visits to 894 people.”

The absence of such an existing capacity has been a principal cause of the outbreak in Liberia and its neighbors.  Sunday U.S. Army Maj. Gen. Gary J. Volesky, commanding general of the 101st Airbone Division and his thirty member command team arrived in Monrovia to assume leadership of DOD contributions to Operation United Assistance. The Army is sending approximately 700 Soldiers from the 101st, including members of the division headquarters staff, sustainment brigade, combat support hospital and a military police battalion. Another 700 troops will be deployed from multiple engineering units to build 17 100-bed medical treatment units and a 25-bed hospital. MORE.

New cases of transmission in Nigeria — the United States and elsewhere — are likely.  Until we can bend the exponential growth of transmission in Liberia, Sierra Leone, and Guinea, a networked and increasingly densely populated planet will be vulnerable.  (A few hours after the original version of this post appeared, a new case of Ebola was confirmed in New York City.)

The Foreign Affairs Council of the European Union met on Tuesday.  Despite some additional progress, the readiness and urgency of the European response will depend on the results of a summit of EU leaders that opens today in Brussels.

October 19, 2014

Who is my neighbor?

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care,Strategy — by Philip J. Palin on October 19, 2014

EBOLA_James harris

I perceive it is prudent — as well as accurate — to make the case that the best way to mitigate Ebola risk in the United States is to significantly degrade the risk in West Africa.

Recently Thomas Frieden, Director of the CDC, felt it was politically necessary to say, “I am not protecting West Africa. My number one responsibility is to protect Americans from threats.”

Over the last few weeks at HLSWatch we had cause to consider the potentially warping effects of self-interest too narrowly conceived or fatally denied.

Last week The Telegraph (London) offered a gallery of online photographs entitled, “Survivors: Portraits of Liberians who recovered from Ebola“.  Above is James Harris, age 29, who recovered after two weeks at death’s door.  He is now a nurse’s assistant in a Doctors Without Borders treatment center in Paynesville, Liberia.

October 18, 2014

Ebola source sitrep 1

Filed under: Biosecurity,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on October 18, 2014

This is the first in an irregular update on efforts to engage Ebola’s center-of-gravity.  As noted previously, I am concerned US media is not giving sufficient attention to fighting this disease where it matters most for all of us.

If the rate of transmission can be suppressed at the source, then the risk to the United States will be substantially mitigated.  If the rate of transmission in West Africa cannot be significantly reversed in the next 60-to-90 days some epidemiologists are concerned Ebola will establish itself well outside it’s historically native range.

Data collection in Guinea, Sierra Leone, and Liberia — the current outbreak’s epicenter — is far from state-of-the-art.  But following is the best information now available from local health agencies as aggregated by the World Health Organization:

Ebola Chart

These numbers will get worse — probably much worse — before they get better.  Current projections suggest 10,000 new cases per week by December.

But there is also some encouraging news.  The Ebola transmission cycle in Senegal and Nigeria has evidently been successfully interrupted and contained.

Ebola survivors who have developed an immunity to the disease are now involved in caring for other patients and may be the source of life-saving blood transfusions.

Population behaviors, such as burial practices, are adapting to the risk.

Several new treatment centers are under construction.  Early identification, isolation, and effective treatment of those with Ebola will cut transmission rates and improve survival rates.  This week US military operations to expand local capacity got seriously underway. (Further details)

There will, almost certainly, be more cases of Ebola presenting in the United States.  The best way to reduce vulnerability is to eliminate the threat at its source.

 –+–

Editorial Note:  It has long been my personal opinion that “homeland security” is most meaningful when it offers its legacy professions, policy-makers, and the public a strategically integrated angle on risk.  The risk environment is usually complicated, often complex and even chaotic.  There are important roles for an array of specializations, threat-specific strategies, operational expertise, and tactical competence.  Homeland security will be more successful to the extent it is well-informed of these related domains.  But homeland security delivers added-value when it can stitch together these diverse elements into a coherent — ideally mutually amplifying — whole.  Strategy, at least in my use of the term, is especially concerned with how risks can be intentionally engaged in a manner that deploys the threat against itself and reduces self-generated vulnerabilities.

What is the most effective strategy for the risk of Ebola?

October 17, 2014

The Ebola Czar and the missing Homeland Security Council

Filed under: Biosecurity,General Homeland Security — by Christian Beckner on October 17, 2014

The President has announced the appointment of Ron Klain as his new “Ebola czar”, as numerous news outlets have reported this morning. From the New York Times:

President Obama will appoint Ron Klain, a former chief of staff for Vice Presidents Al Gore and Joseph R. Biden Jr., to manage the government’s response to the deadly virus as anxiety grows over its possible spread, a White House official said on Friday.

…..

Mr. Klain will report to Lisa Monaco, Mr. Obama’s homeland security adviser, and Susan E. Rice, his national security adviser, the official said. His appointment was first reported by CNN.

The official praised the work already done by Ms. Rice and Ms. Monaco, but said that Mr. Klain would provide “additional bandwidth” in the fight against Ebola, which is important because the two women have to manage other national and homeland security issues.

I view this appointment of an “Ebola czar” and the need for such “additional bandwidth” as a symptom of a broader problem within the policy-making apparatus at the White House, due in part to the decision in 2009 to merge the National Security Council and Homeland Security Council staffs into a single integrated “National Security Staff” (since renamed the “National Security Council staff”).

Prior to the integration of the HSC and NSC staffs, the Homeland Security Council played a very active role on pandemic planning and response issues. It issued the National Strategy for Pandemic Influenza in November 2005, and the subsequent Implementation Plan for that strategy in May 2006, and a progress report on implementation in 2007. During the H1N1 flu pandemic in 2009, the Homeland Security Council was utilized as a primary convening mechanism by the White House.

But since the end of the H1N1 crisis in late 2009, the Homeland Security Council (which was retained as a policy-making entity, in part because it was mandated in law in Title IX of the Homeland Security Act) has almost entirely disappeared from view. From January 2010 to the present, I can find only one public record of the Homeland Security Council being convened: a meeting in July 2014 to address the unaccompanied minor issue on the southern border. (It is possible that there have been additional meetings of the HSC during the last five years, but there is no public record of it).

These concerns about homeland security issues being downgraded were predicted by opponents of HSC-NSC integration at the time. In February 2009, I helped to staff a Senate Homeland Security and Governmental Affairs Committee hearing where we heard a variety of opinions on the potential HSC-NSC merger, including from former DHS Secretary Tom Ridge, who was critical of a potential merger. His prepared remarks highlighted biosecurity as a particular area of concern, and are prescient in light of today’s decision to appoint an Ebola czar (emphasis added):

From HHS to Energy to DOD to the FDA and elsewhere – more than 30 departments and agencies have homeland security functions. Take biosecurity, for example. What the United States needs to do to improve our biosecurity against major biological threats is complex. Biosecurity depends on different programs managed by different agencies – there is no way to simplify it. DHS is in charge of the biological risk assessment that analyzes biological threats. HHS is responsible for the research and development of medicines and vaccines. DOD does its own R&D. The Food and Drug Administration has its role. Let’s not forget NIH. CDC is responsible for our national stockpiles and for coordinating the grant program and technical assistance to state and locals. The intel community is responsible for assessing the biological threats posed by our adversaries. Without close White House coordination, our bio programs will move in different directions to different goals and different timelines. Putting this and other challenges under the NSC’s purview would only complicate the NSC mission and the HSC’s ability to receive adequate attention from a Council that already has Iran, North Korea, Russia, Pakistan-India, the Mideast and other matters in its inbox.

There have been some benefits as a result of integrating the HSC and NSC staffs, in terms of breaking down domestic vs. international policy stovepipes and allowing for integrated decision-making on transnational issues such as cybersecurity. But I have become increasingly concerned over the past few years that the downsides of HSC-NSC integration are outweighing its benefits, largely due to the “bandwidth” issue highlighted in this post, but also because of the decreased public visibility into homeland security decision-making at the White House due to the adoption of NSC protocols, as I discussed in a blog post last year.

In the near-term, the focus needs to be on dealing with the Ebola pandemic, but these broader structural issues also deserve to be reviewed during the last two years of this Administration and/or by the next Administration, whomever is elected President in 2016. And in light of the Homeland Security Council’s statutory role, this is an issue that Congress should also take a fresh look at, including by convening hearings and requesting information on the activities of the Homeland Security Council since 2009.

(Note: this commentary is cross-posted by the author from the site HSPI.org)

Less czar than troika

Filed under: Biosecurity,Media,Preparedness and Response,Public Health & Medical Care — by Philip J. Palin on October 17, 2014

CNN, the New York Times, and others are reporting the imminent announcement of a White House “Ebola Czar”. The man-of-the-hour is Ron Klain.  The former chief-of-staff to Vice President Biden (and Vice President Gore) has been in the private sector since January 2011.

The appointment responds to a burgeoning cry of “who’s in charge?” from the news media and others.

It’s a very primitive question, not well-suited to an infectious disease emerging into a highly-networked global system.  Mr. Klain will, I perceive, actually be part of a troika involving Lisa Monaco and Susan Rice.  He is very experienced riding the back of both the “interagency” and the media. Despite rough rides in the past, the tigers have not yet eaten him up.

Hold on and best wishes.

October 16, 2014

Adjusting our signal to noise ratio

I am currently involved in planning three different tabletop exercises.  Each are efforts to enhance “whole community” involvement.  My particular role is to enhance private sector involvement.  Currently the news media is not targeted for participation in any of these exercises.  In my several years of being involved with various homeland security training and exercises I can only recall two occasions when news media have been involved as participants.

There are several impediments to involving news media in these sort of activities, including:

  • Effective exercises are designed to expose gaps and shortcomings in order to improve preparedness.  News media are inclined to expose gaps and shortcomings in order to increase readership/listeners/viewers.
  • Many public sector participants tend to be “authoritative” or “officious” or “control-freaks”.  This is troublesome enough with other private sector participants.  With members of the media it can be explosive.
  • News media participation can discourage the involvement of other private sector parties due to fear of exposure (see first bullet).

But it seems to me increasingly clear we must find a way to involve news media in preparedness activities or continue — and deepen — the risk of serious mis-communication and public mistrust on the very worst days.  While major media are no longer the only or even primary sources of information, they are a significant source of amplification and confirmation.  Too often they are amplifying and confirming misleading information.  An ongoing example:

The media’s attention to symptoms can obscure attention to the source of problems.  I am astonished by the extraordinary attention given to a few instances of Ebola in the United States in contrast with lack of attention to sources of the problem in West Africa… despite clear and consistent and, at least to me, very reasonable analysis that until the source of the problem is better managed the risk to the United States will only grow.

On Tuesday afternoon the United Nations coordinator for Ebola response told the Security Council that the world basically has sixty days to contain the virus or face a serious risk of pandemic.  In much of the world, this was the Wednesday morning headline.  Not in the United States.

Below are two screenshots.  The first is for the Google News US edition.  The second is for the UK edition.  According to Google, “articles are selected and ranked by computers that evaluate, among other things, how often and on what sites a story appears online.”  The source stories can be found in US media, but too often buried beneath the symptoms.

Google US edition

UK edition

In my judgment a similar symptom vs. source issue is endemic to most US media coverage of terrorism, urban wildfire, flooding, and many aspects of border security.  It even erupts in how longer-term electrical outages are reported.

I am not arguing against news coverage of symptoms.  The attention given to the series of false steps in Dallas has clearly facilitated enhanced readiness across the US health System. But these are tactical –symptomatic — issues, not strategic issues addressing the problem at its source.

When novel and especially deadly threats emerge, the failure to distinguish between symptom and source is at least distracting and too often misleading… in a manner that can undermine public health and safety and, certainly, competence.  Sources can be even more complicated to understand than symptoms, but this further underlines the need for insightful media coverage.

There are very few editors, producers, or reporters who can afford to specialize in any of the so-called “low-probability, high-consequence” risks that confront us.  That’s a problem for most of the private sector and across the public sector as well.  We all need help adjusting our standard-operating-procedures to these non-standard events.  We should start to do so in workshops and exercises before the symptoms explode.

Some possible discussion topics and exercise issues:

In dealing with “high-intensity-risk-environments” (HIRE), do not mistake ambiguity for inattention.  Recognizing ambiguity may be evidence of close attention.

In engaging a HIRE, do not confuse uncertainty with incompetence. The compulsion to sound certain in the midst of complexity is, in my opinion, a principal cause of incompetence.

In the midst of a HIRE, complexity and lack of control does not necessarily signal lack of organization or progress.  Efforts to control can escalate complexity and suppress resilient self-organization.

In a few months I should be able to let you know if I am successful in involving media in any of the exercises currently being planned.

–+–

And since I’m writing about attention to sources as well as symptoms, in regard to Ebola here are some potentially helpful sources on sources:

FrontPageAfrica – A Liberia based newspaper. (BTW, this is not the largest circulation Liberian newspaper, but some of its competitors have, in my opinion, their own serious noise-vs-signal problems.)

The Concord Times – A Sierra Leone based newspaper.

The Telegraph – A Sierra Leone based newspaper.

Doctors Without Borders Guinea News

Guinea (Conakry) Guinee Focus (French)

World Health Organization Africa Regional Office

US Department of Defense Africa Command

CDC Ebola Hub

Resources from the London School of Hygiene and Tropical Medicine here and here and here  (and it’s worth looking for more)

FRIDAY UPDATE:

Thursday evening NPR broadcast an interview with Dr. Lewis Rubinson.  An intensive care physician with the University of Maryland Medical Center, Dr. Rubinson spent three weeks in September serving Ebola patients in Sierra Leone.  The full interview (with transcript) is, I suggest, a good example of well-informed, realistic thinking about dealing with symptoms.  Following is an excerpt:

RUBINSON: There are nearly 6,000 hospitals in the U.S. It wouldn’t have made sense to me that every single facility would have the ability to be honestly prepared. It doesn’t mean that there doesn’t need to be an appropriate level of the ability to identify patients and provide early treatment and keep staff safe. I think that’s really on every institution because we can’t control where patients present. But I think out in West Africa, we got very, very good at being 100 percent all of the time. You had to. In the U.S. there’s no technological fix for this. We can’t buy a widget and just solve it and give it to the hospital and say, you’re prepared right now. Most of this is about diligence, it’s about discipline and it’s about 100 percent adherence. And I think, again, that’s very hard to imagine that every facility could do that. Not because they aren’t good facilities, it’s just there are other priorities that they need to be taking on at the same time. Again, every facility needs to be able to identify the patient, take care of the patient early, keep the staff safe, but I think it’s very hard to imagine that every facility would be good at managing a patient throughout their course of the disease, especially if they get very sick, like had happened in Dallas.

MORE

SECOND UPDATE:

In regard to sources rather than symptoms, here’s “top of the fold” attention being given British operations in West Africa.  According to Friday’s Telegraph,

Ebola is the “biggest health problem facing our world in a generation”, David Cameron has said, as he urged foreign leaders to “step forward” with more resources to fight the crisis.

The Prime Minister urged other leaders to “look to their responsibilities” to help tackle the Ebola epidemic ravaging parts of West Africa… 

He said: “Britain, in my view, has been leading the way. The action we are taking in Sierra Leone where we are committing well over £100 million, 750 troops, training 800 members of health staff, providing 700 beds; we are doing a huge amount.

“I think it is time for other countries to look at their responsibilities and their resources and act in a similar way to what Britain is doing in Sierra Leone, America is doing in Liberia, France is doing in Guinea.

“Other countries now need to step forward with resources and action because taking action at source in West Africa is the best way to protect all of us here in Europe.”

MORE

August 6, 2014

Ebola is not a homeland security risk…but insufficient public health funding is

Filed under: Biosecurity,Public Health & Medical Care — by Arnold Bogis on August 6, 2014

Ebola is scary. Ebola is exotic.  Ebola normally occurs “over there” not “here.” Ebola sounds like the stuff of Hollywood movies.

However, what Ebola is not is a homeland security threat.

Forgive me for being crude, but basically to catch the Ebola virus you have to come into contact with the bodily fluids of an infected individual.  That definitely means their blood and vomit, and I’m just guessing so please any public health professional feel free to correct me, but perhaps also urine, diarrhea, and any other fluid the body could eject in sizable amounts.

As the CDC describes it:

When an infection does occur in humans, there are several ways in which the virus can be transmitted to others. These include:

  • direct contact with the blood or secretions of an infected person
  • exposure to objects (such as needles) that have been contaminated with infected secretions

The viruses that cause Ebola HF are often spread through families and friends because they come in close contact with infectious secretions when caring for ill persons.

During outbreaks of Ebola HF, the disease can spread quickly within health care settings (such as a clinic or hospital). Exposure to ebola viruses can occur in health care settings where hospital staff are not wearing appropriate protective equipment, such as masks, gowns, and gloves.

The important takeaway here is that the virus is not airborne. The people getting sick are the caregivers — family, friends, medical personal — who lack or are not taking proper infection control efforts or using protective clothing. Infected people are not infectious until they are sick, and when they are sick they are SICK.  So you are unlikely to run into an Ebola patient on the subway who then proceeds to either bleed or vomit on you.  And if that unlikely scenario occurs, public health officials will have a relatively easy time mapping the direct contacts that the original patient has as well as yours. They can then take appropriate measures to monitor those folks for any signs of infection. This results in no larger outbreak.

There has been some discussion about the possibility that terrorists could take advantage of this situation. Here is HSToday:

As the World Health Organization (WHO) and US Centers for Disease Control and Prevention (CDC) are on high alert to the international spread of the unprecedented outbreak in West Africa of the most lethal strain in the family of Ebola viruses, questions are being raised about whether individuals from West African nations where the virus is spreading trying to illegally enter the United States could bring the highly infectious pathogen into the country.

Federal and public health authorities who spoke only on background said “this simply isn’t a farfetched possibility, despite what some say to the contrary,” one told Homeland Security Today.

Since 2011, the majority of apprehensions of “Other than Mexicans” (OTMs) has been highest in The Rio Grande Valley, including individuals apprehended in Fiscal Year 2013 from Guinea, which is in the African Ebola hot zone. Other OTMs from West African nations bordering the region’s Ebola hot zone – Gambia, Ghana, Guyana, Nigeria and Burkina Faso – were also apprehended in FY 2013 trying to illegally enter the United States, according to Border Patrol data provided to Homeland Security Today.

Also:

“All any one of these terrorist groups would have to do is to have members infect themselves prior to departure, or, more likely, once they’re on the ground making their way to the Rio Grande Valley or some other human smuggling pipeline to the US border,” one of the officials said, noting that Al Qaeda has in fact discussed the deployment of so-called bio-martyrs, according to intelligence. “If they’re willing to stick a bomb up their ass and blow themselves up, then I have no doubt they’d be willing to be a carrier of a highly infectious virus like Ebola,” the official said.

“Now, would one of these groups be crazy enough to try something like this … who the hell knows,” the official said. “But what you have to understand is that these are extreme jihadists who believe a suicide mission in the name of jihad against us, the infidels, is the one true way to Allah. And some of them have already done some pretty crazy stuff … like the bomb up the ass, or the intelligence that they’re working on surgically implanting bombs. So being a host for a virus, like Ebola – no, I don’t think it’s a crazy notion at all. Not when it could set off an epidemic in the US.”

I think I’m going to go with the idea that this is far-fetched.  Terrorist groups have committed some impressive operations over the years, and I would argue the bigger ones that was not 9/11 came in the period before 9/11.  However, for this to work a terrorist would have to make sure they become infected in a time period that allows them to travel to Mexico and over the border before becoming incapacitated.  During that trip or shortly thereafter, they have to be sick enough to expel bodily fluids on others who would likely not seek professional medical help at the same time without becoming sick enough to remain mobile. Those exposed individuals would then have to contract the disease, not seek medical help, and expose others who would hypothetically attend to them during this illness.

This is not going to keep me up at night.

What is concerning is the lack of appropriate funding for the public health systems that are our front line protection from all natural and man-made biological threats.  As the Trust for America’s Health explains:

  • Inadequate Federal Funding: Federal funding for public health has remained at a relatively flat and insufficient level for years. The budget for CDC has decreased from a high of $7.31 billion in 2005 to $6.13 billion in 2012. Spending through CDC averaged to only $19.54 per person in FY 2012. And the amount of federal funding spent to prevent disease and improve health in communities ranged significantly from state to state, with a per capita low of $13.72 in Indiana to a high of $53.07 in Alaska.
  • Cuts in State and local Funding: At the state and local levels, public health budgets have been cut at drastic rates in recent years. According to a TFAH analysis, 29 states decreased their public health budgets from FY 2010-11 to FY 2011-12. Budgets in 23 states decreased for two or more years in a row, and budgets in 14 states decreased for three or more years in a row. In FY 2011-12, the median state funding for public health was $27.40 per capita, ranging from a high of $154.99 in Hawaii to a low of $3.28 in Nevada. From FY 2008 to FY 2012, the median per capita state spending decreased from $33.71 to $27.40. This represents a cut of more than $1.15 billion, based on the total states’ budgets from those years, which would be $1.9 billion adjusted for inflation. According to a survey by the Association of State and Territorial Health Officials (ASTHO), 48 state health agencies (SHAs) reported experiencing budget cuts since 2008. According to the Center on Budget and Policy Priorities (CBPP), states have experienced overall budgetary shortfalls of $540 billion combined from FY 2009 to FY 2012, and 31 states have projected or closed budget gaps totaling $55 billion in FY 2013. State and local health departments have cut more than 45,700 jobs across the country since 2008.6 During 2011, 57 percent of all local health departments reduced or eliminated at least one program.

If you want to worry about something public health related this week, worry about that.

For the latest from the CDC on this Ebola outbreak, see: http://www.cdc.gov/vhf/ebola/index.html
ADDENDUM: I meant to write, but forgot, that while I do not consider Ebola a broader homeland security issue for the nation, nor a potential terrorist threat, I do support current CDC actions that include travel warnings for the areas heavily hit by the spread of this disease, as well as increased awareness for U.S.-based medical personnel and even airline crews.  Just because we shouldn’t stay up at night worried about this disease outbreak doesn’t mean that there are not prudent steps to be taken.

March 17, 2014

Sometimes government regulation is good; or how Medicare/Medicaid increased preparedness

Filed under: Biosecurity,Business of HLS,General Homeland Security — by Arnold Bogis on March 17, 2014

The phrase “government regulation” usually implies something bad.  But sometimes, a few new seemingly minor regulations can have a positive impact. The Centers for Medicare and Medicaid Services (cms.gov) provides the latest example:

Describing emergency preparedness as an “urgent public health issue,” the proposal by the Department of Health and Human Services offers regulations aimed at preventing the severe disruptions to health care that followed Hurricane Katrina and Hurricane Sandy. More than 68,000 institutions would be affected, including large hospital chains, “mom and pop” nursing homes, home health agencies, rural health clinics, organ transplant procurement organizations, outpatient surgery sites, psychiatric hospitals for youths and kidney dialysis centers.

It might seem like common sense, but previously health care organizations and facilities were required to do very little in terms of preparedness. Because of the market share that Medicare and Medicaid holds, that is going to change:

The regulations would require hospitals, nursing facilities and group homes to have plans to maintain emergency lighting, fire safety systems, and sewage and waste disposal during power losses, and to keep temperatures at a safe level for patients.

Those inpatient facilities would also be expected to track displaced patients, provide care at alternate sites and handle volunteers. Transplant centers would need to identify alternate hospitals for patients awaiting organs — a challenge because centers maintain different transplant criteria.

Home health care agencies would be required to help patients create personalized disaster plans. Hospices and others caring for frail, homebound patients would need procedures to help rescuers locate them. And health care employees would have to conduct disaster drills, while administrators might have to coordinate drills and response plans with local business competitors.

What is aggravating is that the seemingly sensible is so strenuously contested:

One of the most contested of the requirements calls for hospitals and nursing homes to test backup generators for extended periods at least yearly rather than once every three years, as is currently recommended. The generators have sometimes failed catastrophically during prolonged power losses.

This is not a narrow effort, but instead applies to a wide range of health care organizations:

The current proposal is unusual because it applies to 17 types of providers at once, which together serve an estimated nine million fee-for-service patients each month, as well as other patients covered by Medicare Advantage and Medicaid. Federal officials said this broad approach was needed to ensure that the health care system pulls together and that poorly prepared institutions do not stress others during a crisis.

You can read more about this effort, including the push back , here: http://nyti.ms/1fndiuP

January 14, 2014

Private-public collaboration essential to water restoration effort

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With the active, coordinated, nearly  synchronous involvement of neighborhoods and individuals across the region the Kanawha Valley is currently engaged in a process of flushing and restoring a 1700-mile water network.  A continually updated map is available here.

This is an amazing example of “whole community” in action.

January 13, 2014

Water everywhere, but not a drop to drink

MONDAY EVENING UPDATE:

Several media outlets — and some private emails — indicate some areas of the Kanawha Valley are being told their tap water is again safe to consume.  Different areas are being “cleared” in a step-by-step process of flushing and multiple-testing.

–+–

Last week an unknown amount of the chemical 4-methylcyclohexanemethanol leaked from a storage tank into the Elk River near Charleston, West Virginia (one estimate referenced 5000 gallons, another estimate is 7500 gallons). About one mile downstream from the discharge is the intake for a water system serving most of nine counties and up to 300,000 persons.

By Thursday evening a “Do Not Use” order was announced. Water customers were instructed to avoid bodily contact with tap water. Water has continued to flow for sanitation and firefighting (and to flush the system).

Even 24 hours after the spill the contamination risk was not well-understood. While not thought to be toxic, the chemical can cause irritation of the eyes and skin. Ingestion could cause nausea, gastrointestinal distress, and liver damage.

The chemical is known to be harmful in concentrations of 500 parts per million. By Friday evening levels of the chemical’s concentration in the Elk River near the water intakes had dropped from 2 to 1.7 parts per million.  On Saturday it was announced the “Do Not Use” order would not be lifted until a comprehensive testing process found concentrations of less than 1 ppm throughout the Kanawha Valley water network.  On Monday morning several spot-checks are reporting levels below 1 ppm.

The water network involves over 100 storage tanks and 1700 miles of pipeline.  On Saturday the water company explained, “Concentric flushing beginning at a central location and moving out to the far ends of the distribution system is expected to take several days but will not be simultaneous based upon the construction of the system. The timeline may vary based on geographic location, customer demand and other factors that impact water usage and availability.”

Retail supplies of bottled water quickly sold out on Thursday night and Friday.  But by Saturday most stores had been resupplied and some major retailers were providing customers water at no charge.  Several public distribution locations had also been established.  FEMA has shipped over 1.5 million liters into West Virginia.  Proactive efforts are being made to ensure drinking water distribution to the elderly, disabled, and other vulnerable populations.  Both private and public supply chains will continue to surge water into the greater Charleston area.

This is a still developing situation.  Lots of lessons — and pseudo-lessons — are likely to emerge.  With appropriate trepidation, let’s begin to gather some observations and hypotheses.

Prevention and Mitigation

In my personal experience secondary-effects on water systems are especially consequential. I have seen urban areas emerge from a detailed analysis of a nuclear detonation in what seemed a survivable condition only to have the water system fail and unwind an entire region.

As with many — most — modern systems of supply urban water systems are nodal networks.   These networks are innately more efficient on good days and innately predisposed to catastrophic cascades on bad days.  Trouble at any node is likely to propagate to other nodes.   The nodes — electrical, logistical, water, whatever — are especially susceptible to no-notice concentration stresses.   (This is what is currently speculated to have happened at the UPS Worldport on the weekend before Christmas causing one of the best supply chains in the world to nearly collapse.)

A significant aspect of the problem in West Virginia is that the — largely unknown — chemical was released in considerable quantity so close to the node.  There was not sufficient time-and-space for dilution to do its magic before the whole system was contaminated.  Electrical, computing, fuel, and other networks are vulnerable to analogous risk.

Response

West Virginia is on the edge of four regional supply chain networks.  This is so rough to be at least a bit misleading, but think of large circles radiating out from Washington-Baltimore, Pittsburgh, Cincinnati, and Charlotte/Roanoke.  Depending on the commodity or sector, these circles overlap in West Virginia.

I expect — but it is only an informed guess — that the spike in demand signals began emerging after Thursday orders and Friday morning deliveries were processed.  So it took until Friday morning to seriously engage the unexpected explosion in demand.  Then it was late Friday or early Saturday before sufficient commercial stocks of bottled water could be redirected into the network.

Again just an informed guess, but Kroger, Walmart, Sysco, and  McLane are probably the principal distributors of bottled water in West Virginia.  They will also be the principal sources for sanitizers, baby wipes, paper plates, and related products  For players this size, there is an existing strategic capacity to surge supply.  While 300,000 with a no-notice loss of drinking water is non-trivial it does not exhaust capacity… especially because this is on the edge of four regional supply networks, each with very deep resources. The challenge is more an issue of transport than supply.  So… by Saturday the commercial supply chain was aware of the problem, reorganizing to supply the problem, and largely successful doing so.

Provision of water by local fire departments, state emergency resources, and FEMA is a crucially important complement to the commercial supply chains.  Red Cross, churches and similar organizations are especially important to filling the demand-and-supply gap for non-mobile populations.

My off-the-cuff analysis would not be nearly so benign if a similar event hit a much more densely populated area that was served by a less diverse supply chain.

Recovery

Contamination events are especially challenging.  How do you prove a negative?  Rumors will fly faster than facts.  Bottled water is going to be more popular in the Kanawha Valley than ever before, enjoying sustained demand long after chemical concentrations fall below 1 part per million.

Nodes are important here too.  What and who are the psycho-social nodes in this (these) communities?  What relationships have already been established?  How can those relationships be energized in this instance to deal with this issue?  Will these communities respond as victims, as survivors, as heroes? And what, in retrospect, will they decide to learn?

One of my West Virginia friends who contributed to this report offered,  ”Tell your readers that if they want to help they need to plan their next vacation or convention for Charleston.” Basic human needs are being addressed, but the long-term economic consequences will be very troubling.

Much more to come.  This crisis continues. But in any case, Coleridge was right:

Water, water, everywhere,
And all the boards did shrink;
Water, water, everywhere,
Nor any drop to drink….

He went like one that hath been stunned,
And is of sense forlorn:
A sadder and a wiser man,
He rose the morrow morn.

Rime of the Ancient Mariner

December 4, 2013

Expanding or Diluting Our Preparedness Priorities

Today’s guest blogger is “Donald Quixote”  Don comments frequently on Homeland Security Watch.  He writes under what he likes to call his nom de guerre because his agency frowns on its employees posting material without agency approval. 

————-

The House Committee on Homeland Security recently passed the Medical Preparedness Allowable Use Act (HR 5997)/ (HR 1791) authorizing the expansion of the use of existing grant programs for enhancing medical preparedness, medical surge capacity and mass prophylaxis capabilities during a natural disaster or terrorist attack.  Reportedly, it does not furnish any additional funding, but provides the ability to leverage the Urban Area Security Initiative and State Homeland Security Grant Program.

The pending bill can be viewed from several different perspectives.  The optimist may view this initial accomplishment as Congress finally addressing a very serious threat of a chemical or biological attack that may be looming, or  – rather more likely — the threat of a serious novel pandemic illness.  The pessimist may view it as the continued, wider distribution of limited resources between numerous partners in the ever-vague world of homeland security (whatever that entails, but that is another conversation).  I tend to believe it is both.

According to a Los Angeles Times article, the 2009 H1N1  influenza virus killed 10 times more than previously estimated by the World Health Organization.  A study published in the journal PLOS Medicine estimated the number that died was 203,000.  Although the number appears quite small when compared to the current world population and the momentous number that perished during the H1N1 Spanish Flu pandemic of 1918-1919, it remains a relevant number, if accurate, as a warning indicator.

However, how many of us truly appreciate the conceivably massive cascading consequences of a serious novel pandemic threat?

Are MERS, SARS, H1N1, H5N1 and H7N9 warning shots over the bow or just natural occurrences that come and go over time without serious implications?

The topic of biosecurity is not new to this blog.  Mr. Bogis and Mr. Wolfe have identified numerous areas of interest regarding the funding and resources already appropriated for biosecurity and biodefense.  There have been valuable discussions and debates regarding the perceived and actual risks and returns on investment.  The practical value of the previous investments and effectiveness of the many programs shall remain the subject of debate until they are partially or fully tested by an incident or event.

In the realm of a serious novel pandemic illness, I controversially continue to argue that it could easily outrank a conventional terrorist attack as a current threat due to the possibly catastrophic consequences to our citizens, critical infrastructure and civil stability on a broader scale.

We can only ignore the low-probability\high-consequence biological attack or serious novel pandemic illness threat until it happens.  Unfortunately, there is a long history of ignoring this threat because of limited resources and impaired strategic vision.

The Medical Preparedness Allowable Use Act, if ultimately enacted, may affect some change in this area or at least spark interest in expanded medical preparedness.


 

 

 

May 2, 2013

Catastrophe: Should’a, Would’a, Could’a

“I should prefer Mozart. Mostly I listen to 70s hits.”

“I should eat a hot breakfast, but usually have a powerbar instead.”

“I should work-out three or four times a week, maybe I walk around the block twice.”

Should has become moralistic.  It is typically used as a kind of anti-verb, ascribing — often anticipating — non-action.

I have heard a lot of “shoulds” in regard to the explosion of the West, Texas fertilizer storage facility. The April 17 blast killed 14 and injured more than 190 in the town of 2700.

“We should regulate better.”

“We should put buffer zones in place.”

“We should be more realistic about the threat.”

“We should do a better job sharing what we know about the risk.”

“We should focus more on pre-event prevention and mitigation.”

More plural pronouns than singulars it seems.

According to a November 2012 analysis undertaken by the Congressional Research Service, 6,985 chemical facilities self-report they pose a risk to populations greater than 1,000. There are 90 that self-report a worst-case risk affecting up to 1 million people.

The West facility was not included in the CRS analysis.  They did not self-report — or evidently self-conceive — a worst case scenario that would seriously harm anyone.

As regular readers know I have for a few years worked on catastrophe preparedness.

One of the most remarkable — and absolutely predictable — aspects of this gig is the readiness — preference really — by nearly everyone to define catastrophe as something non-catastrophic.  I saw it again last week and this.  It extends across the public-private divide and every level of government.  When a few of us argue otherwise we are being pedantic, unrealistic, and wasting people’s time.

We should give regular time and energy — maybe five percent of overall effort — to truly catastrophic risks: Global pandemic, significant earthquakes and cyclonic events hitting major urban areas, sustained collapse of the electrical grid whatever the cause. Each of these could have far-reaching secondary and tertiary effects.  In some regions I would include wildfire and flooding. If you have a chemical storage or processing facility nearby that is absolutely worth worst-case thinking now not later.

In many cases the most important issues relate to the mitigation of systemic vulnerabilities that are threat-agnostic.  ”Fixing” vulnerabilities can reduce consequences for a whole host of threats, including non-catastrophic threats.

USA Today editorialized, “The Boston Marathon bombings overshadowed the disaster in Texas, but what happened in West was deadlier, and preventing the next fertilizer accident should command serious attention.”

There’s that anti-verb again.

–+–

And how I wish I’d, wish I’d thought a little bit more
Now shoulda, woulda, coulda I means I’m out of time
Shoulda, woulda, coulda can’t change your mind
And I wonder, wonder what I’m going to do
Shoulda, woulda coulda are the last words of a fool

Can’t change your mind
Can’t change your mind

Beverly Knight

August 14, 2012

Another National Strategy to Implement

Filed under: Biosecurity — by Alan Wolfe on August 14, 2012

Without much fanfare at all, the White House released a “National Strategy for Biosurveillance” on July 31, 2012, promising to “unify national effort around a common purpose and establish new ways of thinking about providing information to enable better decisionmaking [sic].”

Unfortunately,  this strategy lacks clear ways and means that would allow for a coordinated national biosurveillance effort. Rather than leveraging the “whole of government” approach and implementing an oversight process that has broad authorities, this strategy avoids directing roles and responsibilities that are necessary to avoid duplication of effort and power struggles over who is supposed to be in charge of this overall program.

This is not a new issue.

After the 2005 avian influenza flu scare, Congress directed the Department of Homeland Security (DHS) in 2007 to stand up a National Biosurveillance Integration Center (NBIC). So DHS obediently complied, with a plan to stand up the NBIC in 2008 and have it fully operational in 2009.

Its responsibilities included rapidly identifying and tracking biological events; integrating and analyzing data from various environmental and clinical sources; disseminating alerts and appropriate information; and overseeing the development of interagency coordination through a National Biosurveillance Integration System (NBIS).

DHS’s Office of Health Affairs stood up NBIS in 2004, an IT system that relied on open source information and added some intelligence and threat analysis.

In 2007, the White House released HSPD-21, “Public Health and Medical Preparedness,” tasking the Department of Health and Human Services (DHHS) to “establish an operational national epidemiologic surveillance system for human health, with international connectivity where appropriate” that included working with the Federal, State, and local surveillance systems (where they existed) for public health purposes.

DHHS has oversight of the Centers for Disease Control and Prevention, which of course has a long history of monitoring and tracking disease outbreaks that might affect human or animal health.

In 2008, DoD created an Armed Forces Health Surveillance Center to be a global health surveillance proponent for its deployed forces.

The Government Accountability Office (GAO) immediately criticized the DHS plan in this 2008 report. It stated  “Threats of bioterrorism, such as anthrax attacks and high-profile disease outbreaks, have drawn attention to the need for systems that provide early detection and warning about biological threats, known as biosurveillance systems.” DHS had not, from the GAO’s point of view, taken the necessary steps to plan and budget its NBIC and would not meet the statutory requirement to be operational by September 30, 2008. DHS had not formalized information sharing agreements with outside agencies (such as the Departments of Defense, Agriculture, Health and Human Services, Interior, State, and Transportation), and of course, Project BioWatch has to feed into the NBIC.

Project BioWatch is hardly a “national” system with only 30-odd sites in U.S. metropolitan areas, but it is part of the overall data collection effort.

The GAO returned in 2010 to report that there did not appear to be a comprehensive national biosurveillance strategy that clearly identified the USG objectives or a focal point with responsibility, authority, and funding to lead the effort. In particular, the GAO noted that the NBIC had not been fully successful in collaborating with its Federal, state and local partners, because (surprise) those agencies had basically stonewalled NBIC, citing excuses such as lack of funds, lack of authorities, and so on.

The Presidential Decision Directive-2, “National Strategy to Counter Biological Threats,” which was released in December 2009, called for a national biosurveillance capability, as did the DHHS National Health Security Strategy. The lack of clarity on roles and responsibilities, joint strategies, policies, and procedures for operating across agency boundaries had limited NBIC’s ability to do what it had been chartered to do – maintain situational awareness of biological threats across the nation and effectively communicate to decision-makers what the current state of biological threats were.

So the National Security Staff has responded to the GAO recommendation after about two years of discussions and reviews.  With the White House’s release of this (yet another) national strategy, surely the roles and responsibilities of the various USG agencies involved will be clarified.

Except … they aren’t.

The strategy does detail four core functions of the national biosurveillance enterprise, to include scanning and discerning the environment; integrating and identifying essential information; alerting and informing decision-makers; and forecasting and advising on the impacts of biological disease outbreaks.

But this is hardly startling stuff. Everybody gets the goodness of a concept proposing an “all-nation” system that saves lives by providing actionable and timely information on biological threats.

What may be less well understood and not fully recognized is the startling scope of this effort. Biosurveillance does not, as a layperson might expect, involve the collection and analysis of only biological threats (both natural and man-made), but rather all hazards – chemical and radiological incidents and accidents included – that might affect the health of the biosphere (humans, animals, and crops). This is a huge task, and one might wonder if any one agency could hope to integrate and make sense of this data, even if all the Federal agencies cooperated with DHS’s NBIC as they’ve been directed.

But that’s all going to be addressed in 120 days, when a “strategic implementation plan” will lay out the roles and responsibilities, specific actions and activity scope, and perhaps most importantly, a mechanism for evaluating progress toward specific goals within those four core functions.

It’s doubtful there will be any additional funds for this effort (given budget realities), but the developers of this strategy are optimistically calling for “new thinking and revised methodologies” that will enable this enterprise to work and to allow those timely decisions to save lives and reduce the impact of whatever threats this biosurveillance enterprise takes on.

My personal concern is that the deliberate inclusion of tracking bioterrorism incidents and naturally-occurring biological disease outbreaks, in addition to chemical and radiological incidents and accidents, is simply too much to handle. It’s information overload. The focus of this enterprise ought to have been kept to natural disease outbreaks, which is certainly where the legitimate concerns originated. There is no appreciable threat of terrorist misuse of the life sciences today; rather, the insider threat caused by the creation of hundreds of biological laboratories, in response to numerous DHS and DHHS grants, may be the greater threat source.

The USG has this bad habit of trying to develop optimal strategies that attempt to eliminate risk and prevent incidents by controlling the threat, rather than focusing on the more achievable mitigation and resilience measures that might be implemented at the State and local level.

I am even less confident that a single office will get the authority to convince the three major players, DHS, DHHS, and DoD, to play nicely –  specifically, to standardize their biosurveillance information and release it in a timely fashion so that these decision-makers can be informed.

A more likely outcome will be the jockeying of political appointees to create new authorities and to obtain additional funding for an effort that remains poorly scoped and poorly overseen.

But hey, let’s come back in four months and see if that “strategic implementation plan” is out. Maybe we’ll see some realistic direction and achievable goals and objectives in that document. And maybe we’ll see an effective interagency approach that employs a “whole of government” concept, with a program that is both resourced and executable within the next year.

But I’m not counting on it.

 

 

April 2, 2012

Biosecurity and Crisis Standards of Care

Filed under: Biosecurity,Catastrophes,Preparedness and Response — by Arnold Bogis on April 2, 2012

I wish I could weave a proper narrative connecting the two issues I mention in the title of this post.  But beyond the obvious facts that a natural pandemic or bioterrorist attack could strain medical and public health resources at every level to the breaking point, thus requiring what is referred to as “crisis standards of care” –the basic concept of expending available if limited resources in helping the most people instead of just a few at everyday levels of effort where everything possible is tried to save lives. Alternatively, there are scenarios that could require crisis standards of care that aren’t related to biology, say a nuclear attack, or biological attacks or naturally occurring outbreaks of disease that can be adequately responded to without extraordinary measures.

All that a wordy explanation that the following is just for your information in case you missed it.

The first is a collection of biosecurity-related articles from the journal Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. The publishers, the Center for Biosecurity at the University of Pittsburgh Medical Center, describe this effort as looking back at progress made over the past decade:

To document and synthesize the achievements of the past decade and help chart the direction of future efforts, the Center for Biosecurity, with support from the Sloan Foundation, has assembled this series of 7 review articles as a special feature A Decade in Biosecurity. These articles, commissioned by the Center and peer reviewed, describe the current state of affairs in biosecurity policy and practice, identify remaining challenges and priorities, and articulate priorities for the field in the years ahead. The articles are authored by leaders in the field, with topics chosen to address the most critical policy issues and to offer recommendations for the future.

Hopefully they won’t mind me reproducing their content page below:

A Decade in Biosecurity: Contents

Introduction
By Tom Inglesby and D. A. Henderson, Coeditors-in-Chief
Journal contents


Public Health Surveillance and Infectious Disease Detection

By Stephen S. Morse
Despite improvements in the past decade, public health surveillance capabilities remain limited and fragmented, with uneven global coverage. Recent initiatives provide hope of addressing this issue, and new technological and conceptual advances could, for the first time, place capability for global surveillance within reach.
Read article
| Journal contents


Preventing Biological Weapon Development Through the Governance of Life Science Research

By Gerald L. Epstein
Since before the September 11 attacks, the science and security communities in the U.S. have struggled to develop governance processes that can simultaneously minimize the risk of misuse of the life sciences, promote their beneficial applications, and protect the public trust.
Read article
| Journal contents


The Evolution of Law in Biopreparedness

By James G. Hodge, Jr.
Over the past 10 years, a transformative series of legal changes have effectively (1) rebuilt components of federal, state, and local governments to improve response efforts; (2) created a new legal classification known as “public health emergencies”; and (3) overhauled existing legal norms defining the roles and responsibilities of public and private actors in emergency response efforts. Read article | Journal contents


A Decade of Countering Bioterrorism: Incremental Progress, Fundamental Failings

By Richard Danzig
This article suggests that our responses over the past decade can be sorted into 4 levels in order of increasing difficulty: we rapidly appropriated funds, augmented personnel, and mandated reorganization of agencies; we amplified ongoing efforts; we have so far had only glimmers of possibility in evolving new strategies to deal with this largely unprecedented problem; and, still to be realized, we need to overcome resistances inherent in our country’s cultural and political framework. Read article | Journal contents

 

Assessing a Decade of Public Health Preparedness: Progress on the Precipice?
By Elin Gursky and Gregory Bice
Balancing traditional public health roles with new preparedness responsibilities heightened public health’s visibility, but it also presented significant complexities. Currently, a rapidly diminishing public health infrastructure at the state and local levels as a result of federal budget cuts and a poor economy serve as significant barriers to sustaining these nascent federal public health preparedness efforts. Read article | Journal contents


U.S. Medical Countermeasure Development Since 2001: A Long Way Yet to Go

By Philip Russell and Gigi Kwik Gronvall
The U.S. government has taken significant steps toward developing and acquiring vaccines, drugs, and other medical countermeasures (MCMs) to protect and treat the population after a biological attack, but the efforts lack central leadership and accountability and the pace of progress has been slow. This article reviews areas of progress and summarizes the areas where improvements are needed. Read article | Journal contents

 

The People’s Role in U.S. National Health Security: Past, Present, and Future
By Monica Schoch-Spana
Over the past decade, assumptions have been made and unmade about what officials can expect of average people confronting a bioterrorist attack or other major health incident. The reframing of the public in national discourse from a panic-stricken mob to a band of hearty survivors is a positive development and more realistic in terms of the empirical record. Read article | Journal contents

The crisis standards of care piece comes from the Institute of Medicine.  It builds off of an earlier report that defined the topic and provides templates for those organizations that will need to do the difficult work of planning for such an ethically fraught state and implementing altered standards of care with all of the potential repercussions:

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response 

In 2011 alone, a tornado devastated Joplin, Missouri, and earthquakes rocked New Zealand and Japan, underscoring how quickly and completely health systems can be overwhelmed. Disasters can stress health care systems to the breaking point and disrupt delivery of vital medical services.

At the request of the HHS, the IOM formed a committee in 2009, which developed guidance that health officials could use to establish and implement standards of care during disasters. In its first report, the committee defined “crisis standards of care” (CSC) as a state of being that indicates a substantial change in health care operations and the level of care that can be delivered in a public health emergency, justified by specific circumstances. During disasters, medical care must promote the use of limited resources to benefit the population as a whole.

In this report, the IOM examines the effect of its 2009 report, and develops vital templates to guide the efforts of professionals and organizations responsible for CSC planning and implementations. Integrated planning for a coordinated response by state and local governments, EMS, health care organizations, and health care providers in the community is critical to successfully responding to disasters. The report provides a foundation of underlying principles, steps needed to achieve implementation, and the pillars of the emergency response system, each separate and yet together upholding the jurisdictions that have the overarching authority for ensuring that CSC planning and response occurs.

The report can be downloaded here: http://www.nap.edu/catalog.php?record_id=13351

It can be read online here: http://books.nap.edu/openbook.php?record_id=13351

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