Homeland Security Watch

For the last two or three weeks I have noticed much more attention to flu stories — and especially H1N1 – in the British media than I have seen in the United States.  But when I have checked the health  informatics I have seen no statistically significant difference. 

The divergence in attention has, however, finally gotten to the point where I will at least aggregate some of the recent reports for the benefit of the — mostly stateside — HLSWatch reader.

If swine flu pandemic is over, why the panic?  (The Telegraph)

Warning over number of previously healthy swine flu patients suffering lung problems (The Mirror)

Doctors warn of flu crisis (The Guardian)

Seventeen people die from flu this winter (The Press Association)

Swine flu now dominant virus as cases rocket (The Mercury)

Region is facing major flu crisis (Norther Echo)

Sussex facing flu epidemic as patients refuse vaccines (The Argus)

There is some indication that — unlike in the US — the percentage of the British population receiving flu vaccinations has dropped from last year.   How much of this is a “health vector” and how much this is a “perception vector” would require more attention than I have given the issue.

Basic information on the status of influenza is available from:

World Health Organization Flu Net (information is a bit dated)

UK Health Protection Agency Weekly National Influenza Report (December 16)

US Centers for Disease Control and Prevention Weekly FluView (December 17)

The re-introduction of cholera to Haiti — the US and Dominican Republic — is a huge step backward in a century long effort to corner, contain, and eliminate the highly infective and deadly disease.  The precise cause of the outbreak is not yet known, but experts have said the simple absence of hand soap has considerably accelerated the spread of the bacteria that causes the disease.

This week for the first time in seven years a human case of Avian Influenza was confirmed in Hong Kong.  But already this year there have been 22 confirmed cases and nine deaths in Egypt and seven cases and two deaths in Vietnam.  Most epidemiologists continue to consider the world past-due for a serious pandemic. The Avian H5N1 virus is thought to be the most likely source.

Last year’s Swine Flu or H1N1 pandemic should have been – and in some ways was — a fantastic real-world exercise for pandemic preparedness.  We were lucky the particular virus was fairly low-grade.  Our weaknesses were exposed, but the consequences were modest.  But from what I can see, the less-than-dire consequences of H1N1 may have suppressed personal and institutional preparedness for H5N1 or other potential strains of pandemic influenza.

Wednesday a series of cyber specialists told the Senate Homeland Security and Governmental Affairs Committee that the Stuxnet Wormhas viral capabilities. “What makes Stuxnet unique is that it uses a variety of previously seen individual cyber attack techniques, tactics, and procedures, automates them, and hides its presence so that the operator and the system have no reason to suspect that any malicious activity is occurring,” according to Sean P. McGurk, acting director of the DHS National Cybersecurity and Communications Integration Center.

But while Stuxnet is visciously sophisticated once it infects a system, prevention measures are classic.  According to PC Magazine these include, ”Deploy an anti-malware solution; watch out for vendor security notifications and alerts, and apply patches; ensure that users are updated via security education and awareness programs; and be aware of their assets.”  Attention and discipline are the most important preventive measures.

A Russian biologist, Dmitry Ivanovsky, discovered viruses in the late 19th century.  The word virus has a Latin origin that usually referred to a poisonous ooze.  

Virus is closely related to the Latin virulentus.  The English “virulent” also means poisonous, but today is probably more often used for anything that is extremely infective and rapidly spreading. Especially in this context, it has made sense to use the biological term for malicious computer code and now for anything digital that is rapidly consumed.

The John Tyner — “don’t touch my junk” — video and narrative has certainly gone viral.  I am disgusted by it.  The combination of a puerile wanna-be passenger and a couple of aggressively bureaucratic TSA agents has certainly produced a poisonous ooze of invective going every which way. 

Like soap in Haiti and disciplined attention with our computers, a reasonable dose of recognizing the humanity of one another might have avoided the entire drama. 

In regard to transportation security, there are meaningful issues of privacy and security that deserve serious consideration. In their Tuesday post Chris Bellavita and Dee Walker outlined several.  Most persuasive to me is that TSA is too often  preoccupied with going through the motions.  They need our help, as informed and active citizens, to focus on delivering real security value.

But John Tyner is no Rosa Parks.  Neither are the two slightly obnoxious TSA agents a latter day Sheriff Clark and Governor Wallace. John Tyner missing his plane is no Bloody Sunday.

What I perceive in most — not all — reactions to the John Tyner incident is an epidemic of self-righteous rage.  I saw similar symptoms yesterday on the streets of Baltimore.  I can’t always flip the channel quickly enough to miss it on television.  I hear it on radio talk shows and in the halls of Congress.  I don’t know the epidemic’s source, but the destruction caused is easy enough to see.

I can understand the rage of some Haitians – ten months after the earthquake, two weeks after being flooded out of their tents and shanties, and now told the water on which they depend is deadly — in some moments I share their rage. 

But how do we diagnose — or treat — the rage of  the well-fed and warmly housed?  There seems to be some virus attacking our sense of relationship with one another, of being Americans together, of our shared humanity.

In 1992 the rap metal band Rage Against the Machine wrote what seems to have become the angry anthem of those from the left, right, and plenty in the middle:

I’ve got no patience now
So sick of complacence now
I’ve got no patience now
So sick of complacence now
Sick of sick of sick of sick of you
Time has come to pay…
Know your enemy!

It is an epidemic: virulent, poisonous, and just as deadly as any other infection.

According to the Miami Herald:

Civil unrest since November 15 has slowed several activities of the response to the outbreak. In the northern city of Cap Haitian prevention and treatment supplies are were not delivered in last three days. WHO/PAHO cholera training was postponed, as well as an Oxfam initiative to chlorinate water for 300,000 people. A nearby World Food Programme (WFP) warehouse was looted and burned. In Hinche, six MINUSTAH personnel and a number of bystanders were injured, according to the MINUSTAH.

The full Situation Report and other updates are available via a new PAHO blog focusing on health conditions and operations in Haiti: http://new.paho.org/blogs/haiti/index.php?lang=en

As we have previously discussed at HLSWatch, catastrophes – especially in contrast to disasters – are almost always the result of a cascade of events over time.  It is the cumulative affect of the cascade, especially on human expectations, that permanently interrupts the status quo ante and results in a “new normal.”

Albert J. Mauroni is an analyst with twenty five years experience in chemical, biological, nuclear, and radiological (CBRN) defense policy and program development.  He has written six books about chemical and biological warfare.

Mauroni recently wrote an article about how the US homeland security enterprise addresses the threat of chemical, biological, radiological, and nuclear terrorism.  He argues that our policy is flawed fundamentally.

Here are selected excerpts from his contrarian –  very readable and compelling — article (the full document is available here ).

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Some History

Our current homeland security approach to CBRN terrorism seems to have its basis in the incidents of 9/11 and the U.S. anthrax attacks in October-November 2001. However, our history of homeland defense goes back to 1941 (at least); to understand from a policy perspective how the government ought to address domestic CBRN terrorism, we need to put it all in context.

… Initially, the federal government saw its role strictly as providing a response to the intentional use of military weapons against U.S. cities and noncombatants. First it was the fear of German and Japanese bombers and missiles hitting U.S. cities on the coast. Then it was the threat of Soviet bombers and missiles. But the congressional response was not to spend great deals of money on this threat. Over time, the state and local officials were not as concerned about the possibility of external attack as they were the power of Mother Nature. Congress, influenced by those state and local officials, decided it was more important for the federal government to respond to states and locals affected by natural disasters and accidents rather than external threats. That balance was rudely jarred after 9/11, and we have yet to re-establish a more balanced view.

What does “WMD” mean?

The term “WMD” was the word of the year in 2002, but quickly fell into abuse as a term of political rhetoric and comedic punch lines. It was originally developed in 1948 by the United Nations as an accepted arms control term to describe the nation-state use of nuclear, biological, and chemical weapons.…

The military defines WMD as nuclear, biological, or chemical weapons that can cause a “high order of destruction.” I would add to this definition that the intentional use of these weapons needs to cause mass casualties….

The presence of mass casualties is a key aspect of the WMD incident, but “mass casualties” is an undefined and nebulous phrase. In general, people use the term to describe a situation in which there is one more casualty than the number of available hospital beds in the local area…. The Department of Health and Human Services (DHHS) chose the number of 1,000 injured or dead people for the trigger for its Metropolitan Medical Response Forces.

I disagree with the FBI’s use of the Title 18 U.S. Code definition of WMD because of its deliberate lack of reference to the scale of the incident. To the Department of Justice (DoJ) lawyers, any amount of CBRN or explosives, no matter how small, constitutes a WMD. Even [inert] devices or hoaxes can have WMD aspects.

In my mind, the term “WMD” is only useful as an arms control term…..

…I’m not against consideration of high-yield explosives, directed energy lasers, or other weapons that could realistically cause mass casualties. Ricin and botolinum toxin, often used in small amounts for assassinations, are not WMD. Airplanes used to cause mass casualty events are not WMD. Pipebombs and grenades are not WMD.

What do you think about CBRNE?

I don’t like the term “CBRNE” because that’s an antiterrorism term, not a WMD term. The military police and emergency responders within the DOD antiterrorism community started using “CBRNE” in the late 1990s because of numerous terrorist incidents such as the bombing at Khobar Towers, the Oklahoma City bombing, and the Aum Shinrikyo’s Tokyo subway incident. But the antiterrorism community really doesn’t worry about the “CBRN” as much as they do the “E.” When it comes to assigning resources and time to the most credible threats, the more probable threat of explosives wins over CBRN hazards every time.

Terrorists get their material and technology where they can, from the local economy. They don’t have the time, funds, or interests to get exotic. That’s what we see, over and over again. The [National Counter Terrorism Center] noted that, in 2008, there were approximately 11,800 terrorist attacks resulting in more than 54,000 deaths, injuries, and kidnappings. Nearly all were caused by armed assaults, bombings, suicide attacks, kidnappings, and other conventional forms of assault.

DHS and CBRN

In 2003, DHS began developing its CBRN terrorism response efforts by basically copying the DOD’s CBRN defense concept. This included recommending the use of plastic sheets and duct tape for homes and businesses to provide “shelter in place” collective protection and the use of point detectors to identify lethal levels of chemical, biological, and radiological hazards.

There were two major problems with this approach. First, the threat of CBRN hazard exposure to people at home (or even businesses) was about near zero, and second, the low probability of a CBRN hazard being used on any one day during the year at any one particular site within the United States was practically zero.

It was not a sustainable strategy if one demanded eternal vigilance at all locations with the goal of eliminating all threats. And of course, the U.S. government wasn’t protecting all potential terrorist targets.

Homeland Security Planning Scenarios

The Homeland Security Planning Scenarios are ridiculously unrealistic in portraying the expected threats to the homeland. Of the fifteen scenarios, eleven are CBRN-focused, and not just typical CBRN hazards but significant quantities of military warfare agents such as anthrax, smallpox, sarin nerve agent, and mustard agent.

They are “worst-case” scenarios, which are good for leadership exercises where you want to encourage interagency communications or to identify whether policies or resources are a limiting factor, but they are lousy for making resourcing decisions.

Worst-case scenarios rely on movie-theater plots that maximize the threat only because that’s the best way to get a maximum number of senior leaders within multiple agencies at the federal level involved to play in a short, annual national exercise. The 10-kiloton nuclear scenario is particularly ridiculous….

Terrorists and WMD

I don’t believe in the popular assumption that terrorists are actively working with “rogue nations” to exploit WMD materials and technology. The evidence isn’t there. Nation states invest heavy amounts of people and funds to develop specific unconventional weapons, and if they were to give or sell them to terrorists, one of two things could happen – either the weapons would be traced back to them, or the weapons might get used someplace where the nation state regrets.

The basic approach used by terrorists and insurgents is to seek out and use low-risk, easily-acquired weapon systems. Any weapon that can be improvised using available and accessible materials is good; any weapon that can be bought on the open market and easily used is good. CBRN materials don’t fit that niche.

The generic terrorist threat is often referenced without any specific understanding of specific group motivations or activities. Al Qaeda has stated intentions to use CBRN hazards, but this has not led to the actual development of any specific capabilities. …. We’re blindly attacking the tools instead of the terrorists.

The reason why terrorists are interested in CBRN hazards is because so many senior [US] leaders keep vocalizing how afraid they are of this particular threat. Before 9/11, the interest was not as strong (and the senior leader rhetoric about “WMD threats” wasn’t, either).

While terrorists are interested in CBRN hazards, they can’t get the dangerous precursor materials, they don’t have any training in handling or dispersing these hazards, and they don’t understand the particular effects on their targets. So we see some scattered use of industrial chemicals, some production of ricin toxin from castor beans, a few grams of radioactive material stolen from a facility – not exactly mass casualty threats.

As terrorists attempt to develop more sophisticated weapons in an effort to create mass casualties, their machinations become more public and it actually becomes easier to catch them.

Chemical Weapons

Chemical terrorism has been downplayed recently, ironically because it doesn’t cause enough casualties for high-consequence scenarios. Chemical terrorism remains the most likely form of CBRN terrorism, if one looks at the relative ease of obtaining industrial chemicals from the economy and low threshold of training and equipment required.

Still, people focus on the nerve agents as the “likely” threat, not because they’re available, but because they’re the most lethal.

Actual cases show terrorists seeking available industrial chemicals rather than making nerve agents, with one exception. Aum Shinrikyo had millions of dollars, facilities, trained chemists, and years of practice to make its sarin nerve agent. Most terrorist groups lack those resources.

DHS and Chemical Weapons

I’m not a proponent of the DHS Chemical Facility Antiterrorism Standards, where the department looks to identify all chemical storage facilities and to make their owners assess the security of their chemicals. All this does is cause incentives to industry to move the chemicals somewhere else. Instead of focusing on the major producers, DHS diminishes its efforts by trying to cover tens of thousands of small facilities and anyone using a chemistry kit. It becomes a paperwork drill where no one addresses the really tough problems.

The railcar discussions are particularly amusing, in that there is so much concern about a hazmat derailment within a major city. So the answer is to divert hazardous materials around a city, right? There are two things wrong with that – the secondary rails are less well maintained, and so represent a greater safety risk. And legal issues with regulation of interstate rail transport get in the way.

Bioterrorism

Bioterrorism is the flavor of the year, thanks to a recently-released government report titled “World At Risk” by former senators Bob Graham and Jim Talent.  Hollywood and fiction novels have done their best to ensure we all believe that a contagious virus without any cure is being secretly developed in a government lab and will wipe out civilization as we know it….

One requires a large amount of biological warfare (BW) agent to successfully cause mass casualties, and these agents can’t be made in a bathtub. You can’t go to Wal-Mart stores to obtain dangerous biological assays or to Home Depot for equipment to grow biological material. Bruce Ivins was successful because he had a full laboratory suite and starter material available to him, plus decades of experience in handling anthrax.

There are at least a dozen top BW threats, but under Project Bioshield we have vaccines for only two of them. Maybe in another ten years, we’ll have a few more vaccines, but certainly not twelve. For the 270 cities in the United States with a population of more than 100,000, only thirty-odd cities have Project Biowatch detectors. It’s a very expensive project to sustain against a wide variety of potential threats. ….I already mentioned the lack of vaccines and medical countermeasures for biological agents. The challenge was, and continues to be, that Big Pharma has no incentive to get involved in researching these specialized medical countermeasures. It’s too expensive, it’s not profitable, and it could lead to lawsuits if the drugs are incorrectly used.

… [W]e’ll never get adequate coverage for the entire United States, or even a majority of the nation’s major cities, because it is too expensive to run 24/7 and to test all the samples in a lab. Even with the proposed Gen 3 biowatch detector, which doesn’t exist right now, DHS plans to roughly double its monitors to cover sixty cities. Using point detectors for national special security events makes sense. Biowatch doesn’t.

Radiological Weapons

Radiological terrorism gets people excited because, even though the nature of radiological hazards hasn’t changed in more than six decades, there’s something about radiation that spooks us. The term “dirty bombs” has a sinister sound. But of all the terrorist CBRN hazards, radiological devices (RDD) are certainly not WMD. We have never had an RDD incident to date, and yet so many people like to worry about the loose or available radiological isotopes that could be grabbed up by terrorists.

I’m very critical about the approach to addressing radiological terrorism. It’s no surprise that the easiest way to reduce our risk in this area is to secure all the radiological material that industry uses and to place it in one location that could be guarded. Instead, because of NIMBY politics, the decision was made to close down a $9 billion nuclear material repository and to maintain the status quo of storing nuclear material in “temporary” storage near more than 120 nuclear facilities across the nation.

The Nuke Threat

[L]et’s look at the real 800-pound gorilla in the room. Some people fear that al Qaeda is going to somehow obtain a nuke from Pakistan, disable the safety mechanisms, and transport it to a U.S. city. Some fear that al Qaeda will build a crude nuclear bomb, using technical expertise and material through the global economy. The scenario of a 10-kiloton nuclear blast is what causes people to “lose sleep,” allegedly. And yet, if you examine the facts, it’s not likely at all that this is a credible scenario.

[N]ations with nuclear technology or materials need to consider whether the bomb will be traced back to them, and where the bomb might be used. It might not be in the United States, it might be in a neighboring country.

The number of people who would need to be engaged to get/build a bomb and move it to the United States, let alone engineer a successful detonation, would make this a complex operation that would be visible to law enforcement and the intelligence community.

We have no compelling evidence that any nation has provided a terrorist group with chemical or biological weapons – why on earth would they provide a terrorist group with nuclear weapons? It doesn’t make sense.

The “high-altitude EMP blast” scenario is particularly outlandish, suggesting that a terrorist organization would be able to move a ballistic missile to the coast of the United States and set off a megaton nuke 200 miles over the country just to collapse the electronic infrastructure and turn America into a pre-industrial society. There are better odds that an asteroid the size of Texas might collide with a major city within the United States.

Bottom line, we’re already petrified that al Qaeda is going to nuke America, even lacking any evidence that it has one or could get a nuclear weapon. So why does al Qaeda need a nuclear bomb? It already has accomplished its purpose of terrifying the country. And yet, we see the unfolding of this massive “Global Nuclear Detection Architecture” that’s designed to ensure our politicians can sleep well at night. We could cite the statistics – the hundreds of ports, the thousands of miles of border, the “second line of defense” – and ask is this the most effective way to address the challenge of a terrorist rad/nuke incident?

The scope of the global architecture keeps growing. In addition to the major air and sea ports and border crossings, the DHS Domestic Nuclear Detection Office has proposed going after all the smaller air and sea ports that cater to private vessels. And then there’s the idea of populating the major cities and interstate roads between cities with radiological monitors. Is this a sustainable plan? Is it really effective, considering the limits of radiological detection technology? I would argue, no. The false alarms and cost of maintaining such a nation-wide system are prohibitive, considering the very low probability of occurrence and other options available to the national security community.

But what if?

Let’s assume that, worst case, a nuclear bomb is smuggled into a major U.S. city. Let’s not pick New York City, that’s been debated enough. But say a nuke goes off in Atlanta or Chicago or Seattle. Let’s assume that the terrorists had a functional bomb that yielded a 10-kiloton blast, not a crude device that resulted in a 1-2 kiloton fissile. Certainly thousands of Americans would die and a city would be irrevocably damaged. But would the United States stop, falter, collapse as a nation? No. A single nuclear terrorist event is not an existential threat to such a massive country. It can be managed, and given all the effort already in place to prevent such an incident, it’s not what ought to be keeping us up at night.

If the current US approach to CBRN homeland security policy is wrong, what should we be doing instead?

[We] need serious reviews of the policies that are in place and to use [a] … “risk-based” management approach to ensure that we are spending our funds wisely.

We continue to view WMD or CBRN hazards as the threat – that’s a myopic focus. We need to look at the process by which terrorists develop their tools and understand that it is by defeating the terrorists that we can stop the CBRN threat. When you take a realistic look at the threat and what terrorists can actually do – outside of a television show like 24 – it’s not a difficult thing. We can do this more smartly.

[We] need to [stop] the loose use of the term “WMD.” It only confuses the discussion and presents an unachievable goal that obstructs serious discussion.

We need to clearly separate the concepts of how militaries defend against NBC weapons and how emergency responders address terrorist CBRN hazards.

We should not act as if a terrorist group has the capability to do as much damage as a nation with an active WMD program.

The Homeland Security Planning Scenarios have to be changed to reflect realistic and probable threats, not “worse-case” scenarios. By using the scenarios as the basis for national-level exercises, we risk the danger of overestimating the actual need for unique and specialized resources that may never be employed within our lifetimes.

We should not lose sight of the fact that the majority of incidents requiring federal response to state and local emergency responders will be for natural disasters and industrial accidents rather than WMD.

It actually is a question of “if, not when” we ever see a CBRN terrorist incident that results in mass casualties. We need a sustainable, effective approach, which requires us to stop overhyping the threat. It’s not September 12, 2001, anymore. We need to realistically assess the challenge and all possible threats – natural and man-made – and calmly, rationally, develop a plan that doesn’t bankrupt the annual operating budget.

None of us have enough money to provide perfect protection for everyone throughout the year, and there are better things to spend money on….

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The complete article, Homeland Insecurity: Thinking About CBRN Terrorism, is available at this link.

Today’s guest columnist is Dr. Gloria N. Eldridge, a health and security policy analyst in the Washington, D.C. area, who offers her thoughts on the nexus between health care reform and national security.

We have all been bombarded since the 2008 elections with politicians or pundits projecting what national health reform proposals or the actual bill will mean in terms of our family member’s visits to the doctor’s office, the money coming out of our pockets for health care expenses, or our choice of health insurance carrier in the future. What about connecting the dots between policy sectors and considering what the measure means for national security and our preparedness for a homeland security event?

The twin bills of national health reform, The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) and the Health Care and Education Reconciliation Act (HCERA, P.L. 111-152) of 2010 bolstered national security.  The United States is better prepared for a homeland security event, such as a terrorist attack or a natural disaster, after national health reform than before.  For one, every American will have insurance coverage in case they require health services after an event.  Second, Medicaid eligibility is rationalized with all individuals with incomes below 133% of the federal poverty level (FPL) eligible for coverage.  Previously, Medicaid’s cobbled eligibility standards left most poor single adults and others uninsured and state officials scrambling to negotiate federal financing for the uninsured’s health services costs after an event.  Sixteen million uninsured, a half of those newly covered under the 2010 measure, are scheduled to receive coverage under the new Medicaid rules.  Third, national, state, and local officials will not have to build and negotiate institutional frameworks in the wake of an event.  Instead, these institutional frameworks will be in place ahead of time.  The politics of building institutions can, therefore, be removed from our response.

September 11, 2001, Terrorist Attacks in New York City

Consider the events following the September 11, 2001 terrorist attacks.  New York City’s (NYC) Medicaid computer systems were damaged during the attacks, and state and city officials had to negotiate with the federal government regarding financing the health care of the uninsured.  The Medicaid program, a program financed by both federal and state dollars, became an instrument of the homeland security state.  A temporary public health insurance program called Disaster Relief Medicaid (DRM) was created, and nearly 350,000 New Yorkers – including many who were uninsured — enrolled within four-months after the attacks (Kaiser 2002).  In designing DRM, the requirements of a planned Medicaid waiver initiative called Family Health Plus, scheduled for implementation in the fall of 2011, were used.  Medicaid maintains federal minimum requirements for state governments but states retain the ability to “waiver” federal requirements through petitions.  For DRM, the usual NYC eligibility levels for parents were expanded from 87 percent to 133 percent and for single adults and childless couples from 50 percent to 100 percent of the FPL (Kaiser 2002).  Pre-reform Medicaid required an assets and resources test in order for individuals to be eligible, while the DRM did not.  DRM also implemented minimal documentation requirements, brief interviews, and the ability to use services right away (Kaiser 2002).

August 29, 2005, Hurricane Katrina hits The Gulf Coast

In the days following the Katrina disaster, Congressional action was proposed in the Emergency Health Care Relief Act of 2005 (S.1716), introduced by Senate Finance Chairman Chuck Grassley of Iowa and Ranking Member Max Baucus (D – MT) on September 14, 2005. The proposed legislation provided for temporary federally funded Medicaid coverage to low-income individuals affected by the hurricane.  It also planned to provide $800 million for uncompensated care provided to the uninsured hurricane victims (Lambrew and Shalala 2006).  This approach, however, was not supported by the G.W. Bush Administration.  Instead, Medicaid financing, through the waiver process, provided financing of health needs of many evacuees across state lines, as the hurricane created a Diaspora of more than a million evacuees to every state in the nation (Lambrew and Shalala 2006).

As Diane Rowland testified before the Subcommittee on Oversight and Investigations, U.S. House Committee on Energy and Commerce, “Under these waivers, states could provide up to five months of Medicaid or SCHIP coverage to eligible groups of survivors and could also create an uncompensated care pool to reimburse providers for uncompensated care costs.  The waivers did not allow states to expand coverage for adults without dependent children, regardless of income, and did not include any funding to support the temporary coverage or uncompensated care pools. Federal funding did not become available until the Congress authorized $2 billion for the Medicaid coverage and uncompensated care pools nearly six months after the storm through the Deficit Reduction Act of 2005” (Rowland 2007).

Discussion and Conclusions

Although members of Congress, and the American public, may not have thought of national health reform as a national security issue, it does prepare us for a national event – whether a natural disaster or terrorist threat.  Now that the 2010 national health reform is passed, all Americans will have health insurance if they require it after a major event.  In fact, the legislation requires all Americans to have health insurance.  State health insurance exchanges are being developed to assist with access to coverage.  Also, Medicaid is more rational with all Americans under 133% of poverty covered by the program.  This establishes financing guidelines between the federal and state governments, and it makes very clear the individuals who will receive that coverage ahead of time.  The health financing institutions developed during national health reform — whether the new health insurance exchanges or rationalized Medicaid eligibility – are in place.  The country will not have to negotiate these policy institutions shotgun.  This removes the political calculus that comes with developing health financing institutions from our post-event agenda.  We can focus on our nation’s security and our people’s health without the bipartisan wrangling that accompanies the creation of new institutional structures.

References

The Kaiser Commission on Medicaid and the Uninsured and United Hospital Fund.   “New York’s Disaster Relief Medicaid: Insights and Implications for Covering Low-Income People,” August 2002.

Lambrew, Jeanne M. and Donna E. Shalala.  “Federal Health Policy Response to Hurricane Katrina: What It Was and What It Could Have Been,” JAMA 296, no. 11: 1394 – 1397, September 20, 2006.

Rowland, Diane.  “Health Care In New Orleans: Before and After Katrina,” Testimony before the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, United States House of Representatives, March 13, 2007.

Today’s edition of Nature includes a report worth the attention of anyone engaged in risk strategy.  According to the authors,

Our study found that vast areas across both the developed and developing world arrive at similarly acute levels of imposed threat to their freshwater resources. Sources of degradation in many of the developing world’s most threatened rivers bear striking similarities to those of rivers in similar condition in wealthy countries. However, the highly engineered solutions practiced traditionally by industrialized nations, which emphasize treatment of the symptoms rather than protection of resources, often prove too costly for poorer nations.

Reliance of wealthy nations on costly technological remedies to overcome their water problems and deliver water services does little to abate the underlying threats, producing a false sense of security in industrialized nations and perilous water insecurity in the developing world. In addition, lack of comparable investments to conserve biodiversity, regardless of national wealth, help to explain accelerating declines in freshwater species.

More at the Guardian

More at http://riverthreat.net/

More at Nature (subscription required)

In responding to catastrophe – an 8.0 and above earthquake, a thousand year flood, a cascading  biological contagion, etc.  –  right after providing potable water is the problem of food distribution.  In some of Lee Clarke’s worst case scenarios there is a more basic problem of maintaining food production.

This week both of Australia’s leading political parties added food security to their list of policy priorities for the current national election. One member of the Australian Senate writes, “The world has embarked on a dangerous era of food insecurity and imperialism which will fuel conflict and famine if it is ignored. Australia is not immune. Land and water should be treated as strategic resources by us as they are by many in the world.”

The Department of Homeland Security explains that  Homeland Security Presidential Directive 9, “establishes a national policy to defend the agriculture and food system against terrorist attacks, major disasters, and other emergencies. America’s agriculture and food system is an extensive, open, interconnected, diverse, and complex structure providing potential targets for terrorist attacks. U.S. agriculture and food systems are vulnerable to disease, pest, or poisonous agents that occur naturally, are unintentionally introduced, or are intentionally delivered by acts of terrorism.”

Given the obvious importance of food, are there vulnerabilities in the current food system worth particular attention?  Well, as a possibility, help me refine this hypothesis: Economies of scale suppress risk resilience.  

The food system is one context where this hypothesis might be tested. Over the last half century increasing scale and specialization of production and processing have significantly reduced the consumers cost of food as a proportion of overall income.  The source of this savings has, however, also substantially reduced the number, diversity, and  distribution of producers and processors. This narrows the ability of the food system to bounce back from a catastrophic event. 

If this is true for the food system might it also be the case for other supply chains?

I am the son and grandson of grocers.  I grew up working on the farms of downstate Illinois.  In my lifetime I have seen the food system move from what now seems simple, to complicated, to a sort of complexity and – if a catastrophe would occur – to potentially teetering on the edge of chaos.

Some of my earliest memories are of farmers backing their trucks up to grandpa’s slaughterhouse.   The hogs and cattle — rarely some sheep — were off-loaded into the two dozen wooden stalls attached to the white cinder-block slaughterhouse.

Monday through Saturday nearly everyone listened to the Dick Herm Report on WBYS radio (We Bore You Stiff, the older kids called it).   With the bark of an auctioneer Herm would give the regional and Chicago prices for agricultural commodities. Grandpa paid a few cents less per pound than the Peoria market. For some bigger producers it made financial sense to get more per pound by trucking their livestock to Peoria or beyond. But for others, given the cost of time and gasoline, one of several nearby receiving yards or processing plants did fine.  For most farmers livestock was only one of several products.  When I chored with my friend Jeff we would slop the hogs, feed the chickens, hay the beef cattle, weed the beans, and give the dairy cows grain to eat while we milked them.

My dad’s grocery stores bought dressed hogs from my grandpa’s (and other’s) slaughterhouse.  At each grocery store a butcher would saw the carcass into various cuts of pork and grind the sausage. 

Cause and effect was knowable even by a six year-old.  The livestock were born, raised, slaughtered, packaged, sold, and eaten all within several miles of each other. I knew the farmer, processor, butcher, and buyer. The production, processing, and distribution nodes of the food system — at least in downstate Illinois — were thick and overlapping.  The supply chain was densely redundant, complicated and in some ways complex.

Above, the Cynefin Framework

Today pork production — and most agricultural production – is much more highly concentrated.  In 1969, according to the US Department of Agriculture, 644,882 farms raised 89,296,278 swine.  By 1992 186,627 production operations sold 109,775,439 pigs and hogs.  That’s a shift of 138 head per farm to 588 per farm.  In 2002 the number of production sites had fallen by more than half to 78,895.  In 2002 over half of all swine were raised on “farms” with over 5000 head each.

The geographic range of pork production has also narrowed.  Take out Northern Iowa and Eastern North Carolina and very few of us will have ham for Christmas or even a ham sandwich for lunch.  Pork processing is even more concentrated than production.   Many food products have experienced similar consolidation and concentration.

Today, compared to my early days, the supply chain for food is much more streamlined, specialized, and price efficient.  In 2004 a hog producer with 1000 head spent about $40 per hundredweight.  The same year raising a hog farrow-to-finish cost the producer with fewer than 100 head almost $80 per hundredweight. (See Hogs Lead Way in Transformation)  In 1969 the retail cost of pork chops was about $1.39 per pound.  This week many stores are selling assorted pork chops at $2.49 per pound. At least one regional chain is advertising a “Big Sale” with pork chops at $1.99 per pound. Given forty-one years of inflation that is an extraordinary bargain.

Economies of scale in production, processing, and distribution have contributed to price containment of pork and other foodstuffs.  This is a real benefit.  Is there a cost?

I just came back from several days visiting my parents. Most of the 400 acre  family farms that I knew as a kid have been consolidated.  Except for acreage owned by the Amish and a few small organic operations, corn, soybeans and cattle are what you see again and again stretching over the horizon (and there are long horizons in central Illinois).

Dad has sold his grocery stores and grandpa’s slaughterhouse closed twenty years ago. When I asked the local market’s meat manager (no longer a butcher) about where his meat comes from he laughed and said, “Off the truck, before that who knows.”  Because the supply chain originates far away and draws on unknown sources there is an impression of complexity.   And across these attenuated supply chains there are complex characteristics: lots of filters, need for pattern recognition, and some aspects of adaptive response.

But is the food system “complex” as defined by the Cynefin framework?  The crowd sourcing of many more independent producers and processors has been reduced and standardized.  Open markets have been replaced with much more predictable production contracts.  The entire system has been reengineered and squeezed to maximize every penny-per-pound.  In some ways, with fewer participants and fewer relationships the food system is actually much simpler than four or five decades ago.

Toward the end of his brief video overview of the Cynefin framework David Snowden warns, “The boundary between simple and chaotic is different from the other boundaries…  If you start to believe that things are  simple — you start to believe that they’re ordered, you start to believe in your own myths, you start to believe that past success means you are invulnerable to future failure — you effectively move to the complacent zone which is the boundary between simple and chaotic and you fall over the edge in a crisis… and recovery is very, very expensive.”

Have economies of scale so simplified the food system that we can now sense it on the very edge of chaos?

(Editorial Note:  Last week John Comiskey encouraged me to apply Cynefin and/or Tara to a prospective problem.  He suggested a cyber threat.  I decided to focus on a network — the food system — that I understand better than I understand most cyber networks.  But it seems to me these issues of consolidation, centralization, simplification, and such might have analogies to the cyber domain.  For now, though, that is only a hypothesis.)

In 2005, Stewart Baker joined the Department of Homeland Security as Assistant Secretary of Policy for the entire Department of Homeland Security under Secretary Michael Chertoff. The position, which evolved from the Assistant Secretary for Border and Transportation Security Policy and Planning position, has the following responsibilities, according to the DHS website:

• Leads coordination of Department-wide policies, programs, and planning, which will ensure consistency and integration of missions throughout the entire Department.

• Provides a central office to develop and communicate policies across multiple components of the homeland security network and strengthens the Department’s ability to maintain policy and operational readiness needed to protect the homeland.

• Provides the foundation and direction for Department-wide strategic planning and budget priorities.

• Bridges multiple headquarters’ components and operating agencies to improve communication among departmental entities, eliminate duplication of effort, and translate policies into timely action.

• Creates a single point of contact for internal and external stakeholders that will allow for streamlined policy management across the Department.

Baker would hold the position for the next four years, tackling a variety of issues from border and travel to cybersecurity and the Committee on Foreign Investment in the United States (CFIUS) to bioterrorism.  In his upcoming book, Skating on Stilts: Why We Aren’t Stopping Tomorrow’s Terrorism, Baker offers an intriguing view of our homeland security posture that ties back to the central theme that technology is both our savior and our enemy as it empowers not only us but our foes.  Coming from Baker, who has been described by the Washington Post as “one of the most techno-literate lawyers around,” the analysis of homeland security technology from a policy/legal prism is refreshing.  This is not a Luddite’s view of why technology harms, but an expert’s finely woven story of “how the technologies we love eventually find new ways to kill us, and how to stop them from doing that.”

A subtheme throughout the book is that information sharing, or lack thereof, has hindered our nation’s efforts to fight terrorism, especially when “privacy” has played a role.  In setting up a discussion of what led to his time at DHS, Baker recounts some of the failures leading up to 9/11, including the information sharing wall put up at the Department of Justice between intelligence and law enforcement elements of the agency, as well as challenges at the Foreign Intelligence Surveillance Court. His view is of someone who has spent time in the intelligence world as the General Counsel of the National Security Agency and as General Counsel of the Robb-Silberman Commission investigating intelligence failures before the Iraq War. The account dives into the intricacies of Justice and its overseers, as well as how bureaucracy and personalities can so easily define our government’s most sensitive policies.

The book then looks at his days at DHS and attempts to strengthen border and travel programs and policies for acronym-named programs, including Passenger Name Records (PNR), the Visa Waiver Program (VWP), Electronic System of Travel Authorization (ESTA), Western Hemisphere Travel Initiative (WHTI), and Computer Assisted Passenger Pre-Screening System II (CAPPS II),  among others.  If you have ever doubted Washington’s love of acronyms and initialisms, this read will certainly change your mind.

In evaluating efforts in the aviation space, Baker is critical of a number of groups that he deems to have stood in the way of the Department’s mission during his tenure, including the private sector, European governing bodies, bureaucrats, Congress, and privacy/civil liberties groups, all of whom he argues are all about the status quo and not open to change.  Some of his criticisms are valid while others seem to simplify the views of the various actors.  For example, in dismissing some of the tourism industry’s concerns related to travel policies, he argues that the industry did not want innovation in government security on the border. Having been in the trenches at the U.S. House Homeland Security Committee during many of these debates, I would argue that the balancing of the numerous parties’ interests and concerns was not always that simple or easy to discern, especially when assessing the right security path forward.  Some programs mentioned in the book, such as WHTI, succeeded, in part, because they were implemented once necessary infrastructure had been deployed.

His strongest concerns are reserved for privacy and civil rights advocates and the government policies they either tout or hate.  There is a great deal of skepticism for “hypothetical civil liberties” and “hypothetical privacy concerns,” without evidence of demonstrated abuses by the government. He cites numerous incidents, some of which certainly demonstrate the tension between privacy and security co-existing.  A few of the examples he uses have even been explored here at HLSWatch, including complaints about whole body imaging machines in airports.  See, e.g. The Right to Be Left Alone (October 27, 2009) and “Where are all the white guys?” (November 10, 2009). Reading the book, privacy and civil liberties supporters may find it hard to balance Baker’s call for imagination when tackling homeland security policy and decisionmaking without calling for a similar level of creative thinking when addressing how those policies and decisions will affect privacy and civil liberties.

The book goes on to describe how the Department and Administration tackled (or failed to tackle) cybersecurity and biosecurity and the differences between the approaches. In both sections, privacy and information sharing are undercurrents, though we also see some interesting discussions of such topics as patent protections, self-regulation, and the evolution of security in each of these areas.  The discussions are intriguing and provide both a history and analysis of why we are where we are on those issues.   The cybersecurity and related CFIUS discussion brought back some memories to this self-proclaimed cybergeek, including some of my first interactions with Baker when he was in private practice and I was at the Justice Department.

One last observation: while the focus on the book is obviously on the time that Baker served at the Department under Secretary Chertoff, it leaves much to the imagination of what work Secretary Ridge and his team- from their early days in the White House after 9/11 until the changing of the guard to Secretary Chertoff – undertook and how that may have contributed to some of Secretary Chertoff’s and Baker’s successes, challenges, and mindset.  In addition, despite the focus on privacy and civil liberties, there is little mention of the other DHS offices, including the Privacy, Civil Liberties, and General Counsel’s offices, who may have been engaged in many of the battles noted by Baker. The book is not lacking in detail or intrigue because of these exclusions, though I wonder how they affected the decisions of Baker and his policy team. Perhaps these items are the subject of another book for another time.

Stewart Baker provides insight into a D.C. perspective of homeland security and the struggle of a Department to tackle technology, privacy, and information sharing. The book provides some valuable lessons for those who are on the frontlines of homeland security policy as they attempt to tackle future threats. For an observer of homeland security development, Skating on Stilts: Why We Aren’t Stopping Tomorrow’s Terrorism is a must-read. The book will be released on June 15th and is available for pre-order on Amazon.com.  In the meanwhile, excerpts from the book and other missives from Baker can be found at a blog with the same name, http://www.skatingonstilts.com/.

A zombie is a “re-animated human corpse that feeds on living human flesh.”

Mostly they serve as fodder for popular entertainment.  But an attack by real zombies would be anything but entertaining.

Four Canadian mathematicians who wrote  “When Zombies Attack!: Mathematical Modeling of an Outbreak of Zombie Infection” warn,

“… if zombies arise, we must act quickly and decisively to eradicate them before they eradicate us.”

The scholars — Philip Munz, Ioan Hudea, Joe Imad, and Robert J. Smith — are from  Carlton University and the University of Ottawa.  They developed what is surprisingly “the first mathematical analysis of an outbreak of zombie infection.” The article will be published as Chapter 4 in the soon to be released book  “Infectious Disease Modeling Research Progress.”

While obviously not realistic, their analysis “demonstrates… how modeling can respond to a wide variety of challenges in biology.”

The link between their work and biological attacks, pandemics, and related public health threats to the United States is an obvious one.

Why zombies matter to homeland security

The authors describe their basic model for zombie infection, discuss equilibria and stability issues, and then suggest conditions under which eradication of the zombie infection can occur. Based on their analysis, they conclude “only quick, aggressive attacks can stave off the doomsday scenario: the collapse of society as zombies overtake us all.”

The chapter starts by discussing the origins of zombies in the Afro-Caribbean spiritual belief system of “Vodou.”  But the idea of the zombie dates back at least to the Middle Ages, and has appeared in the cultures of China, Japan, the Pacific, India, Persia, Arabia, and the Americas.

As the reader familiar with the concept may recall, zombies have no will of their own. Their heart and lungs and all their body functions operate at minimal levels, at least according to the traditional view.

Modern zombies are very different from voodoo and folklore zombies. Contemporary zombies are mindless monsters who do not feel pain and who have an immense appetite for flesh.  They have a particular hunger for human brains (as the disturbing video at this link illustrates).

A zombie’s objective is to kill, eat or infect people. When a susceptible person is bitten by a zombie, it leaves an open wound contaminated by saliva, thus infecting the susceptible individual.

Informed speculation suggests the saliva disrupts oxygen flow to the brain.  The lack of oxygen seems to be the specific mechanism that turns otherwise normal people into zombies.

Consequently in the few cases of zombie-ism that have been adjudicated by courts, authorities have concluded that because the zombies suffer from brain damage, they cannot be held accountable for the havoc they cause.

This clearly has hampered — but not eliminated — the search for effective prevention and mitigation strategies.  Here is where the Canadian team makes its, probably inadvertent, but still foundational contribution to Homeland Security

Summary of the argument

In Section 2 of their paper, the authors outline the basic model describing how — like a deadly virus — zombies grow and increase (please see Figure 1, where S are those who are susceptible to attack, Z are the zombies, and R are those who have been “removed” but who can return to the arena after an encounter with Z). The authors correctly note their model is “slightly more complicated than the basic SIR [susceptible, infected, and removed] models that usually characterize infectious diseases.”

The authors discouragingly find that from the perspective of their basic model, “In a short outbreak, zombies will likely infect everyone.”

The remainder of the article discusses strategies available for dealing with a zombie attack:

• Section 3 (The basic model, with time latency),
• Section 4 (The model, plus quarantine),
• Section 5 (The model incorporating a cure for zombie-ism), and
• Section 6 (Rapid and aggressively escalated destruction of zombies)

The interested reader can view the full analysis of each variation by downloading the original paper here.  I found the math to be slightly impenetrable (see the figure below for an example). But the authors’ conclusions are starkly clear:

“An outbreak of zombies infecting humans is likely to be disastrous, unless extremely aggressive tactics are employed against the undead. While aggressive quarantine may eradicate the infection, this is unlikely to happen in practice. A cure would only result in some humans surviving the outbreak, although they will still coexist with zombies. Only sufficiently frequent attacks, with increasing force, will result in eradication, assuming the available resources can be mustered in time.”

The authors acknowledge the key difference between their model and traditional views of infectious disease is in their model “the dead can come back to life.”

They admit their scenario is unrealistic if taken literally, “but possible real-life applications [of their model] may include allegiance to political parties,… diseases with a dormant infection,” and — one might add — a zombie-like commitment to certain beliefs, attitudes, policies, and organizational arrangements.

The article ends by summarizing the strategic implications of the analysis:

“A zombie outbreak is likely to lead to the collapse of civilization, unless it is dealt with quickly. While aggressive quarantine may contain the epidemic, or a cure may lead to coexistence of humans and zombies, the most affective way to contain the rise of the undead is to hit hard and hit often. As seen in the movies, it is imperative that zombies are dealt with quickly, or else we are all in a great deal of trouble.”

On Friday, the Department of Justice ended its  investigation of the 2001 Anthrax attack, which killed five, sickened 17, disrupted postal service, and caused the evacuation of a Senate building.  In order to bring closure to what has been a much-questioned and controversial investigation, the Department issued an investigative summary, along with tons of additional documents, some requested by FOIA requests.  The nearly 3000 pages of documents can be found at: http://www.justice.gov/opa/pr/2010/February/10-nsd-166.html.

According to a press release issued by the Department:

The Amerithrax Task Force, which was comprised of roughly 25 to 30 full-time investigators from the FBI, U.S. Postal Inspection Service and other law enforcement agencies, as well as federal prosecutors from the District of Columbia and the Justice Department’s Counterterrorism Section, expended hundreds of thousands of investigator work hours on this case. Their investigative efforts involved more than 10,000 witness interviews on six different continents, the execution of 80 searches and the recovery of more than 6,000 items of potential evidence during the course of the investigation. The case involved the issuance of more than 5,750 grand jury subpoenas and the collection of 5,730 environmental samples from 60 site locations.

The conclusion of the report:  Dr. Bruce E. Ivins at the United States Army Medical Research Institute of Infectious Diseases (“USAMRIID”) was the lone individual responsible for creating and mailing the “RMR-1029″ anthrax-infected letters.  Ivins committed suicide in July 2008.

The report includes two sections describing an early suspect, Dr. Steven Hatfill, who “became widely known in August 2002 as a person of investigative interest.”  The report spends a page and a half explaining why Hatfill was an early suspect and how he was eliminated through scientific breakthroughs.  The report contains no mention of the  apology and $5.8 million settlement Hatfill received from the government for being wrongly exposed as a suspect.

The report lays out what would have been the government’s case against Ivins if he had lived.  First, it discusses “opportunity, access, and ability,” noting that:

• RMR-1029 was the source of the weapon and originated from Ivin’s flask
• Ivins had suspicious lab hours just before the Anthrax was mailed
• Other suspects who could have accessed RMR-1029 have been ruled out

In terms of Motive, the report notes:

• Ivins life’s work appeared destined for failure, absent an unexpected event
• He was increasingly being criticized for his efforts
• He felt abandoned in his personal life

The report then assesses his mental health before proceeding to evidence that revealed that the envelopes used were sold at a post office in Maryland/Virginia and included language that was similar to the writings of Ivins.  The report then said that Ivins acted suspiciously and took many actions that suggested he had a guilty conscious.  It also noted that he had a habit of using false identities and ended with evidence showing the letters had been mailed from Princeton, NJ, across from a sorority for which Ivins had a “long-standing obsession…dating back 40 years.”

Not everyone appears satisified with the report.  Congressman Rush Holt, who has introduced the Anthrax Attacks Investigation Act of 2009, stated that “Arbitrarily closing the case on a Friday afternoon should not mean the end of this investigation,” adding that the “evidence the FBI produced would not, I think, stand up in court.”

Holt has long been a critic of the investigation and his legislation, which had been introduced in previous years, would establish a Congressional commission to investigate the 2001 anthrax attacks and the federal government’s response to and investigation of the attacks.

While it is not clear that the legislation is needed to review a single investigation, especially nine years after the fact, it is clear that the government should have a systematic approach for dealing with a biological attack, whether committed by a sole actor or a terrorist organization.  The report issued by Justice does not explain what has been done on the preparedness and response side to assure that U.S. officials are prepared.  Its release, however, does give the Departments of Homeland Security and Health and Human Services opportunities to highlight their efforts on the biosecurity front.  If those efforts are not enough and more needs to be done, then now is a good as time as ever to start pushing biopreparedness and response.

Yesterday Senators Lieberman and Collins, chairman and ranking member of the Senate Homeland Security and Governmental Affairs Committee, introduced  the Weapons of Mass Destruction Prevention and Preparedness Act of 2009.

Senator Lieberman explained, “Our bill would strengthen security at labs using the most dangerous pathogens, improve our capabilities to assess the threat of terrorists acquiring WMD, ensure that citizens get critical safety information, and develop a means for quickly delivering life-saving drugs to areas that have been attacked.”

According to a joint statement available on the Senate Committee’s website, the legislation would also,

• Require HHS to designate the most dangerous pathogens which have significant potential to be used effectively in a biological attack.
• Require DHS to set new security standards for labs using the most dangerous pathogens, including risk assessments, personnel reliability programs, and staff training.
• Require a national strategy for dispensing antibiotics and other medicines to the public and expand a pilot program for using the Postal Service to dispense them. 
• Require communications plans to convey instructions to the public – including whether to evacuate or shelter-in-place – in the critical moments after an attack.
• Support a National Bioforensics Analysis Center to identify the perpetrator of a WMD attack rapidly. 
• Provide personal medical kits to emergency responders in order to enable them to respond quickly to a WMD attack without jeopardizing their own safety. 
• Require DHS and the Federal Bureau of Investigation to provide better terrorism threat and risk assessments to the public.
• Promote citizen and community preparedness for WMD attacks, including by authorizing grants to States.

The  bill is not yet available via the Thomas website. The Senate Committee’s website  provides a pdf of  the proposed legislation.

In the Washington Post’s Saturday Style section Brigid Schulte brings us a great feature story on the down-and-dirty of catching H1N1.  She packs alot of facts into a  personal context.  Read her story at How, Gulp! You Get Sick.

This week the CDC released child care guidelines.

Friday the Pan American Health Organization released a new regional update on H1N1 infection.

Friday’s Wall Street Journal had a good update on vaccine development: Swine flu remains mild as vaccine advances.

On September 1 there was a White House afternoon meeting focused on H1N1.   It was a gorgeous day in DC.  After the meeting the President offered some comments to the media in the Rose Garden. 

In my judgment his most helpful comments were,

And most importantly we need everyone to get informed about individual risk factors, and we need everyone to take the common-sense steps that we know can make a difference. Stay home if you’re sick. Wash your hands frequently. Cover your sneezes with your sleeve, not your hands. And take all the necessary precautions to stay healthy. I know it sounds simple, but it’s important and it works. Finally, for people who want to learn more about this virus, please go to www.flu.gov, or talk to your doctor.

It is a good example of management discipline that the President brought together his generals:  Napolitano, Brennan, the secretaries of Education, Commerce, Health and Human Services and the CDC Director as the influenza “battle season” begins.  If any other more specific purpose was being advanced, no one is  telling me.

(Politico has a video of the Rose Garden remarks (after an annoying ad).)

(YouTube: Lynne Anderson singing, I Never Promised You a Rose Garden)

“This report is being read very carefully.”  That’s what John Brennan said about the PCAST’s H1N1 study released yesterday morning.  I assume you have already heard or seen the headlines full of worst-case numbers.

You, too, can give the 64-page document a close read. Here it is: Report to the President on US Preparations for 2009-H1N1 Influenza (a bit more than 2 megs).

After reading  I hope you can correct a couple of my key take-aways.  It was late (or actually, early) and I was grumpy while reading, so I probably missed something important. 

First, it is unlikely that a vaccine will be available early enough to be of much help.  And other means of medical mitigation are more case-based than population-based. Here’s a quote from the report,

The fall resurgence may well occur as early as September, with the beginning of the school term, and the peak infection may occur in mid-October. But significant availability of the 2009-H1N1 vaccine is currently projected to begin only in mid-October, with several additional weeks required until vaccinated individuals develop protective immunity. This potential mismatch in timing could significantly diminish the usefulness of vaccination for mitigating the epidemic and could place many at risk of serious disease.

Second, the report’s authors seem conflicted regarding the principal means of non-medical mitigation. Another quick quote:

A key element in mitigating the spread of an epidemic is compliance with social distancing measures—for example, staying home from work or school or avoiding public gatherings such as concerts or sporting events when ill. However, compliance is unlikely when economic or other disincentives punish individuals for these behaviors. It is critical that appropriate Federal officials take the lead in identifying these disincentives and removing or minimizing them. Since immunizing large segments of the popula­tion likely cannot be completed before late November or early December, the use of social mitigation measures may represent the most effective means for reducing transmission of virus in the fall when it is spreading most efficiently.

Actually, that paragraph — by itself — seems stronger because it is taken out of context.  The tone of the whole report left me with a sense that support for aggressive social distancing is squishy. 

The reluctance I read between-the-lines may emerge from the PCAST’s entirely reasonable preference to impose a social distancing strategy only when and where there is clear empirical evidence for doing so. But as the report also notes, a key shortcoming in national preparedness for pandemic,

… is the lack of a rapid system for assembling detailed clinical data on severe cases that can provide a statistically adequate and continuously updated picture of risk groups and clinical course. Current systems rely on non-standardized reports from local health departments and on peer-reviewed case series, which are slow to become public.

Even if the existing disincentives to social distancing can be minimized in the next few weeks — which strikes me as less than likely — we don’t have a surveillance and reporting system sufficient to make fine-tuned strategic interventions.

So… where does that leave us? Interested in your take-aways.

 More background:

Press Secretary’s positioning of the PCAST report

President’s Council of Advisors on Science and Technology

Surveillance and studies during a pandemic (European Centre for Disease Prevention and Control)

Epidemiology of fatal cases associated with H1N1 (Eurosurveillance)

City has closed mind on closing schools (Juan Gonzalez, Daily News)

While written before the PCAST report was publicly available, this Washington Post indepth piece is relevant: Flu strategists see schools on the front line.

An H1N1 vaccine is unlikely to be ready on time — or in sufficient quantity — to have much impact on its spread this fall. 

Tom Randall with Bloomberg reports, “Just 45 million of 195 million doses ordered for the U.S. will be delivered by mid-October, said health officials who lowered their estimates yesterday. The vaccine will probably require two shots given three weeks apart, and the body won’t produce antibodies for two additional weeks, according to an Aug. 7 report by the Department of Health and Human Services.”

“’This has been a virus that’s been smoldering, particularly among children at the many summer camp outbreaks,’ said William Schaffner, of the Vanderbilt University School of Medicine. ‘There’s no doubt it’s coming, and we could see it as early as September. Every pediatrician, internist and public health official is cross-eyed’ with worry, he said.”

Shortfall expected in US swine flu vaccines (AFP)

US tries to counter some delay in swine flu shots (AP)

US government to advise businesses on swine flu (Reuters)

The Erasmus University Medical Center in the Netherlands, in cooperation with Ranj Serious Games, has produced an online game focused on preventing, mitigating, and responding to pandemic.

It’s a great idea reasonably well executed.  If you are on broadband you can access the game at http://www.thegreatflu.com/.  Don’t try unless your connection is solid and speedy.

According to the game-makers website, the goal of the game is “to increase the awareness and the level of knowledge about viruses and the complex way viruses spread and evolve.” 

The Great Flu is fundamentally a strategy game where you deploy assets in anticipation of or in response to emerging events. You decide what and where you should invest and you only have so much budget, so every choice begins to limit future choices.

If you make bad choices the number of infected and dead increase more rapidly.  If you make good choices body-count slows and the spread across the planet can even be stopped.

Here are some of your action options and their cost.  You have a budget of 2 billion Euros at the start of the game.

• Distribute face masks: 7 million Euros
• Improve health care: 20 million Euros
• Close schools: 10 million Euros
• Close markets: 5 million Euros
• Close airports: 250 million Euros
• Isoloate symptomatic individuals: 80 million Euros
• Establish early warning system: 100 million Euros
• Inform civilian:s 5 million Euros
• Improve research facilities: 200 million Euros
• Stockpile vaccine type A: 120 million Euros
• Stockpile vaccine type B: 120 million Euros
• Stockpile antiviral medicine: 100 million Euros

The game is slow to load and is mostly a visually enhanced interactive spreadsheet.  By adjusting variables in one cell you impact other cells.  Anyone who has played around with “dynamic” budgeting knows the basic drill.

The key to winning, if it can be called that,  is timing.  Early investments in research, surveillance, and basic health care will pay big benefits.  The timing of where and when to stockpile vaccines and antivirals can get complicated and expensive.  In this game, you are more likely to lose than win.  And most “wins” still involve lots of disease and death.  So does Grand Theft Auto.  In managing a pandemic, so does the real world.

On Thursday Treale Fristoe, a thoughtful critic of gaming, complained that, “It takes quite a while before the virus even appears, during which time the player can do nothing but wait (or quit, which I expect many players would do).”  This is not precisely true.  Because I know something about pandemic mitigation, I started deploying assets before there were any disease reports.  But there is no way most players will realize this.  Otherwise I agree with Fristoe’s balanced critique of what is good and bad in the game.

Fristoe  hightlights the need for a tutorial.  Even more helpful would be a user-friendly backgrounder.  Most gamers don’t mind losing.  In fact many find losing motivational.  But then they want some clues to doing better.  That would be a great moment to have easily available a user-friendly primer on pandemic preparedness… including washing your hands.

I bet the budget for The Great Flu was under $200,000 and I wouldn’t be surprised if it was designed and delivered in less than nine months (six months?).   The return on investment will be high.  It would have been even higher with a bit more investment.  Just as in fighting a pandemic.

-+-

For the last ten years, until my semi-retirement last June, I was CEO of a small company that developed, among other things,  ”serious games” for corporate, defense, and homeland security clients.  So I am biased, but this approach to public information and public education has enormous potential when it is done right.