Homeland Security Watch

News and analysis of critical issues in homeland security

August 20, 2014

Boston prepares for Ebola

Filed under: Public Health & Medical Care — by Arnold Bogis on August 20, 2014

Here is a good example of a local public health system getting ahead of the potential (just wanted to underline that point) threat of Ebola appearing in U.S. cities.

The Boston Public Health Commission (BPHC) hosted a media briefing Wednesday morning with various leaders of the city’s public health branches to outline the plans for the “very low” likelihood that the deadly Ebola virus disease (EVD) would make it to Massachusetts.

“While the risk to our residents is very low, it is always better to prepare so that we can appropriately identify and care for suspect cases and work with the community to prevent further illness,” said Dr. Barbara Ferrer, executive director of the Boston Public Health Commission (BPHC). “We want a well-coordinated plan in place in the event a case of EVD is found in the city.”

Apparently, this morning’s briefing was not a one off:

This morning’s media briefing in Boston was the first of many public awareness campaign steps city health officials are taking in order to prepare Massachusetts and Boston in the case of an outbreak.

“As a result of years of practice, investment and responding to real emergencies, hospitals in Boston are well equipped and trained to appropriately and safely care for a suspect case of EVD,” said John Erwin, executive director of the Conference of Boston Teaching Hospitals. “To ensure the best possible preparations, however, hospitals will need the support of city, state and federal health officials. That’s why this planning effort is so important.”

While specifically concerning Ebola, this message is about public health threats and even homeland security in general:

“Every successful preparedness campaign requires the support and strong involvement of the community,” said Atyia Martin, director of the BPHC Public Health Preparedness Program. “We will work hard to make sure that residents have the information and resources that they need to stay informed and healthy. That is what this effort is all about.”

As the Boston.com article points out, learn more about the Ebola and the city’s public awareness campaign at bphc.org/ebola.

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.

June 11, 2014

The Atlantic hosts “Going Viral: Keeping Communities Healthy Through Public Health Emergency Preparedness”

Filed under: Public Health & Medical Care — by Arnold Bogis on June 11, 2014

By the time you read this post, you are likely too late to go to this event (sorry…I just learned about it yesterday).  However, there is a live webcast involved and I am hoping for a video to post when it ends. See the end of the following announcement from The Atlantic for video and twitter information.

The program will feature a one-on-one interview with Irwin Redlener, MD, Director of the National Center for Disaster Preparedness at the Earth Institute and Professor of Health Policy & Management and Professor of Pediatrics at Columbia University.  Following the interview, Redlener will join with Eric Toner, MD, Senior Associate at the UPMC Center for Health Security, for a broader conversation on how public and private sectors can support each other to reduce risks, respond to crises, and enable healthier living. GSK is the underwriter of the event.

Media interested in attending the event should contact The Atlantic’s Alexi New (anew@theatlantic.com). For those unable to attend in person, the event will be webcast live via The Atlantic’s Events Channel.  Follow the conversation on Twitter via @Atlantic_LIVE#GoingViral.

AT A GLANCE:
Going Viral: Keeping Communities Healthy Through Public Health Emergency Preparedness

Wednesday, June 11, 2014
8:30 – 10:00 AM (8:00 AM Guest Arrival and Registration)

National Press Club
529 14th Street, NW – 13th Floor
Washington, D.C. 20045

Webcast Link:http://bit.ly/1hyM7iR
Follow the conversation on Twitter:@Atlantic_LIVE#GoingViral

AGENDA

8:30 am Welcome Remarks

  • Emily Akhtarzandi, Managing Director, The Atlantic
  • William Schuyler, Vice President for Government Relations, GSK

8:35 am Interview

  • Irwin Redlener, Director, National Center for Disaster Preparedness, Earth Institute; Professor of Health Policy & Management and Professor of Pediatrics, Columbia University
  • Moderated by: Steve Clemons, Washington Editor-at-Large, The Atlantic

9:00 am Panel Discussion

  • Andrew GarrettDirector, National Disaster Medical System, Office of Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services
  • Irwin Redlener, Director, National Center for Disaster Preparedness, Earth Institute; Professor of Health Policy & Management and Professor of Pediatrics, Columbia University
  • Robin Robinson, Director, Biomedical Advanced Research and Development Authority; Deputy Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services
  • Eric Toner, Senior Associate, UPMC Center for Health Security
  • Moderated by: Steve Clemons, Washington Editor-at-Large, The Atlantic

UPDATE: Video of the event is now available here: http://www.theatlantic.com/live/events/going-viral/2014/

June 4, 2014

Keep your government hands off my Medicare! – unless, maybe, if ASPR wants to help you during a disaster…

Filed under: General Homeland Security,Public Health & Medical Care — by Arnold Bogis on June 4, 2014

The New York Times recently ran an article by Sheri Fink, author of Five Days at Memorial (which is about a New Orleans hospital immediately following Hurricane Katrina), titled “U.S. Mines Personal Health Data to Find the Vulnerable in Emergencies.”

The phone calls were part Big Brother, part benevolent parent. When a rare ice storm threatened New Orleans in January, some residents heard from a city official who had gained access to their private medical information. Kidney dialysis patients were advised to seek early treatment because clinics would be closing. Others who rely on breathing machines at home were told how to find help if the power went out.

Those warnings resulted from vast volumes of government data. For the first time, federal officials scoured Medicare health insurance claims to identify potentially vulnerable people and share their names with local public health authorities for outreach during emergencies and disaster drills.

The article mentions several other similar uses of medical data — from text message reminders about vaccinations to identifying ambulance “frequent fliers” — but I’d like to focus on this use of Medicare data to identify patients that rely on power-reliant medical equipment.

Were privacy concerns addressed?

“There are a lot of sensitivities involved here,” said Kristen Finne, a senior policy analyst at the Department of Health and Human Services. “When we started this idea,” she said, referring to using Medicare data for disaster assistance, “there was a lot of ‘are you crazy?’ ”

Ms. Finne noted that the program was painstakingly designed to comply with privacy laws.

Have they tested it?

Aspects of the Medicare program were tested in New Orleans; in Broome County, N.Y., which includes Binghamton; and in Arizona.

Sounds good, right?  Any concerns?

Others find the program troubling, however well intentioned. “I think it’s invasive to use their information in this way,” said Christy Dunaway, who works on emergency planning for the National Council on Independent Living, which supports disabled people living at home.

She and others said they were worried that identified individuals could be forced to evacuate to shelters that cannot accommodate people with disabilities, or that incomplete data could provide false assurances of government rescue.

On balance I think this is a good use of data held by the federal government (in this case CMS) for preparedness/response that originally was collected for other purposes. It represents a type of flexibility that is often called for in homeland security missions.  An added benefit is a bit of shaking of the obstinate bureaucracy — government agencies are loathe to change or deviate from SOP.  An ingrained belief that “this is the way it’s done/this is the way the law is written/etc.” despite almost constant production of new strategic planning documents.  CMS is especially guilty of this behavior, institutionally worried about earning any sort of new Congressional attention or even wrath.

Here ASPR (the office of the Assistant Secretary for Preparedness and Response in HHS) is not only looking at the granular level of identifying individuals who Medicare has paid for certain medical equipment that is especially vulnerable in the aftermath of disaster, but providing tools to local agencies to help in the development of general response plans:

The Department of Health and Human Services also plans to release an interactive online map this year indicating how many Medicare beneficiaries have wheelchairs and other medical equipment in various ZIP codes, in part to help health officials think about where to place shelters, stockpile supplies, and inform hospitals and power companies about potential needs.

“Even that information is light-years ahead of what they have currently,” Ms. Finne said.

This article brings up two related, if not obvious, issues regarding ASPR.  First, the office is getting slightly better at advertising if not explaining their work.  In my view ASPR has been dismal in both regards over the last couple of years.  It plays a central role in domestic preparedness and response (while beginning to work in recovery and talk a lot about resilience while waving their collective hands…), with a direct focus on perhaps the most important mission of the health of people following a disaster. Yet institutionally it has a difficult time communicating its work outside of the medical and public health communities.  There is a bias towards publishing in peer reviewed journals rather than reaching out via alternative venues to a range of potential stakeholders. Essentially doctors writing for other doctors.

Fink’s article is both a good example of simultaneously trying to get out of this practice, albeit with a reporter naturally inclined toward reporting on such a topic, while at the same time hewing close to their established SOP.  The initial exercise took place in New Orleans a year ago.  As Fink mentions, they published a description of the underlying method in the Federal Register…last April. While I might understand a desire to cement the program in place and test it in various locations before rolling it out to the public, it wasn’t a secret.  At least not to the local New Orleans press who reported on the exercise a year ago:

On Friday, the city and the U.S. Department of Health and Human Services embarked on a new pilot project — the first of its kind in the country — to take a more systematic approach to identifying people with medical needs and helping them during disasters.

During the three-day “emergency preparedness exercise,” focused on New Orleanians with at-home oxygen tanks or ventilators, the two agencies are looked at whether federal Medicare data can be used to track down people on electricity-dependent machines after the power goes out.

If the New Orleans exercise is successful, the model can be rolled out across the country, said Dr. Nicole Lurie, an assistant secretary with the federal health agency.

The exercise was successful.  A year ago.  It has been rolled out.  To state and local public health officials.

The program was presented to state and local public health officials last month. “We are now moving to scale this really across the country,” said Dr. Nicole Lurie, the assistant health secretary for preparedness and response.

“Last month” was literally last month.  A year after the successful exercise in New Orleans.  I suppose slow and steady wins the race?  Just not the race for implementing government innovation or altering ingrained SOPs.

The second issue is an unfortunate characterization of local responsibilities and/or capabilities.  In the Fink article, THE ASPR, Dr. Lurie, is quoted:

The idea for the program began in Tuscaloosa, Ala., after a tornado struck in April 2011. An ambulance rolled up to one of the houses left standing to take a woman to the hospital because she had run out of oxygen. “That’s kind of crazy, why can’t somebody bring her an oxygen tank?” Dr. Lurie recalled thinking after watching the scene.

She witnessed a similar phenomenon in New York after Hurricane Sandy. Patients who relied on medical equipment needed a place to plug it in before draining the batteries. Many crowded into emergency rooms, stressing the health care system. Others had no way to call for help. Eventually, emergency teams knocked on every door of darkened high-rises, because officials did not know where the people who needed assistance were.

“All of these people just came out of the woodwork,” Dr. Lurie said one public health official told her after a disaster in New England.

“I started to seethe,” Dr. Lurie said. “It’s your job to know who lives in your community.” And if local officials did not, she added, it was the federal government’s responsibility to help.

All good until the point she “started to seethe.” Exactly how should local public health officials know “who lives in your community?” What mechanism exists to make that possible? What information do they have access to that makes it possible? Under what circumstances, when state and local budgets have long been under stress and the federal agencies – such as the one Dr. Lurie works for – helpfully suggests new requirements and capabilities while cutting funding at the same time?

I’m not arguing against the concept of having situational awareness at the local level.  Just that outside of  programs involving voluntary self-identification from at-risk groups, what are local officials not doing that cause her to “seethe.” What programs, if she worked at the local or state level, would she implement to do her job to know who lives in her community? What money and manpower would she take away from other programs to accomplish these goals?

A federal program such as Medicare presents unique opportunities for the type of data mining accomplished on at-risk communities described by Fink.  I think it is time and money well spent.  However, federal officials should refrain from seething at the limitations faced by state and local officials. These days they aren’t exactly helping matters.

April 22, 2014

“If a foreign nation were doing this to our children, we would defend our families.”

Filed under: Public Health & Medical Care — by Christopher Bellavita on April 22, 2014

“One of the great public health epidemics of our time.”

“The epidemic here is worse than was previously estimated. Much worse.”

“Over 95% of all Americans will be overweight or obese in two decades.”

“The government is subsidizing the obesity epidemic”

“By 2050, one out of every three americans will have diabetes.”

“There are 600,000 food items in America. Eighty percent of them have added sugar.”

“Junk food companies are acting very much like tobacco companies did thirty years ago.”

“Ronald McDonald never sells to children. He informs and inspires through magic and fun.”

“This is the first generation of American children expected to lead shorter lives than their parents.”

“If a foreign nation were doing [this] to our children, we would defend our families.”

————————————————————————

All the quotes come from a trailer for the muckraking homeland security movie called Fed Up (thanks, Dan).

More about Fed Up in a moment, but I call it a homeland security movie because if the claims about the epidemic are accurate, here is another issue affecting the safety and security of the nation that is not within the DHS portfolio: i.e., a generation of children whose life expectancy may be shorter than their parents.

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Theodore Roosevelt gets credit for originating the term muckraker.

In April 1906, he said “The men with the muck rakes are often indispensable to the well being of society….” 

He went on to say they shouldn’t be raking muck all the time, but in the same speech he noted,

There are, in the body politic, economic and social, many and grave evils, and there is urgent necessity for the sternest war upon them. There should be relentless exposure of and attack upon every evil man whether politician or business man, every evil practice, whether in politics, in business, or in social life. I hail as a benefactor every writer or speaker, every man who, on the platform, or in book, magazine, or newspaper, with merciless severity makes such attack, provided always that he in his turn remembers that the attack is of use only if it is absolutely truthful.

————————————————————————

Switch over now to the food you and your family eat. How’s that going? Do you understand what foods help you and your family stay healthy? What foods don’t? Do you even pay attention to food? Where do you get your knowledge about nutrition?

Enter the muckrakers to give us what may not be an objective set of answers to those questions, but they do claim to be accurate.

The film “Fed Up” is scheduled to open in theaters on May 9th. It was produced by Katie Couric and Laurie David. David also produced “An Inconvenient Truth,” a film not exactly without controversy or complaints about skewing data to make a point. (See, for example, Section V in Richard A. Muller’s Physics for Future Presidents , or this Washington Post fact check article: http://voices.washingtonpost.com/fact-checker/2007/10/an_inconvenient_truth_for_al_g_1.html).

I can’t imagine going to a theater to watch a video about the food industry. But I guess people actually do that.

As one person who watched the Fed Up trailer below commented,

“I swear to god, there’s going to be people watching this movie in the theaters with a large soda and popcorn with extra butter….”

 

April 9, 2014

Boston Marathon Bombing Roundup

With the Boston Marathon quickly approaching, along with the one year anniversary of the Marathon bombing, you can imagine there has been a surge of related events and releases.

Here are some of the more informative, in case you missed them.

Today, the House Committee on Homeland Security held a hearing “The Boston Marathon Bombings, One Year On: A Look Back to Look Forward.” It mostly focused on the law enforcement-related decisions, and served as a podium to denounce the Administration’s stated plans to consolidate homeland security grants into one block grant to states.  However, it also contained interesting questions and answers/testimony on the current and future state of NIMS in disaster response.

The Committee’s page for this hearing can be found here: http://homeland.house.gov/hearing/hearingthe-boston-marathon-bombings-one-year-look-back-look-forward

A better quality video can be found here (apologies, but I couldn’t find one I could post on this blog): http://www.c-span.org/video/?318765-1/boston-marathon-bombings-anniversary-review

The Witness list with links to written statements:

Witnesses

Mr. Edward F. Davis, III

Former Commissioner, Boston Police Department and Fellow

John F. Kennedy School of Government

Harvard University

Witness Statement [PDF]

 

Mr. Edward P. Deveau

Chief of Police

Watertown Police Department

Witness Statement [PDF]

 

Mr. Jeffrey J. Pugliese

Sergeant

Watertown Police Department

Witness Statement [PDF]

 

Prof. Herman “Dutch” B. Leonard

Professor of Public Management

John F. Kennedy School of Government

Harvard University

Witness Statement [PDF]

Witness Truth in Testimony [PDF]
Two of those testifying, Dutch Leonard and Edward Davis, participated in the development of the report, “Why Was Boston Strong, Lessons from the Boston Marathon Bombing.” Among it’s conclusions:

 The report highlights a number of factors that contributed to a largely successful response and emphasizes what, exactly, made Boston Strong and resilient in the face of tragedy. It also provides a set of recommendations for jurisdictions to consider going forward. Among other findings, the authors urge responders:

•    To quickly establish a cross-agency, senior strategic and policy-making level of engagement and secure command post — with dedicated space for strategic, tactical and logistical teams — that looks to both the big picture and a longer timeframe.

•    To provide responders and political leaders with more training and experience in the doctrine of incident command in complex circumstances through exercises and utilization of regular “fixed events” to develop skills.

•    To develop a more effective process to manage the inevitable self-deployment of responders who in response to crisis arrive as independent individuals rather than in organized units.

•    To critically review current training and practice on control of weapons fire, which may call for new paradigms.

•    To design and routinely establish a staffing schedule for all levels of personnel ensuring rotation and rest that are essential to sustained performance when critical events last for days.

•    To consider a legislative change to the HIPAA regulations regarding release of information to family members about the health status of patients critically injured in an attack, in order to provide them the best care possible and to cater to their wide range of needs.

The National Preparedness Leadership Initiative, a joint Harvard Kennedy School and Public Health School venture, just released their preliminary findings on “Crisis Meta-Leadership Lessons From the Boston Marathon Bombings Response: The Ingenuity of Swarm Intelligence.” What’s it about?

The Boston Marathon Bombings required leaders of many agencies – scattered over numerous jurisdictions and with different authorities and priorities – to rapidly respond together to an unknown and complex set of risks, decisions and actions. This report analyzes their leadership through the event. It seeks to understand how they were able to effectively lead an operation with remarkable results. These outcomes are measured in lives saved, suspects quickly captured, public confidence maintained and population resilience fostered. These leaders were observed to exhibit “Swarm Intelligence,” a phenomenon in which no one is in charge and yet, with all following the same principles and rules, leaders are able to accomplish more together than any one leader could have achieved separately. These rules include: 1) unity of mission that coalesces all stakeholders; 2) generosity of spirit; 3) deference for the responsibility and authority of others; 4) refraining from grabbing credit or hurling blame; 5) a foundation of respectful and experienced relationships that garner mutual trust and confidence. That confidence, both personal and systemic, bolstered these leaders individually and as a coordinated force over the 102 hours between the attacks and the conclusion of the incident. They handled difficult decisions in the face of credible risks: Whether to keep public transit open? Whether to release blurry pictures of the suspects? The study found that over the course of the week, they learned how to lead and lead better, so that by the time they reached the chaotic conclusion of the event, they acted as a coordinated and unified cadre of crisis leaders.

Finally, 60 Minutes aired a segment several weeks ago about the decisions made behind the scenes during the manhunt for the Boston Marathon bombers.

April 8, 2014

How the quest for short-term efficiency creates vulnerabilities in public health and medical service; and what to do about it.

Filed under: Public Health & Medical Care — by Christopher Bellavita on April 8, 2014

Today’s post was written by Jeff Kaliner.  Kaliner works in health security and preparedness at a state health department. He holds a Master of Arts degree in Security Studies from the Naval Postgraduate School as well as a Master of Science degree in Education from Northern Illinois University.

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The other day I checked the American Society of Health-System Pharmacists (ASHP) website for current drug shortages. The ASHP uses the following criteria to determine if a drug qualifies under the “new shortage” heading:

“A drug product shortage is defined as a supply issue that affects how the pharmacy prepares or dispenses a drug product or influences patient care when prescribers must use an alternative agent.”

The ASHP also states that:

“Shortages can adversely affect drug therapy, compromise or delay medical procedures, and result in medication errors.”

I must admit I was a little surprised to find approximately 250 Current Drug Shortage Bulletins listed on the site.  Is this an average day’s shortage?  I don’t know, and to be fair, some drugs are listed more than once because different predetermined measurements of the same drug may have their own bulletin. For example, Sodium Chloride 0.45% and Sodium Chloride 0.9% are both listed. It’s actually my interest in Sodium Chloride (normal saline solution) that brought me to the ASHP website in the first place.

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A few months back some of our healthcare partners started to inform us that they were at low levels for 0.45 1000cc bags of saline. These types of shortages are not necessarily unusual and can normally be resolved through internal sharing protocols within larger healthcare systems. We had heard that the shortage was nationwide and was due to increased demand on the three major manufacturers (Baxter, Braun and Hospira). This reason is also the one indicated on the ASHP website.

However, this instance was anything but normal; the situation was becoming critical. For instance, a few of our health care partners stated that patient diversion due to lack of the needed supplies was possible. Another facility activated alternative treatment guidelines, consolidated saline supply and verified necessity prior to patient distribution.

After a little probing, we began hearing that some of the larger saline vendors had contracts with hospitals that prohibited them from purchasing product from a different vendor. In other words, the hospitals were restricted from purchasing saline outside of their initial vendor agreements. Even if the hospitals could contract with other vendors, we were also hearing that the vendors themselves were running low. And, it turns out that there are vendor restrictions on adding new clients when products are under allocation.

We also learned that larger systems will sometimes purchase directly from the manufacturer. Of course buying in volume reduces the amount paid but these types of contracts may also prohibit the larger facility from selling product to partner systems to discourage possible profit making.

Regardless, the option for some systems to purchase product at different points in supply chain influences overall supply availability and may leave smaller hospitals and systems at a disadvantage.

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Another problem with these overly efficient supply chain models is that the practice of just-in-time ordering does not allow for a large enough buffer if there is a legitimate emergency. In an effort to decrease costs by reducing the number of storage points in the network, just in time ordering leaves a facility vulnerable in case of a catastrophic hit to the regular supply chain.

For example, in the case of an earthquake that takes out road access to a healthcare facility, a just in time policy may exacerbate an already challenging situation. A policy that relies on receiving product when it is needed instead of keeping large quantities readily available is at greater risk in an event where the supply chain is compromised.

Additionally, hospitals are often times unable to store these types of products in-house due to limited space.  Actual “storage wars” between hospital departments are not uncommon. Even if a hospital does have available storage areas, product rotation can also become an issue. Depending on when saline is manufactured, it will probably need to be rotated every six months to a year to keep  the supply fresh. Thus, the critical dependency on vendors to keep the supply change moving.

Regardless, the usual protocol for a health care facility when they are unable to receive product from their vendor or their own internal systems is to reach out to other nearby facilities and initiate formal or informal mutual aid agreements. However, due to the nationwide shortage, requests to other facilities for product were being denied. If a facility only carries three days worth of saline, sharing one day’s worth of product with another facility during a shortage would only leave the lending facility more vulnerable. In this type of situation, it’s not worth the risk to a lender to assist a partner agency in need.

Ultimately, after about a week of intense consternation and consideration, our emergency saline situation subsided (at least for the short-term). The few hospitals that were critical were finally able to get the product they needed from their vendors…just in time. In the end, the system work perfectly.

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It was also about this time that it finally hit me.  While state and local public health emergency preparedness programs focus on building public and private capabilities to handle the added systemic stress of an emergency, such as a patient surge during the aforementioned earthquake scenario, many health and medical partners in the private sector are undermining the effort by creating just in time systems that could possibly leave healthcare facilities and their patients more vulnerable during their greatest time of need.

Using the saline example, if a surge in patients created a need to use excess product during an emergency, the just in time system of product delivery would not allow for the most effective patient care. As the situation narrated above outlined, many hospitals are already operating on slim product stockpiles (usually a maximum of three days). If they were unable to receive product for longer periods of time because of an event, patient care would be compromised.

As it occurs to me, the manufacturers, vendors and healthcare facilities share responsibility in this scenario. I have to believe that building in added risk during a crisis is not intentional on the part of our private partners.  However, creating such efficient systems is working at odds with the greater public health. Hospitals that are unwilling to add robustness to their systems by adding extra storage space are basically averse to stockpile necessary product.  Manufacturers and vendors operating on just in time delivery schedules are also seemingly more concerned with the bottom line than the needs of the patient. In all cases, profits win out over patients.

Ted Lewis describes this phenomenon as self-organized criticality (SOC). In his book Bak’s Sandpile (2011), Lewis write:

“I propose a unifying theory that explains how accidents, disasters, and catastrophes are intensified by the way modern society has evolved into a collection of highly connected, optimized, and cost-efficient systems. Everything has been optimized—principally by eliminating surge capacity that allows a given system to deal with any overload it experiences. Add to this optimization of capacity the fact that modern just-in-time systems have squeezed out any tolerance for error, and you have the ingredients of what the Danish physicist Per Bak called self organized criticality. This has brought modern society to the brink, and it is our own fault. Modern systems weren’t designed to be resilient, self-correcting, and secure, but rather to be low-cost, efficient, and optimized for profitability. As a consequence, the critical infrastructures supporting modern civilization have evolved over the centuries into fragile, error-prone systems. We have reaped the benefits of short-term efficiency, but now we are suffering from it. Efficient, optimal, and cost-effective systems are why $#^! happens.” (Pgs. 8-9)

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Although there has been much talk about private/public partnerships within the ESF 8 landscape, I have never heard (at least at the state or local levels) any of these conversations put within the context of self-organized criticality.  Using the SOC lens to view the problem makes it clear to me that when Public Health encourages partners to come together and discuss increasing surge capacity within our health and medical systems, we must include product manufactures and vendors.

Leaving these partners on the sideline of the health and medical system during preparedness and response conversations focused on surge planning will only lead to the creation of more unnecessary fantasy documents. If collaboration is the key, all players in the supply chain must be at the table and all the accompanying issues, including SOC, must be honestly and directly addressed.

However, when one player in a system is trying to maximize economic gain, while the others have more altruistic goals in mind, the possibility for overall systemic collapse would seem to be amplified as public and private agencies work at their opposing missions.  Thus, these types of conversations would ideally need to take place at the highest policy levels. In other words, tackling problems that impact free market behaviors need to be addressed at the federal level so that any resulting policy or regulations can be implemented on a national basis. In this way, entire national health and medical supply chain systems are addressed in any proposed solution.

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What has also become clear is that the Public Health Emergency Preparedness enterprise needs to reevaluate how it trains and educates its practitioners. Encouraging professionals to take the latest Incident Command class will not help problem-solvers at all levels to identify and apply concepts such as SOC to supply chain and other systems related problems. Understanding and using these types of theory based concepts in relation to increasingly wicked problems needs to be at the foundation of the 21st century homeland security practitioner’s tool kit. Otherwise, professionals in the field will not have a fertile soil to ground their practice.

Yet entering into conversations without 21st century knowledge tools is exactly what I see happen on an almost daily basis. Most everyday I witness emergency management and homeland security professionals discuss problems and propose solutions that have no grounding in any type of researched or scientific theory. In this context, meetings dominated by assumption, personal preference and group think can easily become the status quo.

An inability by professionals in the field to understand systems, network and other related theories is no longer acceptable in an enterprise that has now been in existence for over ten years.  Although Public Health Emergency Preparedness may not have its own specific and unique set of concepts to apply to the field, borrowing these types of ideas from other disciplines (including Public Health!) must be encouraged and supported.

To be clear, I am not suggesting that an understanding of concepts like SOC is all it will take to solve difficult issues like the saline supply chain situation. A complex problem like this will need any number of solutions (at all levels) interacting together to achieve the desired outcome for both the short and long term.

However, redesigning a 21st century Public Health Emergency Preparedness training and education curriculum that provides practitioners at all levels these types of cognitive tools is crucial so that players at all points in the system can view problems though a common lens. If we do not make these fundamental changes in how we develop these professionals, the millions of dollars we have endowed into the human resources of this nascent field will certainly provide a more than disappointing return on investment. In a knowledge based economy, critical and independent thinking, intellectual courage and beliefs based on facts and evidence are our stock-in-trade.

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Good intentions, an understanding of the Incident Command system and an ability to mimic “grant jargon” is no longer enough to confront our ever changing and increasingly complex world. It’s now time that Public Health Emergency Preparedness programs provide up to date evidence based and research supported professional development opportunities to its practitioners.

If we don’t move in that direction, the next time you need some basic saline solution, it just might not be there.