Homeland Security Watch

News and analysis of critical issues in homeland security

October 21, 2014

Ebola, Fantasy Documents and Our Collective Inability to Tolerate Ambiguity

Filed under: Public Health & Medical Care — by Christopher Bellavita on October 21, 2014

Todays post is written by Jeff Kaliner. Kaliner is a public health emergency preparedness professional with twelve years in the field. For the last few years he has spent an unreasonable amount of time considering the intersection between complexity science, lessons that never get learned and homeland security. He holds a Master of Arts degree in Security Studies from the Naval Postgraduate School and a Master of Science in Education from Northern Illinois University.

Over the last few days the media has suggested that hospital emergency plans and procedures are basically unsuccessful with respect to the ongoing Ebola event.  The narrative lays out that hospitals (and in effect the larger public health system) have failed to plan properly and in turn are now reaping the consequences of poor preparation. The evidence is apparent: one dead Liberian national and two infected Texas nurses.

Connecting these dots in a linear fashion gives us the proof we need to believe what this narrative suggests: The last twelve years of federally fueled funds to enhance emergency health and medical programs at the state and local levels have not worked.  The implication is easy to understand; better planning and procedures (and more money?) would have prevented this very serious situation.

Although the story seems to have a tidy and easily understood cause and effect relationship, it is wrong.

The problem with this tale is the dirty little secret that a well-crafted plan or procedure cannot and will not be enough to manage a complex event. When implied that they can, these documents take on a symbolic quality that suggest they are somehow able to control reality.  As Lee Clarke (in his book Mission Improbable: Using Fantasy Documents to Tame Disaster) points out, plans in this realm “…are rhetorical devices designed to convince others of something.”  The “others” in this case might be federal or state grantors, the public, the media, response agencies, etc.  Clarke goes on to state:

It seems that fantasy documents are more likely to be produced to defend very large systems, or systems that are newly scaled up. When they are proffered as accurate representations of organizational capabilities then the stage is not only set for organizational failure but for massive failure of the publics those organizations are supposed to serve.

Sound familiar?

In other words, the plans the media have been referring to are fantasy documents.  They were partly crafted to give an illusion of safety and security.

To be clear, I am not arguing that plans should not be written and that capabilities should not be exercised.  What I am saying is that the best we can ever do in the face of an increasingly complex catastrophe is write a bad plan and admit that a capability that was pulled off flawlessly during an exercise will probably not produce the same results during the actual bad day. This is not an indictment of all the dedicated and committed emergency planners across the world.   This is an invitation to acknowledge what the best of them already know: response documents become more useless as the event becomes more complex.

Maybe one possible solution to the plan as fantasy document is to conceptualize an emergency situation as an unfolding set of unpredictable events in a unique eco-system. Every eco-system has a pre-determined elasticity or resiliency that allows it to bend a certain distance before it breaks. In this narrative, instead of asking whether or not our plans have worked (and in turn placing blame on a variety of systems) we might wonder if the resiliency of our current health and medical system has actually been compromised and to what extent by an emergent event.

This idea has become clearer to me as I have been reading The Age of the Unthinkable  by Joshua Cooper Ramo.  Ramo suggests that one way to think about the resiliency question is to visualize the eco-system of a lake.  He writes

“The stability of a lake ecosystem can’t possibly be reduced to a few variables. What matters isn’t something you can score quickly but rather the strange mesh of interactions that make a lake resilient or not….  What you can easily measure in these systems matters much less than what you cannot: How strong are the relationships between different parts of the lake ecosystem? How fast can it adjust to shocks? How far can you bend the food chain on the lake before it breaks? In short, how resilient is it?”

What if we tried to apply aspects of this idea to how we define, manage and evaluate emergency response? What if instead of trying to bend reality to our whims by absurdly trying to measure the potential success or failure of our plans, procedures and capabilities (before the event), we looked a little deeper at the complex set of variables that make up a health and medical eco-system during an event and drew conclusions about how well we were doing based upon a more nuanced and admittedly ambiguous set of factors?  Factors including our ability to adapt, learn and change in real time.

As Ramo states: “Resilience allows us, even at our most extreme moments of terror (in fact, precisely because we are at such a moment), to keep learning, to change. It is kind of a battlefield of courage, the ability to innovate under fire because we’ve prepared in the right way and because we’ve developed the strength to keep moving even when we’ve been slapped by the unexpected.”

Preparing in the right way certainly means developing plans and procedures.  But that’s just where it starts. Ultimately there is no one playbook or plan that will quickly solve the multitude of problems that occur during complex events. In an unordered world, we all will have to become more comfortable with the messy reality that there is not just one factor that means we have won or lost the battle (think: Mission Accomplished).

In the book Complex Adaptive Systems: An Introduction to Computational Models of Social Life, Miller and Page write, “Complexity arises when the dependencies among the elements become important.”  Certainly there are many elemental dependencies involved in the current Ebola outbreak.  Understanding and learning how these dependencies interact with one another to create new and unexpected aspects of this ongoing situation is critical to an effective response.

We can no longer reduce the negative events (the death of a Liberian national and the infection of two Texas nurses) that take place within quickly evolving eco-systems to simple platitudes. In this respect, false narratives (such as the ineffectiveness of a magical plan) need to be quickly identified and confronted as the simple and all too easy explanation for a very complex set of events that will probably never be truly understood.

If we do not identify these narratives for what they are, we diminish the two critical capabilities that we will need to consistently practice if we are to truly be prepared for 21st century challenges:

1) an emergency response system that has the political will and ability to quickly learn and adapt during the course of an emergent event; and

2) a media and public that will provide a type of unconditional support and understanding to let it happen.

Regardless, until we are all prepared to think about and understand the world in ways that reflect a more interdependent and non-linear sensibility, our reliance on simple narratives will remain. That reliance certainly works well for the media, but it’s just bad news for the rest of us.

October 19, 2014

Who is my neighbor?

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

EBOLA_James harris

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

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

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

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

October 18, 2014

Ebola source sitrep 1

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

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

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

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

Ebola Chart

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

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

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

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

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

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

 –+–

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

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

October 17, 2014

Less czar than troika

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

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

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

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

Hold on and best wishes.

October 16, 2014

Adjusting our signal to noise ratio

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

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

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

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

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

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

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

Google US edition

UK edition

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

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

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

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

Some possible discussion topics and exercise issues:

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

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

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

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

–+–

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

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

The Concord Times – A Sierra Leone based newspaper.

The Telegraph – A Sierra Leone based newspaper.

Doctors Without Borders Guinea News

Guinea (Conakry) Guinee Focus (French)

World Health Organization Africa Regional Office

US Department of Defense Africa Command

CDC Ebola Hub

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

FRIDAY UPDATE:

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

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

MORE

SECOND UPDATE:

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

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

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

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

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

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

MORE

October 9, 2014

Retrospectively, it is often so clear

The Ebola outbreak is, almost certainly, a precursor for a future pandemic that will be much worse.

The current California drought is, almost certainly, a precursor of more to come.

The recent series of cyber-attacks are, almost certainly, a precursor of many more — and much worse — to come.

The intention of Australian terrorists to undertake random attacks is, almost certainly, a precursor for such attacks there and elsewhere.

In each case a current threat-vector is amplified by human behavior, especially increased population density and mobility.  Ebola is naturally occurring. Until the last four decades its natural range was isolated from humans and, especially, human networks.  Drought is naturally occurring in the American West and Southwest. Until the last six decades, this region was sparsely populated. Never before has so much monetary value been so concentrated and (at least virtually) proximate. Violence is naturally occurring in human populations, its mimetic mutations now facilitated by many more of us in communication, contact, and perceived competition.

In the case of Ebola, the rapidly increasing population of Guinea (Conakry) —  up 220 percent since 1960 —  has created substantial ecological and economic stress.  This has been especially the case in the forested uplands of Eastern Guinea neighboring Liberia where the current outbreak first emerged.  With about 70 people per square kilometer this region has twice the density of the Virginia county where I live.  It’s less than 300 miles to Monrovia, the capital of Liberia, which has a population density of 600 per square kilometer.  No wonder Monrovia has been hit so hard.

Macenta Epicenter

We don’t know precisely when or how the virus was transferred to humans in this epidemic, but consumption of bushmeat infected with the virus is a good guess.  That has been the origin in several previous — but much smaller — outbreaks in Congo and Gabon.

Mid-March is when I first read about what has unfolded into the Ebola outbreak:

(Reuters) – An outbreak of hemorrhagic fever has killed at least 23 people in Guinea’s southeastern forest region since February when the first case was reported, health authorities in the West African nation said on Wednesday.

At least 35 cases have been recorded by local health officials, said Sakoba Keita, the doctor in charge of the prevention of epidemics in Guinea’s Health Ministry.

“Symptoms appear as diarrhea and vomiting, with a very high fever. Some cases showed relatively heavy bleeding,” Keita said.

“We thought it was Lassa fever or another form of cholera but this disease seems to strike like lightning. We are looking at all possibilities, including Ebola, because bushmeat is consumed in that region and Guinea is in the Ebola belt,” he said. No cases of the highly contagious Ebola fever have ever been recorded in the country. (March 19)

Well into summer I assumed this Ebola outbreak would be contained as others have been contained.  I neglected to notice that this  time the threat had emerged in a region much more densely populated than previous outbreak zones (and with much easier access to even more densely populated areas).  I overestimated the vigilance and capacity of the World Health Organization. I underestimated the power-amplifiers of human need and social interaction and fear… multiplied exponentially as the vector penetrates more deeply into the matrix.

This is how it happens.  Prior success encourages undue confidence.  And maybe you’re  a bit distracted. The threat morphs and emerges into — then out of — a different context.  So it may not initially be recognized. The critical contextual cues are unnoticed.  The threat is given time and space to strengthen.  This is especially likely to happen with places or people already neglected.

What worked last time is not quite calibrated with the new context.  Besides, for many of those engaging this threat, this is their first time.  Former lessons have not been learned, are being re-learned.  This threat in this place is in many respects unique — at least in the experience of those who confront it this time.

It is a threat that, if recognized early-on, might be quickly suppressed or contained. But instead it proliferates, filling the void opened by neglect. Thus amplified the threat is much more likely to find and exploit vulnerabilities; even those that until the threat’s  emergence were seen as strengths. Which is typically how tragedy unfolds, when what had been strong makes us weak.

October 8, 2014

The drawstrings on your jacket are more likely to kill you than Ebola

Filed under: Public Health & Medical Care — by Arnold Bogis on October 8, 2014

So says Chelsea Rice, a Boston.com staff writer in her provocatively titled piece, “104 Things More Likely to Kill you than Ebola:”

Ebola has made it to the U.S., and everyone is freaking out. They shouldn’t be—at least not until they’ve sufficiently freaked out about these 104 things that, according to nationwide data, are even more likely to kill them.

  • Walking to work
  • Stroke
  • Hunting accidents
  • COPD
  • Drawstrings on your jacket
  • Wrong-site surgery
  • Alligators

Yes.  Alligators.

This should not be taken as demeaning the suffering of any Ebola victims anywhere, and especially the horrific conditions faced by those living in nations hit especially hard in West Africa.

It is, however, a reminder that despite the constant drumbeat of fear coming from cable news and internet pundits that the threat to Americans remains astonishingly low. A couple of other favorites from that list:

  • Falling in the shower
  • Bunk bed accidents
  • Cheerleading
  • Mowing the lawn
  • Roller coasters
  • Bouncy houses
  • Trampolines

What has surprised me most about this entire situation is the lack of calls for increased public health spending.  There are cries for cutting off travel to afflicted nations, increased monitoring at our international airports, and even attempts to tie this situation with border security. However, I haven’t heard a peep about cuts to spending on public health.  A note to advocates out there: if not a teachable moment, it is definitely what they call a “hook” in making the case to spend more on public health. While it may seem unseemly, this is the time to push your argument.

One of the few exceptions, that unfortunately makes a weak case in my opinion, is from Frances Bevington of the National Association of County and City Health Officials.  While Ms. Bevington lays out a scholarly argument, it unfortunately won’t move any Congressional officials to increase grant funding, nor state or local decision makers to shift limited resources back to public health.  She concludes:

Will cuts in preparedness funding to local health departments make an Ebola outbreak in the United States more likely? The answer is no. The conditions that would limit the spread of Ebola, including better infection control in healthcare facilities and different cultural traditions, are not factors influenced by preparedness funding at local health departments. Despite funding cuts, the public health workforce stands ready to do whatever is necessary to stop Ebola from spreading. But those cuts have put deep dents in the public health shield that protects the lives of all Americans and make it more likely that local health departments faced with even a few cases of Ebola would significantly strain their already thinly stretched workforce and financial resources during the response.

Her point is correct.  And I’m not asking for people to stretch the facts to make a point. Nor hype the threat of Ebola.  But it might do some good to point out at least a little more strongly that the systems, infrastructure, and most importantly people protecting this nation from an outbreak of Ebola have recently experienced significant cuts in their funding.  There is probably no better time to make the argument for increased public health funding than when both CNN and Fox reference the public health system roughly at least once each hour.

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.”

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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.

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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.

———————————————————————–

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.

———————————————————————–

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.