Effect Measure

One resource the incoming Obama administration is certainly to find no shortage of is advice. We don’t know whom they will listen to, although we know much of it — maybe most of it — is likely to be of the self-serving variety. How to separate the wheat from the chaff will be a delicate task. Powerful people who give lousy advice still get bent out of shape when it isn’t followed. So we’ll have to see. Meanwhile we will be scanning whatever advice is made public. An example is a report from the Defense Science Board, issued on Election Day, no less. It purports to give the next administration a list of priorities on how to prepare for a possible bioterrorism incident:

Bioterrorism is a rising concern, because biotechnology advances have made it easier to prepare infectious agents within the United States, according to the report. Reducing the nation’s vulnerability to such attacks requires preventing enemies from acquiring the materials, improving the ability to identify perpetrators, and devising effective retaliation options.

Terrorists could stage a weapon-of-mass-destruction (WMD) attack with materials or equipment purchased or stolen within the United States. The board wrote that one such vulnerability is a “dirty bomb” that could be made with the radioactive isotope Cesium-137, which is used at hospitals and clinics throughout the country.

[snip]

“Our recommendation argues for realistic and repeated planning and replanning, repeated exercising and improvement, and a radical increase in our medical surge capabilities,” the report says. The board also emphasized the need for high-payoff medical, decontamination, and early-detection countermeasures.(Lisa Schnirring, CIDRAP News)

There also appears to be a recounting of all the very same topics discussed ad nauseam for pandemic planning: just-in-time inventory, poor coordination and overlapping and vague roles for key sectors, liability issues, planning incentives, encouraging a culture of preparedness, vulnerable infrastructures, etc., etc.

I haven’t seen the report, only this second hand account of it, but it sounds pretty worthless. We have known about all of these problems in the context of preparing for pandemic influenza. There is nothing new here. And if we are so concerned about materials being diverted, why do we keep ramping up production and potential access to them by building more and more “biodefense” laboratories (when no needs assessment for how many we need has ever been done and no accurate and up-to-date inventory exists of how many we have already); and why do we want to move to irradiating food for food safety reasons when it would greatly increasing access to materials for dirty bombs?

The best way to harden our communities against a bioterrorist attack is the same way we can make our communities more resilient against a pandemic: strengthen our public health and social service infrastructures by investing in the human resources needed to staff them adequately.

I think I may have said that here before. A few dozen times.

Comments

  1. #1 Ann P
    November 10, 2008

    What is your take on ‘syndromic surveillance’?

  2. #2 revere
    November 10, 2008

    Ann P: Syndromic surveillance is a plausible and worthwhile research task. It’s research because we really don’t know how to do it at this point. Not ready for Prime Time.

  3. #3 daedalus2u
    November 10, 2008

    It seems like a no-brainer to me too, but the Bush administration has less than zero brains (that is the mindset to do that which is harmful rather than merely useless). The Obama administration can’t do any worse.

    Since “medical care” isn’t something you can store in a can on a shelf, the only way to increase the “surge capacity” of medical care is by increasing the capacity of the system to provide medical care all of the time.

    Since “medical care” is only provided by individuals doing stuff, the only way to get more of it is by having more people with the expertise doing it more. Since expertise requires constant practice, those individuals have to be kept busy doing actual medical care.

    Since virtually no clinicians have actually seen cases of illnesses actually caused by any of the select bioterrorism agents, the only way they will be able to identify them if they do see them is by having experience with everything that is not a select bioterrorism agent.

    Since there is no shortage of individuals without access to medical care, there are lots of people for these clinicians to practice on. Since those individuals actually need medical care that care is not “wasted”.

    “Just in time” delivery only saves on the carrying cost of what is delivered “just in time”. If the asset is actually put to good use during that time, the savings in putting off acquiring the asset is small to non-existent.

  4. #4 Monotreme
    November 10, 2008

    revere, I don’t think your title is fair. The advice given is quite sound. Even you seem to agree with many of the recommendations, you just find them redundant. Given that we remain mostly unprepared for either a pandemic or a bioterrorist attack, I would suggest that the more people who convey this information to the new administration, the better.

    You have suggested that we need to “strengthen our public health and social service infrastructures by investing in the human resources needed to staff them adequately” many times. Perhaps I have missed this, but have you ever spelled out exactly what that means? How much money? Who should it go to? How should they spend it? What is your empirical evidence that such a strategy would be effective?

    Note, I am not questioning the need for more money or resources for public health, but if you want to suggest that this should be our primary defense against a pandemic, it would be helpful if you would be more specific about what you think should be done and why you think this strategy will be effective.

  5. #5 revere
    November 10, 2008

    Mono: I consider the advice platitudinous and unhelpful. Everyone knows those things need to be done. Regarding you request for “empirical evidence,” what kind of evidence are you asking for? You contend in para. 1 that the advice is quite sound. Do you have empirical evidence of this?

  6. #6 Monotreme
    November 10, 2008

    revere, I’m not sure everyone does know how urgent it is that those things be done, else they would have been done.

    There is empirical evidence that the advice is sound. Our medical surge capability is inadequate to deal with even seasonal flu. Many ERs have to go on divert every winter because they are overwhelmed by cases. Our response to the anthrax attacks was terrible. Several people died as a result. Earlier detection would most certainly have saved lives.

    Still waiting for a response to my request for specifics from you. It would make a great blog.

  7. #7 daedalus2u
    November 11, 2008

    Mono, as someone who is not a health care provider (except by doing research), the first paragraph quoted is nonsense. The first sentence is a platitude, the second one is nonsense.

    ”Reducing the nation’s vulnerability to such attacks requires preventing enemies from acquiring the materials, improving the ability to identify perpetrators, and devising effective retaliation options.”

    Anthrax is epidemic and endemic in most of the world. It is sporadic virtually everywhere else.

    http://anniej.myweb.uga.edu/incidence.htm

    The US has “enemies” living in regions where anthrax is epidemic. How much effort is being spent by the US to counter bioterrorism by reducing the incidence of anthrax in countries such as Afghanistan, Pakistan, Somalia, Iraq, Iran, Turkey? What level of anthrax eradication would be necessary before one had effectively “prevented” an enemy from acquiring anthrax? Is that the level of “prevention” being proposed?

    The only known instance of an anthrax attack in the US was perpetrated using anthrax from a US military source which had anthrax for bioterrorism research. The perpetrator(s) has not been identified (the nonsense of the scapegoat the FBI blamed posthumously not withstanding). Retaliation against the wrong party does nothing to deter an attack, as the “retaliation” against Iraq for 9/11 has shown.

    Shouldn’t those who propose to spend effort trying to prevent enemies from acquiring agents such as anthrax be required to show that those efforts will be productive? Shouldn’t they show what benefit will derive from what cost? Has there been a cost/benefit analysis associated with the massive proliferation of level 3 and 4 biocontainment labs working on bioterrorism agents? Doesn’t that increase the availability of agents to potential enemies? How does that in any way “prevent” an attack or reduce the nation’s vulnerability?

    We know that increasing the availability of health care will save lives, improve the health of the uninsured, and will provide benefits the instant it is implemented, even if there is never another bioterrorism attack. The problem with a cost/benefit analysis of this approach is that the costs and the benefits accrue to different groups. The costs accrue to tax payers, the benefits accrue to the uninsured, the contingent benefits (due to increased surge capacity in a pandemic or terrorism attack) accrue to the public.

  8. #8 Nigel Thomas
    November 11, 2008

    Bravo now that Obama is in charge we should see some real progress towards pandemic planning.

    We need to keep pandemic preparedness at the forefront of every business manager’s mind. It won’t go away so better start preparing.

    For free references, resources and to join their free pandemic preparedness eCourse certification program, go to Bird Flu Manual Online or, if you need more comprehensive tutorials, tools and templates, consider Bird Flu D-I-Y eManual for your influenza pandemic preparedness.

  9. #9 Lea
    November 11, 2008

    Do appreciate what you’ve written and asked for Monotreme.

    Would love to hear a response from revere versus a commenter.
    FYI revere: Believe it or not, I am for you rather than against you. You have been very kind to me as of late, (Thank You), but please extend this kindness to those who ask what I am perceiving as a sincere question.

  10. #10 Monotreme
    November 11, 2008

    daedalus, I agree that anthrax would be relatively easy to obtain. I used it as an example where quicker identification would have saved lives, not as an example of an agent that we could keep out of evildoers hands. The passage that revere excerpts cites Cesium-137 as something we should have better control over. I agree with this statement. Scavengers were sickened and some died as a result of improper disposal of a radiotherapy machine in Brazil. Securing the ingredients that could be used to make dirty bombs seems quite reasonable to me.

    I won’t defend every expenditure made in the name of Bioterrorism. Much of this money was allocated in haste without proper peer review. I would also agree that the events that occurred at the US Army Medical Research Institute of Infectious Diseases require further investigation. An external peer reviewed site visit would be beneficial, imo. However, misallocation of funds to counter a threat does not invalidate the nature of the threat.

    We cannot prevent those with the necessary knowledge from making highly infectious, highly lethal agents. This would be frighteningly easy to do. Far easier than the general public imagines. Like a high CFR pandemic, even a single occurence of a release of such an agent would be catastrophic for the entire world.

    Although most people are concerned about bioterrorism from Islamic fundamentalists, I am far more concerned about nation-states who might be tempted to use such agents as strategic weapons. The Soviet Union had a very extensive bioweapons program. The H1N1 flu virus currently circulating is thought by many virologists to have escaped from a Chinese bioweapons laboratory.

    This is not an imaginary threat.

  11. #11 Monotreme
    November 11, 2008

    Thanks Lea.

    My request is sincere. Although I don’t think PH can do the job alone, I do think that there are beneficial steps that PH could take to prepare for a pandemic. revere would be a good person to lay these out. Without specifics, however, “strengthening public health” sounds like a platitude, not a plan.

  12. #12 revere
    November 11, 2008

    Lea, Mono: I hope you do not interpret my very short responses as hostility. I am under a lot of pressure at work and at home and often don’t even have a chance to read the comments, much less reply to them in full. You are not the only one to have asked me to specify what I mean by strengthening the p.h. and social service infrastructure. The request (which is reasonable on one level) has me on the horns of a dilemma. On the hand the answer is easy: if we put a paltry $10 billion into the public health depts of the states (we’ve already plowed $6 billion into “biodefense” with little to show for it), split evenly among the 50 states (just for a back of the envelope calculation) this would be $200 million per state which could be used just to beef up routine public health activities. That would more than double the budgets of some states, and even large states be a substantial addition.

    That’s just untargeted money to strengthen weakened agencies. The other horn of the dilemma is to really work out a detailed and thought out plan for making public health more robust in this country. I’ve thought about it a great deal but don’t have the time or space to lay it out. It’s a task that needs to be done, but to do it you have to have the resolution and will and have to go beyond the handwaving platitudes we have seen from reports like this. At least my “strengthening” handwaving is specific to the extent that we provide state health agencies the resources to restaff and rebuild after several decades of attrition and demoralization.

  13. #13 Monotreme
    November 12, 2008

    revere,I did not take offense at anything you wrote.

    As regards your proposal to send $200 million to each state’s PH establishment, I would suggest that this is the same sort of mistake made by the Biodefense money allocators – no rationale for specific expenditures or peer review. Your proposal amounts to throwing money at the problem and trusting that the people who receive your largesse will spend it correctly. I have no such confidence. Many in Flublogia have tried to interact with with their local PH officials with (usually) a negative result. They have been ignored, condescended to, insulted or even threatened. A PH establishment that is so completely out of touch with the public seems unlikely to spend large sums of money to the benefit of the public. Further, we have the example of the Leader of PH, Director of the CDC Gerberding to judge how PH will spend money. What’s CDC’s budget? 10 billion dollars or so? How has that been spent? Wait a minute. Isn’t a lot of the bioterrorism research money funded by the CDC? According to you, they haven’t managed that too well. Other expenditures by this Leader of Public health: $10,000,000 for furniture at the swank new HQ ($12,000 per person) and a $200,000 fitness club with:

    “quiet rooms” and “zero gravity chairs” complete with “mood-enhancing light shows” for stressed out employees.
    CBS

    I know you are not one of Dr. Gerberding’s biggest fans, but perhaps you can understand why many in the general public are reluctant to throw more money at PH.

    Step 1 in restoring confidence in public health is to replace Dr. Gerberding with a Director who is truly willing to engage the public and model this behaviour for others in PH to see. Dr. Roz Lasker, Director of the Division of Public Health and the Center for the Advancement of Collaborative Strategies in Health at The New York Academy of Medicine would be my first choice. She has shown a real ability to listen to the citizens whose health she is trying to preserve.

    Dr. Gerberding will be resigning soon, right?

  14. #14 revere
    November 12, 2008

    Mono: No, it’s far from the same mistake. The biodefense money came with all sorts of strings attached. It severely crippled the health departments, worse than if they had not gotten the money (see some of my previous posts on how this funding distorted riorities and was like a cancer in public health). I am suggesting a return to the successful block grant programs, that is capacity building where the priorities are those of each health dept. to use for routine operations.

    As for Gerberding, she has been the Bush lap dog and worse. She continues to destroy CDC with her reorg and I keep hearing stories she is feathering a future nest. I am assuming she will go out at the end of the Bush administration but I have no confirmation of that.

  15. #15 Monotreme
    November 12, 2008

    revere, I really think the key to improving the public’s perception of PH starts with the Director of the CDC. If, somehow, Dr. Gerberding retains her position, expect a lot of opposition from Flublogia to PH playing a major role pandemic preparedness.

    btw, shouldn’t there at least be rumors by now of Dr. Gerberding’s job search? If there is any suggestion whatsoever that she wants to stay, I hope those with influence in the blogosphere or with the next administration will forcefully describe the results of her reign at the CDC.