The RAND corporation is one of the country's foremost non-profit consulting companies. Their Reports carry weight. So I was interested to see the announcement of a new Rand panel report on key components of public health emergency preparedness. Emergency preparedness means many things to many people, and immediately after 9/11 it meant responding to a terrorist attack. These days we think more in terms of hurricanes and pandemics. I think that's progress. But I have to say the RAND report didn't seem to advance the ball much. Here are the three broad categories they believe communities should have:
- Have a coordinated rapid-response capability. This should include well-defined roles and responsibilities for officials and the public; a clear command structure; strong public communications; the ability to provide emergency health care to large numbers of people; and the ability to monitor the spread of a public health emergency.
- Develop and maintain adequate numbers of operations-ready public health workers and volunteers.
- Engage in a continuous process of testing, improvement and maintenance of systems for tracking and reporting information on readiness to decision-makers and the public.
I think they've left off some things: practice harmony of mind and body; bring about World Peace; eliminate poverty and discrimination. Said another (and less snarky) way, the problem is how do you get to this point with the resources state and local public health agencies have at their disposal. I think most of them didn't need a RAND report to tell them these things.
I think I can be fairly criticized for not having read the whole report but only the description of it through EurekAlert, but there is something so mechanical and naive about it I couldn't stop myself from commenting. If I am unfair I apologize. The panel has devised their own definition of public health emergency preparedness ("The capability of the public health and health care systems, communities and individuals to prevent, protect against, quickly respond to and recover from health emergencies, particularly those whose scale, timing or unpredictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action.") and then go on to say:
"If you ask public health and government officials, 'What is a public health emergency?' no two people will give you the same answer," said Nicole Lurie, MD, co-director of the RAND Center for Domestic and International Health Security. "Without a clear definition of what a public health emergency is and how to prepare for one, communities and states cannot assess whether or not they are prepared."
[snip]
"The conceptualization and definition of public health preparedness proposed in this editorial is concise, clear and to the point," said Paul E. Jarris, MD, executive director of the Association of State and Territorial Health Officials. "The authors provide a framework to guide the development of performance metrics and continuous improvement of our nation's public health readiness." (EurekAlert)
The definition tries to cover everything, but doesn't seem to cover pandemic preparedness, or at least it covers it in a vacuous way. And why should we accept this definition? The idea that you won't know how prepared you are unless you have an explicit definition and "performance metrics" is clearly incorrect. Most of us know we are unprepared and don't need their definition or performance metrics (whatever they are).
I am sorry to be so harsh. But frankly, this reeks of the worst kind of bureaucratic-beancounting-planner-expert-consultant mentality. Not very helpful.
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Revere,
You are not being too harsh in any way. The RAND Report is typical of the disconnected, acontextual, vapid reasoning (or lack thereof) that permeates all official approaches to "public health preparedness." Failing to differentiate the dimensions and parameters of a pandemic that push it into a separate category of "emergency" leaves people completely clueless about the different measures needed to actually prepare -- (not that ordinary people, bless 'em, would ever bother to read the RAND report anyway, thank goodness). No one ever mentions the responsibility to train people in home care! No one is demanding funding to support local health educators who could provide community education about care for dehydrated family members sick with possible pandemic flu. Since the hospital systems will collapse within a matter of days or a couple of weeks, at most, and since we know there won't be any Tamiflu for the public (even it it were effective, which is already widely questioned), and since we know the vaccines won't be there either (even if the formula is 'in the works" the distribution system doesn't exist), it is guaranteed that people will be stuck at home trying to deal with this. No one talks about that. A few home care guides have been published, but they are inspite of, not because of, all this bureaucratic b.s. on the websites. Lists upon lists upon lists do not get people prepared. How can a family of four that is barely surviving on 3 or 4 jobs stockpile enough food for 6 weeks? (And when you realize that the US State Dept tells its overseas people to stockpile for 3 months, you realize we're all being fed nonsense about the severity of supply chain disruptions.) I have been in this "pandemic preparedness" racket for about a year and a half now and I'm not just discouraged, but really perplexed and sometimes alarmed -- not by the pandemic potential, but by the idiocy and downright pathology of most of the chatter that is going on locally and at the state level. The "command and control" junkies from Homeland Security and its multiple offspring in local communities (CERTS, OEMs, Citizen Corps, First Responders,etc) are all looking for weapons, anticipating that the National Guard will be the best backup option. Backup for what, exactly?? What will they be for? Even vaccine distribution would be marginally acceptable if it were not such a fantasy. But the National Guard is being talked about in the context of keeping the local population from storming the hospitals! That's right. The pandemic preparedness people have not only usurped public health (which in most small towns has no awareness of the pandemic issues whatsoever, and is given no guidance from state health departments to get up to speed), but they're anticipating martial law. Since the statutory framework has quietly been re-written to equate a "disease outbreak" with a "national security threat," giving authority to the feds and the state governors to declare martial law, we're basically already in a militarized public health world. Why isn't anyone writing about this? Maybe you all could do so. The RAND report is not really surprising. They don't connect to ordinary folks in their communities. They don't even know how half of America lives these days -- from paycheck to paycheck, poorly nourished, under employed, uninsured and unaware because no one is reaching them with accurate information. So, no, Revere, you are not being too harsh. You have been way too polite. The RAND report just adds more paper to a vast accumulation of largely useless "preparedness" rhetoric.
If the extracts you posted are indicative of the report as a whole then may I suggest the best use would be to get the entire print run, cut the pages into squares (about 6 per side), take about 50 sheets & punch a hole in one corner, run a loop of string through the hole and hang on a convenient nail or hook in a hospital toilet.
They have no clue what they're doing, and don't care -- the pay's the same.
Think Katrina. We learned that every government agency has a disaster plan, and every plan is totally secret -- secret from the public and secret from every other agency. Only when the plans gets unleashed on the public do we learn the idiocies they had in store for us.
No evacuations from some care facilities holding crippled patients. Lots of buses readied to transport people but nobody to drive them. Everyone forced to use the single escape route north, making a six-hour 200 mile traffic jam. Refugees ordered to abandon their pets. Refugees order to surrender their firearms. Law enforcement clearing streets at gunpoint. Volunteers with boats turned back -- at gunpoint -- because there was no mention of volunteerism in the law enforcement plan.
The list goes on and on and on. A small percentage ever made the news at all, and the rest are still secret failures.
After the catastrophic failures in Katrina, the government agencies haven't fixed anything.
Roy, be aware that Katrina wasnt a federal diaster until three days after it hit. Sure we all saw that on TV but Gov. Blanco by federal law HAD to sign a declaration of emergency and federalize it. Bush couldnt do a thing and I mean a thing without that request being made and accepting it. That is due to the law being what it is and it was a very weak law. The states and Congress wanted it that way to limit the federal governments control of them. It truly goes back to the 50's and 60's and is a "states rights" issue.
To mobilize even one troop, agency, or whatever would have been a violation of the law without that order. I agree that they could have done it a lot better, but Nagin depended on Blanco, Blanco wanted the troops under her control (not in a federal disaster-again the law), and they got into a pissing contest on Air Force One and she didnt sign it until AFTER Bush left She failed to sign that order until three days later. Then it took two days to mobilize the real forces even though the USCG and other agencies by mutual aid agreement were able to participate immediately as a part of mission statement. If Bush had mobilized those troops without declaring a state of national emergency and that requires a notification to congress, he could and would have been impeached. The only other legal avenue is if she had signed it.
The law was changed slightly last year to allow for limited use of federal troops under state control BUT there still must be a declaration by the governor of the affected state. Lawton Chiles did the same thing to Bush 1 when Andrew rolled in. They could have written it on a brown paper sack and given it to Brown, or any Federal official making the declaration.
Then there is common sense. You see a category 4 hurricane that has been a five bearing down on you, then you ready the declaration and sign it the second you see winds over 100...dumb bitch!
ississippi is still screwed up but they are ten times better off than Louisiana. Barbour lost the power in his entire state and Hattiesburg Ms. barely had a tree standing afterwards. 72 hours afterward except directly on the coast they had the main power grid back on line. We could go on about the Louisiana pump technicians who left their posts too that could have pumped the water out as fast as it came in, but thats a whole different story.
Re: secret plans. Those plans are on the websites of every agency and who is what. Put in your state name and EMA or abbreviate it. Federal agencies are brought on line as needed by then FEMA and now DHS when a disaster hits. This will be one though that no one can avoid if it comes. 500 Katrina's.... I'll buy that one. Nothing secret about it. Its under NIMS in your websearch. I encourage you to join, take the online courses and participate in what will be the test of this entire world if it comes in highly pathogenic and with high CFR's.
Revere is dead on for this one. My little acetate overlays caused all sorts of problems with a few of the higher ups in my local organizational chart. The NGO telling the bosses what to do isnt supposed to happen. I even had one that did the ugly little math equations for them. I told them that I would take it at just half of what it was now rather than the bullshit 5% they keep hanging their hat on. G. Ford was lambasted for expending the money for the Swine Flu pandemic alert and the preparedness. It didnt happen. If it had, it wouldnt have made much difference then or will it now. There just isnt much RAND, FEMA, DHS etc can do in a situation until it happens.
I have been trying to find out how much emergency food is on hand and in storage in the US in the State, Federal, local and NGO reserves. What I am finding is about a 5-10 day supply total nationwide by state, nothing yet on the Fed level. Some have very, very little. The resource is perishables and by nature, they dont allot money each year for enough to get us to even one month. So it sits, the problem hits and then 5-10 days later we will be out or done.
Dont kill the messengers though they are trying and that trying starts with people at home. Government aint gonna solve this one until its over and done with and likely taking as many as it wants too before it goes.
Doom and gloom? Yup and being accused of it nearly every day here. Okay, so someone give me the bright and shiny link that tells me all will be well.
I am waiting.
It's rare at my advanced age for me to find myself singing ditties remembered from having watched Sesame Street in my early formative years.
However, as I read the following, I began to hum to myself, "One of these things is not like the others; one of these things just doesn't belong."
This should include well-defined roles and responsibilities for officials and the public; a clear command structure; strong public communications; the ability to provide emergency health care to large numbers of people; and the ability to monitor the spread of a public health emergency.
Most of this stuff is relatively inexpensive to implement. Although *all* of it requires administratively competent leaders, the existence of whom we seldom have any guarantee at any level of government.
But that point number four, "the ability to provide emergency health care to large numbers of people," that is the (presumably literal) killer. That is not something that one gets by moving the lines and boxes around on the org chart, nor by commandeering a TV news set. That capability requires spending money, and a hell of a lot of it, for a long time in advance. It means buying facilities and equipment and consumables, none of which come cheap. It means training and paying people in expensive professional capacities.
The emergency rooms near me visibly can not handle an ordinary Saturday night. I do not think that is atypical of the nation as a whole.
The move to managed care has left the MBAs who now set American health care policy with a real dilemma. They want to make money and to run profitable operations. Yet they face a legal mandate to provide care to any and all comers at their ERs (including a never-ending stream of guaranteed no-pay illegal immigrants).
Those operations hence consistently lose money. What to do? The response in general has been down one of two paths. Either close the ERs by facilities juggling and consolidation, or starve them for resources. Neither of these are in any way compatible with what RAND is recommending. And the MBAs will be as pleased to implement the changes in question as they would have been to swallow a frozen dead rat.
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My understanding of the matter differs from Randy's.
Blanco was described in various quarters as not having signed a declaration of emergency in a timely manner. She signed one on the evening of Friday, August 26th, two days before Katrina made her Gulf Coast landfall.
Among the media who incorrectly accused Blanco of delay was the Washington Post.. Note their later correction above the headline.
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Marquer-I dont see how you could draw that conclusion when the Bush Administration was trying desperately to get Blanco to sign the order and thats in your WP post. Yeah, it was a Bush document but its better than what Blanco had which was nothing. Blanco declared a statewide emergency but that aint a federalization request. That document you said she signed wasnt a declaration nor a request. It was only for the state services to come up to speed.
That order has a format, it is known to every Governor and Blanco knew she would lose control of the biggest game in 20 years. She also ducked Congress when she was questioned about it after and they gave her a pass. All in all they failed miserably. But next damned hurricane that comes in and a Democrat fails to sign the order is going to get handed their teeth regardless of whether there is a Dem or Republican in charge at the White House. Thats twice the Republican Guy in the White House got blamed for following the law.
Politics rotten levee's... What comes out? Corps of Engineers failed in the management of those levees. They didnt fail because the Corps didnt manage them. Thats a parish pork barrel. They cant account for 330 million dollars of money in Louisiana and thats the reason that Blanco didnt want to talk to Congress. That money started under Bush 1, Clinton 1 and 2 and was finishing up with Bush W 1.5. They know they built an overpass to a casino and a fountain. But they cant account for anything else. Just stolen. The Corps approved the construction of the levees and the materials, N. Orleans parishes just never used anything but mud and sand in them. If the levees hadnt failed then this would be a moot discussion.
Blanco could have signed the order, lost control of the situation and then bitched later. Bottom line, all of those resources were available to her and she played politics because she didnt want to lose control.
I dont recommend that they do this with BF because H5N1 is going to clean everyones clock if its high path/high CFR. Sign the order. The return from the White House will be, "Roger, number 50 in the emergency response list. Be back with you." That applies to all of the states.
The Posse Comitatus Act, passed in 1878, merely forbids (with exceptions) use of Armed Forces to enforce laws. It does not forbid their employment in disaster recovery. The Robert T. Stafford Disaster Relief and Emergency Assistance Act, passed 1988, amended 2000, specifically permits their deployment.
Dubya's good buddy, FEMA Director, Michael Brown, walked the plank, or was scapegoated. It is to this day unclear whether he and his people did nothing, or they were prevented from doing anything.
http://www.cnn.com/2006/POLITICS/02/10/katrina.brown/
http://www.cnn.com/2006/POLITICS/02/10/katrina.levees/index.html
"a clear command structure" is easy. We simply recall the remanents of our various National Guards from the Middle East. And wait.
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To quote someone at a recent panel I sat on, "We don't need another fucking white paper!" (said in private, during a break). Considering we can't even get the logistics of ordinary influenza down, I'm not confident at all.
You are right Greg. The only problem still remains to this day. A governor has to sign the federalization order. That clear command structure is way oversimplified. Cutting orders for a division and/or the logistics of getting them back would take six months. Yeah that would have fixed the problem.
No Bush did the right thing and put Honore in charge and thats when things began to happen. Brown was goated to an extent. He wasnt very good at his job and if he had wanted it then he should have been pointing the finger at Blanco on the tube and saying in loud terms that the USGOVT couldnt intervene until she signed the order. Lots of blame to go around but it should have stopped where the buck did.
Again my friends it goes back to personal responsibility though. No one would have drowned if they had left, no one would have been left in a hospital to die had they been transported. New Orleans and Louisiana in general have always had this mind set that nothing would happen and the place is run by crooks. What else would you have expected?
To get back to the issue at hand, pandemic influenza, I have to say that I have been working on pandemic preparedness at the state level for several years and totally agree with everything Margot wrote.
We should be training people now in the basic care of sick people. One possibility would be to make nursing assistant training programs free. That way we would have more people trained in these basic tasks in the event of a pandemic, but would also have more nursing assistants available now. They are in short supply every day in our nursing homes. The tragedy that is our nursing home system will have to wait for another post.
EpiF-Has your state made any preparations for the HCW's that might actually volunteer for their protection E.g. full face plate mask and suits? So far and in the pentastate area no one has enough budget to fund it. Any different from where you are ?
To my knowledge, some states have purchased respirators and other PPE. I suspect that the states that have purchased respirators have primarily purchased N95s. Equipment such as Tyvec suits are not thought necessary for pandemic influenza (and I agree with this view).
Yes, to get back to the business at hand, thank you, revere and Margot. I am currently reviewing all of the UK plans, in a probably naieve attempt to generate some coherent responses to their 'public consultation' exercise. Since 'official-ese' often give important clues to what tptb are thinking or actually going to do, or think they can get away with, I've printed them out in hard copy to read in detail, together with related documents and references. Right now they fill up one of those filing boxes, and I've only just started.
Anyway, what I've been reading is making me feel right at home with what you have written. ;-)