Monday, October 29, 2007

Notes on HSPD 21: Public Health and Medical Preparedness

Last week the White House released the new Homeland Security Presidential Directive (HSPD) 21: Public Health and Medical Preparedness.

In terms of national preparedness, this is an extremely important HSPD. Many potential catastrophes, both natural and man-made, are capable of creating major public health emergencies. You just have to imagine the health impacts of a pandemic illness, bioterrorism incident (or other WMD attack), major earthquake, or west coast tsunami to imagine how quickly existing resources could be overwhelmed.

Our healthcare system has been built with efficiency in mind. If you're running a hospital, unfilled beds and unadministered medications cost you money, so you don't build a lot of excess capacity into the system.

But of course, as HSPD 21 notes, excess capacity is exactly what's needed during a major healthcare catastrophe. This is a significant shortcoming of our current preparedness regime. HSPD 21 does some sensible things to address the problem, but there are a couple of areas where I'm skeptical.

First things first. The directive is based on sensible principles:

This Strategy draws key principles from the National Strategy for Homeland Security (October 2007), the National Strategy to Combat Weapons of Mass Destruction (December 2002), and Biodefense for the 21st Century (April 2004) that can be generally applied to public health and medical preparedness. Those key principles are the following:

(1) preparedness for all potential catastrophic health events;
(2) vertical and horizontal coordination across levels of government, jurisdictions, and disciplines;
(3) a regional approach to health preparedness;
(4) engagement of the private sector, academia, and other nongovernmental entities in preparedness and response efforts; and
(5) the important roles of individuals, families, and communities.
It is very nice to see an acknowledgment of both the nature and severity of the problem:
The assumption that conventional public health and medical systems can function effectively in catastrophic health events has, however, proved to be incorrect in real-world situations. Therefore, it is necessary to transform the national approach to health care in the context of a catastrophic health event ...
To deal with the problem, HSPD 21 suggests the creation of an entirely new discipline:
Ultimately, the Nation must collectively support and facilitate the establishment of a discipline of disaster health.

On a more strategic level, HSPD 21 emphasizes 4 elements of public health:
Currently, the four most critical components of public health and medical preparedness are biosurveillance, countermeasure distribution, mass casualty care, and community resilience.
And sets goals for each of these 4 elements:
Biosurveillance: The United States must develop a nationwide, robust, and integrated biosurveillance capability, with connections to international disease surveillance systems, in order to provide early warning and ongoing characterization of disease outbreaks in near real-time. ... A central element of biosurveillance must be an epidemiologic surveillance system to monitor human disease activity across populations. ... State and local government health officials, public and private sector health care institutions, and practicing clinicians must be involved in system design, and the overall system must be constructed with the principal objective of establishing or enhancing the capabilities of State and local government entities.

Countermeasure Stockpiling and Distribution: In the context of a catastrophic health event, rapid distribution of medical countermeasures (vaccines, drugs, and therapeutics) to a large population requires significant resources within individual communities. Few if any cities are presently able to meet the objective of dispensing countermeasures to their entire population within 48 hours after the decision to do so. Recognizing that State and local government authorities have the primary responsibility to protect their citizens, the Federal Government will create the appropriate framework and policies for sharing information on best practices and mechanisms to address the logistical challenges associated with this requirement.

Mass Casualty Care: The structure and operating principles of our day-to-day public health and medical systems cannot meet the needs created by a catastrophic health event. Collectively, our Nation must develop a disaster medical capability that can immediately re-orient and coordinate existing resources within all sectors to satisfy the needs of the population during a catastrophic health event.

Community Resilience: The above components address the supply side of the preparedness function, ultimately providing enhanced services to our citizens. The demand side is of equal importance. Where local civic leaders, citizens, and families are educated regarding threats and are empowered to mitigate their own risk, where they are practiced in responding to events, where they have social networks to fall back upon, and where they have familiarity with local public health and medical systems, there will be community resilience that will significantly attenuate the requirement for additional assistance.
None of these are easy fish to fry, but some are a bit more straightforward than others. The Department of Health and Human Services is in charge of implementation (though it's not clear from this document whether they would be in charge of response - or if DHS would):

The specific plans regarding Biosurveillance indicate that:
The Secretary of Health and Human Services shall establish an operational national epidemiologic surveillance system for human health, with international connectivity where appropriate, that is predicated on State, regional, and community-level capabilities and creates a networked system to allow for two-way information flow between and among Federal, State, and local government public health authorities and clinical health care providers.
Comparatively speaking, the biosurveillance is one of the more straightforward elements of the plan. It has the virtue of primarily involving health professionals, and it involves a defined set of threats. It should be simpler to develop this type of information-sharing system, as opposed to an all-hazards system such as the Homeland Security Information Network, which has been fraught with complications.

The problems get a little thornier at the next stage in the plan, Countermeasure Stockpiling and Distribution. The plan lays out a fairly ambitious logistical objective, especially considering the potential transportation obstacles that might accompany some types of disasters:
[T]he Secretary of Health and Human Services, in coordination with the Secretary of Homeland Security, shall develop templates, using a variety of tools and including private sector resources when necessary, that provide minimum operational plans to enable communities to distribute and dispense countermeasures to their populations within 48 hours after a decision to do so.

The Secretary shall also assist State, local government, and regional entities in tailoring templates to fit differing geographic sizes, population densities, and demographics, and other unique or specific local needs.
Of course, moving medicine is relatively easy. Moving people, and then finding suitable space for their treatment, is harder. The next component of the plan, Mass Casualty Care, addresses this issue:
Within 180 days after the date of this directive, the Secretary of Health and Human Services, in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security, shall:

(a) build upon the analysis of Federal facility use to provide enhanced medical surge capacity in disasters required by section 302 of PAHPA to analyze the use of Federal medical facilities as a foundational element of public health and medical preparedness; and

(b) develop and implement plans and enter into agreements to integrate such facilities more effectively into national and regional education, training, and exercise preparedness activities.

Here's where I start becoming skeptical. The call here is to use federal facilities for excess capacity. That's sensible, of course, but it begs the question: "Just how much excess capacity might we need, and are these federal facilities capable of providing it?" The question is unanswered but vital.

One way the plan intends to limit the need for bedspace is by (sensibly) anticipating and attempting to mitigate the problem of the "worried well."
The impact of the “worried well” in past disasters is well documented, and it is evident that mitigating the mental health consequences of disasters can facilitate effective response. ... [T]he Secretary of Health and Human Services, in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security, shall establish a Federal Advisory Committee for Disaster Mental Health. The committee shall ... submit to the Secretary of Health and Human Services recommendations for protecting, preserving, and restoring individual and community mental health in catastrophic health event settings, including pre-event, intra-event, and post-event education, messaging, and interventions.
That's good. But what if actual healthcare needs exceed current capacity?

When it comes to Community Resilience - creating a well-prepared public that is ready for a major health catastrophe - the strategy devolves into wishful thinking. To some extent this is understandable, as preparing the public for disaster - any disaster - is always a struggle. Here's the entire plan:
The Secretary of Health and Human Services, in coordination with the Secretaries of Defense, Veterans Affairs, and Homeland Security, shall ensure that core public health and medical curricula and training developed pursuant to PAHPA address the needs to improve individual, family, and institutional public health and medical preparedness, enhance private citizen opportunities for contributions to local, regional, and national preparedness and response, and build resilient communities.

Within 270 days after the date of this directive, the Secretary of Health and Human Services, in coordination with the Secretaries of Defense, Commerce, Labor, Education, Veterans Affairs, and Homeland Security and the Attorney General, shall submit to the President for approval, through the Assistant to the President for Homeland Security and Counterterrorism, a plan to promote comprehensive community medical preparedness.
That's it? Include more community-focused subject matter in public health curricula and submit "a plant to promote comprehensive community medical preparedness"? This sounds like the classic case of the boss having a clear idea of the goal, but no clue how to get there - so he tells the subordinates, "You solve this."

Again, I sympathize. It would be easier if we still lived in a 19th-century world, where most health care was administered at home. People would be better prepared to deal with problems themselves. (Though more people would become more ill and more people would die.) But we're not. We live in a world where, when you get really sick, you expect to be able to go to the doctor - or the hospital.

It's a huge job to try to prepare citizens for a major health emergency. Just changing the public health curricula and "developing a plan" doesn't seem like it's going to cut it.

Update 2007-10-31: Over at In Case of Emergency, Jimmy Jazz (who knows more about these things than I) provides his first impressions of HSPD 21. His eyebrows are deeply furrowed:
My first reaction after reading it? It’s completely undo-able. I commend the drive, no doubt, but the timelines are totally pie-in-the-sky.
Jimmy plans to review the document in much greater detail in coming days and weeks, which will be worth keeping an eye on.

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