State-by-State Report on the Status of Emergency Medicine

As a nice complement to the "Ready or Not?" report released earlier this week, the American College of Emergency Physicians has published its annual "National Report Card on the State of Emergency Medicine," which examines emergency medicine on a state-by-state basis and concludes that:

The emergency care system in the United States remains in serious condition, with numerous states facing critical problems. That is the disturbing but unmistakable finding of the 2009 edition of "The National Report Card on the State of Emergency Medicine," a report designed to provide the American public with an objective assessment of the emergency care environment across the country.

Which is, of course, not a surprise. For years, hospital managers have applied "just-in-time" principles to their operations, in an attempt to hold down spiraling costs. They've trimmed as much fat as possible, leaving hospitals with little surge capacity.

Granted, we are stockpiling vaccines and other medications, which will help in the event of the inevitable health care crisis. (I'm less sanguine about our ability to deliver them in a timely, organized, effective manner; but that's another story.) Unless we re-build some excess capacity in our health care system, other necessities such as bed space, health care staff, respirators, etc., are simply not going to be there.

We pays our money, we takes our chances...

Worthwhile Reading: "Marrying Prevention and Resiliency"

There's some good food for thought in this occasional paper from RAND, which advocates a "hybrid" approach to prevention and mitigation:

Instead of seeing an either/or choice between traditional prevention and mitigation or resiliency measures, it is more productive to consider them together in an integrated way—as two complementary elements of a strategy aimed at lessening the consequences of successful terrorist attacks. Doing so essentially stretches the concept of prevention beyond the ideal of halting attacks before they happen to also include efforts to limit the human and economic costs of even successful attack operations.

It's not a terribly long read, and it's worth the time.

We still haven't found the right balance of prevention, mitigation, and response. The unfortunate political reality is: It's much too easy to allow preventive efforts to devolve into "security theater"; it's much to easy to give short-shrift to mitigation, despite the effectiveness of many mitigatory efforts, because mitigation almost always lacks sex appeal; and it's much too easy to overemphasize response, since everybody wants to take the credit for a successful response to the inevitable disasters and nobody wants to take the blame for an unsuccessful one.

Earthquakes in the Midwest: Who's Prepared?

Not good news:

Tennessee is the only one of eight states in the Central United States Earthquake Consortium to finish its revision to the Catastrophic Event Annex of our state's emergency-management plan.

Anyone in the Midwest who's unprepared for a major earthquake simply doesn't appreciate history. In 1811 and 1812, three enormous quakes in the New Madrid seismic zone devastated a wide area. Fortunately the population was very low at the time. But today? Memphis and St. Louis are both in the zone and could sustain major damage from a big quake.

Check out November's report by the Mid-America Earthquake Center, which said:

[T]he total economic impact of a series of New Madrid Seismic Zone (NMSZ) earthquakes is likely to constitute by far the highest economic loss due to a natural disaster in the USA.

An earthquake of magnitude 7, as has been predicted, or a recurrence of the 1811-1812 series could have devastating impacts on the region, with considerable national repercussions, as transportation routes, natural gas and oil transmission pipelines are broken and services are interrupted. Preliminary estimates, including those completed by the Mid-America Earthquake Center (MAEC), found that economic losses from a magnitude 7.7 (Mw7.7) event in the NMSZ could reach $50-$80 billion dollars in direct losses alone. Additionally, there could be thousands of fatalities, tens of thousands of injured victims, and even hundreds of thousands left without homes.

According to Hildenbrand et al. (1996), the chance of a magnitude 6 or 7 earthquake occurring within the next 50 years is roughly 90%.

1812 seems like a long time ago, but complacency is unforgivable.

Quickly Noted: Annual "Ready or Not?" Report Published

The Trust for America's Health has released its annual "Ready or Not?" report, analyzing the readiness of the U.S. public health system for a major biological disaster. The report includes state-by-state rankings and always makes for interesting, if somewhat depressing, reading.

Here's the press release and summary of key findings. Here's the full report (pdf, 2.6MB).

LA Re-thinks Emergency Management

The Mayor's office in Los Angeles has released a new emergency management initiative.

This initiative ... involves several components to enhance the City’s planning and preparedness efforts, train city employees in disaster response, better prepare the community in disaster preparedness, and modernize the City’s antiquated emergency management structure.

Here's one thing I find interesting. To describe the current state of preparedness, the city uses measures such as staffing levels, training exercises, programs and strategies. For example:

[T]he City Council recently approved the Mayor’s request to add three new positions to EMD to work on planning and preparedness activities, emergency operations, and public information. In addition, through the leadership of General Manager Jim Featherstone, a former Captain in the LAFD’s Planning and Tactical Training Division, EMD is modernizing its operations, procedures, and principles to reflect a contemporary emergency management approach to the numerous dangers the City faces.

But that's not the best measure of preparedness. Real preparedness has to be measured in terms of capabilities. It's not just how many training exercises you have, the size of your staff, or the strategies and tactics you employ. Those are necessary, yes. But they're not sufficient. If you're going to assess your state of preparedness, you need to be able to declare with some confidence what your capabilities are.

Planning for a Pandemic? Meh.

In direct contrast to the immediately previous blog entry, and a week after the NYT's Freakonomics blog asked, "Why do voters reward poor disaster preparedness?" a story comes out of Georgia about some local elected officials who haven't even shown up to the meeting to prepare for a pandemic flu:

Jones County’s biggest problem with a pandemic flu occurrence may be the perceived apathy demonstrated in planning for the event by local elected officials.

Jones County’s pandemic flu preparedness committee met July 17 at the Emergency Management office and has the task of educating the public to the reality of having to be self-sufficient if the disease hits. In the case of a pandemic, communities cannot be dependent on federal or even state assistance.

City and county elected officials were conspicuous by their absence at the meeting with Probate Judge Mike Greene the sole representative.

They also didn't show up to a table-top exercise in February:

An after-action report by the North Central Health District Office about Jones County’s Feb. 20 table top exercise stated, “The fact that no elected officials or business leaders were present at the exercise lends itself to the belief that the leadership of Jones County does not seem to have bought into this concept.”

Any local official who isn't involved in this type of planning is doing their community a great disservice. A pandemic is not a question of if, but when. And every community will be affected.

I've bolded the key concept in red. Every local official needs to realize that in the event of a major pandemic, local communities are going to be largely on their own. Local planning is essential.

Preparation In the Absence of Press

The threat of pandemic flu has gotten a lot less press lately, mostly because the incidence of avian flu seems to have plateaued somewhat (though Indonesia is still being really tight-lipped about what's going on there, so who really knows?)

But even though the issue is getting less attention in the media, some communities are continuing to do the smart thing and developing plans to address a pandemic flu. It's worth remembering that there's no guarantee that the source of the next human pandemic will be avian flu. It could come from another source, and it could conceivably come out of nowhere and surprise us.

So it's good to see local communities, like these in South Dakota, working together to develop plans to deal with the threat, which in its severest instances (e.g., an event comparable to the 1918 Spanish Flu outbreak) could have more widespread impacts than almost any other catastrophic event:

After more than a year of work, the members of a local planning committee will present their pandemic influenza response plan to the public.

The 131-page plan was developed by committees from Aurora, Davison and Hanson counties and it provides guidelines on how to deal with a pandemic flu outbreak that many medical professionals believe is inevitable.

[The plan] provides action checklists to help schools, businesses and other community organizations develop a coping plan, in the event of a flu outbreak.

A family preparedness kit will ... demonstrate what items should be on hand in the event of an epidemic. Such preparedness will be important in the event of a flu outbreak.

While the Centers For Disease Control and the state Health Department will monitor and report on all flu outbreaks, said Assistant Mitchell Fire Chief Steve Willis, local jurisdictions will largely be on their own.

Apathy is the greatest danger when it comes to planning for a dangerous flu outbreak, says Jim Montgomery, Davison County Emergency Management director.

Mr. Montgomery is absolutely right - the best community-based plan will be useless unless individual citizens, businesses and other entities such as churches and community groups do their part to prepare.

In my humble opinion, the effort to create the plan ought to be dwarfed by the effort to distribute it, publicize it, and follow up to ensure that people are prepared. According to the Red Cross, more than 90 percent of Americans are not prepared for a major disaster. In Mitchell, only about 40 people (in a population of 15,000) showed up at the meeting to learn about the pandemic flu plan. But as the dedicated John Solomon regularly and diligently reminds us (because repetition makes a message stick) citizen preparedness is vital.

The Holy Grail of preparedness is getting more individuals to prepare on their own. Every citizen that's adequately prepared will help the system - not only by being better off themselves, but also by reducing the strain on community services, improving the situation for their neighbors as well.

Cool Tool For Tracking Disease Outbreaks

Healthmap

(h/t Effect Measure)

Sensible Medicine

The Florida legislature recently passed a law that makes sense. It will allow people to refill prescriptions in an emergency, even if their insurer says they're not yet due for a refill:

Recently, the Legislature passed the Emergency Prescription Refill bill (Florida Statute 252.358 and 462.0275). This law requires all insurers and managed-care organizations to suspend refill-too-soon restrictions when a patient seeks a refill in a county that:

• Is currently under a hurricane warning issued by the National Weather Service
• Is declared to be under a state of emergency in an executive order issued by the governor
• Has activated its emergency operations center and its emergency management plan

This law also allows patients outside of these areas to get an emergency 72-hour refill if the pharmacist is unable to readily obtain refill authorization from the doctor.

In certain cases, simply telling people to "be prepared" is not enough. Sometimes you've got to remove obstacles for them. This law is a good example of that.

FEMA: The Iceman Will No Longer Cometh

Catching up on this one:

FEMA Administrator R. David Paulison said in April his agency will only distribute ice for medical emergencies or life-threatening situations following a disaster. Since its inception, FEMA has provided ice to disaster victims, especially in areas where power outages occur.

“We’re not in the ice business anymore,” Paulison said, and that it is not a “life-saving commodity” for most people. “It takes a tremendous amount of resources, and it really doesn't accomplish much, other than making people feel good because they have a bag of ice," Paulison added. “Ice is more of a comfort thing.”

“My response is that during July, August and September in South Mississippi, ice is not necessarily used to cool water to drink,” said Don McKinnon, director of the Jones County Emergency Operations Center (EOC). “During emergencies, it is used for medical purposes to keep specific medications cool, to help keep food good in refrigerators until power can be restored, and for cooling people off. It is a necessity here."

With the current situation (FEMA out of the ice business), McKinnon said the “state is trying to take up the slack. They (state emergency agencies) have limited resources, and can’t do it quite as effectively as FEMA did. Our pockets aren’t that deep. Locally, we hope we keep water pressure and generators to try to provide ice. Large chicken plants produce large amounts of ice and they have been kind enough to share it with the citizens of Jones County. After Katrina, they provided several thousands of pounds of ice.

“Who will distribute the ice?,” McKinnon asked. “We don’t have the manpower or resources to do that, or don’t have funds to buy ice and give to people. It’s a big void in our plan right now; we don’t know what we’re going to do. If we’re able to get any ice at all, it will probably be from the state if local providers are down. We will definitely focus on medical needs, and the elderly and young to keep them cool to prevent heat stroke and deaths."

This needs to get worked out. Your bottled water may not need ice, but your food and medicine do. The big question: How does FEMA define a "medical emergency" or "life-threatening siutation"?

Here's what's puzzling to me: It's fine if FEMA doesn't deliver the ice themselves - they have already vowed to get out of the logistics and transportation business, leaving that work to contractors. But with their buying power and their network of suppliers, they ought to be able to facilitate the supply of necessary ice during an emergency.

This also seems to show a disconnect between state and local homeland security and DHS/FEMA. Did FEMA get local input before making this decision?

Disaster Preparedness: Status Update

Shameless linking:

HSToday does a good job summarizing a number of recent reviews of the federal disaster preparedness system.

Shameless quoting of a few key points:

DHS “needs to better integrate stakeholders in its revision of key policy documents, particularly the National Response Framework,” stated William O. Jenkins, Jr., director of GAO homeland security and justice issues.

[In] the National Pandemic Strategy and Implementation Plan, [GAO] found that there are numerous shared leadership roles and responsibilities, leaving uncertainty about how the federal government would lead preparations for and response to a pandemic.

[G]iven what a good many authorities – including federal preparedness insiders – have told HSToday.us about preparedness problems throughout the federal government (see HSToday.us’s reporting on emergency medical care, pandemic planning, and FEMA disaster preparedness), the ability of the federal government to adequately respond to a major and catastrophic disaster or crisis clearly is in doubt - despite the fact that the government's readiness today is clearly far, far better than it was just a few years ago.

"There is a real concern among the state homeland security directors around the country that there are people in the federal government who want to put the interests of the accountants ahead of the interests of our citizens. That would be a grave mistake," the subcommittee was told by Alabama Department of Homeland Security Director, James M. Walker, Jr.

It's not all bad news, though it may seem so from the excerpts above. DHS is moving forward slowly, slowly...

Defining Resilience Isn't Enough; It Must Also Be Facilitated

Rich Cooper at Security Debrief points out that the flooding in the Midwest provides a good example of resilience:

If you are looking for real-life resiliency happening today, pay close attention to what is happening right now in the heartland of America. Over the past several days, the citizens of Cedar Falls, Iowa, have filled hundreds of thousands of sandbags to save their City from the rising waters of the Cedar River. Thousands of volunteers of every age and walk of life have stepped forward to fill bag after bag and put them in place to save their ‘homeland’ and preserve the ‘security’ that it brings to them.

Cedar Falls and others like her in the Midwest that are fighting the ‘battle’ for survival represent the personification of resilience. They are offering us all a teachable moment and we all have a lot to learn.

There was no legislative mandate that made the citizens of Cedar Falls step forward to fill sandbags and stack them atop one another. Nor were there FEMA checks handed out to make them come downtown to save the City streets from more ruin. They just showed up and did it. They were business owners, employees, parents, students, etc. – all citizens committed to the survival of what is important to them. That is what resilience is: action that enables survival. Before we allow the word to become so overused that it loses its meaning (e.g. interoperability), we need to remember that people focused on a mission are at the center of resilience.

True enough, but it leaves out a crucial point: It's not enough to rely on the willingness of citizens to step forward, pitch in, and try to save their own communities. Citizens have always done so, and will continue to do so. And this sort of activity has always been more organized and effective in localized disasters such as the Midwest flooding than in widespread, catastrophic disasters.

The key to resilience, especially for catastrophic disasters, is to create systems that facilitate those efforts - by citizens, by businesses, by public agencies - so that they are as effective as possible. I'm talking about communications systems, logistical systems, healthcare systems, etc.

In a catastrophe, these systems will spontaneously organize themselves through whatever means are available, even if no planning is done. But it's the job of homeland security professionals to ensure that the planning is done, and that when the disaster happens, the systems that support citizen action are as robust as possible.

So while the activity of "people on a mission" is at the heart of resilience, it's only a necessary but not sufficient condition. The engine that makes resilience go is the creation of reliable systems that facilitate the actions of those responders.

FEMA's Revised Logistics Operation

The Federal Times takes a look at FEMA's revised logistics operation:

“Katrina showed we did not have the capability in place to replenish what we had,” said Eric Smith, FEMA’s national logistics coordinator. “Our reliance was too much on what we had in stock.”

FEMA has developed several new approaches to disaster preparation. One is transparency: making visible to everyone concerned what FEMA has in stock — items such as blankets, generators and portable housing units.

Another is partnerships with first responders, such as the Red Cross, which is often first on the scene with first aid, food and temporary housing, and the Army Corps of Engineers, which is charged with providing ice, water and emergency power.

Also, FEMA has forged a closer link with the Defense Logistics Agency to help it provide fuel, food, water, cots, blankets, “anything in their inventory,” Smith said.

Tom Essig, chief procurement officer at the Homeland Security Department, FEMA’s parent agency, gives another example.

“After Katrina, FEMA bought ready-to-eat meals. We don’t do that now. Now we contract. When we need it, we provide it. We don’t buy and store any more. We buy the service, which includes the transportation. The companies themselves are responsible for the logistics of transportation,” Essig said.

This is more in line with FEMA's structure and purpose. FEMA is not supposed to be a massive agency that stockpiles emergency supplies and delivers them in the event of a disaster. FEMA is a relatively small agency that needs the authority (and often the political cover) to direct other, larger agencies to do what needs to be done.

As Katrina showed, situational awareness and communications are two more critical requirements for FEMA. The best logistics system in the world won't do you any good if you don't have information on what is needed where, or if those needs can't be communicated.

Cheap Preparedness Stuff

Good idea: In conjunction with Florida's Hurricane Preparedness Week, retailers have lowered the prices on items that can help citizens become better prepared:

Governor Charlie Crist today joined state and local emergency managers and the Florida Retail Federation to promote Florida Hurricane Preparedness Week, May 25-31, 2008. He announced that some Florida retailers will be hosting special sales on hurricane supplies, beginning Friday, May 30, and continuing through June 8.

Some of the items included on the emergency supply list include:

· Flashlights and portable, self-powered light sources
· Portable radios, two-way radios and NOAA weather-band radios
· Flexible waterproof sheeting (tarps)
· Gas or diesel fuel containers
· Batteries
· Medications
· Ice chests or other food storage coolers
· Portable generators
· Carbon monoxide detectors
· Storm shutter devices
· Pet carrier and supplies

That's nice public-private sector collaboration.

Review - Disaster Response and Homeland Security: What Works, What Doesn't

It's time for another book review. This one is James Miskel's Disaster Response and Homeland Security: What Works, What Doesn't (2006). In general, I found that the book accurately identified some of the problems with disaster response, but I'm somewhat skeptical about some of the proposed solutions. Let's dig in:

Problems With The Current System

In discussing the problems with the disaster response system in the U.S., Miskel argues that it often works well for smaller, more common disasters, but not for major catastrophic events:

There has, indeed, been a pattern of "failure" in meeting the needs of the victims of certain types of catastrophic disasters. ... Where preparedness is lacking is in the realm of out-of-the-ordinary disaster.

But the disaster response system has not been improved because it generally works well and fails only in less frequent catastrophic disasters, especially hurricanes:

In fact, few studies look at disaster relief as a system that is built upon a network of interdependence among too-numerous organizations. That network usually functions reasonably well, but it has repeatedly stumbled over its own feet in certain types of major disasters. ...

[A] review of the history of the disaster relief program indicates that the system has never responded well to major hurricanes.

Given that after-action reports on many catastrophic disasters have identified the same problems, again and again, Miskel argues that big changes are needed:

It seems clear that this fine-tuning has not made enough of a difference and there is no reason to believe that the answer is more fine-tuning.

As I said earlier, Miskel identifies a number of problems inherent in the system. First, there are many cooks in many kitchens, which seriously complicates the response to major disasters:

Private sector organizations, state and local government agencies, and federal agencies each have their own disaster relief programs and the challenge imbedded (sic) in the system is how to orchestrate these multiple programs effectively. ...

Just as uncertainly and information overload are inescapable features of war, they seem as well to have been inevitable in the responses to major relief operations. What has made them inevitable is, of course, the scale and geographical dispersion of the disaster itself and the complexity of the response system itself - with its too-numerous actors at the federal, state, and private sector levels...

This problem plagues the response at all levels, not just the federal level:

When Hurricane Hugo struck the state [of South Carolina], the governor's office chose to rely upon the state police radio network to collect information about storm damage, rather than the network that had been set up by the emergency management agency. ... Whatever the motive, the result was that there were two emergency operations centers in the state: one in the governor's office and the other at the emergency management agency, and there were reports that for ten days the emergency management agency did not even know that the second emergency operations center existed.

Another problem, Miskel argues, is that the current reimbursement system provides an incentive for state and local governments not to prioritize preparedness. In the wake of a disaster, the president decides whether to issue a formal disaster declaration, making the state or local entity eligible for federal reimbursement of costs. Then, the federal government makes a political decision regarding the rate at which reimbursement will be provided - usually, 75%, 90% or 100% - though in major disasters the rate tends to creep up, as federal elected officials want to be seen as generous in a time of crisis. Miskel argues that this has a negative effect on the preparedness efforts of state and local governments:

Ninety or 100 percent reimbursements amplify the incentives for states, local governments, and even individuals and private sector organizations to spend less on preparedness on the presumption that whatever the costs are of inadequately preparing for disasters, most if not all of them will ultimately be assumed by the federal government.

The only time there is a focus on preparedness is in the aftermath of a major disaster such as Katrina. But the focus and energy soon fade:

Coordination of before-the-disaster preparedness efforts, on the other hand, is rarely either proactive or consistently effective. Except in rare circumstances (such as the immediate aftermath of disaster when the images of the destruction and suffering are still vivid and the political pressures for action are still strong) preparedness measures have historically been regarded as a low priority relative to other government functions. As a result, the coordination of preparedness at the federal and state level has been only intermittently energetic.

One noteworthy exception: Miskel points out that some private-sector entities, such as insurers and utility companies, have a strong economic incentive to respond quickly and effectively to disasters. And as a result, these entities have generally done a better job of focusing on preparedness.

For its part, the federal government tried to deal with the problem of insufficient preparedness in 1979, when it created FEMA. But FEMA was never vested with sufficient authority to overcome this structural obstacle:

[When FEMA was created in 1979] the prescription was for centralized federal orchestration of preparedness planning at all levels of government by a new agency, FEMA. The executive order did not, however, give FEMA enough clout to overcome the low priority that is ordinarily assigned to preparedness.

As a result, when there a major disaster does strike, the White House usually finds it necessary to play a direct role:

[O]ne of the lessons that can be drawn from tropical storm Agnes [in 1972] is that a heavy White House hand is sometimes necessary to achieve responsiveness and unity of effort within the family of federal agencies. ...

[Hurricane Andrew] was another example of the need for the White House to take special steps to ensure unity of effort by the federal agencies. The other examples that have been noted so far are Vice President Agnew's fact-finding tour after tropical storm Agnes; Jack Watson's interagency strategizing in the Carter White House, and the appointment of Harold Denton as the president's "personal representative" during the Three Mile Island episode; President Clinton's flood relief summits during the Midwest floods; and the replacement of the FEMA Director by Coast Guard Admiral Thad Allen in the response to Hurricane Katrina.

So, federal operational leadership is not the reason why the system tends to succeed in response to disasters that are relatively limited in scope. Miskel credits others:

When it succeeds, the disaster relief system does so not because of inspired operational leadership at the federal level, but because it is a system whose pieces have been built beforehand, over time in response to federal preparedness policies, state and local government initiative, and private sector response to market incentives and regulation, as well as the dedication of private voluntary organizations, and the acumen of individuals and families.

Miskel expects nothing to change:

Given the fact that preparedness has always ebbed in the months and years after events such as a major earthquake, hurricane, or terrorist event, there is no reason to expect anything different in the future as long as the existing structure of the disaster relief system remains in place.

So, in review, the basic problems are a too-complicated system, a low priority on preparedness, and an overreliance on federal assistance, especially operational assistance.

Solutions

In discussing potential solutions to these problems, Miskel compares the disaster relief systems in the U.S., Canada, and Australia. These other countries are like the U.S. in that they have developed economic infrastructure, and each also has a federalist system of government in which states and provinces have important - and in many cases, primary - responsibilities.

In making these comparisons, Miskel spends much effort on describing the process by which reimbursements are doled out to Canadian and Australian provinces, in comparision to U.S. states. It is clear that the reimbursement system in both Australia and Canada is both de-politicized and less generous than the U.S. system. Miskel argues that there's an important effect to this:

Lower reimbursement rates are an important consideration. Not only do they restrain federal spending, they also give a stronger incentive for states to take emergency preparedness seriously because that helps reduce costs and to manage their disaster relief expenditures carefully.

Miskel suggests the Canadian model as exemplary. Under Canada's system, provinces are responsible for all disaster response and recovery costs up to $1 per capita, after which the federal government kicks in 50% of all costs up to $3 per capita, 75% of costs from $3 to $5 per capita, and 90% of costs over $5 per capita. Miskel writes:

If the right [reimbursement] trigger were established, as it appears to have been in Canada, states would always have the financial incentive to manage relief operations effectively because their share of the costs would never get as low as it does in the United States.

Recalling the earlier point that federal operational leadership is not often the determining factor in the success of a respons, Miskel's more significant proposal is for the federal government to largely abandon the disaster response business and focus on preparedness. He argues that the federal government's direct involvement in response activities is actually a detriment to an effective response:

One of the surest ways to weaken the self-organizing features of response in the private sector and at the state and local government level would be for the federal government to assume a more direct role in managing disaster responses. The very last thing that the federal government should do is crowd initiative at nonfederal levels out of the system in the name of improving the federal response to catastrophic disasters. ...

The more effective and proactive the federal government becomes at providing disaster relief and the more generous it is in reimbursing state/local governments, the more it may be encouraging the states to trim their investments in preparedness.

As the federal government preempts the states in more and more disaster responses, the result will be the displacement of the very things that make the system work most of the time - state, local, and private sector preparedness and initiative.

Miskel argues that unless the federal government abandons operational assistance for "routine" disasters, not only will state and local governments continue to provide a less effective response, but the federal response to major catastrophes will always be less effective than desirable, because FEMA will always train and prepare for routine events rather than catastrophic ones:

[A]s long as the responsibility for routine and catastrophic disasters remains in FEMA or a successor agency, the habits and protocols that the agency learns and repeatedly relearns during the course of responding to the forty to sixty disasters that are declared in a typical year will necessarily dominate its culture and influence how it responds to atypical disasters.

The answer, Miskel argues, is for the federal government to focus almost exclusively on preparation for major disasters:

[I]f the federal government were to get out of the business of responding to routine disasters, it would be better able to concentrate on addressing the shortcomings in preparedness that have been identified after each of the catastrophic disasters since 1972.

If the Canadian or Australian model were adopted for routine disasters, presidential disaster declarations would become considerably less frequent as they would be required only when a state requested physical, operational assistance from the federal government. ... As state governments would then become unambiguously responsible for disaster response, this should result in greater political attention to preparedness at the level of state and local governments.

So state and local governments would be clearly in charge for routine disasters - but what about major disasters? What sort of steps would the federal government take, once it took charge of preparedness for major disasters? Miskel would give the military much of the job of designing the response system:

[C]onsideration should be given to assigning the military with the mission of developing and managing both a command and control structure for disaster operations and a program for conducting drills and exercises that would work out over time the kinks in command and control procedures, identify gaps in operational plans, and train federal agency personnel.

And since White House pressure is always needed in major disasters anyway, Miskel would formalize this:

In any event, greater White House involvement will be essential if the shortcomings of the past are to be avoided in the future. ... The responsibility for overseeing federal and system wide preparedness should be taken from FEMA and added to the vice president's portfolio or assigned to an Emergency Management Council based in the White House.

I like Miskel's ideas regarding the de-politicization and limitation of the reimbursement process - it never makes sense to incentivize inadequate preparation.

I also agree with his argument that the disaster response system generally deals quite effectively with smaller, more localized disasters.

But I'm less persuaded by his proposed fixes for the federal system. Essentially the argument seems to be that if the military and the White House take over, they will have sufficient capability and power to bring the federal operational response under control, even during a chaotic response to a catastrophe. But how will the federal government interact with state and local governments? How would federal agencies perform during catastrophic operations that are, by definition, infrequent events? How much more seriously will the federal government take its preparedness efforts? Won't the tendency to short-shrift preparation for unlikely catastrophic events persist, even if the charge is led from the White House? Would the White House be able to improve the response under the proposed system, moreso than in the current system, when it has to get involved anyway?
Essentially it seems like the details of the federal response would be kicked over the wall, into the Pentagon and the White House. And it's not clear to me that those are the silver bullets to fixing the federal response system.

On Resilience

HLS Watch has a nice recap of yesterday's hearing on resilience by the House Homeland Security Committee. A key takeaway from Jonas' post:

DHS Assistant Secretary for Policy, Stewart Baker, represented the federal government and its views on resilience, as well as current efforts to invest in this capability. Much of A/S Baker’s prepared remarks focused on the ability to “bounce back” as the goal of resilience. This is important, but it leaves out other dimensions that make the concept of resilience valuable (i.e. deterrence, measured response, dual use, etc.).

Yep.

You're not going to be able to sell resilience as a policy unless you can argue that a resilient target is an unattractive target. Politically, you just can't say, "We must beef up our systems so that when the terrorists destroy them, we'll be able to rebuild quickly." But given that al Qaeda seeks to harm us economically, there is a persuasive argument to be made that resilient systems will be a less tempting target.

Dumb analogy: You know all those action, sci-fi and horror movies, where it doesn't seem to matter what you do to the bad guy - he reacts as if nothing happened? Well, this attribute - all by itself - makes him a pretty formidable adversary. As viewers we begin to despair for the hero. We think, "Why even bother fighting this guy - nothing works!"

Of course in the movies, the small, scrappy good guys always win because they're the good guys. But in the fight against terrorists, the small scrappy guys are pretty darned abominable. If the U.S. is a resilient, indefatigable force for good (read: soft power), we are clearly the stronger horse and the more attractive option. Choosing terrorism becomes a dual loser: You choose not only an abhorrent ideology, but futility as well.

In Case of Terror Attack, Good Luck Getting in the Hospital

Not surprising: Emergency rooms in major cities may not be sufficiently prepared for an influx of patients that would result from a major terrorist attack.

There are certainly some politics being played here, but the basic fact that we've lost hospital capacity in general, and ER capacity in particular, is accurate:

[T]he House Committee on Oversight and Government Reform, chaired by Rep. Henry Waxman, D-Calif., conducted a survey of 34 hospitals on March 25 and found that not one was prepared at that moment on that day for a terror attack.

"The situation in Washington, D.C. and Los Angeles was particularly dire. There was no available space in the emergency rooms at the main trauma centers serving Washington, D.C. One emergency room was operating at over 200 percent of capacity: more than half the patients receiving emergency care in the hospital had been diverted to hallways and waiting rooms for treatment. And in Los Angeles, three of the five Level I trauma centers were so overcrowded that they went 'on diversion,' which means they closed their doors to new patients. If a terrorist attack had occurred in Washington, D.C. or Los Angeles on March 25 when we did our survey, the consequences could have been catastrophic. The emergency care systems were stretched to the breaking point and had no capacity to respond to a surge of victims."

In the interest of keeping costs down, hospitals have shed excess capacity, shortened hospital stays, kept fewer supplies on hand, etc. At the same time, the 47 million uninsured know the only place they can reliably get immediate medical care - emergency or not - is the ER.

So you've got a situation where many ERs are regularly maxed out. A surge in patients, whether it results from a major accident, terrorist attack, or naturally occurring disease, could very quickly overload the system.

It reminds me of an example Steve Flynn provided in The Edge of Disaster: After a 2003 nightclub fire in Warwick, Rhode Island, in which 96 people died and 215 were injured, the health care system in New England was fully taxed in trying to accommodate even that number of patients. Considering that the concentration of hospitals is relatively more dense in New England than it is in most locations in the U.S., that ought to give public health professionals and emergency response planners something to think about.

Update 2008-05-09: HHS Secretary Michael Leavitt agreed that there's a lack of surge capacity:

"There are deficiencies in our surge capacity..." Leavitt testified.

Leavitt said HHS will report by the end of the year the results of a nationwide survey of surge plans and capabilities. He said a survey is underway of hospitals' ability to electronically track and report the number of available beds on one hour's notice.

"Surge capacity is about using existing assets to convert to a hospital capacity very quickly. It is not simply using the emergency room," Leavitt said.

It's not clear to me what reason - other than politicking - there is for just studying the scope of the problem rather than beginning to address it. If you know there's a lack of surge capacity, you could start mitigating it even as you study its scope.

Disaster Response in Israel: Relationships Count

Interesting comments in this article from the National Guard Bureau on the trip made by NG representatives to a disaster exercise in Israel. They accompanied the Israeli Defense Force’s (IDF) Home Front Command (HFC), which is Israel's version of a National Guard.

For me, this was the key take-away:

Guard leaders also observed how the HFC works with civilian authorities and shares civilian assets to supplement its own after a disaster. Contrasts and similarities between how the National Guard and the HFC do business include:

• Bottom-up versus top-down. “Everything in the United States is local and then it ratchets up to the state and then the governor asks for the feds,” explained Col. Brent Feick, chief of the National Guard Bureau’s future operations division. “It’s a little quicker response from the feds in Israel, where the fire battalions and the police have a much more limited capability, and they rely more heavily on the HFC. Normally the governor wouldn’t call the National Guard until it was a much larger event because we put more effort in each state trying to take care of themselves. We’re the last in and first out. That’s our concept. In Israel, the HFC is almost always in there very quickly.”
  


• Close local relationships. State National Guards are building relationships with mayors, police departments and other agencies at the most local level, Feick said. The military service required of every Israeli has helped the HFC build close ties with local agencies. “No matter where you are in the country, you have an appreciation for how the IDF and the HFC works,” Feick said of the Israeli system. “The mayor of Nazareth knew to donate the building … for this exercise because of his prior military experience. He knew that this would be an advantage to the brigade commander up here.”

The lesson? It doesn't matter if your system is bottom-up or top-down. What matters is relationships - being able to see what's needed from others' perspectives. That's an irreplaceable key to success.

Every Special Event Is A Disaster

And no, I'm not talking about the upcoming wedding season.

I'm talking about the fact that Boston used this year's marathon as an opportunity to test elements of its disaster preparedness system. It only makes sense to do so, as the marathon brings in large numbers of people and creates an inherently complicated environment for a disaster response. Large gatherings also provide tempting targets for potential terrorists, as we have seen before in other places.

According to Boston Emergency Medical Service (BEMS) chief Richard Serino, his department considers events like the marathon and the Fourth of July celebration as "planned disasters" - safe, controlled environments that present "an opportunity to test some things you would never want to test in a real disaster."

Although the principal goal during such events remains the safety of everyone involved, organizers have realized that these annual gatherings of hundreds of thousands of people present the perfect opportunity to evaluate new technologies, exercise disaster plans, and build vital relationships between public safety agencies and the private sector.

That last bit, public-private sector partnerships, is especially important, as I've argued before. But let's give credit where it's due. The fact that Massachusetts is focusing on public-private sector collaboration is not much of a surprise, considering that public-private sector engagement is one of the three major goals of the state's homeland security strategy. (Also see this post.)

Preparedness involves casting a wide net for potentially beneficial relationships. It's all about the network:

To successfully manage the marathon, BEMS and other public safety agencies must have relationships not just with the Boston Athletic Association, which organizes the race, but also with a diverse set of private organizations. These include, but are not limited to, private ambulance services that back up BEMS, and hotels and other businesses along the route that help make the behind-the-scenes operation of the marathon run smoothly. When a real disaster strikes, these contacts can be called upon to lend needed supplies and other assistance.

With the summer schedule full of activities in towns and cities nationwide, this is an idea that any community could employ.

(h/t W. David Stephenson)

Exemplary Disaster Response in Minneapolis

The U.S. Fire Administration (USFA) has released a new technical report on last August's collapse of the I-35 bridge in Minneapolis. It should be an inspiration for every jurisdiction to set dual goals:

1. To the extent possible, prevent and mitigate the risk of disaster in the first place. (It's worth remembering that this was a thoroughly preventable disaster.)
   
2. In the case that a disaster does happen, earn an after-action report as good as this one.

While the bridge collapse was no Hurricane Katrina, it was still a complex event involving two different disaster sites/access points (one on each side of the river), multiple jurisdictions, and a witches' brew of hazards. Yet the response was exemplary in many respects because local officials had prepared rigorously:

Local and State staff and officials from fire, law enforcement, emergency management, and public works received immediate alerts and, having trained together in classroom settings and through field exercises, knew what to do and with whom they needed to coordinate their response. Years of investing time and money into identifying gaps in the city’s disaster preparedness capabilities; acquiring radios for an interagency, linked 800 MHz system; and participating in training on the National Incident Management System (NIMS) and on the organizational basis for that system (the Incident Command System (ICS) and Unified Command) paid off substantially during response and recovery operations.

In 2002, Minneapolis elected officials and key staff took a hard look at its state of preparedness ... and conducted a risk assessment that identified areas where improvements were needed. The city wasted no time in resolving the gaps, aggressively pursuing Federal grant dollars, e.g., the Urban Area Security Initiative, and general fund dollars to pay for radio and communications upgrades, equipment, and training that together elevated its level of preparedness.

The local response to the bridge disaster—and the coordination with metro, State, and Federal partners—demonstrated the extraordinary value of comprehensive disaster planning and training. The City of Minneapolis was as well prepared as any local jurisdiction could be to handle a major incident.

The critical element was a collaborative working relationship that had been established among all agencies involved in the response. There is simply no substitute for a trusting working relationship to get things done:

The excellent working relationships that had been developed through joint interagency training, planning, and previous emergency incidents was one of the primary reasons that response and recovery operations went as smoothly as they did. As one leader commented “We didn’t view it as a Minneapolis incident; it was a city/county/State incident.”

When key personnel from the primary response agencies were asked to what they attributed their excellent response, without exception they answered, “relationships.” Those relationships were developed as a result of all the planning, training, and exercises that multiple agencies and levels of government shared in recent years. Responders knew whom to call for what resources. They knew to work through the established chain of command. They knew each other’s names and faces and had built a level of trust that made it possible to move quickly through channels and procedures. ... Turf battles, not uncommon in events of this size, were not a factor because of the relationships that had been developed over the years.

If there were just one factor that predicts success or failure in a crisis situation, collaboration is it.