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The Perfect Disaster Storm: Wrong Capabilities, Wrong Approach and Wrong Mindset:
Why We Are Not Better Prepared for a Bioterrorism or Other Major WMD Attack
By James Rush
Chief Operating Officer
JVR Health Readiness Inc.
August 2, 2010
As bad as the Gulf Coast oil spill is and as profound its effect will be on the environment, wildlife, the economy, and the lives and livelihoods of Gulf States residents, I believe it is just a preview of a much worse, human disaster that could come in the form of a weapon of mass destruction (WMD) attack.
The General Accountability Office (GAO) reports consistently point to America’s lack of capabilities to manage terrorist attacks involving biological agents, nuclear material or chemical agents.
Over the past decade, tens of billions of federal grant dollars have been awarded to states, selected cities and US possessions, along with guidance to help state and local governments develop systems for Bioterrorism preparedness. However, after years of preparedness funding, America is still largely unable to respond to and recover from a large-scale weapons of mass destruction (WMD) attack. While there has been a heavy emphasis and some success in building state and local capabilities, there has not been a significant increase in the capabilities to fulfill the federal missions outlined in the National Response Framework.[1]
This reality begs an answer to the question “why are federal agencies unprepared to back up state and local governments during natural disasters or a host of potential bioterrorism attacks on the USA?” I believe the answer to this question is that federal agencies lack senior operations experts capable of designing, procuring and managing National assets which could be used to support states and/or local governments during large-scale natural disasters or bioterrorism attacks.
A catastrophic disaster will require a large, comprehensive and long term federal response. The Gulf of Mexico oil spill disaster pointed out graphically how helpless federal agency leaders appeared, as they were forced to defer to BP to stop the spill, provide mitigation equipment to the affected areas and develop an ad-hoc response. Had the Mineral Management Service employed senior staff who understood the oil exploration business, it could have established a competent and effective deep water oil spill working group years ago. This group could have been chaired by the senior MMS operations expert and included group members with International experience in oil exploration inspections, mitigation equipment, oil rig safety equipment and response and remediation systems.
A recent Presidential executive order tasks HHS, DHS and the US Postal Service to develop the “national U.S. Postal Service model,” of distributing medical countermeasures to the American people during a biological attack. The idea calls for the US Postal Service (USPS) mail carriers, with appropriate law enforcement escorts, to deliver pharmaceuticals and other medical countermeasures to postal route customers. If there is a biological attack on large American population centers, this approach to dispensing antibiotics and other countermeasures will further illustrate a severe shortage of federal senior-level staff who understand the medical distribution and dispensing business. The designers of this model of countermeasures distribution and dispensing had little or no healthcare supply chain experience.
Federal response agencies are staffed with dedicated public servants who have exceptional academic, public health and research credentials. However, there are few people in federal response agencies with senior level operational systems design expertise who understand the healthcare response business of supporting a disaster requiring a federal response under provisions of the National Response Framework (NRF). The Federal Government’s lack of response experience may be part of the problem in future disasters, due in part to hiring officials with the wrong skill sets, taking the wrong approach to disaster readiness, and planning with the wrong mindset.
Wrong Capabilities: During the 1950s and 1960s the United States effectively planned for a nuclear attack by the Soviet Union. Leaders prepared the population for the real world consequences of an attack, and built healthcare capabilities to care for the potential huge surge of patients. The Federal officials didn’t say…. “Healthcare is a Private Sector responsibility” or “Our planning and response approach will be to provide grant dollars and advice to American hospitals for nuclear casualty care.” America had recently fought World War II and the Korean War and there was no shortage of medical and public health experts with real-life experience in developing mobile hospitals (like the ones we saw in the TV show MASH), as well as inventories and supply systems capable of distributing pharmaceuticals, medical supplies and equipment as well as a full complement of facility support equipment to sustain mobile hospital operations in the field.
We also had a very robust public health infrastructure and a well staffed Public Health Service Commissioned Corps, experienced in hands-on patient care. The Office of Civil Defense, the forerunner of FEMA, looked to the medical logisticians who had designed the medical facilities and support systems for the hundreds of thousands of war wounded, to design a Disaster Medical Care system. These experts designed the Packaged Disaster Hospitals, which would augment the Private Sector Healthcare Industry for caring for casualties resulting from a Soviet Union attack or any other large scale disaster or catastrophe. The system they designed was called the “Civil Defense Program.” The U.S. built 2,600 Packaged Disaster Hospitals to care for the anticipated medical care needs of America during a nuclear attack. Each of these Packaged Disaster Hospitals had 200 beds, three operating rooms, autoclaves an X-ray machine and laboratory department, a back-up power generator and enough medical supplies to last for seven days without resupply. These hospitals were backed up with a vast network of 21 GSA warehouses full of medical sustainment supplies and pharmaceuticals. Federal Health Officials understood the need to reinforce the private sector hospitals and medical centers.
Today, any major national disaster will likely cause irreparable damage to the healthcare supply chain and thus, to the American Healthcare Industry itself. In 2010, if a catastrophic attack takes place in a major American city (or worse, in multiple American sites), the Federal Government now has only cots and blanket sets with little more than sick room supplies with which to open or support state and local shelters. While these Federal Sets are supposed to be for sub-acute care only, these assets will inevitably be used as overflow facilities for overwhelmed hospitals. These units, known as Federal Medical Stations, are not supported with a dedicated medical logistics supply chain, and cannot provide care for trauma, burn, acute pain, diabetics, and persons with mental health diseases, people in need of dialysis or folks with a host of other special needs. Recent testimony of FEMA officials indicated that they were not prepared to meet the needs of the most vulnerable among us; persons with disabilities. [2]
Today, we have a profound shortage of senior-level disaster response experience at the Federal response agencies. A recent, vivid reminder of this was in the initial Federal response to the Gulf Oil Spill. We simply didn’t have the operational leaders who were able to pull together people with the right skill sets from industry to give the President the options he needed in the early days of the disaster.
Instead of hiring an appropriate mix of academics and very senior operations experts, Federal response agencies are “top heavy” with persons with only academic or general preparation and not enough “been there done that,” boots on the ground type folks. Often, academics and “think tank” experts who have little if any operational experience at all are developing operational policies. They simply do not know how to begin to develop operational response plans and develop mission support and logistics support plans. They may not understand the requirements development processes for mobile medical facilities; special needs support sets and in building and managing inventories of medical materials to augment healthcare, public health and non-governmental organizations during disaster operations and throughout the recovery process.
Worse, some of these folks may not know the additional experience they need to acquire in order to develop an effective National Disaster Response System. Thus, when a public health or medical response fails during a major catastrophe, these same folks may feel that if with all their knowledge they couldn’t develop robust response systems, certainly no one else could. There is certainly a place for those exceptionally prepared at major universities and those with extensive research backgrounds, but there is also a critical need for operational experts who know how to design, refine, build, field, sustain, recover and reconstitute a complete medical and public health disaster response system for ESF-8 and ESF-6 support.
Wrong Approach: The National Incident Management System (NIMS)[3] and the National Response Framework (NRF) got it right on paper and in principle that all responses are initially local. The NRF prescribes how each jurisdiction requests additional support from the next higher level jurisdiction. But that is not how the funding was distributed.
Preparedness funding has almost all been pushed down to state and local governments to develop “tactical” capabilities for initial response during the opening hours of a large scale disaster. The problem is there are almost no “Strategic” assets prepositioned around the country to be flowed into the breach during a high intensity, long duration disaster. Thus, when state and local staffs are exhausted, local assets are expended, hospitals are overwhelmed and utilities are insufficient to support surge requirements, there will be insufficient Strategic reinforcements from the Emergency Support Functions (ESF) federal agencies. In short, the cavalry is the strategic resource and right now, the cavalry has no horses, no riders (who can stay for months or years) and no material. The answer the Federal response agencies will give after a catastrophe will likely be “We funded the states and locals through grants….we gave guidance, provided coordinators and response tools and wrote primers…..Readiness is a State and Local responsibility with Federal coordination and funding.” When asked why the Federal ESF agencies are unprepared, the Federal officials will state correctly that Congress appropriated funds for specific jurisdictions and never funded ESF agencies for their response obligations. For years I have been saying that ESF agencies must include their staffing, facilities and materials augmentation requirements in their Secretaries’ budget requests. How can Federal agencies expect Congress to appropriate funds for Federal ESF-level missions in accordance with the NRF unless the Secretaries inform Congress of their mission requirements and funding requirements through their budget requests?
Thus, we are unprepared for any long term large-scale disaster, let alone a catastrophic event despite the tens of billions of dollars spent by the Department of Homeland Security (DHS) and other Federal agencies that have been tasked with preparing for large scale disasters. While tens of billions have been expended, the manner in which Congress has mandated that the disaster preparedness dollars be distributed dilutes the value of this huge investment. DHS itself has advised states and local governments to prepare for the top 15 Federal Planning Scenarios. Congress and Federal agencies may try to assert that “We have awarded states and local governments billions of dollars in Preparedness and Readiness funding for them to prepare to manage future disasters.” The fact is that states and local governments will undoubtedly require a robust Federal response to large-scale disasters and National catastrophes. Since most of the Federal funding was spent at the local and state levels, there are almost no Federal medical assets available for deployment to future disaster areas.
So what is the right approach to disaster readiness? As we look at the National Response Framework and outline our Target Capabilities Lists, we should have tasked and funded each response level to accomplish their respective missions. The local governments should have been funded for the types of functions required to respond to the opening hours of a disaster. State governments should have been funded to back up cities and sub-state regions during the ramp-up of the response effort as cities’ requirements exceed resources. Finally, the Federal agencies with Emergency Support Function (ESF) missions should have been funded to build the capabilities necessary to bolster states and local governments during the response and recovery phases of the disaster.
Wrong Mindset: The issues surrounding the lack of attention to Readiness and the need for a “culture of preparedness mindset” has been covered in a number of my previous articles.[4] Some examples of the wrong mindset are listed below.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">Individuals want to go about life without taking prudent steps to be able to care for themselves and their families during the first couple days after a disaster.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">The American people have an expectation that in the worst of times, they can depend on their Government to protect them and their way of life.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">City and State Emergency Managers have an expectation that the Federal Government will provide the types of goods and services called for in the NRF Emergency Support Function missions.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">Federal response agencies expect the states and locals will manage all essential response and recovery functions during disasters, using the grant funding these jurisdictions have received for many years.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">American industry expects that Government has built resiliency in terms of stockpiled goods and services.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">Manufacturers believe that Government understands the very long lead time required to ramp up manufacturing and stimulating the American industrial base.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">Some States and local jurisdictions erroneously feel they have adequate measures in place to maintain law and order during disasters.
Those state and local communities that have failed to educate their citizens in voluntary commitments and fully resource their local law enforcement agencies to control unruly crowds and protect people and supplies during catastrophic events will find that gap filled by federal troops specifically trained to provide that protection. [5] It will too late to talk about 10thAmendment rights and the appropriate use federal manpower.
Thus, we have many conflicting expectations and erroneous beliefs of how future disasters will be managed and resourced. Below is a short list of scenarios from the DHS 15 Federal Planning Scenarios,[6] the likely consequences of each scenario and the actions that need to be taken to rectify our current lack of Disaster Readiness.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">1. If there is a nuclear detonation of a 10 Kiloton nuclear device in a major US City (DHS Planning Scenario #1.):
There will be no large scale evacuation of the living, away from high-radiation zones to safe areas. Result: People who could easily survive if they could receive radiological antidote and be evacuated to hospitals away from high levels of radiation will absorb ever larger levels of radiation. After a nuclear detonation, it is likely that hundreds of thousands if not millions of Americans will die where they lie from acute radiation sickness. Solution: HHS must preposition radiological chelating / blocking and pain medicines in high risk area hospitals and EMS organizations for rapid administration of those exposed to high levels of radiation. FEMA must build rapid radiological response teams and develop mass evacuation and resettlement plans. Either DHS/FEMA or HHS must purchase and manage mobile disaster hospitals and specialty treatment centers and be ready to quickly deploy these mobile healthcare facilities to safe areas outside the impact jurisdictions and in resettlement communities.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">If we have a widespread well coordinated biological attack on our food supply chain (DHS scenario #13)America has no Strategic Food Inventory to provide food to Americans while scientists and food inspectors can ascertain which portions of our food supply is safe to eat. We have a strategic petroleum reserve to bridge a disruption of oil from major oil producers, but if an attack by well trained terror cells infiltrates major food processing centers and poisons our food, Americans will be no longer be confident of what we eat. Solution: USDA must purchase a 30 day supply of meals ready to eat or similar long-shelf life ready-to-eat food products AND develop emergency food purchase programs with our allies to keep Americans fed until the American food supply chain is certified as safe. During the Cold War, America had enough stored grain to feed the entire United States population for one year.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">3. If we have a worldwide killer Pandemic (DHS planning scenario #3):
The Department of Health and Human Services (HHS) will have no mobile hospitals and no meaningful quantities of medical supplies and equipment to bolster our already overloaded and heavily stressed healthcare system.
In the past, civilian leaders could depend on the Armed Forces War Reserve Programs to assist with supporting the Healthcare Industry during any large scale disaster. Until 1992, the Defense Logistics Agency (DLA) had a number of medical depots with large quantities of medical items. The DLA depot system was used in a number of instances to bolster the healthcare supply chain during crises or disasters and to provide immediate aid to foreign governments during their disasters. Had those depots remained in operation, America’s response to the Haitian earthquake would have been dramatically enhanced.
In 1992, DLA Medical Depots were phased out except for military unique medical items. Thus today, even the Armed Forces healthcare facilities around the world tap into an already lean and vulnerable civilian healthcare supply system. Some emergency managers mistakenly still believe that Armed Forces medical materials will be made available during disasters.
Today the Federal government has no mobile facilities and support systems to treat patients needing acute healthcare services. There are no treatment facilities capable of treating persons with special needs such as dialysis, diabetes support or mental health needs. What HHS has are cot and blanket sets called Federal Medical Stations which contain and no meaningful inventories except first aid and basic sick room supplies. There are a number of Disaster Medical Assistance Teams (DMAT) capable of augmenting state and local medical care providers, but DMAT is a staffing package without facilities and no formal logistics support package other than their start-up medical materials packages for team use. There are no hospital resupply and sustainment systems other than the Strategic National Stockpile (SNS) for biological and chemical events. The SNS is neither designed nor capable of sustaining hospitals and medical centers during disasters. Early misunderstandings around what the SNS is and is not, may still be causing confusion.
There are a few National Medical Response Teams (NMRT) that have a basic starter set of supplies and equipment for their deployments. There is no Logistics Support System dedicated to keeping NMRTs supplied for their entire deployment and to supply incoming NMRTs as they relieve the outgoing units. Thus we have very limited medical capabilities and no medical material sustainment system.
Solution: (1). Purchase and maintain mobile disaster hospitals and specialty care facilities such as radiological care units, trauma, burn, wound, dialysis, mental health, diabetes care and acute pain centers etc.
2). Purchase Federal Reserve Inventories (FRI) consisting of pharmaceuticals, medical supplies and medical equipment which can be managed and stored in wholesale level civilian healthcare distribution centers for rapid deployed to any disaster location when needed.
(3). Develop a Public Health Service Reserve Cadre which is paid during training weekends and throughout deployments similar to the Armed Forces Reserve units. While volunteer healthcare personnel staffing from Medical Reserve Corps units may function well for short term duty in civilian hospitals, a PHS Reserve Cadre would offer the same continuity and certainty of availability as do our Armed Forces reserve units. It would also offer the same opportunities for advancement, pay and allowances and retirement benefits as Armed Forces reserve units enjoy. The PHS Reserve Cadre would be required to train together as units and would be assigned to mobile hospitals and specialty care centers and deployed as a fully staffing package, along with their mobile facilities for the duration of a disaster deployment. After a deployment, PHS Reserve Cadre would also enjoy the same rights to return to their full time civilian job after a deployment.
- http://www.biopolicy.org/sites/default/themes/biopolicy/images/bullet1.png); background-attachment: initial; background-origin: initial; background-clip: initial; background-color: initial; line-height: 18px; background-position: 0px 4px; background-repeat: no-repeat no-repeat;">4. If we experience a well coordinated series of terrorist suicide attacks on subways, train stations etc in DC, New York, San Francisco, Los Angeles, Seattle, Chicago, Philadelphia and other large cities’ transportation systems (DHS Planning Scenario # 12):
Healthcare Systems, Hospitals and Medical Centers may collapse under the pressure of enormous spikes in demand for trauma care, radiation sickness, wound and burn care, acute pain medicines, blood and tissue supplies, orthopedic surgery hardware and soft goods and all other specialty care.
Solution: The solution outlined in 3 above will also fulfill this requirement.
These are just a few examples of scenarios that the Department of Homeland Security has forecasted for years. Still, as a nation, we are almost as unprepared now as we were on 9-11. Worse, apparently we have not learned lessons from the tragic Katrina deaths and injuries, Galveston’s health system collapse during hurricane Ike and the chaotic response to the H1N1 mini Pandemic of 2009.
For now, we have assembled the wrong mix of skill sets in personnel, taken the wrong approach to Medical Readiness and developed an unrealistic mindset for managing the very scenarios that Federal Officials have identified as likely events. The solution is to get very serious about readiness and resiliency, work from the scenarios that DHS outlines, and build systems capable of supporting known numbers and categories of casualties that may be generated in each of the Federal Planning Scenarios.
[1] National Response Network document, FEMA, 2008 accessed at
http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf
[2] Testimony by Marcie Roth, Director, Office of Disability Integration and Coordination. Federal Emergency Management Agency .Department of Homeland Security “ Caring for Special Needs during Disasters: What’s Being
Done for Vulnerable Populations?” Before the House Committee on Homeland Security, Subcommittee on
Emergency Communications, Preparedness, and Response, accessed at
http://www.fema.gov/pdf/about/odic/written_statement_roth.pdf
[3] Homeland Security Presidential Directive 5, Feb. 28, 2003, accessed at
http://www.dhs.gov/xabout/laws/gc_1214592333605.shtm
[4] Previous books and articles by Mr., Rush cited on JVR Heath web site http://www.jvrhr.com/resources.php
[5] See http://www.governmentattic.org/2docs/DA-CivilDisturbPlanGardenPlot_1968.pdf
[6] National Planning Scenarios (Final Version 21.3), Homeland Security Council , March 1, 2006,https://www.llis.dhs.gov/docdetails/details.do?contentID=13712