The Need for Preparedness at all Levels: Initial Observations of the Pandemic Response
By Academy Fellow Don Bathurst
NAPA Fellows Shelley Metzenbaum, Kay Goss, Katherine Willoughby, and Louis Uccellini contributed to this article.
Preparation is not important, until it is.
Whether we like it or not, preparedness is time and again relegated to the back shelf, where it is “out of sight, out of mind.” The tragic costs of that mindset are vividly clear. While it is not time to point fingers in our current crisis, it is time to start taking notes and to look for opportunities for future improvement.
Policy officials and program managers at all levels of government, as well those in the private sector and non-governmental organizations (NGOs) will be looking to make changes in their operations. However, we all need to make sure that any adjustments go beyond just treating our symptoms, are well reasoned, and address the root causes of our problems.
Over the past few weeks, we have seen many reports in the media where healthcare providers comment that their hospitals and organizations never saw such a pandemic coming and were not prepared. In fact, what we are seeing was not unexpected. There has been significant effort at federal, state, and local levels to estimate what a pandemic might look like and to develop plans for response. Those plans and proposed exercises appear to have either stopped on the way through the levels of organizations, or were overtaken by other events.
My initial observations related to the preparedness for the response to this pandemic follow below.
Preparedness is like insurance.
We all have insurance to protect against or prepare us for potential loss (primarily financial) for our homes, cars, and even life. Many of us will never have a significant claim. In the case of life insurance, the insured never even sees the claim. So, why do we carry insurance? It helps us recover from the impacts of rare but potentially catastrophic events. We hope we never need it, but when we do need it, we’re glad we have it.
However, insurance is a sunk cost. If we never use it, we don’t get our premiums back. Does this model color our view of other preparedness actions? We often hear people comment that fire protection improvements aren’t necessary because they’ve never had a fire. We saw the press mock Department of Homeland Security guidance in 2004 to have food, water, plastic sheeting and duct tape in home emergency kits.
From a risk management standpoint, we know there is the potential for bad things to happen, and we need to put our preparedness efforts in place in proportion to the risk (threat or hazard, potential, and consequences).
Everybody has a preparedness responsibility.
Right now, we all need to focus on response to and recovery from the coronavirus pandemic. We’re all in this together and all should be pulling in the same directions. However, we should be taking notes to look for opportunities for future improvements. I'm confident that there will be a 'blue ribbon" panel or something similar, when this is over.
When I ran the dam safety program at FEMA, many state dam safety officials told me they were not part of their state’s emergency management planning efforts. I see something similar in this situation where the front-line service delivery organizations are raising concerns about supply and capacity shortages, but don't seem to understand the national supply system and how it is working. I was involved for years in developing and implementing various emergency plans at the federal level, as well as working with state and local officials. Over the past several years, I was involved with development of plans for pandemic response. My specific focus was on how to assess and react to specific disease risks, including biological attacks, in order to protect personnel, especially those that may have to work directly with infected persons. This included work on anthrax, SARS. MERS, bird flu, H1N1, and Ebola.
Planning is great, but it is said that no plan survives first contact with the enemy. Plans must be developed with input from all involved, and must be practiced (table top, functional, and full scale) in order to make sure that plans are not just theoretical.
The task to develop emergency preparedness plans is often relegated to a person or small office, with few resources. We've seen the steady decline of planning in many organizations since 9/11. These staffs are responsible to pull plans together, coordinate with all the stakeholders, and develop and run various tests and exercises. But, in my experience, it is often difficult to get the stakeholders who will have to take action and benefit from that action excited about developing and testing plans.
When I directed the national dam safety program, I found that the state dam safety directors were not tied into the states' emergency management offices, and I was able to change that. What I'm seeing today regarding coronavirus appears to be a lack of coordination in the states with the public health operations (usually tied to CDC), the local health providers, and the Emergency Management offices. When nurses and doctors say they did not have a plan, but we know there are at least state level plans, we know the message did not get through and there certainly has been no practice.
I am aware of the pandemic planning and preparedness efforts at the federal level, and know of counterpart plans at the state and local level. Those state and local plans were developed with the health departments and all stakeholders were briefed on expected actions. The health departments were responsible to coordinate and represent the hospitals in the effort. I am not aware of what actions may have happened since the original plans were developed. However, now just a few years later, there are reports that when the plan was requested, no one knew of it. This indicates, as I would expect, that those plans are still up on the shelf and not in the hands of those who need them most.
Plans need to be on everyone’s mind, not on the shelf.
When a major disaster like 9/11hits, we see wide-spread attention and investments in emergency management. But the further we move away from disasters, the more people lose focus and funding is cut in favor of more public facing programs. When disaster hits again, politicians and the public complain that we don’t have enough funding.
Prior to 1993, many preparedness programs were focused on the threat of a nuclear attack. We remember Civil Defense programs, fall-out shelters, and duck-and-cover drills. There were also significant efforts carried out by dedicated staff who planned and practiced in the unthinkable event that they would respond for the good of the country and might never see their families again.
After 1989 and the fall of the Berlin wall, many of these programs were dismantled, and there was a decline in preparedness for nuclear attack. Because of actions by James Lee Witt at FEMA, certain assets were retained and there was significant work at FEMA on natural disaster planning and response coordination within the emergency management community. These actions served the country well, especially when we were attacked in 2011.
9/11 was a wakeup call in overall preparedness, including business continuity. While there had been some attention paid this in the prior decade, at the federal level, emphasis was largely left to individual agencies based on their programs. But just 10 years later, we saw emphasis within agencies and activities fall back to prior practices where preparedness is done by the “preparedness planning folks.” People became too busy with the crush of the immediate to plan for a “bad day” from their program or activity perspectives.
This is not a political phenomenon, but rather one of organizational atrophy, requiring strong managers to constantly review risk profiles and appetites.
Models support decisions, they do not make decisions.
Many decisions are based on approximations by models, which are based on assumptions and data. There are several models involved in predicting potential impact and requirements in response to disease outbreaks. Different models are used for different purposes, they look at different impacts, and all are adjusted based on assumptions about the disease and response. (see The Problem With Coronavirus Models Is How We Talk About Them, DefenseOne, April 15, 2020)
Models play a significant role in the current event, and are important when planning and responding to earthquake, floods, and fires, to name a few. However, it is important that practitioners understand the assumptions, data, and limitations, and that decision-makers are informed of such. Models are approximations, not an absolute predictor, especially if any of the assumptions deal with human behavior.
It is critical that our models be based on reliable and valid data. Most of our early data in this current coronavirus pandemic came from China and we may never know what really happened (and is happening) there. China recently adjusted their reported deaths with a 50 percent increase. There have been reports that measurements local governments in China were sending in were being gamed because the locals feared the consequences of submitting data showing problems. Even here in the US, we are not reporting consistently. The number of cases is based on positive test results, but reporting deaths that are clinically presumed to be covid-19.
We have seen much criticism of the White House task force, the Centers for Disease Control and Prevention, the Surgeon General and others, because they seem to be changing their minds and guidance, often contradicting previous guidance. However, I contend that they are using information from models and other analyses that are fluid based on changes to data, actual experience, and evolving information about the nature of the disease. This is why models are useful input to decisions, but cannot be relied on as the decisionmaker.
Hold all accountable for data honesty and improvement, not punishment.
In January, we did not know how infectious the coronavirus was, nor that it was being transmitted by asymptomatic persons. We still don't understand how it affects different people, other than those with heart, lung, or immunity issues, and new medical insights continue to emerge.
Until we establish accountability systems that value honesty and the use of data to find ways to do better, not to reward or punish, this will continue to be a problem not just for fighting the coronavirus but across most policy areas.
Everyone must understand the supply chain, and their role in it.
Logistics wins the war. When the locals are screaming need, need, need, it's not helpful without context. For example, the Governor of New York requested ventilators, expressing a need. But it was not an immediate requirement, and when he received additional ventilators, he warehoused them in anticipation of future requirements. It was a projected point in time need, and should have been described that way. It makes allocation of scare resources easier if managers have the whole picture. FEMA appears to have brought some order to the chaos by analyzing what is being used, what is on hand, projected requirements, and projected recovery. FEMA can now report with more specificity what is being shipped to whom and how it is meeting the requirement.
FEMA is bringing structure to the logistics fight, but there is some gap to fill before we get to steady state. The week of April 13 was the first time I heard the term "burn rate" used to describe the logistics need.
The Strategic National Stockpile (SNS), frequently a topic of discussion in the early stages of coronavirus response, is designed to be a backstop, not the “go-to” source for all supplies. Comments from state and local officials, and hospitals’ staff, reported in the media, indicated that they did not have a plan for supplies for such an event. Some have suggested that perhaps the federal government should have visibility of medical supplies at all levels of government to project for and plan for disasters such as this situation. Such central management of reusable supplies and other resources could be modeled after the National Interagency Fire Center, but would have be a deliberate effort that would require significant restructuring, authority realignment, and resource allocation.
On NBC recently, they talked about former NYC police chief O’Neill, now working at Visa, working with NYC to oversee the supply and distribution of personal protective and medical equipment within all New York City hospitals. This would seem to emphasize the lack of practice in the response plan--why would they need to bring someone in if the plan was well practiced. The federal emergency management structure assigns FEMA as the logistics coordinator in declared disasters. State and local governments have emergency management plans and NYC had a pandemic plan. A central issue, raised by logistics but applicable across the board, regards how involved the hospitals and public health were in the development of the plan, and how often they practiced it.
Planning is not enough. Practice, practice, practice is critical.
NPR Morning Edition in early March ran a story on why Taiwan was so prepared, acted quickly and suffered relatively little. The story focused on how Taiwan immediately jumped to action as soon as they confirmed the news that the outbreak in China was related to a new virus. Masks were made available and people wore them, people leaving and coming to the country were screened, ....and the list went on. Since the SARS outbreak in 2003, Taiwan developed a nationwide plan for addressing any new virus outbreak, especially if it originated in China. The plan focused on testing everyone, containing infections, blocking new vectors at the point of entry... and they practiced it every year for the past 17 years. What resonated so much was the emphasis on practicing the plan. The last time we checked, Taiwan was still being viewed as a success. Taiwan has a small geographic area, and being an island nation helps, but they had the plan, they practiced it, and it seems their preparation played a big part in their success. This is not to say that Taiwan’s actions were perfect or translatable to the US, but to emphasize that practice makes perfect (or nearly so).
Practice does not make perfect, but does make things a whole lot better.
As stated above, no plan survives first contact with the enemy. You may have the best plan on paper, but until you walk through it in a table top exercise, go through a functional exercise, and actually subject it to a full scale exercise with everyone who would be involved, you will not know how it works, or if it will work. Comments by staff members from various hospital staff indicate that, whatever plans existed in the states, they likely were not regularly communicated, practiced, or updated.
Exercises are difficult to plan, and time-consuming and expensive to carry out. But they can be done in ways that leverage regular operations (and in fact should be!). This exercise requirement will be a key to future preparedness and success.
Draft Framework for the future of emergency management.
A group of Fellows of the National Academy of Public Administration has developed a framework for the future of emergency management that, among other things, points out the expansive nature of emergency management and all the parties that are necessary to make it work. The framework describes and is based on various actions from past disaster plans and responses. This pandemic is another great case study.
The framework emphasizes that emergency management needs to be risk-based, locally implemented, state managed, and federally supported. It also emphasizes the significant roles that insurance and NGOs play.
Individuals also must exercise personal responsibility. Our country is founded on individual liberty which comes with responsibility. These initial observations of the pandemic response highlight some of the critical roles necessary at all levels, in government and the private sector, to make the response as smooth as possible.
The “framework” seeks to outline these roles and responsibilities.
Check out the framework here, and provide your thoughts and comments.
Don Bathurst is a NAPA Fellow and served in many emergency management roles in the federal government, including as the Deputy US Fire Administrator, Chief Administrative Officer at DHS, and the Executive Director for Emergency Preparedness at DHS.