New government plan lauded as clear, concise path to all-hazards protection

If implemented, represents "major step forward'

While the federal government has been much criticized for bioterrorism and disaster planning — or lack thereof — experts and scholars are lauding the concise yet ambitious plan recently released as Homeland Security Presidential Directive 21 (HSPD-21).

"This is actually a major change in federal government policy with regards to preparedness for mass casualty disasters," says Eric Toner, MD, senior associate with the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC). "It is a major step forward. This is a very clear statement of federal policy that if fully implemented really would improve the nation's preparedness."

In recent Congressional testimony that generally focused on the nation's lack of preparedness, Tara O'Toole, MD, chief of the UPMC biosecurity center also praised the directive.

"This document, which reflects a wealth of input from medical and public health practitioners and experts in disaster response, begins to display the extent and complexity of what it will take to construct a robust biodefense," she said. "Creating a homeland defense that secures the country against devastating bioattacks will be the work of a generation. If we do it correctly, we will create the capacity to eliminate bioweapons as agents of mass lethality and take a major national security threat off the table."

EDs need help

Though it promises no funding, the directive acknowledges the federal government must help hospital emergency departments and create "a firm foundation for community medical preparedness. We will . . . explore options to relieve current pressures on our emergency departments and emergency medical systems so that they retain the flexibility to prepare for and respond to events."

"For the first time, it recognizes that the federal government has to engage hospitals," Toner says. "Previously, there were federal plans for disaster and hospital plans, and they weren't real effective. The government gave a relatively small amount of money to hospitals but the guidance wasn't very good about what you should do with the money. Hospitals did not synchronize with any clear national plan. This at least says that that needs to be done now."

Ultimately, the nation must collectively support and facilitate the establishment of a discipline of "disaster health," the directive states. "The specialty of emergency medicine evolved as a result of the recognition of the special considerations in emergency patient care, and similarly the recognition of the unique principles in disaster-related public health and medicine merit the establishment of their own formal discipline," the plan states. Such a discipline will provide a foundation for doctrine, education, training, and research and will integrate preparedness into the public health and medical communities, HSPD-21 states.

"There needs to be a national strategy for mass casualty care that incorporates not only what the federal government does, but what the states and what local communities and individual health care institutions do," Toner says. "What that means for hospitals — at least hopefully – [is that] there will be much more clear guidelines for them. It doesn't guarantee there will be any more money. It is not an authorization bill, but it does call for the development of a strategy, and whether or not more money comes, at least it will be clear to hospitals what they are being asked to do."

The directive acknowledges the current threat from the onset, noting that a catastrophic health event, such as a terrorist attack with a weapon of mass destruction (WMD), a naturally occurring pandemic, or a calamitous meteorological or geological event, could cause tens or hundreds of thousands of casualties. "The United States has made significant progress in public health and medical preparedness since 2001, but we remain vulnerable to events that threaten the health of large populations," the directive states. "The attacks of Sept. 11 and Hurricane Katrina were the most significant recent disasters faced by the United States, yet casualty numbers were small in comparison to the 1995 Kobe earthquake; the 2003 Bam, Iran, earthquake; the 2004 Sumatra tsunami; and what we would expect from a 1918-like influenza pandemic or large-scale WMD attack. Such events could immediately overwhelm our public health and medical systems."

In essence, the government is conceding that it has been thinking too small in preparedness planning. "This really does talk about the fact that the scale of disasters that we have been preparing for in the past were much too small compared to the kinds of things that the government actually thinks could happen," Toner says. "[For example] a terrorist attack with an improvised nuclear weapon, a major bioterrorism attack or an earthquake. All of those things would cause many more casualties than our health care system could handle at this time. So HSPD-21 is the first document that really addresses that fact and [acknowledges] that we can't accommodate this with the system that we currently have. We have to a have national disaster medical system that is much more robust."

Surprisingly concise for a government document, HSPD-21 assigns clear responsibilities and deadlines for implementation. (See table.) "It spells out a number of very specific high-level actions that need to be taken and timelines for when those should be accomplished," Toner says. "This is a good thing."

Critical Components

The strategic plan outlines four critical components of public health and medical preparedness: biosurveillance, countermeasure distribution, mass casualty care, and community resilience. These sections are summarized as follows:

• Biosurveillance: The United States must develop a nationwide, robust, and integrated biosurveillance capability, with connections to international disease surveillance systems, in order to provide early warning and ongoing characterization of disease outbreaks in near real-time. A central element of biosurveillance must be an epidemiologic surveillance system to monitor human disease activity across populations. That system must be sufficiently enabled to identify specific disease incidence and prevalence in heterogeneous populations and environments and must possess sufficient flexibility to tailor analyses to new syndromes and emerging diseases. State and local government health officials, public and private sector health care institutions, and practicing clinicians must be involved in system design, and the overall system must be constructed with the principal objective of establishing or enhancing the capabilities of state and local government entities.

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

• Mass Casualty Care: The structure and operating principles of our day-to-day public health and medical systems cannot meet the needs created by a catastrophic health event. Collectively, our nation must develop a disaster medical capability that can immediately re-orient and coordinate existing resources within all sectors to satisfy the needs of the population during a catastrophic health event. Mass casualty care response must be 1) rapid; 2) flexible; 3) scalable; 4) sustainable; 5) exhaustive (drawing upon all national resources); 6) comprehensive (addressing needs from acute to chronic care and including mental health and special needs populations); 7) integrated and coordinated; and 8) appropriate (delivering the correct treatment in the most ethical manner with available capabilities). We must enhance our capability to protect the physical and mental health of survivors; protect responders and health care providers; properly and respectfully dispose of the deceased; ensure continuity of society, economy, and government; and facilitate long-term recovery.

• Community Resilience: The above components address the supply side of the preparedness function, ultimately providing enhanced services to our citizens. The demand side is of equal importance. Where local civic leaders, citizens, and families are educated regarding threats and are empowered to mitigate their own risk, where they are practiced in responding to events, where they have social networks to fall back upon, and where they have familiarity with local public health and medical systems, there will be community resilience that will significantly attenuate the requirement for additional assistance. The federal government must formulate a comprehensive plan for promoting community public health and medical preparedness to assist state and local authorities in building resilient communities in the face of potential catastrophic health events.