NBC News recently posted an article citing a report published by the Presidential Commission for the Study of Bioethical Issues. The link provided to the report in the NBC News article doesn’t seem to work, but I’ve found what I believe to be the report here. The focus of the report is on the ethical challenges faced by the US in responding to this issue. The report summarizes a variety of ethics related concerns and considerations in this ongoing response and paints a fairly accurate picture of our failures and what needs to be addressed – at least within the topics it discusses.
As you might expect from a report on bioethics, it is very public health focused. While they do make mention of very public health centered topics such as clinical drug trials, they do cover topics which are much more broadly rooted in emergency management and homeland security, such as community and responder education, and ethics associated with quarantine. This report, while fairly focused, opens a virtual Pandora’s box of issues related to our domestic response to Ebola.
Needless to say, our collective response to this matter was horrible. Public health policy and guidance was a moving target for weeks; responders were ill prepared to handle potentially infected persons; and the collective of society, politicians, and public safety were largely reluctant to deal with matters of quarantine much less prepared for it. Was this our first consideration of something like Ebola? Of course not. Didn’t we have preparations in place? Kind of.
Back in the late 90s, pushed mostly by the Nunn-Lugar-Domenici act of 1996, preparedness efforts for state and local responders were funded to enhance our capabilities in dealing with WMD incidents. Several years later, after 9/11 and the anthrax attacks, another surge of funding was pushed down to state and local governments from HHS/CDC for the purpose of bolstering public health preparedness including preparedness for WMD/weaponized biologicals and naturally occurring pandemic incidents. These two programs alone, not including other related funding, fostered the creation of plans and organizations to support them, purchased entire stockpiles of equipment and supplies, trained tens of thousands of responders and public health workers, and encouraged exercises across the nation to test capabilities (it was actually these exercises which largely influenced the creation of what we now know as HSEEP). A lot of good came from these programs, but when suddenly tested with the reality of implementation we seemed to fall apart. Why?
First of all, many of these preparedness efforts occurred between 10 and nearly 20 years ago. Many of the people initially trained in these programs have since retired from public service with their organizations losing a great deal of institutional knowledge. While training programs have continued and still exist, there have been systemic gaps in tying this type of training to other preparedness efforts (planning, policy, equipment, etc.). Some equipment purchased near the beginning of these programs has likely been retired as well. Much of it still exists, but has been brought into the fold of other applications, such as HazMat – which is certainly appropriate, but yet again we see gaps, this time our ability to readily utilize equipment specifically for public health threats.
In my opinion many of the planning efforts we saw after 9/11 were misguided. This started with the people who were doing the planning. Many health organizations emphasized health care experience for these positions instead of EM or planning experience – which was their main function. Certainly health care knowledge had some importance, but that could be supplemented through a good advisory committee (EM after all is a team effort). Exacerbating poor hiring decisions was a lack of investing in the people that were hired. Many organizations expected them to churn out pandemic influenza plans in short order, with little/no training on the planning process or integral systems that must be considered. Further, much of the planning had been done in a vacuum – that is, it had been performed with little/no input from other stakeholders. I had reviewed many of these plans, finding things such as inappropriate applications of ICS and wild assumptions of resource availability. In no way were these plans realistic or applicable.
There were many exercises performed and most of them had great value. The problem is that there were a lot of assumptions in these exercises and policy decisions made in the exercises were rarely challenged as they would be in reality. The US Ebola response brought this all to light as decisions such as quarantine were being handled at the governor level and under significant controversy. So in this recent response I ask why were decisions delayed and deferred to higher authorities? Why were adequate local/regional plans not in place to address the care and handling of potentially infected persons? Why did procedural issues take weeks to resolve? The simple answer is that there was a lack of proper preparedness.
Back in October of last year, when Ebola was emerging in the US, I posted an article titled Preparing for Ebola – and Whatever Else May Come. The article still has a great deal of relevancy since I’ve seen very little preparedness for future occurrences – only a harried response to the most recent incident. There have certainly been a great deal of policies and procedures assembled for the current Ebola issue, but these have a feeling of being temporary, throwaway, or single-use documents, applied only for this instance instead of durable and lasting plans. Many will keep them ‘on the books’, only to find that their hasty assembly wasn’t comprehensive enough for the next occurrence. Emergency management and homeland security professionals, public health leaders, and elected and appointed officials need to take a step back and re-look at out preparedness efforts – especially in regard to public health issues. While we should learn from what we have experienced, we also need to think comprehensively about what is needed. Well considered policies need to be put in place, supported by our laws and responsibilities to protect the public while also considering protection of civil liberties. Other preparedness efforts such as planning, training, and exercising need to continue to occur but must have their connections strengthened and intentional. Exercises need to test plans and policies and challenge decision makers who are certainly making difficult decisions that may include ethics and moral issues in the consideration of caring for few while protecting the greater society.
These are not easy things to be done – which supports the need to work on them now, when we aren’t facing an imminent disaster. While Ebola certainly wasn’t a health care crisis and there were a lot of things done right, there is always room for improvement – especially when the next biological occurrence could be a crisis.
What have you and your organization learned from the Ebola response? What gaps have you addressed? What do you feel still needs to be addressed?
© 2015 – Timothy Riecker