Previous IFPA-Fletcher Conferences

National Security Strategy and Policy:
Planning for and Responding to Threats to the U.S. Homeland

October 28-29, 2004
Ronald Reagan Building
and International Trade Center
Washington, D.C.

Patrick Libbey
Executive Director
National Association of County and City Health Officials

Introduction By: Dr. Charles M. Perry

Patrick Libbey: Thank you, and thank you for the opportunity. I'm Pat Libbey. I'm the Executive Director of the National Association of County and City Health Officials. We represent the country’s 2,800 local health departments. By way of background, I was a local health official in Washington State for about the last 29 years before coming to this position two years ago.

Let me also say I'm grateful for an opportunity to spend even two hours this week not talking about influenza vaccine and dealing with issues of that. I'd also like to thank General Dodd for giving me a new way to look at myself and my experience in local public health. Apparently, I am an example of success-induced deterioration. I’ll share that with my colleagues; it may help us.

Looking at the country’s health departments, there are nearly 2,800, and they actually represent the historical development, cultural and economical development of this country. They range in size from Los Angeles County serving a population of 10 million, to health departments in small townships, particularly in the Northeast part of the country, serving populations of under 1,000. By and large, they're connected to local government. County government is the most likely, though larger urban areas tend to be parts of city government and, in some parts of the country, they are stand-alone, special purpose units of government.

Preparedness needs vary across, as do the resources and the threats that those communities experience. But underlying that is a base need, say this with me, all emergencies are local. At least at first. What I hope I can leave you with is the notion, with that local focus, that whatever resources or assets ultimately come into play to deal with a situation in any community, what you will have to deal with will depend on how well prepared that locale was. The foundation for assets to work with that are brought in, that foundation will be what was in place. We need to maximize those assets.

When we think of a bio event in public health, we think in terms of three stages: determining an event has occurred, the response to it, and engaging in the long-term consequence management. Determining is the notion of surveillance, clinical surveillance, syndrominc surveillance, knowing that something occurred, how well you respond to it, the investigation and the containment, and the post-event, particularly in a bio issue, is different than normal-- or, not normal, other emergencies; that is, it’s not only recovery, you are probably still dealing with health consequence issues, those things that have potential for causing health effects.

When we look at how you determine an event, many of the bio scenarios, unlike time and location specific events, we aren’t going to know for a while. Even in the Homeland Security’s 15 scenarios, there’s still an assumption that there is going to be a more clearly identified-- the anthrax example they use in the scenario is a truck dispersal mechanism of aerosolized. We probably aren't going to find that truck. So how quickly we can identify something is occurring is going to be one of the two primary keys as to how well it’s contained -- how well is it identified and how well that’s reported, how quick and how accurate.

Then when we look at some of the tools that we have that were spoken to earlier, the issue of BioWatch, the issue of biohazard detection systems, particularly those that are now employed in the Postal service, it seems to us, at least from where we sit with significant consequence management, that we have put undue focus on the detection tool and the technology perhaps with a false assumption on the policy level that there is a corresponding capacity to respond to the enhanced ability to detect. An analogy that we have heard -- it's like developing a much more sophisticated fire alarm or fire detection service without having also ensured that your fire departments are equipped to respond. They are tools, but we need to make sure we have those connected with the ability to respond.

The response is the second element that I would speak to briefly. How well it’s detected and the quality of the initial response are the two largest determinants in how well contained a bio issue is going to be, regardless of whether it’s occurring in a single community or in multiple communities. Detection, correct detection and the quality of the initial response are the two criteria.

We talk about epidemiology, particularly from the local field, in a little different way. You will hear us use terms like shoe leather epidemiology, the actual disease investigation, the contact tracing, the elements that lead to containment. Much of the quick work in Toronto around SARS dealt with the field investigation and the contact tracing to be able to put the development in place. We are working with Department of Justice, Homeland Security and CDC in developing-- it’s an interesting title, if you think about it, the notion of forensic epidemiology, bringing together law enforcement, the justice community and the public health community, so that there is an understanding an ability for those two systems to work together.

All of this also has to occur, or does occur in the context of overall emergency management planning. At a point that there is an event of a sufficiently known untoward act, it won’t be public health responding alone. This will have activated the emergency management system. Public health is coming to an understanding and developing its capacities to work within NIMS and ICS. This is new in many cases.

And was noted, it is a lot about relationships. One of our members said you can’t be exchanging your business card in the EOC and expect a good outcome if you have not been part of that process, if you're not integrated, if your ESF-8 doesn’t clearly identify a public health role, oftentimes assuming co-command for aspects of the issue, you don’t have a reasonable expectation of good outcome.

The other element, and you’ve heard it spoken to, and I’ll speak very quickly, is the notion of risk communication. It’s not enough to translate information, you have to know how to communicate at a community level with the elements and segments and parts of your community in ways that work. The example used earlier, the switch from Cipro to doxy was probably an appropriate medical decision, but the communication was so badly handled that there is still an absolute perception that it was two classes in quality of care being given. You need to know ahead, you need to have contacts with the communities that you're going to be communicating with, and you need to know, as was stated earlier, be clear in what you don’t know, be able to target your communications, and distinguish between the communications that you're providing for people with operational responsibilities vis-à-vis those that you're speaking to the general public, but making sure they are not inconsistent. Again, the use of NIMS, ICS and the emergency plan is a part of that.

When you think about response, what we have focused in on many cases, and it goes back again, I'd say, to the relationship, it takes coordination, the notion of information systems, GIS. It is a surprise to many in this country that there is no system, and we’ve clearly been answering this question for the last three weeks, there is no information in this system that can tell you how much vaccine is currently available, influenza vaccine for example, in this country, where it’s located, and how well it’s targeted to risk populations. There are gaps in our information management technology and knowledge management.

There are legal challenges. We had our learning quickly. This country’s isolation and quarantine laws have been built over time on a case-by-case basis. We are not prepared, by and large, beginning to deal with numbers of shelter and place, isolation and quarantine in the thousands. We are learning, clearly, from Toronto’s experience, but also looking to say how does that play in the communities throughout this country.

The third element of response in that notion is exercising and testing, how well are we doing that across systems. You’ll note I focused on the public health side of disease investigation and containment. Parallel to that, and I won’t speak to, is the issue of medical care and surge capacity. Clearly, they have to be linked and communicating, but I'm focused this morning on the public health side. As was noted earlier, your planning at a local level has to be down to the level of physical logistics. You cannot have those things being focused on at the point you're bringing external assets into your community.

After the incident, and this is really different in the FEMA mindset and most of emergency planning. I, too, was a local health officer in earthquake country, and post meant recovery. Post now also means that you have a continuing focus on issues that may continue to have impact on health. The World Trade Center is an example, or still issues associated with anthrax. There are still environmental threats involved.

Before we move, just one thing. While Jim had indicated the anthrax actual cases were only within the Eastern time zone, let me tell you, it completely, I won’t say paralyzed, but it came close to paralyzing the entire public health system across this country. Rapidly set-up means of screening and-- I know more about white powder and baker’s dust and printer’s dust, what constitutes white powder and what constitutes a credible risk as a result of that, though we had no anthrax cases, as noted. It did indeed tie up the public health system in this country. Had here been multiple agents or multiple locations, I'm not sure how well we would have fared.

I would suggest though, if you want to take a look at how well your community fared, how did they stand up their emergency management plan to that issue, how many samples did they actually send to one of the labs that Jim talked about for testing? I would offer that a surrogate measure of a well-coordinated and integrated public health system within its emergency management system might be measured as a surrogate by how few samples were forwarded; that is, that there was a shared algorithm, communication was clear across law enforcement, means of determining credible risk were uniformly applied. That takes planning and it takes relations and it takes communication.

It is a challenge for us in public health in the context of ongoing public health work. Flu is an example today, but there are pertussis outbreaks in Florida and other parts of the country. Issues of emergency preparedness, in the last two-and-a-half to three years, have spawned a large amount of information, a large amount of direction, have also brought with it some resources, but still within the context of managing our ongoing responsibilities. We are learning, as are our partners, and a number of our federal partners, homeland security, public health, particularly coming out of some of the agencies that came into that, FEMA and the like, the notion of public health and the kinds of events we’re talking about are new to them also. That newness, in part, is reflected, I think, in the universal task list. We are working to help them refine and understand how to stand up a better and more robust response.

Let me conclude. Bio events are different. They aren't geographically specific, they aren't a specific point in time. How well it’s detected and the nature of the first response is going to be a key as to how well it’s contained. We have a lot of focus on the notion of vulnerability funding. UASI is a good example of that. And there’s a good logic to that, but I would suggest that for bio events, we need to also be looking at some base level of preparedness across all parts of the system, and that takes us back to the issue of mobility, mobility of the release event potentially, mobility of the initially infected, and I would also suggest that there will be an exodus mobility issue also. If I were living up the Hudson Valley, I would be starting to prepare, thinking I may be seeing a lot of New York City’s population moving through my jurisdiction.

As a public health system, federal, state and local, we have not yet done a sufficient job of developing the metrics of what that baseline and those measures are, and it is a shortcoming that I think is hurting us collectively and individually within the public health system.

The silver lining, and I think it’s been noted, the better we do preparedness for an intentional untoward event, the better prepared we will be for the events that Mother Nature will likely still be putting in front of us for the foreseeable future. Thank you. [Applause]

Questions and Answers

JIM NICKERSON: Good morning. Jim Nickerson, public health officer from Boston, and previously with the DoD research community. Several of the panelists here underscored the need for a comprehensive emergency communications plan, and Dr. Walks this morning, his final slide underscored the need for informed caring, careful and redundant leadership. If each of the panelists could comment on some of the qualities of skills and leadership, both local, state federal and communicating during national emergencies such as the anthrax attack here on the Capitol. I'd be interested to hear the perspective on how best to coordinate local and federal comprehensive communications plan, and what best practices there may be there in terms of exercises that have already occurred.

MR. LIBBEY: Two things I'd say. One is we are still learning and publication is still coming out of the Toronto/Ontario experience, and they got pretty close to getting their communications process really right, and there’s a lot we can learn from that. Second, and there is some interest; understand within your community who is listened to, and it isn't always the same in every community. DiGiovanni had done some research that over the course of an event people will look to different sources. The key is whether they are internally consistent, but the party that people want to hear from changes through the life of an event, which means your communication processes have to be connected. We saw that, frankly, in our country in anthrax where we had parties talking independent without having a cross-connection. That’s probably the biggest lesson in terms of communication that came out of that.

__: I understand this is a bio defense session, but I'd like to ask also about the nuclear, radiological and chemical response plans, because we really have only one medical community. I was interested to see the planning and actual funding of a national stockpile of bio defense agents, 747s full of push packages and vendor inventories, and I'm wondering who is stockpiling the radiological medical treatment that would be required for 100,000 deaths and 300,000 injured as a result of the ground burst nuclear attacks that were discussed yesterday, particularly given that the NORTHCOM Command Surgeon says that DoD is not going to fund things over and above what DoD needs for its own force protection. Who’s going to fund the radiological stockpiles?

MR. LIBBEY: Only thing I would say to that, frankly, in the last two-and-a-half years in terms of state and local public health plans, we recognize that radioactive we need to get to, but it frankly has not had the same attention. There are some major exercises, there’s one coming up next month involving the largest metropolitan area in Texas with a field-based exercise. We hope to learn some things out of that, but we’re behind.