Ebola Evokes Executive Decisions
Michael Hopmeier and Melissa S Hersh argue Obama’s new Ebola Czar must quickly work towards a unified concept of operations, domestically and overseas.
A Czar is Born
It is still unclear as to whether or not the Ebola Czar’s purview extends both to the disaster in West Africa and the management crisis in the U.S. This seemingly basic confusion actually addresses some key considerations that Mr. Klain and the general public need to understand: the situation in West Africa is a disaster, whereas the situation in the United States is a crisis of confidence. Should Klain run point on coordinating America’s response overseas as well, it is hoped that he will recognize that the Ebola epidemic in West Africa is an epidemic that has become a disaster with public health components, not the other way around.
If we ask how many aircraft, fuel tankers, security personnel, helicopters, trucks, radios, satellites, shelters, relief funds, etc. the public health community has, it becomes apparent that public health communities are not disaster responders. Public health and clinical medicine’s role, much like every other domain expert, is advisory to professionals who are, first and foremost, disaster and response managers.
A disaster is a highly complex, multi-faceted, and highly dynamic situation. In human endeavors, it is akin only to fighting a war. In a war, however, no particular aspect of the military is in charge (i.e. medical, logistics, infantry, command structures). Instead, personnel trained in management, coordination, and complex operations are “in charge” under the direction of a battlefield commander.
The question of who is “in charge” in the current disaster should be focused on identifying the agency and individuals who most clearly possess the highly complex skill sets, training, resources and backgrounds needed to provide overall management of a crisis, not merely the health aspects of the crisis. Fortunately, we do have people, with the training and the resources, to act here and abroad. Who is tapped to respond and how they are coordinated is most prominent challenge Ebola faces.
Fundamental Questions
Consequently, the question of who is “in charge” should be focused on identifying the agency and individuals who most clearly possess the highly complex skill sets, training, resources, and backgrounds needed to provide overall management of a crisis, not merely the health aspects of the crisis. In order to execute consistent, standardized response procedures using large numbers of personnel, the military seems to be a key supporting player in a disaster solution, though not necessary the leader of the effort.
The Department of Defense (DOD) in the United States is frequently used as a responder of last or first, resort. While this is due in part to its massive infrastructure and available resources, it is more due to its organizational ability, as an enterprise and institution, to manage complex events. Is it time that we consider whether or not we should have the military provide the same temporary services on domestic soil? Likely not at this stage, in so far as in the United States., Ebola has become a PR nightmare, but it is not a disaster in the operational sense of the word.
Fundamentally, there are several questions an Ebola Czar with a dual-front portfolio must answer: How can we contain the Ebola epidemic in Africa and prevent one from occurring in the United States?; What are the actual skills that are needed to fulfill these objectives, and Who are best prepared to provide them? In framing the debate along these lines, we are in fact also making distinction between the duties to contain Ebola versus treat all infected persons with Ebola. The disconnect between these two goals means that we are currently experiencing a fragmented, inconsistent, and possibly ineffective response.
Human capital comes in all forms. In so far as containment is not specifically a medical response, we as a global community may need to look at unconventional solutions. Hospital acquired infections are not just a problem for understaffed and poorly resourced African nations, they are also a problem in supposedly ‘developed’ nations. If the goal is to train teams of personnel who are used to working together in agile environments, we should be looking to target marines, firefighters, SWAT teams, and construction workers rather than just clinicians and lab scientists.
Public health workers, clinicians, and lab scientists must play an important and key role by assisting in the medical response to any large scale incident, including a pandemic-prone outbreak. Professionals with this specific expertise, however, are only part of the response.
U.S. Trends in Managing Population Health
Since we do not currently have a vaccine to prevent against Ebola, and the virus is not spread through the air like influenza or the Black Death, containment procedures that include quarantine, decontamination, isolation, and disposal are the most effective tools in our collective tool belt. These are not specifically medical tools, but instead are control measures that prioritize the prevention of the spread of Ebola. By focusing attention there, we define the problem and our expectations for resolution clearly. Disaster response may require national, regional, or supranational support but, ultimately, response is a local affair. With this understanding, community-level containment can be attained.
Population health is conceptually different from the practice of clinical medicine. In a disaster situation of any origin the primary goal is population health. In real terms, this means keeping the number of people who get sick or injured to a minimum, and failing that (or in combination with it) minimizing the number of people who become very ill, die, or infect others. Population health is also about managing expectations and sharing with the public the strategies that will be employed during a disaster.
Our concept of population health has evolved over the last two decades in the United States. Following terrorist attacks like the 1993 World Trade Center bombings, protocols for managing large numbers of injured people or decedents were evolving. And after the terrorist attacks of September 2001, health responders and disaster managers began moving from a ‘standard of care’ concept, whereby we expect individuals to be treated with the utmost attention to individual treatment, to a concept of ‘sufficient care.’ Sufficient care in situations of mass casualties or possible mass casualties means that population health maintenance takes precedence over individual health. Very seldom do physicians in the developed world ever make a decision that results in the death of a patient or patients based solely on a lack of resources. Framing and articulating expectations such as how triage will work and introducing the concept that developed nation “standard of care” may not be available are crucial for this Ebola outbreak.
In the recent past, fears over a severe pandemic influenza re-vitalized disaster planning in the area of mass casualty management. As it happened, federal funding that had previously been allocated to the management of the biological terrorism threat found its way to a different line item in DHHS. However, the concept of individual health seemed to still play a primary role in planning. And, while the US is not poised to experience an Ebola epidemic of the proportions seen in West Africa, it might be time to once again, have a discussion of sufficient care, and, who should be providing it.
Coordinating American Vital Interests Abroad and at Home
Shortly before Klain’s appointment USAID raised the flag in hopes of recruiting all relevant partners and organizations to help resolve several problems faced in the West African Ebola epidemic, including the development of new, practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed (1) to help health care workers provide better care and (2) transform our ability to combat Ebola.
Inherent in USAID’s approach, however, is that containing the outbreak in West Africa is seen as secondary to the provision of care or treatment. Infection control is absolutely part of a containment strategy, but only one aspect of how to implement infection control or who should be doing it. USAID does not appear to touch upon existing ‘practical and cost-effective solutions to improve infection treatment and control that can be rapidly deployed’: the use of non-clinical, but trained hazardous materials and decontamination teams.
Is there really a need for the humanitarian-industrial complex to reinvent the wheel? We should learn to do more with less and to look at what non-medical tools or countermeasures we have that can safeguard population health. Yes, of course improving the conditions for healthcare workers is necessary to ensure occupational health and safety, to prevent further spread of infection, as well as to facilitate the timely treatment of patients.
Still, these are not the issues in question. Rather, the push to provide a transformative solution to ‘combat Ebola’ may in fact mean that USAID work more closely with the U.S. military. Is there really a need for the USAID to develop its own, parallel solution set to managing Ebola either outside the United States (OCONUS) or within it (CONUS)? Both the CDC and the US Army Public Health Command (USAPHC) have complimentary advice for the management of contaminated persons, materials, vehicles, waste, and waste run-off.
Pentagon coordination and development assistance by USAID are admirable goals, but implementation is key. Population health – whether in West Africa or in the United States – requires using resources and assets where and when available. Consequently, parallel approaches that separate rather than unite the military and civilian seem counterproductive. OCUNUS and CONUS, officials should be looking at strategies that force multiply our ability to contain a highly-contagious virus as well as to treat those that are already affected. And, since the cases of Ebola in the U.S. do not represent a disaster, a different approach is needed to ensure prevention rather than disaster response.
We certainly have lessons of what not to do (Dallas) and what to do (Atlanta) when treating highly-contagious, infected persons. We also know that when MSF healthcare workers effectively implement infection control procedures, they do not become infected. When there is a breech or faulty equipment, infection becomes a high likelihood. Using designated facilities that have expert hazardous materials management teams or using the military seems like a good option at this point. Would we send NGOs in to decontaminate or treat a population affected by a biological weapon? Not likely, because we would designate the areas ‘hit’ to be a hot-zone or disaster zone, whereby only trained hazardous material experts would be able to enter. The brave NGO workers that have put themselves in the line of fire so to speak may or may not be trained in effective infection control procedures. Let’s make sure that these humanitarian responders do not become part of the problem.
So, now that President Obama has appointed an Ebola Czar – whether you are for this appellation and role or decry Obama’s appointment of a “political operative,” – the issue at hand is working towards a unified concept of operations, domestically and overseas. Politicized rage directed at the Administration misses the driving point, however: appointing an experienced manager and communicator to manage the public response to a disaster is a politically savvy and organizationally smart move. The world over, the burden of response should be shifted from the shoulders of public health leaders; while they are essential consultants for best practices, more than their expertise is needed to solve the problem.
Michael Hopmeier is President of Unconventional Concepts, Inc., an engineering and policy consulting firm specializing in national security issues. He is also a consultant and senior advisor to numerous government agencies and organizations and an international expert in crisis response and communciations. Melissa S Hersh is a Washington D.C.-based risk analyst and a fellow of the Truman National Security Project. Views expressed are their own.
