U.S. Department of Health and Human Services.  HHS.gov  Secretary Mike Leavitt's Blog

Preparedness

Weekends of Hurricanes

The past weekends were full of disaster preparation. In previous blogs, I have talked about the competence of the people who manage disaster response in our country and the substantial increase in our readiness in the three years since Katrina. That point of view has only been enhanced watching them manage emergencies in two successive weeks.

As Hurricane Ike moved closer to land fall in the United States, it looked to be a massively treacherous storm. When I woke up Friday morning, the words “may face certain death,” were being used by weather forecasters to describe anybody ignoring the evacuation advice.

Every few hours, I had a conference call among my advisors and emergency managers to update me on the storm. This storm, like Hurricane Rita in 2005, was dancing across the gulf, changing directions at least five times. Each time required responders to begin evacuating a different population. Late in the afternoon, it was evident that it would hit the Galveston and Houston area. The storm was projected to have category 4 winds and ocean surges as high as 25 feet, which would produce widespread disaster— serious disaster.

On the final call of Friday evening, our equipment, supplies and people were in place and all we could do was wait for the storm to pass.

Saturday morning at about five a.m., I got up to watch the early television reports. I was relieved as the morning passed to hear officials say that the massive surges being forecast were not developing. We deferred the call until noon so our command center could gain situational awareness and consider how our preparation needed to be altered.

During the noon call, it became evident there were a number of communities hit hard along the coast. We were well positioned with assets to meet the requests of the states. I got a report on our capacity to respond to the millions who had been evacuated.

By Sunday afternoon, we were discussing when I should visit the area. The decision was made that Monday would be too early, things were still playing out and that I would fly down on Tuesday morning, stay the night in Austin and return Wednesday, visiting four cities during the two days.

Monday morning, we woke to news that problems of another kind had been occurring during the weekend, the collapse of Lehman Brothers and sale of Merrill Lynch, signaling more dramatic fallout from the credit crisis.

My first scheduled event of the day was an arrival ceremony for the President of Ghana on the South Lawn of the White House. Because of HHS’s significant activities in Africa, I had been asked to attend. Following a meeting in the Cabinet room with President Bush and President Kufuor, we briefed President Bush on the storm in the Roosevelt Room.

The storm briefing was lead by David Paulison, the head of the Federal Emergency Management Administration (FEMA), with Sam Bodman, the Secretary of the Department of Energy, who discussed the impact the storm would have on the nation’s energy situation. My part of the report didn’t take long because our assets were in place and services were being provided as planned. At the conclusion of the meeting, Ken Wainstein, the President’s Homeland Security Advisor, asked me to accompany the President on Tuesday morning to the Houston area, so our travel plans changed.

I left the House at 5:50 a.m. for Andrews Air Force Base. As I walked across the tarmac, it was still pre-dawn. It is never that I see Air Force One and I don’t feel a sense of awe. It is such an inspiring symbol of our nation’s stature. It is shaped like any other 747, but there is something special about the remarkable power-blue color and the words United States of America.

Typically, those who accompany the President on these trips get into place about a half-hour before takeoff. It’s actually a very pleasant time. The plane is more like an office building than an airliner. It’s a place of work. There are small offices and a conference room as well as places for the news media to sit and work.

We arrived at an airport near Houston, spent a half-hour being briefed by Texas emergency management officials and then boarded helicopters so we could view the widest possible areas during our visit. One element of the briefing likely hasn’t seen much news coverage. The briefer told the President one significant issue the emergency management officials were having was animal problems. “Cows,” he said, “are running all over the place.” “And,” he continued, “a lion and two tigers on the loose.”

It turns out, some people in remote parts of the island had these wild animals as pets. Somebody wryly said, “Well, that probably takes care of the cow problem.” A good sense of humor in a disaster is always appreciated.

President George W. Bush speaks with state and local officials during a briefing Tuesday, Sept. 16, 2008, at the Galveston emergency operations center.
President George W. Bush speaks with state and local officials during a briefing Tuesday, Sept. 16, 2008, at the Galveston emergency operations center.

I rode, along with Governor Rick Perry and David Paulison of FEMA, with President Bush in Marine One (another fine machine and symbol).

I won’t attempt to duplicate news accounts, except to say that seeing damage like that is always more startling in person than on television. The scene I saw was reminiscent of Katrina, but not as universal as some of the areas of Louisiana and Mississippi at that time. I was not able to visit any of the flooding areas.

As they move from survival and rescue into recovery, the Mayor of Galveston, Lyda Ann Thomas, and her team were beginning to wrestle with public health issues. There were no toilets, or places to wash hands. Disease becomes a serious threat. I linked up to talk with David Lakey, the Texas Director of Public Health. I also discussed recovery resources with Governor Perry. The Texas team is a good one.

When I talked with the Governor on the phone earlier in the week, I simply said, “Well, here we go again.” They are battle-proven and confident. However, it was clear to me the Governor was worried that this one could be a monster. Fortunately, it was bad, but not as serious as it could have been overall.

The President had to get back to D.C. to deal with the financial crisis on Wall Street, which was unfolding as we moved. Occasionally, a reporter would shout a question about AIG, which was leading the news. The President reminded them he was dealing with a grieving Galveston right then. He would deal with that in Washington.

One cannot avoid being overwhelmed by the power of nature. Likewise, it is hard to understand why people build homes in some of the places they do. There were stretches of beach in and around Galveston where homes were not only destroyed, but also completely cleared of all debris. There was no sign anything had existed but a concrete pad.

There were some homes standing that had been built with a different code, requiring hurricane-resistant construction.

Once again, I will say the emergency responders were an inspiration. There are always things we can do to get better, and we’re getting better with each disaster. Texas was impressive. The mayors and their teams in Houston and Galveston were both impressive.

Galveston will be a long time recovering. In my view, homes on the beach areas of that region should not be rebuilt unless they are at a standard of construction that can withstand a powerful Hurricane. I also don’t believe the government should be heavily subsidizing property insurance, or offering big payouts after a storm for private structures in areas where they will obviously be blown away again by a hurricane.

HHS has deployed more than 1,600 people into the hurricane theater. The state of Texas is carrying most of the burden. We are now moving from rescue into a recovery mode.

I would also like to say what an effective operator I think David Paulison is. I’ve watched him for many months now. He’s direct and organized; doesn’t over-promise and is willing to solve a problem with a little ingenuity. FEMA is often the target of frustrated critics. Sometimes, FEMA probably deserves it. However, in an organization as complex as the combined national and state government emergency management system and in the middle of a disaster, there is bound to be some confusion and unpleasantness. With Paulison’s leadership it has been minimized.

Gustav- Blog IV

Resettling after a storm

One of the major lessons learned during Katrina was that when people got displaced and could not return to their homes, the recovery was long and complex.

Every family has a different situation, and therefore, our help to get them back on their feet needs to be customized. We need individual case management.

During Katrina, I proposed using our Office of Refugee Resettlement (ORR) to help. The idea was not adopted, but I felt so strongly about it that I put a team together to develop a pilot, similar to the programs in ORR, to try at a future disaster. Today, for the first time, we will begin using it. I honestly think it will make a major difference in getting people back on their feet faster.

ORR is a little known part of the Administration for Children and Families (ACF) of HHS. Each year, through contracts with a large group of non-governmental organizations, volunteers help people who are immigrating to the United States get settled. It is in our interest to assure it is done in an orderly fashion. Not only is it the humane thing to do, it pays financial dividends quickly to have people become self-sufficient as soon as possible.

When a person is assigned to ORR, a case worker helps them navigate various government programs, and, more importantly, the officer helps the refugees develop a plan for self-sufficiency, then stays with the client until the plan is working. It has been a great success.

Today, we activated a contract through ACF's Human Services Preparedness and Response Office to help Americans in need of similar services due to Hurricane Gustav. The contract will be fulfilled by Catholic Charities, who will coordinate the activities of other organizations, who also do casework for immigrants.

With many families still displaced after Katrina, I’m looking forward to seeing the difference in this more managed approach.

Gustav Blog III

Written September 3, 2008

After spending Tuesday in Texas looking at shelters, the weather and air space cleared sufficiently so that I was able to join the President in Louisiana to review the progress in dealing with Hurricane Gustav. 

Rather than attempt to detail the entire trip or various meetings I want to write a series of observations I made during the day.

First, we are getting much better at emergency response. One example is the fact that in the 72 hours before the storm hit, the largest medical evacuation in our nation’s history took place.  We relocated more than 10,000 people from nursing homes, hospitals and situations requiring special needs.  We did it in an orderly, safe and well planned way.  Was it perfect? No, but it was done extremely well. 

I’m hoping the real story of our nation’s response will not be missed. The media reports on the activities of the federal, state and local government to establish organization and facilities.  However, the big story is the hundreds of thousands of Americans who previously didn’t know what to do this time ended up in shelters across the country.  During Katrina there were more than 600,000 people in shelters.  During this storm we had about 80,000 despite similar numbers being displaced overall. (On Wednesday there were only about 60,000 in shelters.)

There were hundreds of thousands of people who developed individual and family evacuation plans and executed them. Families went to Aunt Mabel’s, friends, motels or camp grounds. Preparedness isn’t just government’s work; it is the reaction of the ordinary citizen.  The aggregate of each prepared citizen played starring roles in the drama.  This is very good news because government simply cannot respond to everyone, we have to create facilities for the exception, the special need, the anomaly.

I report this not as way to be solicitously upbeat. The big story is that positive citizen action is key to successful execution. There were 1.5 million people who were evacuated in less than 12 hours. (During Katrina it took 25 hours for that many) Most of them took care of themselves this time allowing government to do a much better job with those that couldn’t. 

The big problem right now in Baton Rouge is electricity.  There are 1.4 million people without power. The lack of electricity requires constant transfers out of hospitals.  Just before I left, I visited Baton Rouge General.  There was a line of ambulances loading patients for transfer.  As I walked up and down the hall, the conditions were extremely difficult.  There was no air conditioning and few lights.    They had backup generators, but they were proving inadequate for the demand.

A walk through a hospital during a time period like this is an important reminder of two things: how dedicated the staff is to continue working and just how sick many of those people are which makes moving them complicated.

The big commodities at this point in an emergency are water, ice, MREs (meals ready to eat—military prepackage meals) and tarps. 

Secretary Leavitt with the Disaster Medical Assistance Team

Secretary Leavitt meets members of the Disaster Medical Assistance Team in Baton Rouge.

This was the President Bush’s 27th trip to a disaster area during his time as President.  The presence of a President is an important symbol. It reassures people and also serves as a deadline for people to get things done. 

We met at the emergency management operation in Baton Rouge.  The governors, mayor, senior emergency officials from the federal, state and local government were there.  Also some elected officials.  One by one, reports were given regarding the progress that had been made and priorities remaining.   

The President reflected the experience of a man who has been through a lot of emergencies. At one point he said, “By my observation is that there are three phases to natural disasters.  There’s the ‘glad to be alive phase;’ Then the ‘why didn’t you come sooner phase,’ and finally ‘I’m really mad phase.’ People are going to feel those things and our job is to just keep moving forward to solve the problems.”  That matches my experience as well.

It should be noted that the levee system held.  There is a lot of deserved satisfaction among the engineers about that. 

We are obviously not out of the woods on storms this year.  There is a virtual conga line of storms lining up off the gulf coast.  Hopefully, they will dissipate and not throw us into the soup again soon.  If it happens, we’ll be ready.      

Hurricane Gustav – Blog II

I met Jenny in a medical shelter in Tyler, Texas.  She lives in Beaumont Texas where she had just undergone back surgery.  She was at home beginning her recovery when Hurricane Gustuv, approached the gulf coast.  Like thousands of others Jenny called 211, a telephone service offered in her area, registering for help in case evacuation was necessary. 

For days before the authorities monitored Gustav, and 120 hours from the time the storm was anticipated to hit the shore they opened an emergency “playbook” developed to respond to severe storms.  Nobody knew at that point what the intensity of the storm would be, but with the lapse of each hour decisions needed to be made to avoid allowing time to become the enemy.   

There is a hierarchy of evacuation needs. People like Jenny with complicated medical needs are high on the priority list and require emergency managers to start early.  Somewhere between 48 and 72 hours from land fall, officials made the decision to begin evacuation.

I landed in Texas Monday night just hours after Gustav’s dissipated Category two force winds crossed Louisiana and Texas coast lines. Early Tuesday morning we flew from  Dallas to Tyler Texas.  I wanted to see deployment of our Disaster Medical Assistance Teams and Federal Medical shelters first hand.  That’s when Jenny and I met. 

As Jenny sat in a special chair that held her back in proper position to heal, she told me how rescue workers picked her up and took her to a bus.  The three hour bus ride out of the storm’s reach was uncomfortable she said, but it probably saved her life. 

Secretary Leavitt with a patient and medical workers at the shelter.
Secretary Leavitt and Jenny at the medical shelter in Tyler, Texas.

I saw hundreds of patients all of whom had a story to tell.  Many seriously ill before the storm and still struggling but for the most part, deeply grateful for a bed, food and medical attention offered at the two federal medical shelters set up by the state of Texas, operated by local health workers and supplemented by federal equipment, supplies, emergency teams and, of course, money. 

Disaster preparedness is a local and state responsibility and the state of  Texas is good at it.  In Tyler, Dr. Lakey, the head of the State Health Department met me. As the storm approached, state emergency planners determined where the demands were most likely going to be felt.  That’s done by simply asking the question, “If you live in an evacuation area, where are you most likely to go?”  Most of the people I met on Tuesday where from Beaumont, Texas and some from western Louisiana.

Given the nature of this storm, the state chooses to establish medical facilities in Tyler at a county-run community center and a few miles away at Eastern Texas Baptist College. Both the local government and the college responded with great generosity providing facilities and people. 

When the state feels they will not have sufficient capacity to staff and meet the demands of both the local population and the in flowing evacuees, they ask the federal government for help, specifically FEMA.  My Department of Health and Human Services (HHS) is then tasked by FEMA to deploy assets we have.  Those activities are managed through the Office of Assistant Secretary for Preparedness and Response and they have become very good at it.

HHS provided two types of assets in this case.  The first is a federal medical shelter.  This is essentially a hospital in a box, more appropriately, a whole bunch of boxes. The federal medical shelter is deployed from one of our national stockpile sites and can be in place within 12 hours.  We also send a component of medical workers to staff the facility. 

The second asset we deploy is a Disaster Medical Assistance Team (DMAT).  Most states have at least one DMAT.  These are remarkable people who have volunteered to be deployed with only a few hours notice anywhere they are needed.  These are groups of medical professionals as well as others trained in different aspects of emergency medical needs.  On Monday I saw teams from New York, Florida, New Mexico and Oregon in action.  Within a few hours they establish a facility to treat the most acute patient needs.  It is rather remarkable to watch. 

Nobody likes disaster but I must say, I am always inspired by the generosity and competence people willingly bring.  They work unthinkably hard hours in beastly conditions.  However, there is something about the human spirit that when people are engaged in emergency assistance they are happy and upbeat.  I think there are few things more rewarding than the satisfaction that comes by providing assistance for a person in need.  My mother once said to me, “Mike, we get our self esteem from the people we serve.”  I believe that more than ever. 

Hurricane Gustav

The weekend has been dominated by preparation for Hurricane Gustav. Though I am now in Dallas preparing to enter the storm’s footprint with my senior team, I was working from Utah over the weekend.

Assistant Secretary for Preparedness and Response, Admiral Craig Vanderwagen, operated out of our emergency management center at headquarters. He conducted briefings every few hours. The difference in the work atmosphere, by comparison to Katrina, in our department and in our interaction with other departments and states, has made the hard work of the last three years evident.

I'm typing this blog on my Blackberry and therefore a more detailed description of the differences will need to wait for another day. I will simply generalize that all the lessons learned, all the exercises, all the meetings and conferences, and investments have paid off. People knew what to do and when to do it. We followed a play book that had been rehearsed over and over. Were there surprises and departures from the script? Of course, but for the most part, we carried out the plan.

Assets were moved into place, the medically compromised were evacuated (more than 9000 of them), and shelters and field hospitals were erected. HHS had more than 1,500 people deployed to the region. It has been a moment of great satisfaction to see how ably our team has functioned. Admiral Vanderwagen calmly and professionally guided the process from headquarters. Craig was our field commander during Katrina and is intimately familiar with the situation. I'm extremely proud of him and his team.

This effort revealed weaknesses. They were worked around this time, but they need to become the focus of our improvement. The weakening of the storm is a blessing we are all grateful for. However, there is a virtual conga line of storms queuing up in the Atlantic. We are by no means out of harms way.

There are thousands who need help from the devastation they experienced from this storm. We should never view a Category II hurricane as anything but a deadly storm. I will spend the next two days in Texas and Louisiana to see the outcome of our preparation and assessing what must be done now. I will periodically provide updates. However, I will be communicating them by Blackberry, so they will, by necessity, be short.

www.HHS.gov/hurricane

Indonesia

Written April 14, 2008

I’m in the Jakarta Airport, having just finished a day of meetings with Indonesian Government officials. I met with President Susilo Bambang Yudhoyono, Coordinating Minister for Family Welfare Aburizal Bakrie, Foreign Minister Noer Hassan Wirajuda, Agriculture Minister Anton Apriyantono, and Health Minister Siti Fadilah Supari. The meetings involved discussions on a group of issues, among them the control of H5N1 avian influenza, the U.S. Naval Advanced Research Laboratory (NAMRU-2) in Jakarta, and Indonesia’s departure from international expectations on sharing samples of influenza viruses.

I was here in October 2005 as we were scaling up our own pandemic preparedness in the United States. Being here is an important reminder of how different the problem looks from different perspectives. Indonesia has 245 million people, who live in a space about the size of New York State. About 60 percent of the country's area is water, since the nation is really thousands of islands. It appears to me that most of those people must have highly localized lives, and developing a national strategy on anything would be difficult.

The next presidential election in Indonesia will take place in 2009. Just like in the United States, the upcoming election has begun to affect the formulation of policy. The night before I arrived, local elections took place in the largest Province, West Java, and, in what appears to have been a surprise, an Islamist party took power. It would be similar to having a populist movement win a statewide election in California. The election in West Java is an event that will clearly begin to factor into everyone’s political calculus in Indonesia.

I didn’t have any political discussions about this with Indonesian officials. These are observations I am picking up from reading the local papers, and from talking with people at the U.S. Embassy. I’ve always found it important to understand the political context in which foreign government officials are operating- it helps you understand the filter through which they are seeing the world.

My first meeting was with Foreign Minister Noer Hasson Wirajuda. He is a sophisticated and well-educated man who spent five years doing legal studies in the United States. We talked at length about a group of themes related to the challenges of governing an undeveloped country. Later in the afternoon, our discussion continued. I think rather than discuss those in this entry, I will do a separate piece tomorrow.

Next, I visited the office of the Coordinating Minister for People’s Welfare, Aburizal Bakrie. A Coordinating Minister oversees several Ministries or areas of the Indonesian Government, and has the responsibility to coordinate their work. The meeting included the Ministers of Agriculture and Health.

Minister Bakrie is a noted businessperson. His family holdings are extensive, and their reputation looms large within the region. He speaks excellent English, and deals confidently with people. His business background is evident in his willingness to engage directly on problems.

Minister of Agriculture Apriyontono was invited because of the animal-health connection in avian Influenza. I met him in 2005 as well. Likewise, I have met multiple times with Health Minister Supari. She has become a controversial figure within the health world, because she has stopped sharing with the World Health Organization (WHO) any samples of influenza viruses that are circulating in Indonesia. She asserts that if a nation provides a virus from which a manufacturer makes a vaccine, that country is entitled to monetary compensation of some form. This is a dangerous course that threatens to undermine a worldwide agreement honored by nations for nearly 60 years. I wrote previously about this subject.

The Indonesian Health Minister has used the sample-sharing debate and the negotiations over the status of NAMRU-2 in Indonesia to set herself up as an antagonist of the United States, a position I suspect helps her politically among the constituency of her party.

NAMRU-2 is an important public-health asset in Indonesia. The lab is a WHO reference lab, which means the level of expertise there is high enough that the world accepts its work. If a communicable disease breaks out in South East Asia, any country can send samples of the virus there to have them identified. The laboratory has been in Indonesia for decades, and exists under a Memorandum of Understanding (MOU) between our Governments, which is up for renewal.

The MOU that governs the status of NAMRU-2 expired two years ago, and both sides have been trying to renew it. When I was in Indonesia in 2005, the lab was a major topic of conversation in my discussions with various Ministers, and with the President. At that time, I received absolute assurances the Indonesian Government would approve the MOU shortly.

Minister Supari recently issued orders to prohibit Indonesian institutions from providing tissue samples to NAMRU-2, under the justification that such sharing is not legal in the absence of an active MOU and a Material-Transfer Agreement. Her action is obviously linked to her global initiative to seek specific benefits for sharing samples.

To add more drama to this picture, Minister Supari, recently published a book in which she asserts the U.S. military is using influenza samples to create biological weapons. Secretary of Defense Gates was asked about the Minister's accusation when he was in Indonesia this past February; he replied, “That’s the nuttiest thing I’ve ever heard.”

All this background created great media interest in my visit. The morning of my discussion with Minister Supari, an article appeared in the English-language Jakarta Post that said I might refuse to meet with her. The truth is, I came all the way to Jakarta quite specifically to see her. Anyway, all this added up to a minor drama.

We met privately in Coordinating Minister Bakrie’s office for a while, and then joined the rest of our delegation and Indonesian Government staff who had gathered. The conversation was refreshingly straight-forward, an outcome I attribute to the style of the Coordinating Minister. While we talked about a number of other issues, such as HIV/AIDS, most of our time focused on the NAMRU-2 and sample-sharing. After a time, the Agriculture and Coordinating Ministers left, but Health Minister Supari and I continued our conversation.

It is important to remember that, while the NAMRU-2 issue is between the United States and Indonesia, the influenza-sample issue is between Indonesia and the other 192 Member States of the World Health Organization. The United States has been part of a group that has been trying to resolve the problem for the past two years. They have held numerous meetings, and various other types of negotiations. These have yielded a short list of things the parties believe the WHO Secretariat could do to improve its influenza program. The Minister mentioned this several times as "progress."

However, I could see little real progress in the key question whether contributing countries should receive direct, monetary benefits as compensation for sharing samples. The Minister’s main point is that what she wants should not be considered "royalties" or "compensation." What she says she wants is for the contributing countries to be eligible for some share of the value commercial companies create out of the influenza samples they provide. Or, as she expressed it in a hand-delivered letter to me later in the afternoon, “Allow me to reiterate that when I raised the term ‘monetary benefits,' I was not referring to any type of royalty, nor any type of quid-pro-quo arrangement, but rather to a method that leads to the allocation of values derived by commercial interests into one commonly defined system, which will provide benefits to those that have made contributions.”

I told the Health Minister two things. First, I understand her desire to assure people in her country have access to medicines and vaccines. This is a problem in developing countries all over the world. It is a complicated issue, but we need to address it, while preserving the incentives for innovation. I pointed out that technology is improving and might well hold solutions we don’t currently have. I used as an example the billon-dollar investment our nation has made in cell-based vaccine technology. Once we are using cell-based methods of making vaccines, the capacity and cost of making vaccines will dramatically drop, which will change the entire equation. The world is working on solutions.

However, linking sample-sharing to payment in any form will immediately begin to erode our ability to make vaccines at all, because once the practice of free and open sharing of viruses stops, the slope is slippery, and there will be no end to the demands.

The issues of the availability of vaccines and the sharing of samples are both legitimate ones, and we must deal with them both, but we should not link. World health should not be the subject of barter.

The second thing I told her is that I find it impossible to distinguish a difference between what she is seeking and royalties. The bottom line in both is this: share samples, get paid.

I would summarize the conclusion of my meetings this way: We celebrated the small list of consensus recommendations that are emerging from the multi-lateral discussion at the WHO on this matter, and committed to keep looking for solutions. The Coordinating Minister suggested we could find a solution within two months. He later reported that to his President in our meeting with him.

I have instructed my representative on this matter, Bill Steiger, to work with Ambassador John Lange, Secretary Rice's Special Representative for Avian and Pandemic Influenza, to continue our discussions with the Indonesians and others for the next two months. However, we cannot be party to an arrangement that will un-do 60 years of one of the world’s great public-health successes.

There are some situations that, despite our best efforts, we cannot resolve. In those cases, we just live with the added risk. The cost of Indonesia's refusal to share influenza samples is incrementally small. However, the damage done by accepting Indonesia’s view is profound, and simply unacceptable.

We will work on this for the next 60 days. If we haven’t been successful in resolving the matter, I think it will be time for the world to just accept Indonesia’s unwillingness to participate in the WHO influenza system, and move on to other ways of making the world safer. Perhaps when circumstances change, Indonesia will rejoin the mainstream on this issue.

Pandemic Exercise with Bloggers

We routinely hold readiness exercises at HHS on various emergency scenarios. Typically, people from various parts of the emergency management community sit around a square table, and a moderator paints a picture of a disaster unfolding. It is like a reader’s theater. As events are described, each actor assumes their part, describing what they are thinking and doing to respond.

Slowly, the moderator heightens the stakes and intensifies the nature of the problems, throwing out more complicated circumstances, and challenging the reasoning various players use. It is an excellent way to learn and refine emergency protocols.

Monday, we had another exercise on pandemic influenza. Included in the exercise was a group of journalists, including bloggers. Not amateur bloggers like me. Real pros, people who have built reputations with their readers for innovation and speed.

We invite journalists to participate in our exercises because managing their needs for information is a part of crisis management. We need to learn more about how bloggers would react and interact.

Television reporter Forrest Sawyer was the moderator. He has done several of our exercises and he’s very good. He laid out a set of facts that represent routine health news from around the world and laced it with a few interesting tidbits that could attract the interest of people following the flu world.

Turning to public health officials at the table, Mr. Sawyer asked if they found any of the news that day interesting or concerning. He did the same with the journalists, asking what they would do to get more information and how big a story they thought it was. As the facts became more concerning, several observations came to me.

I found it reassuring how important accuracy was to those that attended our session. They were willing to report rumors but made a point of distinguishing them as such. Many of them said they had separate sections of the page for rumors.

The blogs represented at our session tended to be rather specialized and the bloggers knew a lot about the subject matter. It made them better at challenging the facts they were given. I suspect in a major emergency we would be dealing with a broader range of understanding than in our exercise. These people knew their stuff.

I was surprised how much interaction there is between online communities. They seem to share information, monitoring one another’s sites.

More than one of the blogs talked about the way they use traditional news sources but provide added value. One example is translating foreign news articles into English.

I enjoyed watching the interaction between traditional media and blogs. It’s clear television, major radio and newspapers are monitoring blogs all the time. It is also evident most of them are starting to use blogs to supplement their own reporting. The unlimited supply of space and time is appealing to traditional journalists.

The exercise went most of the day. I was only able to stay until noon, but it was a morning full of learning.

The bottom line for me: Government needs to understand the blog world better, and factor it into the way we interact with people. A growing part of the world relies on bloggers for unvarnished information; something they are not sure they always get from us in government.

MRSA

Monday I had Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, brief me on the MRSA bacteria. This is the drug-resistant strain that has been a worry for several years now, especially in health care settings. My interest was peaked by new research reporting the frequency and severity of the problem.

Dr. Gerberding currently administers one of the true public health treasures of the United States. CDC is seen worldwide as the gold standard of public health agencies. Julie also happens to be a world class scientist and, as it turns out, the MRSA (methicillin-resistant Staphylococus aureus) bacteria was the subject of much of her research.

I asked for the briefing after the Journal of the American Medical Association published a study estimating MRSA caused 94,360 life-threatening infections and 18,650 deaths in 2005 within the United States (Klevens et al., 2007). The human suffering created by this bug is enough to make it a serious matter. The financial impact is also profound.

To say Dr. Gerberding is passionate about this work is a huge understatement. I could well have been listening to the head of the CIA talk about current intelligence on a terrorist cell within the United States. She speaks of the different microbial players and describes their personalities. She uses the word community as she discusses the bacteria’s efforts to undermine its competitors so it can unexpectedly overwhelm its host. Scientists are the intelligence analysts in this struggle; the medical family is the armed forces that work to protect us; and antibiotics are the weapons used to fight.

There are serious challenges in fighting MRSA. Like any microbe it is constantly adapting; “learning new tricks” is Dr. Gerberding’s phrase. Tricks like genetically learning to ignore antibiotic treatments, or the capacity to invade into deep tissues and destroy them with a potent toxin.

Some of those “tricks” MRSA learned in hospitals have been transported to staph that healthy people carry into the community, and now they too are MRSA carriers. Dr. Gerberding said this started happening in the late 1990s then began to run wild outside medical areas. She told me of a situation involving a college football team where 10 players developed MRSA through their turf burns. She mentioned prisons, schools and other populations, like Alaskan Natives, where outbreaks of skin and sometimes deeper infection occur. Once the bacteria have a foothold, they easily move to others in close contact.

Her description of the way MRSA adapts reminds me of a computer code breaker. To break a computer code, hackers try sequences of numbers, letters and symbols at high speed until it stumbles upon the combination. Billions of MRSA microbes are testing the genetic codes to find new ways to exploit weaknesses in their host.

After moving through the community and picking up new “tricks,” MRSA has begun to concentrate on medical facilities again. More than 80% of the incidents occur in hospitals, doctors’ offices, etc. Obviously, people with open wounds and weak resistance make easy prey.

This is a remarkably clever bug. Dr. Gerberding told me it will hang out on a person’s skin and then when an IV is inserted in an arm, it will slide down the needle into the system where it will begin to compromise other microbes.

The best defense against MRSA is prevention. Hospitals, doctor’s offices, and nursing homes need to have aggressive programs to deal with this. Patients deserve to know hospitals, nursing homes and doctors do a good job at prevention. Patients need to know if a hospital has a history of regular MRSA infections.

I have to quit now, but I have more thoughts on this. I want to explain how transparency of incidents is critically important. How electronic medical records play a role here. Also, some about who should pay when a patient gets sick from a hospital born infection.

Klevens RM, Morrison MA, Nadle J, et al. Invasive Methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007;298(15): 1763-1771.

Strategic National Stockpiles

Strategic National Stockpiles have had my focus the last few weeks.  Each year Congress appropriates money (just under $600 million last year) so we can maintain stockpiles of medical supplies that would be needed in a national emergency. We have organized the system with the objective of being able to deliver basic supplies to the scene of an emergency within 12 hours.

The stockpile system became a serious undertaking following September 11, 2001. Our level of sophistication continues to increase. The procedures for prioritizing and executing the purchases are improving.  We have a ways to go in my view.

It is easy to underestimate the challenge of keeping supplies current and ready to deploy. It involves advanced logistics and it is not inexpensive.  In many cases, buying the item is a minor part of the cost. Warehousing has to be paid every year. Another challenge is shelf life.  Most medical products have to be constantly monitored for currency and after an appropriate period they are no longer usable. 

Some items are used and rotated constantly, but others don’t lend themselves to that pattern.  Medical masks for example are not reusable and they just plain take up a lot of space. Medicines for certain emergencies would not be useful for any other purpose.

Another difficult issue is what and how much to stockpile.  We have an interagency working group that makes those decisions.  This group weighs the various categories of natural and man made emergencies that could occur and does its best to anticipate the supplies needed to recover from each.  Careful priorities must be chosen because we can’t buy everything.

Among my biggest concerns related to the stockpile are two obvious ones.  I worry about local and state governments and private entities relying on the federal government instead of preparing themselves.  Our national stockpiles are set up to cover gaps, not to provide everything for everybody. 

My second worry is distribution.  The stockpile organization is able to get medicines, etc. to an airport within 12 hours. State and local governments are depended upon to have plans for distribution.  We coordinate closely with them. The drills we have had in recent months with postal workers delivering medications to homes in Seattle, Philadelphia and Boston are examples.