5.4 Primary Incident Command

In a catastrophic event (e.g., major earthquake, hurricane, or terrorist attack), State Government may assume primary responsibility for incident command. A common belief among many States is that the structure of the State EOC is adequate for managing medical and public health response. In reality, however, this may not represent an ideal arrangement since the ESF structure and function are designed to support incident management (hence the name, Emergency Support Function). Thus, States that assume primary incident command authority should establish a separate incident management team, incorporating ICS principles, to manage response functions. This concept was effectively demonstrated by Illinois public health during TOPOFF 2.

The State of Illinois response in Top Officials 2 (TOPOFF 2)—a bioterrorism exercise in May 2003—provides an excellent example of how a State can effectively assume primary incident command responsibility. In TOPOFF 2, Illinois successfully implemented a State public health Incident Command Post (ICP) that was supported by the nearby State EOC. This response organization demonstrated the significant incident command responsibility of State medical and health authorities in response to a major incident. It also emphasized that medical and public health managers can organize as incident managers, rather than attempt to manage from a support position (i.e., an ESF) in the State EOC. This example also serves to highlight the differences between ICPs and MACCs.

The State's incident management team should be composed of State officials from across the range of response disciplines, including State medical and public health authorities. This team defines incident goals (known as "control objectives" in NIMS), operational period objectives, and the overall response strategy for the State. In addition, the State performs the lead information management function. It collects data from intrastate jurisdictions (Tier 3), collates the data and conducts analyses, and then disseminates the aggregate information back to jurisdictional managers to provide the "big picture" of how the incident and response are unfolding.

In a catastrophic event, the role of the State as the primary incident command authority is relatively straightforward. However, in a subtle incident (e.g., onset of an unknown infectious disease), primary command will likely be based initially at the jurisdictional (Tier 3) level. As information begins to emerge on the potential size and scope of the incident, a decision might be made to transfer primary command authority to the State. This decision is made through a meeting of the jurisdiction UC or, if multiple jurisdictions are involved, a meeting of the lead agency authorities from the multiple jurisdictions as coordinated by the State. An alternative may be to develop an "area command"^[6] that coordinates assets across the involved incident management teams.

The role of State political leaders in incident management should be clearly understood.^[7] The Governor bears ultimate responsibility for the safety and well-being of the State population. For events with potentially serious medical or public health implications, the Governor may declare a public health emergency; this generally activates the formal State public health response. The Governor may also temporarily suspend relevant State laws or regulations that impede response activities. Preparedness planning should identify regulations that might need to be revised or temporarily suspended and the legal procedures required to carry out these actions. In addition, as the elected spokesperson for his/her State, the Governor plays a critical role in public information management by:

• Maintaining public confidence: This is accomplished by providing the visible message that the State Government is focused on the incident response, has the intention to assist victims and their families, and is bringing all available resources to bear.
• Providing a context to the incident: This may be established in part by:
  • Recognizing publicly the size and complexity of the incident
  • Describing that the response will take time and extraordinary effort
  • Providing other information that helps the victims and the public understand what has happened. For example, by expressing community outrage after an intentional hazard impact such as terrorism, and verbalizing both the mass impact of the event and the community's commitment to recover, the political leader may help the community come together for both response and recovery.
• Establishing and managing public expectations for the response: This is critically important in medical and public health events, where response is often complicated and solutions are not easily or rapidly achieved. Regularly informing the media and public of ongoing response efforts can help to shape behavior, and promote a better public understanding of how to best measure "progress" in complex events. This can also help to calm fears and minimize psychological impact.

State medical and public health officials (serving in a management role) should consider developing a briefing for the Governor (serving in an Agency Executive role) and his/her staff that describes key MSCC management and response issues. One critical area to explain is that "measures of effectiveness" used to evaluate a medical response may not be directly related to obvious outcomes, such as mortality or disease prevalence rates. For example, if all victims in a radiation incident were exposed to a fatal dose of radiation, the ongoing death of victims over days is not a measure of response effectiveness: the mortality rate had been unalterably set in motion prior to incident recognition and response. True measures of effectiveness for each type of medical incident should be developed during preparedness planning, and then reviewed and revised as indicated as a specific incident unfolds.

The Model State Emergency Health Powers Act (MSEHPA) provides one basic template for State authorities to define their major responsibilities in emergency or disaster response.^[8] Developed after the 9/11 attacks, MSEHPA suggests that States have a comprehensive plan in place for coordinated, appropriate response to incidents that threaten the public's health. It identifies specific laws or regulations that may need to be developed (or revised if already existing) to protect the health and safety of the general population. Key issues addressed that may be relevant for health and medical response include:

• Requirements for reporting illness or health conditions (including animal disease)
• Patient tracking and facility or materials examination
• Examination and decontamination of facilities or materials
• Information sharing
• Quarantine and isolation of persons or property
• Access to and disclosure of public health information
• Licensing and appointment of health or medical personnel
• Public information management
• Financial accounting, liability, and compensation.

In the years since the MSEHPA was published, experience has altered how it is applied. Readers are encouraged to review the published materials on this topic for a better understanding of its current application.

6. The NIMS definition of area command is provided in Appendix D.
7. Because the role of senior political authorities varies from State to State, readers are advised to review their respective State laws and regulations for State-specific information.
8. Additional information on MSEHPA can be accessed at the Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities

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