Review: Two provocative works on health preparedness

After an Attack: Preparing Citizens for Bioterrorism By R.J. Danzig, R. Kleinfeld and P.C. Bleek, Center for a New American Security, 2007, 64 pp, free download here. Pandemic Preparedness: The Need for a Public Health – Not a Law Enforcement/National Security–Approach By G.J. Annas, W.K. Mariner and W.E. Parmet, American Civil Liberties Union, 2008, 40 pp., free download here.

Two sets of authors/organizations who might easily be politically pigeonholed have sounded (mostly) non-partisan alarms over critical gaps in our preparedness for a range of health emergencies. These papers should be thought-provoking for the numerous disciplines involved in planning for or trying to prevent an influenza pandemic or bioterrorism. Both papers make their case with ample documentation; these are policy analyses and recommendations, not political screeds.

Former Navy Secretary Richard Danzig is no stranger to expressing unconventional opinions or meeting substantial resistance; he continues to provide clear, realistic (in my opinion) and all too atypical perspectives on bioterrorism. Although I agree with far more in the CNAS paper than I disagree with, I have a tough time giving BT the priority that they do.

I recognize the potential and agree with his conclusions about how events are likely to unfold if we are attacked. I also agree that it could form our worst-case scenario, but after almost 15 years of antiterrorism marketing programs that rarely rise above "It's not a matter of if, but when," I see us generating equally critical vulnerabilities by ignoring natural hazards — whether seismic or microbial.

That said, I believe that a BT attack would likely generate Danzig's "failure to meet the most fundamental citizen expectations," which are laid out in the following six points, appropriately employing the personalization of risk common to rare, "terrifying" hazards.

• Instruct and equip me to protect myself as much as possible, immediately and in the event of future attacks.
  
• Tell me whether I and those I love have been or could be infected by this attack.
  
• If I cannot reasonably be assured that my loved ones and I are not infected, provide us with whatever drugs or vaccines will protect us and do so quickly, fairly and safely.
  
• Provide health care for me or others who become ill as a result of attacks.
  
• Prevent more attacks of this kind.
  
• Speedily establish conditions and provide information that will permit me and my family to return safely to ordinary daily activities.

Taking each issue in turn, the authors discuss the lack of effective systems to address these needs, and the lack of much progress by the several federally-funded programs that were established to do just that.

The authors recommend focusing the system on the individual/family, that is, on the end-user of the system, rather than on the professionals within the system itself. This includes solutions to allow laypeople to protect themselves, care for themselves and others, and receive medical and other needed supplies without having to report to distribution centers. It also includes better out-of-hospital management of the “worried well,” both to relieve pressure on hospitals and to improve the public’s mindset, and to use social networks to augment centralized risk communication and dissemination of protective actions. Many of themes sounded in this paper echo those raised by Danzig in what should have been a landmark paper four years earlier.

Annas, et al, are concerned about the default focus on security and control for large-scale infectious disease outbreaks, the most relevant current concern being an influenza pandemic.  Drawing lessons from US outbreaks (plague in San Francisco, 1900, and smallpox in Milwaukee, 1894; Boston, 1902; and New York City, 1947), the authors posit that coercive control measures, particularly when used as an initial course of action, are not just ineffective but actually counterproductive.

Although I agree that far too much of federal and lower governmental policy views health emergencies as issues of centralized control and enforcement, I disagree with their assessment of all-hazard planning. "All-hazard" has become an almost meaningless buzzword in many documents, a mandatory mention that too seldom accompanies evidence of practice and has largely become synonymous with "one-size-fits-all."

There is no question that crises such as a pandemic generate impacts and needs unlike those of more "ordinary" disasters, but they also require many of the same underlying systems needed to plan for, respond to and recover from any major event. Unfortunately, in too many processes, the public is asked to do little beyond putting together an emergency kit and "having a plan."

Setting aside for now what may be more of a semantic than an actual difference, the authors focus on what they see as four essential principles at the center of pandemic preparedness:

• Health (pandemic preparedness as a health issue first and foremost, not a security issue)
  
• Justice (fair distribution of resources, maintaining respect for the individual)
  
• Transparency (clear communication of process)
  
• Accountability (holding all involved, public and private, accountable for their actions before, during and after an emergency)
  

There is clearly substantial room for conflict here. The authors do not see initial outbreak containment as realistic, and they recognize the potential for rationing or denying resources once a pandemic takes hold. Both views are shared by many.

On the other hand, a crippling disease outbreak, even if global, is a security threat — it just shouldn't be viewed as one primarily or exclusively. Transparency is far easier conceptually than in practice, as it requires community involvement, which in turn requires not just a very different approach from the side of government, but also from the governed — worthwhile and possibly achievable, but an uphill battle.

Likewise, accountability for all involved is a sound principle in reference to potential abuse of power or unethical behavior, but it's unclear to me whether our legal system could differentiate between that and honest decisions that don't work out. As there currently seems to be very little civil protection for those planning for and likely to help determine allocation of scarce resources during an event, accountability swings both ways.

These papers present the types of discussions that need to take place at all levels of government, in the private sector and in the community.