spacerspacer
Center for BiosecurityUPMC
Disease, Disaster, & Democracy
Summit Site Map | Summit Home 
horizontal rule
Pinstriped background
horizontal rule
horizontal rule
Horizontal rule
Convening Organizations
horizontal rule
horizontal rule

Summit convened by:

Center for Biosecurity

Canadian Policy Research Network

Center for Science Technology and Security Policy at AAAS

National Consortium for the Study of Terrorism and Responses to Terror

vertical rule
Home > Events > Disease, Disaster, and Democracy, 2006 > Conference Speakers > Roundtable 2

 

Roundtable II: What Happens If Hospitals Cannot Take Everyone In?
The Problem of Meeting Immense Medical Needs

Background  |  Issues and participants  |  Purpose and scenario  |  Summary

Transcript
Monica Schoch-Spana:
It’s my pleasure again to introduce my colleague, Dr. Tara O’Toole, the director of Center for Biosecurity who’s in chair number four from the left.  Everyone is seated from left to right according to the names up there [on the slide], and I’ll let Tara take over with introductions and open up the scenario.

Tara O’Toole (moderator):
Thank you, Monica. Can everybody hear me? We’re going to change the format around a little bit this time. I know it’s late in the day and everybody’s exhausted from trying to save two nations from a terrible pandemic, but we’re going to see if we can rev you up again.

Rather than try and compete with Donahue, I’m going to try and take myself out of this conversation except as an occasional provocateur and try and get the panel here to talk to each other as those negotiating actions during a flu pandemic. But before we get to the scenario, let me introduce people and explain who they are in real life and who they’re going to be for the next 50 minutes.

On the far left is one of our token males. We have Dr. Richard Waldhorn.  Richard is a distinguished scholar at the Center for Biosecurity. He was, in his previous incarnation, a critical care physician at Georgetown University and chair of the Department of Medicine there. He is focused on hospital response to pandemics and bio-terrorist attacks since his time with the Center.

Next to Richard is Commander Robert Tosatto. He is director of the Medical Reserve Corps in the Office of the U.S. Surgeon General. He’s been in the Public Health Service since 1988 and served as a responder to a number of disasters including the 2001 anthrax mailings and the refugee crisis in Kosovo.

Next to Rob we have Jan Lane. She is currently the deputy director of the Homeland Security Policy Institute at George Washington University. From 1990 through 2005, however, Jan worked for the American Red Cross in a number of positions, most recently as the vice-president of public policy and strategic partnerships.

To my left is Diane Lapson. She is president of the Independence Plaza North Tenants Association. This is a housing complex in New York City with 3500 people about three and half blocks from the World Trade Towers, and they were in the middle of the red zone during the attack on the World Trade Center on 9/11. She is a founder of the 9/11 Environmental Action Group, and in her free time, she works with music publications in the entertainment industry.

To my right is Dr. Christa-Marie Singleton. She is the chief medical officer in the Baltimore city Office of Public Health Preparedness and Response. She has been a pediatric emergency room doc and she’s worked in a variety of policy positions in Washington D.C. as well as a county health officer.

To her right we have Arrietta Chakos. She is the assistant city manager in Berkeley, California. And she has been a very active citizen in preparation for seismic safety. This work has involved her with policy makers, with FEMA and with U.S. and Japanese collaborations.

And finally, not least, we have Ann Beauchesne. She is the executive director of U.S. Chamber of Commerce’s homeland security division. She previously held a number of positions in the National Governor’s Association including director of Homeland Security and emergency management for the NGA.

Tara O’Toole (moderator):
So, clearly we have a diverse and distinguished panel. We are in the middle of a flu pandemic. We are in our community, which is a city in the District of Columbia about to reach the peak of the pandemic though we don’t know that yet. There are two times as many patients for every ventilator we have. We’ve got about four or five patients for every available hospital bed. People are very sick. We haven’t been able to figure out the mortality rate yet, but it’s much higher than the 1- 2% mortality rate of 1918 and looks a lot more like the 50% mortality rate that we’re seeing now with H5N1.

I’m going to ask people to play very generic roles which stem from their real life experience. Rich is going to be Mr. Hospital. He is going to be both a medical director and CEO of a major hospital in our city. Rob is basically going to be the entire federal government—a dream come true, yes, the stuff of which nightmares are made. But in particular, he is going to be the city’s link to the feds and to HHS and we’re going to ask him a lot of questions about the Medical Reserve Corps and what the federal government can do for us. 

Jan is going to wear two hats. She’s going to be a talking head representing a think tank for the media and we’re also going to ask her, at times, to be Jan Two and serve as our representative to the American Red Cross and other citizen volunteer organizations. Diane actually gets to be herself. She’s going to be Ms. Citizen Activist representing her neighborhood. And then we’re to have Christa be herself; she is going to be our public health representative for the city and we may ask you to be the state as well. Arietta is going to get a promotion and be mayor or city manager. She’s going to represent our elected officials. Ann is going be the entire private sector.

OK. So, here we are. Things are looking very serious and we are going to try and figure out what to do about delivering medical care in some coherent way that provides people with dignity and a sense that the entire community and its values are not coming apart. So Richard, what is going on? What do you have to say about this situation?

Richard Waldhorn:
Well, let me tell you about our hospital. It’s not going too well. Despite years of plans and drills and exercises, the real thing is a lot worse than we anticipated it was going to be. All of our flat spaces in our hospital have been converted to patient care areas. We’ve gotten out of mothballs any beds or any equipment we had in our stockpile. We’ve used every mechanical ventilator that we have, but more difficult than that, we have a large amount of absenteeism. Even when we have a ventilator free from time to time, it’s tough to get a respiratory therapist or nurse available to staff that case, even though we’ve spread patients out to other wards of the hospital.

Our elective procedures have been canceled in our hospital and my CFO is telling me there’s not too much more cash flow left for my hospital because I make my revenue on those elective cases and those are drying up. So I’m running out of cash to run the place.

I have no more capacity in my emergency department. They would be on re-route but there’s nowhere to re-route the patients to, because the other hospitals in the city are reporting the same phenomena. We are unable to care for patients with non-flu disorders such as our diabetics and our patients with heart failure and our children with asthma. We’re short staffed in all clinics and our routine care is suffering in our community. We don’t really have any more capacity than we can generate within the four walls of our institution. We’ve done about as good a job as we think we can.

We’re now in two places in the hospital beginning to face decisions about limiting the amount of care that we can give. In our emergency department we’re going to be forced to make some decisions about who we can admit, whether [we have] the ability to impact those patients, or whether they are too far gone for us to admit. And similarly, in our intensive care unit we have patients with very high mortality, multi-system disease and [for] whom it’s not clear whether the extension of resources is going to do them or anyone else any good.

Tara O’Toole (moderator):
Wait a minute. So you’re telling me you’re going to turn patients away from the hospital? You’re going to tell them they can’t come in when they’re very ill?

Richard Waldhorn:
We need some help from the community in this regard. We need a framework in which to begin to make these decisions. We’re at the point now where I’d like to get some help from the public health department, from community groups. Because we’re at a point now where we can’t develop any more capacity. We have to start limiting the amount of care that we can provide so as to do the greatest amount of good for the greatest amount of people. And we’re going to need some kind of input from our community engagement or our community in making these tough decisions.

Tara O’Toole (moderator):
OK. So you call the Mayor and public health department and they’ve called this meeting.

Richard Waldhorn:
And one of the things….First of all, I want to know, is there any capacity anywhere else in the system? Are there any resources that be shared anywhere in the system? We’ve drilled and practiced that as well. My hunch is, from hearing my colleagues around the city talk, they’re all in the same boat.  But I would want some intelligence, some situational awareness about the rest of the city hopefully from my colleagues in public health and in the private sector and in the rest of the community. First of all, is there any capacity anywhere, and if not, how do we go about beginning to decide what care we’re going defer to do the greatest good for the greatest number?

Christa-Marie Singleton:
Well, from a public policy perspective, I guess one of the first things we would ask is—well, I’ll tell you what public health is going to definitely be doing, [it] is actually being a little bit behind the eight ball in terms of trying to investigate the cases. Unfortunately, public health’s capacity to do that is basically very limited in that we usually only have one or two fully trained epidemiologists on staff. We’re very, very good at doing case controls and trying to catch up with people. But it’s the case of taking one or two individuals that have their normal full-time job and then trying pull them up to do more and more investigations. So, we would be stressed at this point.

If we’re maybe halfway through an eight week epidemic, about four weeks into it, you’ve used up the majority of our staff. We probably too would be having some staff absenteeism. And so, a health commissioner at the local level will likely be reaching out to the state health commissioner to say, “Please help. Do you have any available staff? Do you have other disease investigators? Who else can you think through?” Hopefully this health commissioner will have done some cross-training on their staff. So looking at nurses, social workers, and others who can ask basic questions and try to find these people who are either A) sick or B) potentially sick--and try to get them to either stay home or do preventative measures.

The challenge for our colleagues at the hospitals is to say, “OK, who’s going to be message maker? What are we going to tell the public?” ‘Cause if you’re saying, “I’m full, I can’t take anymore people,” where can sick people go? Then one of us has got to be the messenger to the public.

Richard Waldhorn:
Feel free.

Christa-Marie Singleton:
Give a consistent message to the public. And then it would be a local level almost competing with, in some respects, the state to say who’s going to be the main message maker. And hopefully in this state of... whatever we are... here would be a good dialogue between public information officers at the local level and the state level. So there wouldn’t be a local person saying, “We’re in trouble” and the state person saying, “We’ve got it together” or vice-versa. I could see a tension, and turn to my mayor, with the emergency medical system because you’d usually be a on re-route, but the EMS people will still be getting this influx of 9/11 calls and they’re going to be picking up people and dumping them at your door anyway.

In a lot of communities, the EMS community is using these Homeland Security funds to say, “Oh, surge capacity.  Let’s buy all these tents.” So they may come beating my door as the health officer, or you as the mayor to say, “Let’s put up these new tents we have and let them help the hospital out. We can put them at the door to give you some extra space.” The challenge for public health is if we do that, then how do we track these people, and how do we provide appropriate care for them?

Arietta Chakos:
Well, let’s see. A very appropriate response from both of these members of our community…

As the mayor of the city, what I would do is really use the California model, the incident command system, to make sure that we’re talking with all the right people in our community. I would invite our colleagues from the private sector, from the American Red Cross and the volunteer community immediately for a meeting to start looking at where we can house people for palliative care and get some volunteers in from the community so we can start to provide medical support where our hospitals and local clinics are overwhelmed.

The second step I would take would be to get in touch with our colleagues at the federal, upper [tier] at the state level too. Because we have a very ordered system in California on how to handle these sorts of things and route all of our resource allocation requests through operational areas, our counties, up to the state. I imagine that we would be asking for state and federal assistance and activating Medical Reserves Corps.

Tara O’Toole (moderator):
OK, this is not California. This is D.C.

Arietta Chakos:
OK.

Tara O’Toole (moderator):
There’s none of this....

Arietta Chakos:
There’s no...?

Tara O’Toole (moderator):
Everyone is overwhelmed.

Arietta Chakos:
OK. So we’re not to get any outside support?

Tara O’Toole (moderator):
You’re not going to get any outside support from the state. In fact, you can’t get the state to return your phone calls because they’re getting phone calls from everybody. And let me ask our Red Cross representative:  Are you ready to send volunteers in to take care of sick patients for a disease with a 3% mortality rate or 2% mortality rate?

Jan Lane:
I think you have to. Hopefully, we will have had this conversation before—Red Cross would have been a part of the planning. There’d be the understanding about where we can and where we can’t send volunteers and where we’d need to keep them safe and what the limits are to what they can provide to the mayor and to the public health department. One of the areas where we can be of tremendous help is to take a look at who are the trusted messengers to get some of the key messages out to the public. Why is the 9/11 system overwhelmed?  Because you’re probably getting a lot of calls from the worried well. How do you reach those people with the information that they need to empower them to know what to do? You go through trusted messengers.

So let me take off my Red Cross hat and let me go to the faith-based community, because we’ve seen time and again that the faith-based community does have that forum to get the messaging out. They are the ones that are going to reach out to the vulnerable populations. They have incredible networks of networks to get that message out. But from the standpoint of these partners, hopefully they and the Red Cross will have been at the table, and part of the discussions will be how the community can rely on us in the way of volunteer management. What is it we can do for the local hospital? It’s not going to be administering vaccines, but it may be helping the information flow—some of the phone bank calls that you may be getting from the worried well.

Because, I think, any time we are able to empower people to know what to do—where is the sheltering place, how to prepare in advance—we’ll take that burden off of the 911 system, again, overloading EMS. That is definitely a concern as we go through this.

Tara O’Toole (moderator):
Diane, do you think it would be helpful to have hotlines that citizens could use to get basic information and non-emergency....

Diane Lapson:
Am I on? I hate to say I told you so, but if the public had been educated all along on what to do in an emergency, we wouldn’t have to wait to be trained and we could immediately move into action. So I’ve seen, since I live in Washington now with a Brooklyn accent, I’ve seen that in neighborhoods—say in downtown Manhattan during 9/11—that there are hundreds of people that came forward to help. That wasn’t a disease, so in those cases, whatever they were doing worked because it had to do with food and we weren’t contagious.

But I think in this situation, one of the important things to remember about the general public is that everyone’s traumatized. So, helping is part of healing their trauma. And if they can get involved you’ll have that many less problems on your hands. I think everyone, no matter who they are, can do something. I think that we probably will need to get public spaces like one of the hotels that exist in Washington, and a conference room this size, and try to see how we could get people who were sick over there. And then have the instructions on what we could do without getting sick ourselves.

Something that’s really important is that none of us have any supplies.  And if we’re working with the sick and breathing everything in without a mask, we’ll be the next ones to lie down. But, I think that history has proven that people are not going to leave. They’re going to stay. They’re going to be the ones driving the sick people back and forth to where they have to be. So, I personally think the radio system is the best way to go and to immediately go into a mode of: “Here are the instructions, and here’s where we need everyone who’s a nurse. Everyone who’s a social worker show up at this location.  Everyone who’s an electrician come here.” And just start telling people where to go and give them immediate instructions. Problem is, you have the people to train the volunteers.

Christa-Marie Singleton:
Actually, one of the bigger problems is: What is the message? Because, it’s got to be very, very simple. Public health has had a history of being very positive about just simple messages. The challenge though is that we as the community, as the public, have not always gravitated to those. If there’s no vaccine, there’s no antidote—at this point we’re talking probably basic respiratory hygiene and just really reinventing that and underscoring that more and more and more.

And either having a public health person or a hospital person, however we decide whoever is going to be [appointed]. Say that I’m [appointed]…then, a compassionate way of saying it: “This is what we want you, the public, to do, and we need your help. If you volunteer to help, we will do our best to protect you.”

Public health has to spell out how people can protect themselves so they can help other people—
covering their mouths or... maybe you can help out being on the phone bank. You can help out by delivering food. You can help out by watching someone’s children so they can go to work. Whatever. But we, as public health, have to step up and tell people how they [can] protect themselves. Otherwise, we can’t expect them to help each other.

[crosstalk]

Ann Beauchesne:
I would just add that if we’re going to wait to have the conversation with the private sector, wait until a pandemic happens, [and] then say, “Gee, let’s figure out if we use this hotel. Gee, let’s figure out if the trucks are still going to go,” we’re going to have absolute chaos. What needs to happen now is with the money going out to the state for pandemic planning—the money that’s going out from DHS—as a part of getting that money, every state should be required to show how they’re incorporating the private sector into their plans, their training, and their exercises. Unless that happens you’re going to have chaos. You can’t wait until this rolls out to figure out how you’re going to include the private sector.

We also need to figure out, ahead of time, what capabilities and assets the private sector has in your area and can bring to bear. We have the EMAC, the Emergency Management Assistance Compact.  We should have a similar version of that for the private sector to figure out who has what, who can bring it there, especially at a time when you’re going to have a minimum of a 40% workforce issue. That’s going to be essential to figure out what the exact capabilities are.

Tara O’Toole (moderator):
I think all the guidance that’s come out from the state and federal governments has been to include this kind of community planning well in advance of disasters. Karen Marsh spoke earlier today about the Citizen Corps mission, and how we have to start talking right now. So, I think that when our health officer Christa starts talking about the consistent message, she has to be flanked by people from the faith community, trusted community leaders, as well as the private sector and your elected officials, of course. And we’re looking at as well how we can begin to give people, as Diane was saying, some tools to work with in the short term. [And getting] messages out through the mass media of consistent hygiene and self-care message as well as caring for others within your community will all be essential in the short term.

Richard Waldhorn:
You know, Tara, two things were mentioned here that came up on rounds in the hospital. One was about, what about setting up tents in the parking lot? What about using some of the hotels downtown for patients? But my staff was very worried about these two ideas because they’re already having enough trouble segregating out those who are infected with flu from those who are not as they [become] present to our hospital. We’ve run out of rapid flu tests; we’re not sure if it works anyway.

We are worried that our hospital is becoming an amplifier of the disease. We’ve had cases of our own staff becoming ill. The patients who are coming in the hospital are very, very sick and we’re not sure what we’d be able to do for them in a setting where we didn’t have oxygen, suction, mechanical ventilation, etc. So I’m not sure what we’d do if these tents or hotel ballrooms become full of patients other than perhaps amplify the disease even more in the community. I wonder if the public health office has an opinion.

Christa-Marie Singleton:
I would definitely agree. In fact, in my real world life I’d advocated against the active purchase of these, because again who’s going to staff them?  Even they become just sick bays, we don’t have any staff. So, until we have better technology and staffing, I’m kind of moving away from that. My goal is, in both my real world life and in this life in this scenario, is trying to get that message out to say, “Really, public, don’t go to the hospital.” It’s almost what we did last year with the flu...two years ago with the flu vaccine crisis. “Don’t go to the hospital. If you’re sick with A, B, or C, go home or stay home.”

One of the challenges though in this scenario—what I would do is look to my mayor and say, “We’re really going to advocate that people stay home. But if they do so, particularly if they work in the private sector, they’re going to lose revenue. Do we have any kind of financial revenue that we can use to support them staying home?”

Tara O’Toole (moderator):
Before we go to the revenue [question] and the private sector, I want to stay on, “What do we do about managing all these sick people,” for a moment. This seems like a situation tailor-made for the Medical Reserves Corps. Commander, can they help us here?

Robert Tosatto:
Potentially. In working very closely with the public health department.  The Medical Reserve Corps are a resource of medical and public health providers to supplement the existing local resources. So, to that extent, the local public health department would use their staff, their resources to meet the needs. Then those are tapped out, and then they could call on these extra resources from the Medical Reserve Corps. To that extent, they may be helping at the hospital—maybe, maybe not.

But they could also be helping with the goals of getting the word out, getting the messages out. Maybe manning some of those hotlines to answer those questions, where the staff can then do the disease surveillance—do the other things that are needed everyday. The volunteers can come in and help out with this. If there are other sites open—alternative care facilities—then maybe some of these volunteers could help out in those types of situations. We’ve seen a great outpouring of volunteer support to natural disasters—after hurricanes, after situations like that.

Tara O’Toole (moderator):
Isn’t this a little different? We’ve got a lethal disease that you might catch by being altruistic.

Robert Tosatto:
This is quite different. This is quite different, and I don’t think any of us have a great deal of experience. We’re not planning...in our planning, we don’t have great confidence in large numbers of individuals coming to help out. But, we know there will be some that will show up. We’ve seen in every type of situation [that] people are willing to help. What those numbers are, we can’t guess that. So, for planning purposes, our goals are to have a lot of MRC units so that there are more MRC units to draw from. And within those MRC units, to have lots of people sign up, and hopefully you have a bigger pool to draw from within that.

Diane Lapson:
It’s, of course, a very difficult decision to make. I don’t know which is better—having a lot of people sick in their homes [alone or putting them in a central place]. It could be a mother with her children and suddenly the mother falls ill and the children are there by themselves. And if we don’t have them in a big facility, then how do we know which apartment or which house has people who need help? So, on one hand, getting people to a big facility is a risk, but on the other hand, having everyone in their individual spots is very dangerous too, because we don’t know how far the illness is even going.

I think, if we had to do it that way [asking people to stay at home], then it would be easy for the public to get involved because they could become captains—just checking in each house or building or block to see what’s happening in each house. But I don’t know if that would be good way—maybe, unless maybe Red Cross could go and visit each one of those houses, how would we treat people that way? So, it’s definitely...I don’t know if one way is better than the other. It becomes so tremendous, where you’re taking children out of the house because there’s no adult left that can function.

We have to have facilities anyway, even if people are well—shelters to put people into.  I know during 9/11 they turned all the—about five high schools into shelters, when people lost their electricity and they had to go there. But at least we knew 300 people are in this spot; 50 people are here. So it becomes dangerous if…and I also think one of the problems, the negative aspects of what happens in a disaster, is that people left alone and not part of a community sometimes mentally get unbalanced. And I think the community aspect in whatever way—it’s playing a role [as] the healing spot. And it’s the group of people coming together. So I think, just thinking about everyone staying and sheltering in place can’t be the final—I don’t know if that’s the final....

Tara O’Toole (moderator):
What do you think about that, Mayor? You’ve got your public health person telling you the best thing to do scientifically is to keep people isolated so they can’t transmit the disease. You’ve got your citizen activist telling you she thinks that it’s going to deal a real spiritual blow to the community and it’s not going to go over well.

Arietta Chakos:
I think that’s a very strong point that we have to look at. As Ms. Chatigny said earlier, decision makers have to make decisions. And so, I will be making sure that I consult with the medical community, but basically we have to have some kind of hybrid model. I think that looking at the Community Emergency Response Teams that so many communities have established and using the networks that exist, whether it’s through Neighborhood Watch or just neighborhood associations, that we can become a little more nimble in how we respond to this.

I think leaving people in isolation is a mistake. When we look to the 1918 Spanish influenza pandemic, we saw that people actually behaved in a very altruistic and community-minded way. I have no reason whatsoever to think, at this point, that will be different in a pandemic situation now. I think also that we have to look at the assets that communities have. Ana-Marie Jones talked earlier about the whole notion of a community that builds on a positive and healthy approach to connecting with one another. And this is something I don’t think we’re looking at right now.

There is an article published in the April, I’m sorry, September ‘05 issue of Harpers magazine by Rebecca Solnit. It’s called “The Uses of Disaster.” And she is a UC Berkeley journalism professor who took a look at how communities and government responded after Katrina and September 11. And really, our biggest assets in all of this are the community members and residents in our cities. And we have to use them as a strength and not look at them as this sort of detriment to healing and responding to disaster.

Tara O’Toole (moderator):
Certainly, the private sector was important in a lot of the response to Katrina and by some lights was more effective and efficient than the federal government end. You’re the CEO of a large corporation downtown. You’ve got thousands of employees. You’ve got many buildings around downtown. You’ve got a lot impressive communication infrastructure. What can you do for Richard?

Ann Beauchesne:
First of all, again, I would hope you’d know each other prior to this.  Second of all, I’d be wondering where I’m getting my information, how good that information is, and making sure I’m communicating first to my employees, second to my vendors, and third, figuring out what left-over assets we have to build to help the community. I would say that hopefully we’d already be built into the community plan, so they would [know] what we have around town, what transportation we have, what housing we could provide, that kind of thing.  Certainly the private sector, as you said, was ready, willing, and able to help out after Katrina. I think the logistics and management capabilities far exceeded the federal government and state government, and they should be tapped on and looked at as a model during a pandemic [and more].

Tara O’Toole (moderator):
Can you think of anything specifically that the private sector could do for hospital response, for taking care of all of these people? Hospital response is probably too specific—medical response, taking care of floods of sick people in a pandemic?

Ann Beauchesne:
Do you mean for staging?

Tara O’Toole (moderator):
Whatever.

Ann Beauchesne:
Yeah. For that, certainly, these larger stores could provide a place to put beds. The transportation issue is going to be huge. You’re going to find people, are we going to have enough people to drive the trucks? Are we going to have…we’re going to run out of essential supplies very quickly. We’re not stockpiling anything. Certainly, we’re not stockpiling ventilators, we’re stockpiling even the needles to give the vaccine if we were to have one that doesn’t exist. A lot of those things, though, need to be looked at and pre-positioned and talked about ahead of time, or, again, we’re going to find ourselves behind the 8-ball.

Tara O’Toole (moderator):
Jan, you’re now a talking head representing the George Washington (GW) Homeland Security Institute on television. They’ve just gotten a report that Richard’s hospital is turning away ambulances from the door, saying they’re full up. They can’t take anymore sick people. There are reports that someone has actually died outside the hospital because they couldn’t get in. The commentator, I guess that’s me, asks you for your reaction to this. What would you say at that point?

Jan Lane:
First and foremost, the way that we operate with GW’s Homeland Security Policy Institute is that we’re functioning as a bridge, we hope, between the policymakers and the practitioners, so these would most likely be people that we may have had conversations with before. We may know their concerns; we may have been part of conferences like this. In an era where misinformation—we’ve seen the damage that misinformation can cause during a disaster—I’m going to try very hard to get my facts straight very quickly, knowing that everybody else is on deadline and trying to meet their needs.

I’m going to check with the hospital, I’m going to try and run things down. I’m also going to be checking, what are the messages? What are the key messages that have to come out from a public policymaker standpoint and their local public health department? What is the most logical, most practical, most calming statement that could be made that’s factually correct, that moves the ball forward, that doesn’t disintegrate into a finger-pointing exercise?

[eight seconds of silence—previous section repeats]

Tara O’Toole (moderator):
What you just said triggered something. If a hospital turns somebody away, and the person dies on the steps, in that case wouldn’t it be better to have a secondary…no matter how dangerous it might be, a secondary location at least to take those people who cannot fit in the hospital, and put them somewhere and have some kind of assistance? I mean, public relations-wise, you’re certainly not turning them away just because you don’t care, but just to say to somebody who has this horrible disease, “We can’t take you; you’re on your own,” is already making it look like what you’re doing is wrong when actually we could do something.

Jan Lane:
But I think that’s also getting back to running down the facts. Were they in the midst of transporting that person to a VA healthcare facility that may have that excess bed capacity, and this individual was so ill at the time that that’s just what happened? I mean, that’s where we need to really nail down the facts. What did go on in the Superdome? What exactly was going on in New York? All of that, it’s so hard to sort through and get the facts when there’s such chaos in initial reports.

Tara O’Toole (moderator):
But I think there’s two generic points here that are worth highlighting.  One is that in an epidemic, there is going to be a very thick fog of uncertainty and rumor-mongering. Anything that we can do to slow down people’s leap to conclusions is probably going to be constructive and useful. We’re also going to have to have a rich network of communications among all the decision-makers at different levels, which far exceeds anything that we have now or have ever put together in modern experience.

The other point, I think, is the one that Diane made, which is that the dignity of how we die is as important as how many we save. We need to think about how we’re going to deal with the demands for care that are going to exceed our ability to deliver anything close to what we now regard as acceptable standards of care. It’s late in the afternoon and I want to take some questions from the audience. I don’t think we’ve solved many problems yet, though I think we hinted at some solutions or at some of the priority problems, but what I would like to do is...

Robert Tosatto:
I want to bring up one point.

Tara O’Toole (moderator):
You are the federal government. You get to butt in and say whatever.

Robert Tosatto:
Nobody asked for the federal support, I noticed. I think that is a good point to take home from this, and I think that’s one of the points of the meeting today is the community action, the citizen involvement, the local activity—that these issues are being handled at the local level. The Feds aren’t going to be able to come in. You saw the quote from Mike Leavitt; we’re not going to be able to ride in on the cavalry. We’re going to be hopefully in advance providing some good guidance, hopefully in advance being able to provide some of the support, whether it’s technical assistance, whether it’s financial. But when the event happens, I think this is the appropriate thing that would be happening is that meeting being called at the local level.

Tara O’Toole (moderator):
Well said. I’m going to go around the panel here and ask them if they have one wish that they could achieve by waving their magic wand today, four months before the pandemic strikes, what would it be to improve our ability to manage people who are ill and, in particular, improve public participation and cooperation and collaboration in managing the floods of patients? If you have a question, please come to the microphone while we’re going across the panel and we’ll get to you at the end. Richard, would you like to wave your magic wand?

Richard Waldhorn:
If I could wave a magic wand, there would have been already a serious discussion in the country and in every community about the situation of the demand for care exceeding the ability to deliver it and the ability to make decisions about limiting care. I think at some point our capacity will be reached, and we’ll have to start figuring out how to deny care in a graceful and dignified and egalitarian and transparent way. Maybe what’s as important as what we can do, is figuring out what we cannot do and how best to make those decisions.

Tara O’Toole (moderator):
Rob?

Robert Tosatto:
I would say a sense of personal preparedness and a return to self-reliance, family reliance, that ability to care and understand what the needs are for the individual, the family, the community, rather than reliance on others to help.

Jan Lane:
I think, at this point, my magic wand would be—managing expectations would be first and foremost. But then it would be moving from plans to implementation and doing so by training and exercising, and making sure that we have absolutely everybody that’s needed at the table, because this is going to take non-traditional first responders. D.A. said it earlier today, and it was [that] we’ve fallen into that legalistic definition of first responders instead of trying to understand that the first-response community will morph and change depending upon the disaster. If we have an empty seat at the planning table, we’re going to have a kink in even the best-laid plans.

Tara O’Toole (moderator):
Diane?

Diane Lapson:
Are there community boards in every state? Do they have what’s called community boards? OK, I guess not. In New York City, which I’ve heard they have, in New York City, they have community boards for each community, and those community boards make resolutions and talk to the Mayor’s office and the City Council, and much of what goes on in those communities happens at the community boards.

So if there are no community boards…I would say that the Department of Health, my wish would be, that now, this moment, the Department of Health make an announcement that it’s going to meet with all CERT members, citizen’s emergency response teams, and community leaders and other interested volunteers, to have a public health meeting, and right now decide who you can call in an emergency and what those people, who they’d be responsible for, and begin subtly educating through those groups and through television, start educating people so that at the moment of disaster there is no panic because you know you’re going to get the constant communication.

I think now is the time to identify who is going to respond in the emergency.

Christa-Marie Singleton:
My wish is very similar to yours. If I had a wish, I would like to have a workforce, and that workforce is not a paid workforce per se, but a workforce that is built of business community people as well as the members of the neighborhood associations, because I do stand firm with the idea that it’s probably better that people stay at home. We’ve talked about the training. We’ve talked about other natural disasters, but it’s not an illness, and when it’s an illness people tend to want to also stay at home. They like to be close to their surroundings, close to their family.

I look at the Toronto SARS experience—my public health colleagues up there who used that time to make those phone calls so that people weren’t so isolated, to check up on people.  We’re going to need a workforce that is built of public health people, business community people, community activists, that will be ready to stand up and help us by making those phone calls and protecting themselves and helping out each other, so that people can either be treated with dignity in sickness or in health.

Arrietta Chakos:
I’m going to go for two wishes. My first wish is that we will continue to strengthen our communities so that they can be resilient in a natural disaster and a medical disaster. My second is to have a more robust and authentic partnership with the Federal government for local-level municipalities. If I go to another meeting and, forgive me, Mister Federal Government, hear the federal government tell us that we’re on our own, I think that I’d probably run from the room and scream. I would like to move it from a “level one, one-way arrow out” to the locals to that “level five of interaction and partnership” that Ms. McKinnon showed us this morning, because I think only then, with the local, federal, and community people working together, will we have a decent chance to make it through such a situation.

Ann Beauchesne:
I think—I would hope—that the governors of the states would call the CEOs in their states and say, “Here’s our pandemic plan. Let’s talk about expectations—yours and ours. We’re expecting that we’ll be able to use a couple of your facilities for mass care or, God forbid, for bodies when they start piling up, or we’re going to hope that the truckers keep coming through.”  Let the private sector ask, “Are you going to shut down your borders? What do we do then? How are we going to keep food coming in?” To have those very frank conversations about expectations on the private side and the state side, and as well as down into the local level. I think it’s all well and good to have plans, but we’re not talking about, “This is what we think this plan really means and this is how it’s going to be executed.”

Tara O’Toole (moderator):
Those were all very modest magic wands. I didn’t hear anything that isn’t achievable and very practical. I think that it is a reason for optimism, although it may be that we’re shooting too low and we need to be more hopeful and more ambitious in the transformation that we need to [achieve?] in order to get through this situation. Let’s see what you all think. Yes, sir.

Albert Geetter:
It’s been an extraordinary colloquium. I applaud you all.  My name is Albert Geetter. I deal with the medical aspects of disaster management for the state of Connecticut. Dr. O’Toole, you touched tangentially on one thing which I think we need to deal with. It’s an additional public health threat, and that is the dead.

Tara O’Toole (moderator):
The dead?

Albert Geetter:
We will find that if the people are dying at your hospital door or if they’re dying at home and we have insufficient planning for mortuary services. By the by--I’m a retired general surgeon, so I normally don’t deal with that aspect of it, we don’t admit that we have them--but it is extremely important from a public health standpoint, because if we can’t handle the dead, both from a biological standpoint and also from a psychosocial standpoint…this is extraordinarily important…I think we’re going to face a major problem.

Diane Lapson:
Am I still pretending I’m living in Washington, or can I be myself?

Tara O’Toole (moderator):
Whatever you want to do, Diane.

Diane Lapson:
During 9/11, we had a few incidents where I was told to—I’m a community leader downtown—
I was told to please keep everyone indoors because they were bringing body parts down the street and they didn’t want people to start seeing it. It was very amazing in an emergency to forget those little details that can unnerve a lot of people. I remember that day, just standing by the front door of my building, and having someone stand by the other two doors of the other two buildings, and telling people the police are doing something now, we really can’t have you go outside.

This is one of the reasons I’m afraid of people being alone in their houses unless there is enough volunteers to check on everybody, because if a parent dies and the children are still there, or whatever is going to happen, we can’t have a whole city full of people dying in their apartments and not being aware of how to take care of that quickly. I think it’s a very serious question.

Michael Allswede:
Michael Allswede, I’m from the Strategic Medical Intelligence Research Group. I’d like to amplify Dr. Waldhorn’s outstanding point on the issue of—what we’re really kind of working around here is denial of care. In this scenario, as you put it out, there’s 50% of the ventilators that are needed, 20% of the beds that are needed, and that’s just for the flu patients. Now, there are two other groups of patients that we have to consider here, as well. We have the existing patients within the hospital, who will die if their care is diminished, intensive-care unit patients, cancer patients, etc, and we have future patients that will be sick because they’ll run out of insulin, they’ll have babies, they’ll have other sorts of health problems, that need a hospital and access to go to.

In the middle of all this, we have a situation where probably we’re going to be significantly depopulated. If you follow the SARS example, 50% of those victims of SARS in Toronto, Hong Kong, Taiwan, etc., were healthcare workers. My question here, the thing that seems to scream out to me and the thing that seems to be most important for this group to consider is, what are the rules? What do we want a hospital to be able to do, and how do we engage that dialogue with the community, given that we are really working with very finite resources? My view of the medical system [is that] it is 100% full on a normal day, is that we are a lot closer to that breakpoint than any of us would actually like to publicly admit. Dr. Waldhorn?

Richard Waldhorn:
I agree. That’s why it was on my wish list that those discussions begin early and often, because they’re not the kinds of decisions that can be made very effectively on the fly in the middle of a crisis. I think the—reviving the art of triage, which really has been lost in my medical training and in the training of all my trainees recently, because we haven’t been faced with a real triage situation, I think it’s something that we’re going to have to do and begin to figure out, how do we do the most good for the most amount of people. That is going to be— make some tough decisions about who gets in the front door and when do people leave the hospital, and when is care withdrawn.

I think those are the kind of ones that get a lot of attention, limitation of mechanical ventilation, etc., but I think there’s another part of this, which is figuring out what can be safely deferred in medical care. Is it ok to take all the nurses out of the prenatal clinic and put them somewhere else? That sorts of make sense for a while. What kinds of procedures can be deferred? To create sort of a database of a priority list of what can be and cannot be deferred, so that you don’t have to make decisions on the fly at the time of a crisis. There’s a group in Canada, in Ontario, I know, that’s been working on a system of maximal deferral time analysis of procedures and aspects of care. I think communities and medical specialists have to begin to work on that now.

Tara O’Toole (moderator):
I want to make sure we get in all three of these questions, so if you keep your inquiries brief, we can get you out of here on time.

Michael Dunaway:
Michael Dunaway, Chesapeake Critical Incident Partnership.  I actually have a follow-on comment or a question actually. In that same comment about your observation about denial, I think you said “graceful denial of medical care.” It seems to me that, kind of like that Chinese anagram that is crisis and opportunity at the same time. We have an opportunity here through the epidemic to address an issue that is looming on the horizon, that we know is coming, and that is the fact that eventually American society is going to get to a point where we have to deny care as a matter of course, because as the baby boomer generation gets farther along, medical care becomes more intensive.

What we have to deny, may have to deny in terms of influenza right now, or pandemic influenza right now, may be what we look at as a strategic problem in the long run for the nation, about what medical care do we no longer allow because we simply don’t have the resources to handle the demographic problem we’re going to be facing. I wonder if you’d comment on how what we’re dealing with in influenza right now may mimic what we’re going to deal with in the longer run in terms of medical capacity in the country.

Richard Waldhorn:
I understand the analogy you’re trying to make, but I think it’s a stretch, to be honest with you. I think we’re far from that, at least in this country. We have rationing in this country—it’s just done differently, it’s done by economics, it’s done by access to care, it’s done in different ways.  We’re not without rationing now, but the type of rationing you’re describing, I think—we’re a ways off from that. We have more basic problems in this country. We have millions of people with no access to routine care. So, I think, we’re not quite there yet. I think an epidemic, a pandemic, would force us to jump to that very quickly, which is why I would argue that we need to think about those things now in anticipation of that eventuality.

Unidentified Audience Member 1:
One thing that you may want to consider is having a multi-faith clergy response team for the mortuaries as far as out of experience for Katrina; that’s a real big issue. It plays upon different religious backgrounds on how bodies are cared for and how they are, how the rituals go in timing. That’s a big issue. One real quick question. Has FEMA decided whether or not they’re going to declare a pandemic a “disaster,” because that would also have financial implications for the delivery systems and for the families involved.

Tara O’Toole (moderator):
I don’t think FEMA is here. Does anybody in the audience know the answer to that question definitively? Sarah? This is Sarah Lister from the Congressional Research Service.

Sarah Lister:
The Congressional Research Service is trying to look at that question right now. We have no precedent either way for whether an influenza pandemic could be considered eligible for a FEMA disaster declaration. Right now, we say it’s unclear, and we’re proceeding with a legal analysis that may tilt one way or the other. Probably, if it were clear at this point, we’d all know about it, so I think it’s unclear.

Unidentified Audience Member 1:
The closest thing you have towards it, though, is the heat deaths we had several years back, and FEMA now has heat and weather, or as far as cold and heat, as a disaster.

Jan Lane:
Tara, can I go back to the reverend’s first comment with regard to a corps of folks, spiritual and pastoral counselors? We do have a model for that now with the Aviation Family Disaster Assistance Act, where there are teams that are pulled together, multi-faith counseling groups. I think the other corollary, and Diane had gotten at this earlier, is the very important need for mental health counseling, that immediate mental health counseling that would go along as a corollary to that.

Robert Tosatto:
I’ll add a little bit to that. Several MRC units are actively recruiting chaplain corps within the Medical Reserve Corps specifically for that issue, and we do have a mental health working group, a national-level working group for the Medical Reserve Corps, looking at the issues of disaster mental health and what are the best models to use and to get out core competencies training to the volunteers.

Ana-Marie Jones:
Anna Marie Jones with CARD. In all the years I worked with governments and with the Red Cross and different traditional response agencies, the most common way of reaching out to businesses and non-profits was the, “Join my bureaucracy now, ask me how, come and join, help us fulfill our mission,” or to push down an unfunded mandate to do something. The things that we have not really looked at are, one, the bazillion ways there are to incentivize preparedness.

I do a lot of presenting with chambers of commerce, and the truth is, you’ve got businesses that spend billions of dollars to create foam fingers and rubber hats and all sorts of things, and none of the communities I serve would care whose logo is on the whistle or the flashlight or the whatever that saves their lives, so that’s one piece.

The other thing is to really look at how to engage them as the solution for their own population, their own business. They come up with remarkable solutions when the context of the conversation is, “How it is that they can protect their own employees, their community, their business,” and those sorts of things. So my question would be, have we looked at how we start collecting that? There are millions of ways to make this the empowered incentivized conversation as opposed to the, what we’ve already lived with, which actually hasn’t really worked that well for us.

Ann Beauchesne:
Being from the U.S. Chamber of Commerce, I was not really playing that role. One of the things we’re doing at the U.S. Chamber specifically for pandemics is reaching out to our state and local chambers, 3000 across the country. As you know, Secretary Leavitt’s gone around doing his summits. We’re going to do a series of them with the Department of Homeland Security and probably CDC, bringing together the business community with the state and local chambers, one, for an education piece.

The larger multinational companies get it. They know continuity planning; they have the reserves to do that. Smaller businesses don’t know what to do. Just telling them to wash their hands isn’t going to cut it; we need to have steps for them to take. At the Chamber, we have a brochure up on our website now, but we’re looking at model plans; we’re looking at mentor programs and that kind of thing. So you’re exactly right, the local and state chambers are certainly well-positioned. They know their communities, they know their people there, and you’re absolutely right, we are going to reach out to all of our members.

Tara O’Toole (moderator):
Final question.

Roger Bernier:
I just really wanted to make a comment. I don’t know if this is a good time before it closes, but I think one of the things that I have noticed during the day [is] that I think sometimes we’re talking about public engagement fulfilling different purposes.

One of the things that I found very helpful came from Peter Sandman, who’s a risk communication expert, who talked about why—this was in connection with pandemic flu—why we need the public. He gave this very easy-to-remember set of three reasons, which I would just like to put out here. You need their help, you need their advice, and you need their buy-in. I think that really covers the waterfront.  I might add a fourth, which [is that] they have a right, but that’s a different issue.  If you want to know why you need them, it’s those three reasons that really cover the thing.

I think there’s a divide in this audience between many people who are talking about public engagement because they think we need the public’s help. We need their hands, we need their hands and arms, too. We need “extenders” of our capacity. I think that is not very controversial, and is very obvious in the millions of ways we might need that. We ought to be clear about all that, and that’s important.

I think on the other issues, it’s also important to be clear that if you’re talking about public engagement—because you need their advice, or because you need their buy-in—that’s a different kind of public engagement. That’s getting the public because you want their ideas, because you want a sounder policy, and there’s much more debate about the value of that than there is about the fact that we need the public because we need their arms and legs.

I think as we go forward in thinking about how we can make progress in promoting public engagement in disease and disaster planning and so forth, I think keeping those distinctions separate in our minds might help all of us to know which one of those kinds of public engagement purposes are we thinking about while we’re having the conversation.  I think we’ve gone back and forth between those today.

Tara O’Toole (moderator):
Thank you. I think that’s a very useful conceptual distinction, and we have definitely gone back and forth, and on purpose. I wish you had said that at the beginning of the day instead of at the end. Very useful. I want to thank everybody on the panel who volunteered their help and their advice and their buy-in, in being able to participate in this panel. Thank you, all.

Proceedings of the May 23, 2006 Summit: Disease, Disaster, & Democracy

Transcription by CastingWords