Preparing disaster response plans is a difficult task for many reasons, including: the many variables involved, the frequently unanticipated consequences, and the cascading adverse events that emergency managers plan for in today’s complex world. Emergency managers must think clearly and effectively about such threats even when they or those around them are not the leading experts on the characteristics of a specific disaster. To confront the daunting task of developing the strategies needed to mitigate the worst-case consequences of a specific disaster, they would be well advised to adopt an all-hazards approach.
Because many aspects of disaster response are somewhat similar, no matter what the emergency, this methodology has certain unique strengths. When the planning is effective, an all-hazards approach can help ensure a relatively quick and efficient response for dealing with a broad spectrum of disasters. However, it also is important to understand the distinctive characteristics of each specific hazard. This is especially true for those responsible for managing the response to public health emergencies.
The Inevitable Public Health Response
To begin with, no matter what the disaster, it will almost always require a public health response. Major natural disasters – floods, tornadoes, and earthquakes, for example – may require the allocation of public resources to care for displaced persons who have functional needs and/or are suffering from chronic health conditions. Terrorist attacks and other manmade disasters may require the allocation of massive medical resources as well – including doctors and nurses, hospitals, and other healthcare facilities.
In such situations, the public health response can be particularly challenging because emergency managers must also try to determine the long-term consequences a disaster will have on the population immediately affected. Among the many, and unusually complex, questions that must be answered are the following:
- How may the rate of illness, and therefore of survival, change if an effective response is delayed or inadequate?
- What countermeasures will be effective in reducing a surge in admissions at hospitals in or near the area(s) directly affected?
- How will the psychological stresses common in public health emergencies drive the attrition rates of first responders and healthcare workers?
Underestimating the needs of both the people affected by a disaster as well as those responding to a public health emergency can quickly lead to deadly mistakes. Knowing precisely how to interpret and manage the operational constraints of a public health response is, therefore, particularly important. Such awareness is especially crucial, of course, when coping with naturally occurring biological incidents (pandemics) or manmade attacks (bioterrorism). The immediate effects of a tornado, earthquake, or even a nuclear incident – the magnitude of destruction involved, and the area of impact, for example – can be predicted with a relatively high level of certainty.
But that is not necessarily true of biological incidents – largely because the exact time a biological incident begins is often uncertain. By the time the incident is detected, the outbreak may be in full swing, with many people already exposed and very sick, even dying. In addition, the geographical and/or demographic extent of a biological incident is often difficult to characterize in its early stages. Unlike a hurricane or tornado, biological pandemics – or even biological attacks – seldom strike with advance notice.
The Expanding Role Played by Emergency Management
There also are other factors to consider. Although a nuclear attack or an earthquake can also be a no-notice event, the deaths and destruction caused will become clear immediately. In contrast, the beginning of a biological incident is almost always profoundly silent. However, whether it is a biological attack or a newly emerging pathogen, the biological agent can quickly infect those who are exposed, frequently without their knowledge. Recognizing that an epidemic/pandemic has started, in fact, often begins with the realization that an unusual illness has spread and/or that a demographic “cluster” of sick people, suffering from the same rare illness, has been diagnosed. The immediate response strategy usually adopted focuses on the need to quickly contain the known or suspected biological agent and, by doing so, reduce the overall threat to public health.
Most emergency managers understand the importance of enlisting the help of public health professionals and incorporating their collective response capabilities into a broader whole-of-community preparedness plan. However, such integration is often not possible until the response phase of a disaster. Moreover, the fact that a public health disaster has occurred is often communicated to emergency managers only after a new incident becomes a major threat recognizable to the general public. Whatever the reason, though, any delay in mounting an effective response during a public health emergency will almost always cost lives that might otherwise have been saved.
Largely for that reason, the approach followed by emergency managers should: (a) be inclusive from the start; and (b) provide accurate threat awareness before the potential event escalates to the level of a true public health emergency. Moreover, public health officials must at the same time manage the local community’s expectations of how a coordinated public health response is likely to unfold – with special focus, depending on the specific biological agent involved, on possible operational limitations, supply chain bottlenecks, and/or personnel constraints.
By adopting this approach, emergency managers’ planning can focus greater attention on immediate needs and prepare first responders and local communities for what an effective public health response would entail. Among the most immediate needs would be: (a) logistical support – to deploy medical countermeasures; (b) additional security personnel – to manage large crowds of people seeking help; (c) well-trained medical staff – to administer the medical countermeasures and/or other resources needed, both immediately and in the long term; and (d) reception sites and points of distribution – to minimize an overwhelming surge on hospitals. In order to make such plans work effectively, public health officials also should provide the media, and the general public, a clearly stated and well-articulated perspective on current and prospective public health threats.
Pilgrimages & Pandemics – A Deadly Combination?
Coincidentally, the Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV), which emerged in 2012 in the Kingdom of Saudi Arabia (KSA), made headlines globally when several cases were reported by Saudi Arabian public health officials. With the Severe Acute Respiratory Syndrome (SARS) pandemic of 2003 still fresh in mind, public health officials and emergency managers were understandably very concerned. One particularly disturbing similarity between the two newly emerging diseases was that they are from the same family: Coronaviruses. The news media quickly publicized that finding, thereby creating additional global concerns about the still relatively few cases in Saudi Arabia itself that might otherwise have been considered to be a strictly local outbreak.
In early October 2013, well prior to the eve of the 2013 Hajj – i.e., pilgrimage to Mecca, 13–18 October – millions of Muslims had already started to converge on the KSA, where the epidemic is now in full swing. Emergency managers around the globe might understandably view this combination of events as a potential precursor to the next deadly pandemic and start to prepare for a worst-case situation. However, as public health officials were already starting to work more closely on the KSA outbreak with their emergency management counterparts, a better-informed threat awareness was and is leading to a somewhat different planning strategy from the first responder community.
More specifically, the KSA’s own public health officials have been working tirelessly to keep their international counterparts better informed about the MERS-CoV outbreak. As they continue to do so, several important facts have emerged that may change the previously perceived threat level of this epidemic. To begin with: (a) The mortality rate has continued to fall as more and more people have been tested positive for, but have not died from, the spread of MERS-CoV; and (b) Some preexisting health conditions have been identified among those considered to be most vulnerable to the virus.
The SARS pandemic, on the other hand, was somewhat more enigmatic – primarily because it did not discriminate, and many previously healthy victims actually died from the disease. Although there is still a need to remain vigilant, it now seems unlikely that MERS-CoV will later develop into a full-fledged pandemic given the current characteristics of the epidemic. This observation does not, of course, rule out the possibility that the MERS-CoV outbreak may later evolve into a more contagious and more deadly pathogen. However, in its current form that possibility does not seem likely.
It is still essential, nonetheless, to bridge the gap between the public health community and emergency managers to plan effective public health disaster response strategies. Being able to convey a clear and concise message from medical observations to the front lines of disaster preparedness not only can make a significant difference but also will help focus the efforts of emergency managers when and where they are most needed.
To briefly summarize, although the threat of MERS-CoV may not be as imminent as previous media coverage has alleged, there are nonetheless certain concerns that still apply to all types of emerging epidemics or biological attack scenarios. For example, the medical community has very few treatment options in its arsenal that could be used if the MERS-CoV outbreak does in fact develop into a pandemic. For that reason alone, U.S. public health officials and emergency managers must develop plans for immediately using such non-medical countermeasures as isolation and quarantine if such cases are detected in local U.S. hospitals. Ultimately, of course, developing a solid partnership between public health and emergency management officials from the start will prepare the entire nation to fully face the next pandemic threat – or even a biological attack – not only more quickly but more effectively as well.
Patrick P. Rose
Patrick P. Rose, director for pandemic and catastrophic preparedness at the National Association of County and City Health Officials, holds a Ph.D. in infectious diseases and is a subject matter expert on national security issues related to public health security. He works with federal and local stakeholders to address requirements and gaps that produce vulnerabilities in public health security. In addition, he supports efforts domestically and internationally in the field and at the policy level to reduce the proliferation of biological weapons and to increase public health security awareness. These efforts include promoting greater engagement in the Global Health Security Agenda. He is an alumnus of the Emerging Leaders in Biosecurity Initiative and serves as an adjunct assistant professor at the University of Maryland Department of Epidemiology and Public Health.