“The art of progress is to preserve order amid change and change amid order.” –Alfred North Whitehead
Alfred North Whitehead was a physicist, mathematician, and philosopher who witnessed the demise of Newtonian physics and advance of Einstein’s Theory of Relativity during the early 1900s. Whitehead was ically educated to believe that matter is unchanging and always constant, but he ultimately embraced the fundamental concept of relativity (that matter and energy may exchange) and helped usher in the nuclear age. His wisdom, cited above, on the art of progress may also help to guide the development of medical responses to meet future challenges in the era of terrorism.
Today, disaster medical response is undergoing fundamental shifts, primarily because of financial pressures, a long series of natural disasters, and the escalating threat posed by international terrorism. In years past, adequate disaster medical response could be reasonably expected to cope with the occasional weather emergency, some if not all natural disasters, or even a major industrial mishap in which a specific disaster area could be both determined and defined, after which resources could be gathered and lives would be saved. Although the loss of life is tragically inevitable during such events, in the past those events seldom had the capacity to destabilize the American way of life.
That is no longer true. Looking ahead to the potential disruptions that might be caused by such events in the future, it seems obvious that the American way of life may indeed be placed at much greater risk in the future, if only because of flaws and/or built-in weaknesses within the medical response system itself. Today, for example:
- Because of financial pressures, most state and local medical systems have much less excess capacity than in years past;
- The U.S. population is not only growing older but also becoming ever more dependent upon outpatient services – which are not a built-in component of the nation’s disaster medical service capabilities; and
- Certain future disasters, particularly terrorist incidents, pose a greater threat than in the past, if only because of the need for detection and characterization of such incidents before an effective response can be mounted.
Definitions, Descriptions, Determinations
For all of those reasons, and to plan the stockpiling of the resources needed to deal with the next crisis (rather than the last one – i.e., the one most recently encountered), it may be useful to divide disasters into two principal subtypes: “overt,” and “covert.” An overt disaster could be described as one that is both recognizable and definable – e.g., a bombing, a flood, or a hazmat (hazardous materials) event. There would be a defined start to such an event, a defined geography (i.e., the area where the event occurs and is limited to), and a defined population at risk. Each type of overt disaster could then be characterized by victim injury patterns, and the resources needed to cope with it could be logically estimated and planned.
A key factor in the development of such estimates, obviously, would be a thorough understanding of perhaps the most critical component of the estimate: the relevant response time involved. Each specific type of disaster is usually characterized by a recognizable “velocity” of victim deaths – most of which, in most incidents, would occur in the first 24 hours following the start and/or initial recognition of the disaster. To be a useful resource, however, such estimates must be available within a relevant timeframe. Obviously, it does little good to have the world’s best equipped decontamination facility available 24 hours after all victims have either died or fled a hazmat scene.
What is called the National Disaster Medical System (NDMS), a major agency of the The NDMS did not play a significant role either during the anthrax events of 2001-02 or in the less publicized responses to more recent infectious-disease events U.S. Department of Health and Human Services (HHS), was developed specifically to provide an effective response to overt disasters. The NDMS is composed of: (1) a deployable response arm, consisting of volunteer teams such as the 54 Disaster Medical Assistance Teams (DMATs) strategically positioned throughout the country; and (2) a nationwide network of NDMS hospitals. The latter, originally intended to serve as excess capacity for the Veterans Administration hospital system in time of war, are expected to make at least part of their existing capacity available for the care of disaster victims. But that may not always be possible – for a number or understandable reasons.
Unfortunately, because the NDMS is based primarily on volunteerism, the system lacks both rapid-response and sustained-response capabilities. The reality is that most of the working professionals on the NDMS roster not only must extricate themselves from their “regular day” duties but also, in most situations, would be limited in the duration of their deployments. To cite but one example: Of the approximately 200,000 medical evacuations carried out during Hurricane Katrina, only about one percent were carried out by NDMS agencies and personnel. Because of the inherent limitations of almost any volunteer system, in fact, most of the disaster care during and after not only Hurricane Katrina but also after the bombing of the Murrah Building in Oklahoma City and the 11 September 2001 terrorist attacks in New York City and Washington, D.C., was provided by local medical agencies and assets, not by the NDMS.
Fundamental Differences and Other Complications
Covert disasters – e.g., an infectious disease epidemic, food or water contamination, or bioterrorism – create a fundamentally different order of priorities. Because a covert event will, in most cases, initially seem to be some type of illness, the nature of the disaster must first be recognized by the local medical system, then officially characterized (particularly in the case of a bioterrorism event) by a local public-health and/or law-enforcement investigator before a national response can be ordered. Because such illnesses will progress steadily – and sometimes very rapidly – until containment is achieved, the medical response to victims must proceed concurrently with the investigation. Complexities such as a patient’s right to medical privacy, the constitutional law protections mandated for potential criminals, and the duties and responsibilities assigned to a national command authority can be expected to impede the investigation of ill victims who also may be witnesses to a bioterrorism event – and/or, in certain cases, even create difficulties in investigating the terrorists themselves.
There are other complications that must be considered in determining if and when a national disaster medical response may be needed. One such complication is that there are at present either no NDMS assets available for toxicology, infectious disease, or radiation health, or such assets are available in very small quantities. It is largely for that reason, in fact, that the NDMS did not play a significant role either during the anthrax events of 2001-02 or in the less publicized responses to other, more recent, infectious-disease events. Moreover, instead of developing a cadre of trained personnel to deal with covert-event response contingencies, the federal government has instead paid much greater attention to the development of a Strategic National Stockpile (SNS) of the medicines and equipment needed to support existing medical facilities throughout the United States.
Unfortunately, the little-known secret in coping with covert events is that communicable diseases and/or contamination usually will create secondary victims within the local medical and other healthcare facilities mobilized to cope with such events. In addition, at least some – and perhaps quite a few – local medical and allied support personnel may not report to work during a communicable-disease or contamination event because their own first priority may be to save themselves and/or their families. By not providing trained personnel as well as the SNS assets, the federal government has made it possible for a covert event to thwart the SNS strategy through reductions in the local work force.
The Dual-Assignment Path to a Double-Jeopardy Dilemma
The threat of terrorism further complicates the issue of NDMS response, if only because overt events such as the recent bombings in Mumbai are planned by and under the control of America-hating fanatics who have the habit of repeating successful attacks until they are stopped. Because of their volunteer status, DMAT members may defer deployment in anticipation of a future attack on or within their own communities. Moreover, many DMAT members also have affiliations with state and local response teams. Although well intended, such dual assignments would obviously create a “double jeopardy” situation for response personnel. For similar reasons, such covert events as the outbreak of a communicable disease could be expected to degrade or defeat outright the volunteerism component of the DMAT strategy. In short, although most U.S. medical providers – doctors, nurses, emergency medical technicians, ambulance drivers, etc. – are generally receptive to voluntary service, an undetermined but perhaps rather large number can be expected to want to serve their own communities first during a time of widespread crisis.
Given the need to fight the next war, not the last one, it seems clear that the NDMS must evolve from its current system of generic volunteer medical teams into more relevant units – possessing a broad spectrum of specialty skills, and available for rapid deployment. The challenge here is to promote such an evolution while preserving the stronger elements of the current system. A potential methodology for this process could start by: (a) taking a much closer look at the 15 situations that the Department of Homeland Security (DHS) has described as the “most likely” scenarios for future terrorist attacks; and (b) calculating the medical assets needed and the relevant response times related to each of those scenarios. By developing both a list of the resource needs and the probable time frames available for the primary set of homeland security threats, a more accurate determination can be made as to whether a given asset should remain in the current NDMS organization, or perhaps be distributed to state or local teams.
Special attention also would have to be given to the detection assets and strategies needed to cope with covert events. Because such events would almost always first be detected locally, augmenting university medical centers, trauma centers, and/or poison centers to develop and maintain an effective response capacity would be another high-priority concern. By investing in the nation’s existing medical system to develop the capabilities needed for a true national disaster medical response system, the existing U.S. healthcare system may also become part of the NDMS.
These and other remedial actions would necessarily require a rather large investment of taxpayer dollars – always difficult, but even more so during and because of the current economic crisis. However, the cost of not evolving the current NDMS into a larger and more comprehensive – as well as more effective – organization specifically designed to meet the most likely future challenges is that the victims of the next disaster may be waiting for a non-existent or poorly designed “cavalry” to come over the hill to their rescue. And the cost of waiting would be paid not only in dollars, but also in lives lost that might otherwise have been saved.
Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.