Resources: Interim Lessons Learned - After Action Report on the 2010 Influenza Pandemic
This is an interim “After Action” report on a disaster. What separates it from other reports is that this Lessons Learned report can be studied before the event actually takes place. There may be time for Congressional Commissions to not only assign blame for a lack of Readiness after the fact (as they tend to do), but perhaps appoint personnel to the appropriate agencies capable of learning these lessons and putting real systems in place before the Pandemic. It is the hope of this writer that instead of simply assigning blame and writing reports (as most After Action review committees do), the Congress might actually proactively write language into laws that demands operational systems and not just the kind of information papers that currently serve as “readiness.”
Public Health Preparedness was very poor. The Department of Health and Human Services (HHS) underestimated the Pandemic’s impact on the American People in its initial estimate that approximately 92 Million Americans would become ill and that approximately 45 Million Americans would require some level of definitive healthcare, such as in a hospital. While this Lessons Learned report only covers the first wave of the Pandemic, it is clear that even more Americans will be impacted before the last wave of the Pandemic travels across America. HHS was proactive in funding a number of Public Health and Healthcare grant programs targeting syndromic surveillance and Public Health laboratory capabilities. The syndromic surveillance systems, while not perfect, provided advance detection of the novel strain of Influenza almost immediately. However, the American people already knew from news coverage, that the Pandemic was underway before the first cases were detected in the United States. Some lessons learned from a Public Health Preparedness prospective follow. Importantly however, most States did not share Pandemic Preparedness grant funds with hospitals and the “health care” infrastructure, opting to keep the Pandemic funds in the Public Health sector. At the same time, States did not bolster the hands-on care capabilities of the Public Health function, believing hands-on care was the “responsibility” of the Private Sector Healthcare System.
Early detection was not enough. While early detection and timely information to the public was laudable, there were virtually no actions taken to treat the projected 92 million sick Americans. The Public Health position was that public information, primers, and brochures fulfilled their responsibility to alert Americans about a coming Public Health catastrophe. Since no leaders in HHS, CDC or for that matter anywhere in the Public Health Community were alive during the 1918 Pandemic, there was no way for Public Health personnel to know how to care for the sick and dying. There had also been no inclination on the part of Public Health officials to learn how Public Health could expand healthcare services to augment the Healthcare Industry. Thus, there was no “Plan B” in the Public Health system to actually provide healthcare services to persons requiring definitive care if the healthcare industry was unable to care for influenza patients. There was no perceived need to provide additional resources for Private Sector healthcare, since the American Healthcare Industry has the total responsibility for providing actual healthcare services. In other words Pandemic-related healthcare was a Private Sector matter, with Public Health providing guidance only.
The CDC issued a timely Public Health Alert that a novel strain of Bird Flu had mutated to the point of human to human transmission, at about the time where the Pandemic was confirmed in Southeast Asia. Almost immediately, Americans began checking their stocks of prescription medications as well over-the-counter cold and flu products. As a result, before the first case of the new Influenza was diagnosed in America, there was a Nationwide shortage of virtually all prescription medications as well as over-the-counter medications. What was not predicted by HHS or CDC was the societal impact brought on by announcing the pending first wave of the Pandemic. The unintentional consequence of the Public Health alert announcement was an almost immediate failure of the pharmaceutical, medical, food, fuel and retail supply chains. Since raw materials for many American manufactured items are imported from outside the USA, all of these critical supply chains will remain sporadic for approximately 3 years post-Pandemic. In the meantime, those supplies which can be purchased will be in very short supply. Federal officials warn that sporadic violence will continue occurring as limited supplies arrive at retail outlets such as supermarkets, drug stores, gas stations, and retailers everywhere.
The American Healthcare Industry was unprepared. The American Healthcare Industry was totally unprepared to manage even a small percentage of the affected population. The HHS, the American Medical Association, the American Nurses Association, the American Hospital Association and virtually every other known Healthcare Membership Association in America had warned that the American Healthcare Industry was already in a crisis even without any additional stress on the system. However, no Federal agency, organization or association was empowered to do anything about the normal operating crisis, let alone resourcing the Healthcare Industry to effectively manage a major terrorist attack or the Public Health catastrophe which is fully underway now. As a result most of the Healthcare Industry has collapsed under the strain of this first Influenza wave. Since there were no serious plans to drastically expand the Public Health Service to provide “hands-on” health care, most Americans were left to care for themselves and their loved ones. A simultaneous exhaustion of healthcare staff, the healthcare supply chain and overcrowded hospitals, caused a collapse of the entire American Healthcare Infrastructure.
The American Healthcare Industry collapse was due to a lack of elasticity to expand for spikes in demand for a surge in admissions. While numerous studies had confirmed that all study parameters were accurate and that all models were valid, not all external factors were taken into consideration. It seems no Federal agency had predicted a collapse of the American Healthcare Industry under the stress of an Influenza Pandemic. Thus, due to extreme shortages in facilities, healthcare providers, beds, medical equipment, supplies and financial resources, American Healthcare collapsed almost immediately during the early days of the Pandemic. It is anticipated that the American Healthcare Industry will be rebuilt as a National Healthcare System with some Private Healthcare entities providing elective procedures. In any event, it will likely take between 10 to 15 years for American Healthcare to achieve Pre-Pandemic operational capabilities. During this time, religious organizations and charitable non-governmental organizations will provide the bulk of the healthcare available in America.
Factors bearing on the American Healthcare Industry collapse.
- Lack of Healthcare facilities: During the 1960’s the Federal Government had approximately 1900 Packaged Disaster Hospitals. Each of these hospitals had 250 beds, an X-Ray room and three operating rooms. Thus, as far back as the 1960s, America had a total of 475,000 beds, 1900 radiology suites and 5,700 operating rooms. All of these assets came totally outfitted with equipment and sufficient supplies to remain self sufficient for 30 days. The numbers of ready facilities and their operational status of additional facilities in the 1960s were far superior to what was available in 2010.
While there were a number of States that used Federal grant dollars to purchase tent hospitals and other smaller care centers on rolling stock, such as 18-wheelers, none of these care solutions were logistically supportable or staffed for continuous operation in the current Pandemic. - Lack of healthcare beds. The Strategic National Stockpile had stockpiled approximately 20,000 cots instead of beds. These cots were unsuited to providing patient care in any facility and thus, were used only for comfort care in patients’ last hours. These cots could not be reused, since there were no decontamination instructions or equipment capable of decontamination. These cots became single-use assets and were used up almost immediately.
- Lack of caregivers: While there were predictions of an extreme shortage of caregivers, due to the shear numbers of sick Americans, no Federal planning agency placed an actual number on how many skilled and semi-skilled healthcare providers would be needed. As the first wave of the 2010 Pandemic swept across America, the requirement for additional registered nurses (RNs), respiratory therapists, licensed practice nurses (LPN), physicians, medical helpers and support staff rose to 10 million. While the Medical reserve Corps had approximately 200,000 volunteers, many could not respond due to obligations caring for their families or caring for themselves. The end result was that religious congregations, the Red Cross, Salvation Army and other voluntary organizations were and are currently the only entities providing any meaningful care in the United States today.
- Lack of Healthcare financial assets: Financial pressures on the American Health Industry have been immense since the mid-80s. Government reimbursements for Medicare and Medicaid have been tightening consistently since at least 1985. Simultaneously, “Managed Care”, by way of the healthcare insurance industry, had concentrated on driving healthcare costs out of the system. Thus, both the Federal government and the healthcare insurance industry drove down operational healthcare capabilities to a point where a single, albeit catastrophic insult to the Healthcare Industry was sufficient to cause its collapse.
- Federal infusion of dollars made little difference. Similar to America’s Financial System near collapse in the fall of 2008, by the time that Congress recognized the American Healthcare Infrastructure was as shallow as it was, it was too late to turn things around. In the Financial System crisis, huge injections of Federal dollars propped up most major financial institutions.
Unlike the Financial Crisis, injections of federal dollars made no difference at all, since there was little product available worldwide. Once the Pandemic was recognized, countries like China, America’s largest cotton trading partner for surgical masks, surgical gowns, and patient apparel, had stopped the flow of raw materials outside of their country. Similarly, other countries that previously were our major trading partners for both raw materials or for manufactured medical products, had shut down exports to America in order to sustain their own populations.
While DHS, HHS and private organizations all understood that America was operating in a “Just in Time” supply and equipment environment, Federal agencies took no actions to build National Medical Reserves, as they had with the Strategic National Petroleum Reserve in preparation for interruptions in the oil markets. The global nature of supply chains for food, medical supplies and equipment, and raw materials acquisition, while the ultimate in efficiency, turned out to be useless in any unexpected surge in demand. While Federal agencies well understood the “Just-In-Time” supply paradigm, nothing substantial was done to eliminate or mitigate the impact on America’s multiple critical supply chains, or the catastrophic unemployment consequences the manufacturing, processing and distribution industries faced when raw materials from overseas dried up. - Law Enforcement and Societal Norms. During the first several weeks of the crisis, there was widespread looting and vandalizing of supermarkets, drug stores, farmers markets and virtually any marketplace where food, pharmaceuticals, baby formula and other items deemed necessary to provide sustenance or treat the symptoms of Influenza were thought to exist. There were widespread home invasions where gangs in search of food and medicine took whatever goods they found, and then took other items of value in hopes of trading these items for food later. The Law Enforcement and Public Safety communities were themselves degraded in the area of law enforcement, and were essentially out manned and out gunned to protect the population. As expected, persons with disabilities, and the young and old subsets of the population were especially vulnerable to attack (already being more vulnerable to the ravages of the Pandemic and lack of needed food, medicine and shelter).
As larger and larger numbers of Americans were too sick or too weak to defend themselves, society lapsed into a more stoic norm, where religious congregations and other charitable organizations provided the only meaningful comfort for the sick and dying. Federal and State agencies were staffed with employees who either recovered or seemed to have a natural immunity to the novel Influenza strain. The services of these agencies were well intentioned but almost totally ineffective. Sanitation across all affected segments of society was deplorable. Municipal services including waste collection essentially halted. The mortuary affairs departments of State and local governments were overwhelmed with the dead.
Once again, religious congregations and charitable organizations represented the only real remaining societal structure, picking up bodies much the same as they did during the 1918 Pandemic and placing the bodies in communal graves. Grave registries were mainly paper documents, but efforts were taken to achieve a rudimentary accounting for those buried by gravesite. - Impact on the financial system. The financial system in the United States has been decimated by the 2010 Influenza Pandemic. Officials are advising Americans to retain all financial instruments, pending a recovery after the third wave of the Influenza Pandemic. It is felt that any idea of retirement based on a 401K or other stock market based instruments are lost for a generation or longer. Still, the United States is expected to make a more rapid recovery at least in comparison to many other countries around the World.
- Conclusion: It appears that a cascade of failures of America’s critical industries and societal infrastructure began with Healthcare and Public Health functions and have expanded out to municipal services and finally to the fabric of society throughout the United States during this first wave of the 2010 Influenza Pandemic. The results are and will likely continue to remain characterized as “catastrophic” throughout the coming waves. Many of these failings could have been and were anticipated. Better preparedness in advance may have mitigated much suffering now.
- Lessons Learned.
- Develop a serious and sober listing of all Federal, State and Local products, services and utilities that will be degraded or destroyed in a Pandemic and fortify those areas immediately.
- Build Federal Inventories of life sustaining goods such as food, pharmaceuticals, over-the-counter medicines, clothes, shoes, and special needs products for persons with disabilities, the old and the very young.
- Pay manufacturers and distributors to manage federal inventories in order that the taxpayer’s investments in these commodities can be preserved through stock-rotation and quality control measures.
- Enhance all critical infrastructure including items not normally associated with Infrastructure:
- Religious and charitable organizations that will do much to bring America back to normalcy.
- Bandwidth for the increase in communication requirements for any disaster
- Healthcare. Private Sector or not, these are the bastions of America’s health in a disaster or Public Health catastrophe. Build a Public-Private enduring relationship with every American hospital, nursing home, medical center, specialty center, community center etc., because in a disaster, they are all we have….and federally fund disaster-related hospital expansion programs.
- Purchase a minimum 1,000 portable rigid or semi-rigid walled healthcare structures, 200 beds each, with radiology and operating capability for long term use during any disaster that destroys American communities healthcare infrastructure.
- Build a logistical support system with civilian and military transportation assets sufficient to re-supply every healthcare entity in America during disasters.
- Assign Public Health Agencies a “hands-on care mission” for relieving the enormous stress hospitals, nursing homes and medical centers will experience during a pandemic. Provide funding not influenced by the “partisan dabbling” we have seen in our past.
- Insist on a Good Steward mentality for Government agencies and federal, state and local leaders at all levels of government. Rid ourselves of Government power brokers and castle builders and replace those shallow souls with Americans who seek the good of the People, well above any petty self-interest.
Please let the process begin today!