WHOLE IMAGE NEGOTIATION

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generating Connectivity for public health
preparedness Israel United states
investigation and implications For maine
Faculty LEONARD J. MARCUS, Ph.D.
Harvard Center for Public Health
Preparedness Program for Health Care Negotiation
and Conflict Resolution Division of Public Health
Practice / Department of Health Policy and
Management

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On-site preparednessinvestigation in israel

• 2002
• September 29 October 3 LJM

November 23 27 Donlon HHS
2003 January 21 28 CDC Henderson,
Roebuck LJM
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Preparedness readiness

• Final pre-Iraq War 2 arrangements

• Integrating lessons of Iraq War 1

• Vigorous drills and assessments

• Questioning about preparedness capacity

• Mood tense, depressed, on edge

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On-site preparednessinvestigation in israel

• Connectivity

Smallpox, BT, Chemical
Terrorism
Decision-making,risk communication training
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The problem
(Prior to September 11) the airline security
system inspected for guns and bombs, not knives
aircrews were trained to deal with hijackers
who sought hostages or conveyance to Cuba, not
kamikaze attack.
In retrospect, a huge gap existed in the U.S. air
safety system. Terrorists detected it before
the security system did and exploited it.
Ashton Carter in the journal International
Security
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leadership
Who is in charge is one of the most important
questions early in the epidemic
because any large-scale relief effort would
require good management.
Jason Bardi, Aftermath of a hypothetical
smallpox disaster. Emerging Infectious
Diseases, 1999.
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New working relationships
The exercise required state health department
personnel to develop new working relationships.
In a true incident, a central location for
face-to-face meetings should be large enough to
accommodate representatives from all agencies
involved, but one difficulty encountered with
arranging such meetings was that each agency
seemed most comfortable in its own command
center.
Richard Hoffman and Jane Norton, Colorado
Department of Public Health and Environment,
Denver, CO. Lessons Learned from a Full-Scale
Bioterrorism Exercise TOPOFF
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collaboration
Connections between public health agencies and
medicine need to be greatly strengthened an
issue that can also be called improved
connectivity.
Thomas Inglesby, M.D. Testimony before Congress
U.S. Senate Committee on Governmental Affairs.
The State Public Health Preparedness for
Terrorism Involving Weapons of Mass Destruction
April 18, 2002.
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• Connectivity

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MULTI-DIMENSIONAL PERSPECTIVESTHE DILEMMA OF
THE CUBE
Peep hole B
Peep hole A

Peep hole A
Peep hole B
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MULTI-DIMENSIONAL PERSPECTIVESTHE DILEMMA OF
THE CUBE
Peep hole B
Peep hole A

Peep hole A
Biological Chemical
Peep hole B
Silent Terrorism
Terrorism
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RESOLVING THE DILEMMA OF THE CUBE
CONNECTIVITY
A seamless web of
people, organizations, resources, information
that can best
catch, contain, and control
a bioterrorist incident
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RESOLVING THE DILEMMA OF THE CUBE
CONNECTIVITY
Linkages
A seamless web of
people, organizations, resources, information
Operations
that can best
Assets
catch, contain, and control
a bioterrorist incident
Outcomes
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What are the greatest Obstacles to connectivity?
Symptoms of conflict
Linkages
not in place
Operations
Assets
impeded
not ready
Outcomes
Lousy
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The World trade center
Physical terrorism
A failing of CONNECTIVITY
NYPD
based on a history of CONFLICT
NYPD
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SYSTEMIC SOURCES OF CONFLICT
VERTICAL Levels of jurisdiction
HORIZONTAL Areas of responsibility
EXPERIENTIAL Assumptions
INVOLVEMENT New versus Old
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Building collaborative Problem solving
Federal agencies
State agencies
Local agencies
Non-government organizations
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LEADERSHIP FOR Public health preparedness
The ideal leader
Evidence
Scientist
Clinician
Treatment
Bigger picture
Strategist
Humane perspective
Ethicist
What to do
Planner
People and resources
Organizer
Choices consequences
Risk assessor
Politician
Implications
Financial officer
Money spending
Prophet
See into the future
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How do you link the systems necessary to
achieve preparedness?
Since this ideal leader does not exist in one
compact package
people with different expertise, knowledge,
talent, and perspective must work together.
Hence.
CONNECTIVITY
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connectivity
Differential Levels of Connectivity
High
Integrated systems
Parallel systems
Middle
Competitive systems
Low
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connectivity
Decisions
Integrated
Decision-making occurs together on most topics
Decision-making occurs on specific topics
Parallel
Separate decision making
Competitive
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connectivity
Resources
Integrated
Shared, pooled coordinated acquisition and
deployment
Separate resource planning with linkages on
specific items
Parallel
Competition and hording of resources
Competitive
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connectivity
Strategic planning
Integrated
The organization seen as a whole unit in its
environment
Units advance not impeding separate/linked
objectives
Parallel
Separate units seek to advance their individual
status
Competitive
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connectivity
Information
Integrated
Combined info, communication, conceptual systems
Info sharing and linkages occurs on specific
topics
Parallel
Information is used to create differential
advantage
Competitive
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connectivity
Emergency Preparedness
Integrated
Key systems, people, resources, information
closely linked
The job gets done with limited efficiency
effectiveness
Parallel
System components unlinked with overlaps and
gaps
Competitive
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Coping with indeterminant risk

• What is it we know?

Hostilities will stimulate anti-US sentiments
Presence of terrorists
?
Availability of biological and chemical agents
The scope of our capacities to cope with a WMD
What is it that we cannot know?
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Coping with indeterminant risk

• What is it we know?

The problem is that ultimately, public officials
will be held accountable and responsible.
What is it that we cannot know?
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How well will we Cope with this risk?

• PREPAREDNESS

Process
?
Product
READINESS
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How well will we Cope with this risk?

• PREPAREDNESS

People
Resources
?
Organizations
Information
READINESS
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enhance capacities to Cope with this risk?

• PREPAREDNESS

People
Resources
Connectivity
Organizations
Information
READINESS
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• Smallpox, BT, Chemical

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The Israeli Smallpox strategy

• One case of smallpox anywhere

• Close all schools in the country

• Vaccines and personnel report to schools

• Pre-recorded instructional videos on TV

• Routine vaccinations in schools 4 days

• 20,000 people/school, 5,000 / day

• Complicated cases at clinics with VIG

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The Israeli Smallpox strategy Smallpox
Preparedness Strategy

• Re-vaccinate 20,000 health army

• No furloughs or transmission concerns

• Collect VIG (antibodies) post vaccination

• Pre-recording instructional videos for TV

• Develop school sites and personnel

• Drills and exercises to test system

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The Israeli Smallpox strategy BT Chemical
Preparedness Strategy

• Systems for decon in place at hospitals

• Training and equipment for responders

• Sensitive surveillance and detection

• System in place to adapt health system

• Frequent drills and exercises

• Preparation of the civilian population

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The smallpox program Problems

• The crisis of confidence

• Confidence in the quality of the vaccine

• Confidence about vaccination info

• System confidence in its capacity

• Confidence in the terrorists can they do it?

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The smallpox program implementation

• Lower participation rates than expected

• Participation reflects leadership and risk

• Expected transmissions few complications

• No major complications or side effects

• Few missed days of work

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The smallpox program implementation

• VIG collection a prime motive

• Ready access to information and questions

• No exclusions for health personnel

• All vaccinators were vaccinated

• Sensitive surveillance systems in place

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The smallpox program results

• Hadassah 400 vaccinated

• Generous exclusion factors

• Low take rates Hadassah 40
• General 65-70

• 7,000-7,500 before-after samples

• Army, public health, health care,
• responders

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The smallpox program STRATEGY

• Questioning of the one case premise

• Question capacity for perfection

• Question the risk

• Question terrorist strategy

• Think like a terrorist
• What does this mean? Few clues

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The Smallpox threat The international deterrent
effect
The stated primary civilian targets are Israel
and the U.S.
With both able to protect their populations,
smallpox becomes a less attractive terrorist
weapon.
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The Smallpox threat The international deterrent
effect
If smallpox were released on a global scale
There impact upon developing countries would be
catastrophic.
Hence, the importance of global deterrence.
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• Terrorism

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TYPES OF TERRORISM
Physical Terrorism
Silent Terrorism
BOMB - ATTACK
BIOLOGICAL - CHEMICAL
Observable
Unsee-able
Place specific
Mobile spread-able
Time specific
No clear beginning end
Response / Management is Different
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TYPES OF TERRORISM
Scope of observability
Physical Terrorism
Silent Terrorism
Chemical Terrorism
BIOLOGICAL
AGENT
BOMB - ATTACK
Observable
Detectable
Unsee-able
Mobile
Place specific
Moves
Unclear beginning end
Time specific
Time specific
Response / Management is Different
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TYPES OF TERRORISM
Biological
Silent Terrorism
NON-INFECTIOUS
INFECTIOUS
Anthrax
Smallpox
Tularemia
Plague
Botulism
Ebola
The importance of surveillance early detection
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TYPES OF TERRORISM
Chemical
Chemical Terrorism
PREPARATION
AGENTS
Training in personal protective equipment
Nerve Agents
Availability of equipment antidotes
Mustard Gas
Coordination of scene, evacuation,
decontamination
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PREPAREDNESS
QUESTIONS
What is preparedness?
When do you know that you are prepared?
How do you get prepared?
How do you link the systems necessary to
achieve preparedness?
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PREPAREDNESS
ANSWERS
Israel
Geography
Security
History
State-sponsored hostilities as well as
guerilla activities
Surrounded by hostile states groups
Four wars and periods of intense
hostility including the 1991 Gulf War and two
intifadas
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WHAT IS PREPAREDNESS?
Physical Preparedness
Mental Preparedness
Ready to go
State of mind
Vaccination
Accept that there is risk
Supplies
Act appropriate to the risk
Vigilance and flexibility
Concrete feasible plans
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WHAT IS VULNERABILITY?
Physical Vulnerability
Mental Vulnerability
No vaccination capacity
Denial
Supplies not delivered
Lack of urgency
Distraction
Sub-operational plans
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When do you know that you are prepared?
YES
NO
The Event
People, Resources, Organizations, Info
?
Picture of the event
Nuclear, Biological, Chemical, Mass trauma
Number of victims
Incident Command System
Nature of impact
Capacity to implement
Envelop the incident with an instant health system
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Readiness A State of Mind
Think like a terrorist
WMD Terrorism takes us into uncharted territory
This a situation that chooses you
It catches you off-guard
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Overall terrorist Risks and responses

• Greater concern Chemical over Biological

• Surge assigned surge capacity

• Develop a to do list for each alert level

• The first two events will be most difficult

• The third event will be better handled

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Learning from experience
Subsequent Events

• First Two Events

Handled better
Handled poorly
Active learning System analysis System change
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Learning from experience
Active learning System analysis System change
Subsequent Events

• First Two Events

Deterrence
Pre-arranged event inquiry task forces. - - - - -
- - - - - - - - - - - - - - - - Translate
lessons learned into immediate change
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Terrorism timing The health system response
The key objective
The key factor
Reduce morbidity mortality
TIME
Reduce time between injuries and response,
confinement of the contaminated area, treatment
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Terrorism timing The health system response
Capacities
The key objective
The key factor
Reduce morbidity mortality
INSTANTLY
TIME
GROW OR SHRINK THE SYSTEM IN RESPONSE TO THE
EVENT
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• Decision-making,
• Risk Communication
• Training

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The Israeli Smallpox strategy Making the
decision
The Supreme Health Authority
Ministry of Health Secretary General
Surgeon General of the Israel Defense Forces
Director General of Kupat Cholim
Criteria
Considerations
Moral dimensions
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THE PUBLIC FACE OF PREPAREDNESS
Elected Officials
Scientists experts
Authority Options Accountability
Info/Facts Analysis Responsibility
What the public wants
What the public expects
FAMILIARITY
TRUST
BALANCE
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THE PUBLIC FACE OF PREPAREDNESS
Elected Officials
Scientists experts
DONT IMPROVISE WORK THIS OUT IN ADVANCE
What the public wants
What the public expects
FAMILIARITY
TRUST
BALANCE
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THE PUBLIC FACE OF PREPAREDNESS
Elected Officials
Scientists experts
TACTICAL
STRATEGIC
Everyone works with the same picture of the event
Generalist Big picture decisions
Analytic Perform set functions
BALANCE
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PREPAREDNESS TRAINING LEARNING

• Frequent/comprehensive training/drills

• Trainings provide individual confidence

• Prepare to collect lessons learned

• Immediately translate lessons to practice

• Prepare the civilian population

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The Israeli Training experience

• 2-day seminar HC Profs and Leaders

• 70 people per session for interaction

• Day One Chemical events

• Day Two Biological events

• First half of each day Lectures

• Second half Table top exercises

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The Israeli Training experience

• Practical seminar for ER staffs

• One day in length

• Goal Enhance ability to ID BT cases

• 4,000 workers trained/ 3-4 months

• Special training mannequins used

• Mannequins responsive clinical feedback

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Observations Differences between israel And the
united states
Israel
United States
Preparedness Readiness
What is Preparedness?
Close link Decision to action
Who decides?
Vertical competition
Vertical integration
Horizontal competition
Horizontal collaboration
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RELATIONSHIP BUILDING israel And the united
states
Israel
United States

• Exchange of information and lessons

• Collaboration on projects/labs

• Communication in an emergency

• Better coordinated decisions strategy

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Decision-making and communication
CONNECTIVITY
Each person and each entity that is part of the
bioterrorism preparedness effort
has the responsibility to promote efforts
to build collaboration, manage differences
(conflicts), and work toward resolving them.
To create a strong web of surveillance,
detection, and response
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• Questions

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• Thank You

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For more information Leonard J. Marcus,
Ph.D. Harvard Center for Public Health
Preparedness 677 Huntington Avenue Boston, MA
02115 617-496-0867 To contact Dr. Marcus by
e-mail ljmarcus_at_hsph.harvard.edu
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