CALL TO ACTION | Obtaining and Maintaining Local Interoperability

In the aftermath of the terrorist attacks on 9/11, the American College of Emergency Physicians (ACEP) issued a press release on December 11, 2001, announcing the formation of a new coalition to strengthen community readiness for biological, chemical, and nuclear terrorism and other disasters. Entitled “Partnership for Community Safety: Strengthening America’s Readiness,” the announcement calls on the federal government to support and sustain comprehensive readiness efforts in the nation’s public health departments, hospitals, emergency departments, medical education institutions, nursing profession, and first-responder agencies. To work toward these goals, the partnership has brought together the ACEP, the American Ambulance Association, the American Hospital Association (AHA), the American Organization of Nurse Executives, the American Public Health Association, the Association of American Medical Colleges, the National Association of County and City Health Officers, the International Association of Fire Chiefs, and the National Association of State EMS Directors.

Member organizations agree that weaknesses exist in U.S. medical preparedness and response systems and that additional resources are needed to address the following issues (ACEP 2001):

• Improving the communications infrastructure

• Improving community-based planning

• Increasing community capacity to deal with disasters

• Improving disease surveillance, disease reporting, and field laboratory identification

• Protecting responders from the effects of nuclear, biological, or chemical (NBC) agents

• Increasing and enhancing training programs, continuing education, and community drills for mass-casualty incidents

Two of these recommendations are discussed in the following paragraphs.

Improving the communications infrastructure addresses the heart of building interoperability. In most American cities, response organizations, hospitals, and public health agencies are not linked by alternative communications means other than telephones or e- mail. This problem was stated in testimony by the AHA to the DHHS National Committee on Vital and Health Statistics Panel on National Preparedness and a National Health Information Infrastructure (U.S. DHHS, National Committee on Vital and Health Statistics 2002):

In disasters, particularly those involving a large numbers of casualties, it is critical that hospitals have pre-established communications linkages with other frontline responders that are reliable and interoperable. However, in disasters, most organizations experience problems with interoperability. Communications often degrade as a result of saturated cellular and wireless communications systems that interfere with public safety communications. Public health services must be linked using secure connections to the Internet. High speed, dedicated Internet access should be available for all public and private healthcare facilities and related organizations. There is a critical need for funding to upgrade, modernize and link frontline responder communications systems and to address interoperability problems.

The recommendation to increase and enhance training programs is especially important because the new threats posed by terrorists can include NBC agents that are unfamiliar to most medical providers. In addition, the handling of mass casualties has not been studied in U.S. healthcare curricula, nor have the various aspects of community systems and interoperability that must be built for an effective community response to disaster.

Obtaining and Maintaining Local Interoperability

In June 2001, the federal government held a tabletop terrorism exercise, known as Dark Winter, involving a simulated smallpox attack. In the exercise, the spread of the smallpox and its morbidity and mortality were charted. In testimony to Congress on July 23, 2001, Margaret Hamburg, M.D., former assistant secretary for planning and evaluation at the Department of Health and Human Services (DHHS) stated (Committee on Government Reform 2001):

Dark Winter…demonstrated how poorly current organizational structures and capabilities fit with the management needs and operational requirements of an effective bioterrorism response. Responding to a bioterrorist attack will require new levels of partnership between public health and medicine, law enforcement and intelligence. However these communities have little past experience working together and vast differences in their professional cultures, missions and needs.

The solution to eliminating this void in interagency cooperation is to work toward achieving interoperability on local, county, and state levels and to coordinate with federal agencies.

EARLY EXAMPLES OF INTEROPERABILITY
An early example of military interoperability was the Blitzkrieg plan, or “lightning war,” used successfully by the Germans in the early years of World War II. During the years between World War I and World War II, the German General Staff developed a doctrine and tactics that combined the infantry, armor, artillery, and support units with the air force, creating one striking force aimed at the enemy. The U.S. military learned from this example and successfully organized integrated techniques in all of its military services that eventually destroyed Germany’s ability to wage war. The allied troops’ D-Day invasion assembled the mightiest armada of ships, planes, and soldiers in history; it was organized by flag officers and involved troops from many countries. Working together as one unit, they forced their way onto the continent and eventually liberated Europe.

The EMS of the United Kingdom’s Ministry of Health, not to be confused with the American EMS, was among the first examples of medical interoperability. During the incessant German bombing of World War II and the attacks by V-1 and V-2 rockets, the British EMS functioned as a planning, control, and operational program that integrated the casualty plan with the various components and levels of healthcare, from first aid to tertiary care and rehabilitation. London, for example, was divided into ten hospital sectors radiating from the city center outward, like a wagon wheel, into the surrounding counties. This organization was fully coordinated with first responders and civil-government authorities. The entire country had an EMS organization based on 12 national regions (Shirlaw 1940; Dunn 1952).


Interoperability is the effective interfacing of all medical and ancillary service providers (e.g., hospitals, public health agencies, emergency medical services [EMS], pharmacies, and medical suppliers) with public safety agencies (e.g., fire, rescue, and police services), Red Cross, Salvation Army, communications centers, public works, and utility companies. These agencies, in turn, must coordinate with political leadership and the media. To be effective, this all-encompassing effort requires each agency to deliberately and rigorously act to identify the strengths, weaknesses, opportunities, and threats (also known as a SWOT analysis) in their community and among themselves. Finally, the agencies must determine the best use of each other ’s assets for disaster mitigation, preparedness, response, and recovery in various disaster scenarios. This description of interoperability goes far beyond the usual use of the term by public safety agencies, which often simply define it as the ability to communicate—by radio or other means— with each other. While this ability is key to successful interoperability at the scene of a disaster, it is the planning and integration of services that precede the disaster that result in an effective response.

FUTURE OF PUBLIC HEALTH PREPAREDNESS | Terrorism and Disaster Management

On January 10, 2002, President George W.Bush signed appropriations legislation providing $2.9 billion for DHHS, a tenfold increase in the department’s funding for bioterrorism preparedness. The funds have been used to develop comprehensive bioterrorism preparedness plans; upgrade infectious-disease surveillance and investigation through HAN; enhance the readiness of hospital systems to deal with large numbers of casualties; expand public health laboratory and communications capacity; and improve connectivity between hospitals and city, regional, and state health departments to enhance disease reporting. As the lead federal agency in preparing for the threat of bioterrorism, DHHS works closely with states, local government, and the private sector in building the needed, new public health infrastructure and accelerating research into likely bioterrorism-related diseases.

Reflecting the need for broad-based public health involvement in terrorism preparedness and planning, staff from different agencies in DHHS participated in developing a strategic WMD plan. These agencies include CDC, the Health Resources and Services Administration (HRSA), and the Office of Emergency Preparedness. CDC will target state and local programs supporting statewide preparedness activities for bioterrorism, infectious diseases, and public health emergency. HRSA will provide funding, which will be used by states to create regional hospital plans to respond in the event of a bioterrorism attack.

Future goals of federal public health preparedness efforts include the following:

§  Having at least one epidemiologist in each metropolitan area with a population greater than 500,000

§  Developing an education and training plan that will reach health professionals, emergency department physicians and nurses, local public health officials, and the public with information relating to bioterrorism, new and emerging diseases, and other infectious agents

§  Targeting bioterrorism research to new vaccines, antiviral drugs, and new diagnostic tools to better protect against biologics

Implementation of the objectives outlined in DHHS’s strategic plan will be coordinated through the DHHS Office of the Assistant Secretary for Emergency Preparedness and Response. DHHS program personnel are charged with helping build local and state preparedness, developing U.S. medical expertise regarding potential threat agents, and coordinating medical response activities during actual bioterrorist events. Program staff have established priorities for fiscal year 2004 regarding these focus areas 

Successful implementation of these priorities will require state and local public health agencies to collaborate and partner with a number of other persons and groups, including the following:

§  Medical research centers

§  Healthcare providers and their networks

§  Professional societies

§  Medical examiners

§  Emergency response units and responder organizations

§  Safety- and medical-equipment manufacturers

§  Federal agencies

§  International organizations

Recent threats and use of biological and chemical agents against civilians have exposed the United States’s vulnerability and highlighted the need to enhance our capacity to detect and control terrorist acts. The United States must be protected from an extensive range of critical biological and chemical agents, including some that have been developed and stockpiled for military use. Even without threat of war, investment in national defense ensures preparedness and serves as a deterrent against hostile acts. Similarly, investment in the public health and healthcare systems provides the best civil defense against bioterrorism.

Tools developed in response to terrorist threats serve a dual purpose. They help detect rare or unusual disease outbreaks and respond to medical emergencies, including naturally occurring outbreaks or industrial injuries that might resemble terrorist events in their unpredictability and ability to cause mass casualties (e.g., a pandemic influenza outbreak or a large-scale chemical spill). Federal WMD terrorism-preparedness activities, including the development of a public health communication infrastructure, a multilevel network of diagnostic laboratories, an integrated disease surveillance system, and an MMRS will improve our ability to investigate rapidly and control public health threats that emerge in the twenty-first century (U.S. DHS 2003a, 2003b).