Preparing health system's response to bioterrorism

Renegotiating Health Care. By Leonard J. Marcus, PhD, and Barry C. Dorn, MD, AMNews contributors. Oct. 7, 2002.

In July, the Harvard School of Public Health was designated by the Centers for Disease Control and Prevention as an Academic Center for Public Health Preparedness. We are part of a consortium of schools, state and local health departments and agencies across the country working to develop and to disseminate training materials to assist in the massive effort to prepare for and potentially respond to a bioterrorist attack.

Conflict analysis and the development of conflict resolution capacities are among the foci of our center. Knowing that preparation for and response to a bioterrorist attack ultimately will involve all physicians and health facilities, we share here initial observations and recommendations.

What are the potential conflicts? First, there are matters of jurisdiction. Much of the financing for this effort is derived from federal sources. The bulk of the on-the-ground preparation is being directed and managed through state agencies. Large metropolitan areas are receiving special funds to mount their own preparatory efforts. How this ultimately will impact physicians, hospitals and practitioners on the local level -- people at the front lines of first detection -- remains unclear.

Among these different constituencies and authorities, conflicts are emerging about decision-making, control and funding. Local health officials report that they do not have adequate resources or capabilities to respond to a bioterrorist incident and question the concentration of resources on the state level. By way of illustration, the federal government seems positioned to let states determine their own policies regarding the first round of voluntary smallpox vaccinations, a strategy that could cause consternation if different states or localities choose significantly divergent policies.

The overall paradox is that much of this planning, preparation and activity proceeds now almost by necessity in a "top-down" manner, despite the very real fact that if an attack occurs, it will immediately be managed in a "bottom-up" fashion: based in a doctor's office, a patient's home or in a local emergency department.

Second, there are matters of function and sector culture. The effort to prepare for a potential bioterrorist event is requiring different sectors to collaborate and cooperate in an unprecedented fashion. Law enforcement, fire, emergency management, health, military and political leadership are getting to know one another at frequent meetings.

It is apparent, though, that these diverse segments operate differently. Public health tends to reach decisions by committee and consensus. Other sectors employ a command structure. In a recent simulation exercise, public health and law enforcement personnel were in a standoff as to disposition of a case of smallpox. The public health personnel were eager to do an epidemiological investigation, while the law enforcement people restricted access to the affected area, marking it off with yellow tape in an effort to contain the "crime scene."

Third, there are very different attitudes about risk and strategies for managing it. Public health leaders naturally approach bioterrorism preparedness with a different sense of immediacy than disaster management leaders. Relatively speaking, those with a military or law enforcement background are trained for worst-case scenarios. Public health people tend to view bioterrorism as another item on a long list of health risks that includes tobacco use, obesity and substance abuse -- health problems with known mortality rates and intervention strategies. They observe funds being allocated to an unknown risk and intervention while the downturn in the economy leaves programs with a predictable occurrence, effectiveness and history -- such as flu vaccination programs -- underfunded. What is obvious to some is questionable to others.

Finally, there are many people who have spent careers working in disaster management. For them, incident command systems and drills are old hat. The new focus on bioterrorism and other forms of terror in the wake of the attacks on Sept. 11, 2001, has brought a flood of new people into the enterprise. While there is a general camaraderie enveloping these new efforts, there are also tensions between the familiarities of the old timers and the freshness and sometimes naïveté of those new to the scene.

What initial recommendations do we have to smooth the preparation process? How can we break the barriers and resolve the potential conflicts so they do not prove another obstacle to preparation?

First, as you work together with people in other sectors, declare the assumptions that underlie your comments and recommendations. This exercise facilitates understanding and allows parties to best identify what it is they really agree or disagree about. Describe your assessment of different risks, the benefits and downsides of various options, and how and why you reach decisions and recommendations. Be clear and transparent in your reasoning and conclusions.

Second, speak in very specific and clearly delineated terms in making recommendations. Others should understand the "why" of your statements as well as the "what." We call this speaking in "boxes." For example, actual deployment of a plan will occur in stages. Stage one will be very different from the fully deployed stage. During deliberations, distinguish the "box" that describes "first steps" from the one that describes "end-stage deployment." This clarity reduces both confusion and conflict.

Finally, use common language that is understood by all who participate in preparatory meetings. There is a government alphabet soup of acronyms just as there are medical terms that defy understanding for the uninitiated. Encourage others to interrupt the conversation if a word needs to be defined. And certainly, engage the obvious: Don't grandstand, do listen, pay attention and remind yourself of the fundamental purpose that brought you all together.

We share the hope that the world never experiences the horror of a widespread bioterrorist incident. In the meantime, wisdom recommends that we prepare. Ultimately, this country is striving to create a seamless web that can catch, contain and control a potential bioterrorist attack. In the process of developing this web, we can also better link distinct parts of the health system. If we make the most of this opportunity, we will not only be better prepared for the bioterrorist event. We also will be better prepared for the range of regularly occurring incidents and disasters to which the health system must continuously respond.

Dr. Marcus is director and is associate director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health, (617) 496-0867. Dr. Dorn is CEO of Health Care Negotiation Associates (781) 861-6116. The paperback version of their book, "Renegotiating Health Care: Resolving Conflict to Build Collaboration," is available for $38.00 through Jossey-Bass Publishers, (800) 956-7739. Mention this column (code S9771), and Jossey-Bass will waive shipping charges.

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Preparing health system's response to bioterrorism

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