Preparedness: Results and Concerns

While the April 15 Boston Marathon bombing stunned the nation and reminded citizens and policymakers alike of the devastation a terrorist attack can cause, it was also a success story from an emergency-response perspective. There were many factors that contributed to that success, including that EMS personnel were already deployed for the race and that bystanders acted quickly to save lives instead of running to save their own. But chief among the reasons for the successful response was that Boston had prepared for just such an event.

“Years before the incident, Boston’s EMS, fire, and police personnel mapped out how they would handle a terrorist bombing,” Dr. Arthur Kellermann told a Senate committee looking at lessons from the Boston bombing. “Every hospital that received casualties had a well-crafted disaster plan that had been exercised prior to the event,” said Kellermann, an emergency physician and policy analyst with the RAND Corporation.

Since September 11, 2001, the federal government has invested billions of dollars in programs that strengthen the preparedness of state and local responders. The response capabilities of all parties involved after the Boston Marathon bombing shows that these programs have been making a measurable difference, Kellermann said. For example, The Homeland Security Exercise and Evaluation Program (HSEEP), established by the Department of Homeland Security in 2002, has helped communities handle disasters from earthquakes to bombings.

Other cities and states have also used such funds to good effect. Security Management spoke with Bob Spieldenner, the director of public affairs at the Virginia Department of Emergency Management, about how that state has applied its HSEEP money. Virginia has had its share of crises to respond to, notes Spieldenner. They include the Virginia Tech shooting and the 9-11 attack on the Pentagon, as well as floods, hurricanes, and earthquakes. Those incidents have brought home the message that “being prepared for whatever type of circumstance comes up is key,” he says.

Virginia’s Department of Emergency Management oversees how the funds are used in seven regions throughout the state. In each region, a group of coordinators made up of local law enforcement officials develops areas that need to be evaluated and improved through the funding. Often, managers will implement specific training courses or full-scale exercises to address those needs. The funding also goes towards emergency-response-related supplies, such as hazardous materials and bomb disposal equipment. The Department of Emergency Management also offers general Federal Emergency Management Agency (FEMA) training courses.

During a yearly training workshop, the state’s Department of Emergency Management receives suggestions on what exercises and courses would be beneficial for each region. Because there is never enough funding to conduct all the exercises requested, the department prioritizes the suggestions and works with regional exercise planning teams to carry them out. For example, one region decided it wanted to have a better understanding of how to manage a mass casualty event. It began with a roundtable discussion about how the community would respond. The region then executed a full-scale exercise based on an active-shooter scenario at a community college.

Everyone from law enforcement officers and SWAT teams to medical examiners and crime scene investigators participated. In many full-scale exercises, volunteer and private organizations—such as the Red Cross, universities, power companies, and transportation managers—also get involved. “It can get pretty intensive when you get to that full-scale exercise level,” Spieldenner says.

After the exercise, after-action reports are made to identify strengths and areas that need to be improved. Beyond full-scale exercises, HSEEP helps facilitate education and communication among departments and regions, which is useful regardless of the type of incident, Spieldenner says. “Whether it’s a man-made terrorist attack or an earthquake, a lot of the response is going to be similar. The tactical aspects may differ but the recovery is the same in a lot of ways—finding temporary shelter, dealing with mass injuries or fatalities.”

This type of training is of great value, says Spieldenner. But states are becoming concerned because there has been a “significant reduction” of HSEEP funds, Spieldenner notes. Already, states have to carefully allocate what training programs and equipment the funding goes towards. It “impacts how much training we can do and how much equipment we can buy,” he notes.

That concern was also voiced by Kellermann in his testimony at the congressional hearing. “As the horror of September 11, 2001, fades into memory, grant funds...to strengthen preparedness are dropping,” he said. Worse, “the attention of many local officials and business leaders has moved elsewhere,” according to Kellermann. “Emergency managers and public safety agencies remain focused on the mission, but some hospitals have lapsed into thinking that disaster preparedness is a costly distraction from daily business.”

While HSEEP prepares first responders for handling catastrophic events, another program called the Cities Readiness Initiative (CRI) helps prepare communities for responding to large-scale bioterrorism attacks. CRI, which is run by the Centers for Disease Control and Prevention (CDC) and funded through the Public Health Emergency Preparedness cooperative agreement, helps large metropolitan cities develop plans to dispense antibiotics to their citizens within 48 hours of a bioevent. Public health departments in 72 major cities are a part of the program, which could ultimately vaccinate up to 57 percent of the nation’s population.

Tom Bowman, deputy of the CRI, tells Security Management that the program is structured based on how cities should respond to an anthrax attack, which is generally considered the worst-case scenario in a bioevent. When the program began in 2004, 21 cities participated, and it has grown to include at least one CRI city in each state.

The CDC has a national stockpile of antibiotics that would fight most bioattacks, including anthrax. The CRI educates public health officials on how to proceed in setting up a dispensing network, Bowman says. It’s especially important to prepare cities on how to deal with bioattacks because there is such a short window between infection and symptoms, Bowman notes.
In the event of a bioattack, the governor of the affected state must request antibiotics from the strategic national stockpile. Once the request is made, the city has a 48-hour window to vaccinate the community’s citizens, according to the CRI.

First, local officials must set up a Receipt, Store, and Stage site, which would receive the antibiotics and other supplies from the strategic national stockpile within 12 hours of the governor’s request. The site would deliver the supplies to individual points of dispensing throughout the community.

Once the antibiotics are distributed to the dispensing sites and the citizens are alerted, staff must screen each citizen for what type of antibiotic they should receive. The stockpile has two vaccinations against anthrax in case a person is allergic to one. In each city, the CDC collects baseline data—overall population, seasonal population, number of dispensing points, and number of staff needed to give vaccinations. The agency also runs three drills a year to establish how many citizens can be vaccinated at each location. The data are constantly reviewed and procedures are tweaked depending on the results, Bowman says.

But the CDC doesn’t do all the work in the program. The CRI requires city officials to track population numbers and define the most efficient distribution locations. Local officials need to consider seasonal and out-of-town visitors staying within city limits. Often, health officials will establish dispensing locations at hotels to vaccinate tourists, which takes a load off the public dispensing areas, Bowman says.

The CRI also requires local officials to establish the paths of communication during a bioevent: how local hospitals and medical offices will handle the dispensing and how citizens would be notified. Planning is always important, but it is particularly critical in responding to a bioattack. “One thing that is different about this than a lot of disasters is the timeframe,” Bowman says. “The fact that you’re on a 48-hour clock, from the time you decide until you are essentially done with the first 10-day round for the entire population. The timeframe is so tight that almost every detail needs to be planned out.”

Volunteers and staff need to be identified and trained, agreements need to be made with all distribution areas, and numbers need to be analyzed—this isn’t something that can come together at the last minute, Bowman says.

“I’ve been doing disasters for a long time, so I’ve realized how critical it is,” explains Bowman. “There’s very little room for anything to go wrong, and that’s why it’s so important for communities to do this planning. In the anthrax model, the time from exposure to the time patients start having symptoms and dying, [the 48-hour window] is about as tight as we can get.”
The CRI has prepared cities for smaller health emergencies as well, Bowman says. During the 2009 H1N1 flu pandemic, antibiotics were issued through the same points of distribution that would be used during a bioattack, he notes.

However, like HSEEP, this program is suffering from shrinking funds. The Public Health Emergency Preparedness cooperative agreement has seen a steady decline in funding since it was established in 2002. There was a $55 million drop in funding from the prior year to the current fiscal year.

Spieldenner says that programs like the National Emergency Management Association are trying to fight for more funding, but in a time of congressional cutbacks and fading fears of terrorist attacks, advocates are finding it hard to win increased funding for preparedness programs such as HSEEP and CRI. “As funding has been reduced, it definitely affects what we can end up doing,” he says. The resulting reduction in readiness programs “will ultimately affect the quality of the real-world response.”