Healthcare

Black Swans - Preparing for Pandemic & Biological Threats

by Robert C. Hutchinson

In his 2007 best-selling book “The Black Swan: The Impact of the Highly Improbable,” Nassim Nicholas Taleb, a Lebanese American statistician, described a Black Swan event as a highly improbable event with three principal characteristics. “It is unpredictable; it carries a massive impact; and, after the fact, we concoct an explanation that makes it appear less random, and more predictable, than it was.”

It is difficult to argue with Taleb’s assessment. Humans have certain psychological limitations preventing them from foreseeing such events. Even a significant incident or disaster that seems reasonably predictable can still have an element of surprise when the threat is ignored for one or more reasons – limited resources, for example, or competing priorities, wishful thinking, or even willful blindness. In addition, many significant events often seem obvious and/or expected – after they occur.

All of which raise a very important question for the scientific community: Is a future novel pandemic illness, or biological threat, actually a Black Swan event that was not recognized as such until after a major eruption and/or severe international impact? There may be no definitive answer to that question, but the question itself is at least plausible. Pandemics are certainly not new, and have been the subject of many best-selling books and movies, in large part because of their possible real-life consequences. The 2011 movie “Contagion,” for example, sparked numerous conversations, unfortunately rather short-lived, that focused on: (a) the level of national awareness and preparedness for a possible pandemic illness; and (b) the serious and cascading consequences that might occur in any nation not properly prepared to deal with an emerging novel virus or biological attack.

As with many other homeland security and law enforcement concerns, the interest in this low-probability but high-consequence threat faded from the national discourse – in the United States, at least – when, and because, more pressing issues demanded the limited time and resources of the nation’s emergency planners and public health professionals. Nevertheless, the possibility of suddenlyentifying a highly pathogenic virus has not diminished. Moreover, most communities probably have not adequately prepared to deal with such an event, even under the umbrella of all-hazards or whole-of-community planning.

In 2012, theentification of a novel coronavirus – now known as Middle East Respiratory Syndrome (MERS) – raised new concerns about another viral respiratory illness that, it was feared, could evolve into the next Severe Acute Respiratory Syndrome (SARS) or even worse. Not quite half (63) of the first 149 cases reported died after being infected. Most of the fatalities occurred in Saudi Arabia, but cases in the United Kingdom have confirmed human-to-human transmission. In July 2013, to prevent further spread of the disease, the World Health Organization established an emergency committee to effectively monitor this still-emerging virus.

A quickentification of the new coronavirus, particularly if encountered in other nations, will help facilitate its containment and timely typing to institute the appropriate responses and medical countermeasures. A major U.S. concern is the possibility that the new virus could reach the same level of human-to-human transmission experienced during the SARS outbreak.

Serious Impacts Both Overseas & in the United States Recurring events around the world involving mass illnesses and/or deaths in domesticated animal populations, especially those linked to viruses – including influenza – raise serious concern even within the United States. The March 2013 discovery of approximately 15,000 pig carcasses floating down a river in China, for example, caused public health officials throughout the entire world to wonder if it might be another indicator of a still emerging threat. Beyond the cause of death from a reported circovirus found in the pigs tested, there are serious ramifications of any novel or evolved microbes widely spreading to other locations both within China itself and in neighboring countries, especially with the current H7N9 virus threat. In China, ducks and swans were among the additional die-offs in that nation’s other animal populations. These events strongly reinforce lingering epidemic or pandemic concerns – including possible viral reassortment or mutations that today could swiftly travel around the world via the wings of birds, aboard containerships, and/or on commercial aircraft.

The impact of a serious pandemic influenza could be far greater than that caused by a conventional terrorist attack or an act of war. In its October 2011 Bio-Response Report Card, the Bipartisan WMD Terrorism Research Center, a U.S. nonprofit organization co-chaired by two former U.S. Senators – Bob Graham (D-Fla.) and Jim Talent (R-Tenn.) – pointed out that an H1N1 influenza virus strain, known as the Spanish Flu, killed an estimated 20 million people worldwide during the winter of 1918-1919. During that winter, the Report Card stated that, “more U.S. soldiers died from influenza than had died on World War I battlefields.”

If the novel coronavirus MERS, the H7N9 influenza, or any other serious pathogen were to beentified in the United States, it would trigger a response in many of the nation’s critical sectors, especially in such fields as medical services, public health, and law enforcement. It also would severely test the nation’s current medical-detection and surge-capacity capabilities – to a level that at least some officials believe may demonstrate insufficient planning and preparedness in today’s all-hazards environment.

In that situation, one of the first and most important lines of defense, and of possible failure points, would be the initial screening andentification of the virus as early as possible – i.e., in time to implement the pre-designated quarantine and isolation procedures and practices needed to contain the spread of the virus. Containment, if possible, would be the most effective way to assess and control further exposure of any emerging threat. That conclusion implies at least two questions that any of the organizations involved – especially law enforcement and public health agencies – must ask themselves: (a) Are the current law enforcement and public health communities adequately prepared to mandate and to enforce federal- or state-ordered quarantine or isolation procedures – with little or no notice – at a border, medical facility, screening location, or city limit? (b) Do the nation’s law enforcement and public health agencies have in place the comprehensive plans and resources needed to support this infrequently exercised mission?

Plans, Strategies & Other Applications For those not directly involved in this field or area of interest, this topic may be unfamiliar and seemingly irrelevant insofar as their day-to-day duties and priorities are concerned. Too many citizens may view an emerging biological threat solely (and inaccurately) as a federal responsibility to interdict and contain at an international border. It is true, of course, that there already are several national strategy plans in place to assist in the framing and assignment of responsibilities for an obligation shared by all levels of government and by the private sector.

Among the most important examples of these plans are: (a) The White House’s National Strategy for Pandemic Influenza (2005) and National Strategy for Pandemic Influenza – Implementation Plan (2006); and (b) the U.S. Department of Health and Human Services’ (HHS) Pandemic Influenza Plan (2005). Individually and collectively, these documents spell out in specific detail how the nation as a whole should prepare for, detect, and respond to a potential pandemic threat, particularly influenza. Following are selected excerpts from each of those documents.

The 2005 National Strategy for Pandemic Influenzaentifies three pillars for the national strategy, the third of which focuses on Response and Containment: “Actions to limit the spread of the outbreak and to mitigate the health, social, and economic impacts of a pandemic; and, where appropriate, use governmental authorities to limit non-essential movement of people, goods, and services into and out of areas where an outbreak occurs.”

The 2006 National Strategy for Pandemic Influenza – Implementation Plan begins with the following prologue to frame the threat and explain the need for the involvement of all levels of government and private citizens as well: “In the last century, three influenza pandemics have swept the globe. In 1918, the first pandemic (sometimes referred to as the ‘Spanish Flu’) killed over 500,000 Americans and more than 20 million people worldwide. One-third of the U.S. population was infected, and average life expectancy was reduced by 13 years. Pandemics in 1957 and 1968 killed tens of thousands of Americans and millions across the world.”

The 2006 Implementation Plan alsoentifies numerous key considerations such as delaying pandemics, screening procedures, and other proactive measures (covered in the Transportation and Borders chapter) and law enforcement responses that should be considered during outbreaks, quarantines, and other movement restrictions (in the Law Enforcement, Public Safety, and Security chapter). The numerous and detailed topics covered in these national strategies confirm the truism that all incidents begin and end locally.

The 2005 HHS Pandemic Influenza Plan asserts that state, local, and tribal agencies should, if needed, help enforce community containment measures: “In extreme circumstances, public health officials may consider the use of widespread or community-wide quarantine, which is the most stringent and restrictive containment measure.” There are at least two reasons for that strong mandate: (a) The orders given may involve a legally enforceable action; and (b) A quarantine restricts travel into or out of an area circumscribed by a real or virtual cordon sanitaire (sanitary barrier), except for authorized persons, which include public health or healthcare workers. The HHS plan also confirms the need for law enforcement agencies to maintain security at U.S. borders and to enforce movement restrictions during widespread community quarantine, including establishment of the cordon sanitaire.

These pandemic strategies acknowledge that there are in fact several unique challenges that state, local, and tribal organizations would encounter during a pandemic illness that require: (a) expanded mutual aid between and among those various jurisdictions; and/or (b) assistance from the federal government. Primarily for that reason, the national documents encourage governmental agencies to formulate truly comprehensive pandemic response plans as well as to plan and carry out the training required for the effective execution of those plans.

There are a number of other applicable federal strategies, plans, and policy guidance documents that should be taken into consideration by policy makers at all levels when developing a thorough and actionable plan to cope with a pandemic threat. Among the most important of those documents are the following:

  • President Obama’s 2011 Presidential Policy Directive 8 (PPD-8);
  • The Public Health Service Act (PHSA) updated by Congress in March 2013;
  • The U.S. Department of Homeland Security’s 2008 National Incident Management System (NIMS); National Response Framework (NRF), updated in May 2013; 2013 National Preparedness Report; Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act), updated in April 2013; and
  • The U.S. Department of Justice’s 1984 Emergency Federal Law Enforcement Assistance Program (EFLEA).

The EFLEA program is an option for obtaining certain federal law enforcement resources but, depending on the current appropriations level, supplemental funding may be needed to execute various complex or prolonged missions that might be authorized. The Stafford Act gives the federal government the authority to provide additional funding or other national resources through an annually funded mechanism. Exercising that authority, though, requires an approved presidential declaration. Mission support funded by the Stafford Act would be coordinated through the NRF’s Emergency Support Functions process. The PHSA provides the federal authority needed to prevent the entry and spread of communicable diseases from foreign countries into the United States and/or between states.

In addition to the general authority and possible funding sources listed above, federal law alsoentifies the federal officials specifically responsible for certain enforcement and quarantine activities during a public health emergency. The officials possessing the authority, and in some instances specifically mandated, to enforce federal and state quarantines areentified in the 2006 Implementation Plan and in other federal statutes – for example, 42 U.S.C. 97 (State Health Laws Observed by United States Officers), in effect as of 1 February 2010; and 42 U.S.C. 268 (Quarantine Duties of Consular and Other Officers), in effect as of 7 January 2011.

Public health and law enforcement officials must clearly recognize, though, that it is particularly important toentify and understand both: (a) the different authorities needed for the assistance requested; and (b) the appropriate method that must be followed for obtaining support (if available). The enforcement of quarantines is not limited to any one level of government; nor can a single agency successfully execute it without cooperation, coordination, and collaboration with diverse public and private organizations.

The nation’s state and local governments have a long history of using quarantines to contain emerging pathogens. For example, government agencies used qua