An All-of-Government Approach to Increase Resilience for International Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Events: A Workshop Summary (2014)

Chapter 1

Capabilities for Effective Response to an International CBRN Event

The opening speakers outlined the core capabilities required to mount an effective response to international chemical, biological, radiological, or nuclear (CBRN) events. The comments reflected their experiences and lessons learned from past CBRN and other disruptive events. Major General Julie Bentz, Director of Strategic Capabilities Policy on the National Security Staff in the Executive Office of the President, provided the opening remarks. Bentz helped coordinate the U.S. response to the March 11, 2011 Tōhoku Earthquake (Great East Japan Earthquake) and tsunami in Japan. She currently directs a sub-Interagency Policy Committee (sub-IPC) on the U.S. government response to international CBRN events. The Honorable Paul Stockton, President of Cloud Peak Analytics and Managing Director at Sonecon, LLC, gave the morning keynote presentation. Stockton previously served as the Assistant Secretary of Defense for Homeland Defense and Americas’ Security Affairs.

U.S. LESSONS LEARNED FROM FUKUSHIMA

When an earthquake and tsunami hit northern Japan on March 11, 2011, and subsequently disabled the Fukushima Daiichi nuclear power plant, Major General Bentz and her colleagues organized the U.S. response, Operation Tomodachi, based on historic examples of U.S. response to similar events. Bentz requested after-action reports from the 1979 nuclear accident at Three Mile Island Unit-2 reactor in Pennsylvania from the Jimmy Carter Library and Museum, and the 1986 accident at Chernobyl nuclear power plant in the Ukraine from the Ronald Reagan Presidential Library. The lessons learned from these events improved the U.S. government response to Fukushima; an after-action report was also prepared for Operation Tomodachi. Bentz highlighted four key lessons learned from the response to the Fukushima accident (Box 1.1).

Mechanisms for Intra-government Coordination

The first lesson Bentz highlighted was the need to develop a mechanism for intra-government coordination for low-probability, high-impact events; Traditional mechanisms of coordination are not sufficient when additional layers of government are added to the normal processes. The U.S. Department of State (DOS) and U.S. Agency for International Development (USAID) are very adept at responding to day-to-day crises and typical natural disasters. However, Bentz offered, with complex events such as the Fukushima nuclear accident, the additional involvement of the White House National Security Council tends to complicate or slow normal processes. Following the Fukushima nuclear accident, the National Security Staff gathered representatives from several agencies to identify ways to improve decision making for CBRN events because these types of extreme events transcend normal channels.

Bentz noted a distinction regarding the legal framework for a domestic response versus an international response. In a domestic response, funding for response to a disaster is made available through the Stafford Act,¹ which applies to major disasters and emergencies declared by the President of the United States. Under the Stafford Act, decision makers have the legal authority and access to resources to save human lives and mitigate suffering, and to protect property and the environment. In an international event, Bentz noted, U.S. funding and authority provide for humanitarian assistance to save lives and mitigate suffering; property and the environment are not part of the legal structures. For example, with the response to the Fukushima accident, material to shield the core and pumps to cool the core were not considered humanitarian assistance. Bentz noted that contamination or contagion could be an additional complication that is also outside normal humanitarian response. To address this situation, Bentz proposed a framework or annex be developed that identifies the pieces not covered under current legal or statutory authorities for response to an international CBRN event. She suggested one potential solution is to build bilateral agreements with other capable nations that map out the sequence and roles in responding to a CBRN event in a particular region.

Improved Ways of Sharing Technical Data

Bentz’s second message was that the United States needs an improved mechanism for sharing technical data that is useful, timely, and meets the needs of all responding entities. Bentz noted that the Department of Energy (DOE) tackled the question of how to share very technical data within the interagency and with international counterparts through a bilateral or multilateral engagement. DOE developed a Best Practices document (internal interagency document), which outlined six broad best-practice categories:

1. Strategic CBRN Consequence Management Priorities. For example, how to set goals, establish objectives, and allocate response capabilities.
2. Data Management and Policies. This allows for data accuracy and standardization, which is a serious complication in the midst of a crisis.

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¹ Stafford Act: https://www.fema.gov/media-library/assets/documents/15271?fromSearch=fromsearch&id=3564.

3. Data Analysis and Presentation. Good analysis and presentation allows senior decision makers to quickly understand what the data are telling them.
4. Data Integration and Predictive Modeling. This allows scenario building so that decision makers can anticipate future conditions.
5. Sharing, Releasing, Accessing, and Distributing Data. This includes inter-government and intra-government sharing as well as unclassified, classified, or law enforcement sensitive data types.
6. Treaties, International Agreements, and Legal Obligations. This concerns moving information between and among countries while still following existing bilateral and multilateral frameworks and agreements.

Defining Metrics

Bentz’s third lesson highlights a need to define metrics for success and consequence management. Bentz posed several typical questions that are raised following a CBRN event: How safe is safe? How clean is clean? What do we do with the waste? Lessons learned from the Fukushima accident informed the U.S. Environmental Protection Agency (EPA) effort to update and improve 1992 radiation contamination protective action guides, particularly in the area of late phase recovery or late phase cleanup (Environmental Protection Agency, 2013). The updated version includes re-entry and waste disposal guidelines and provides scientifically credible, well-defined drinking water guidance to advise early phase decisions relative to short-term exposure to radionuclides in response to the emergency.

Evacuations of U.S. Personnel and Citizens

Bentz concluded with a fourth lesson learned and the United States’ most difficult challenge: how to evacuate American personnel and citizens from a region that has been hit by a CBRN event. The DOS and Department of Defense (DOD) worked together to define ‘trip wires’ that trigger the evacuation of U.S. personnel, whether through authorized or ordered departures. These trip wires were inserted early in the process so that all parties involved understand when and how they are to act. Bentz noted that DOS and DOD put together a document that outlines consequences of particular drawdown, departure, and evacuation decisions; guidelines for how to conduct an evacuation; and at what point military assistance should become part of the process. As part of this collaboration, a simple checklist was developed with questions that should be considered immediately following an event.

KEYNOTE ADDRESS

An All-of-Nation Approach to International CBRN Preparedness and Response

The U.S. government is making terrific progress with regards to international CBRN preparedness and response in building federal capabilities to support partner nations when they request our assistance following an event, began the Honorable Paul Stockton. However, U.S. state capabilities have not been fully brought to bear to provide similar support. Stockton explained that a large portion of DOD capabilities to conduct life-saving operations in the United States or in support of partner nations is in state National Guard² organizations ordinarily under the command and control of state governors, rather than the President of the United States.

One reason why state capabilities have not been tapped is the challenge of federalism regarding command and control, explained Stockton, adding that these challenges are eminently solvable. More difficult to overcome is the “tyranny of time and distance” in deploying supplies and people to an international location, which impacts how we mobilize state forces and then deploy them effectively abroad. Stockton suggested that one way forward is to support capacity building within foreign nations instead of relying exclusively on the U.S. ability to send assistance. From his perspective, the United States is not doing enough to bring to bear the potentially invaluable capabilities of the private sector in CBRN preparedness and response.

Stockton noted a paradox in how the U.S. government is improving national CBRN capabilities versus its ability to provide these same capabilities outside U.S. borders. Under the Obama administration, the federal government has made solid progress in building CBRN response capabilities. Since 2009, DOD has radically changed and strengthened the ability of troops, soldiers, and airmen to provide life-saving capabilities by distributing response capabilities across the nation; for example, every state has a civil support team to rapidly detect and characterize a CBRN event. Each of the ten Federal Emergency Management Agency (FEMA) regions has a homeland response force that can arrive at an event within six to twelve hours of occurrence. In addition to distributing CBRN response capabilities geographically, he continued, the United States has strengthened its focus on life saving within the different C-BRN areas, such as in building the capacity for decontamination and search and rescue capabilities

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² The National Guard is referenced throughout this report. More information can be found at their website: http://www.ngaus.org/ and a summary of their roles and responsibilities can be found at: http://www.ngaus.org/sites/default/files/pdf/primer%20fin.pdf.

in a contaminated environment. However, Stockton cautioned, the distribution of capabilities and reliance on state National Guard forces could create challenges for gathering these capabilities together at the request of a foreign nation.

Stockton explained that public safety is the responsibility of the governors of the United States under our Constitution, not the President. This means that, although governors take this responsibility very seriously and partner with DOD to coordinate capabilities, homeland response forces are under the command and control of governors on a day-to-day basis. Within a given region, governors will often offer assistance to neighboring states, but a request from a foreign government through the DOS may not be as readily granted. Stockton posed several questions to illustrate the complications that can arise with a foreign request for assistance to a CBRN event. What if requested forces would reach their maximum lifetime radiological exposure limits during a deployment in a foreign country? What is the risk that their equipment will be contaminated and could not be returned to the United States? Stockton offered that there are likely solutions to these command and control questions if imaginative people work their way through these challenges to reach consensus.

A more difficult issue to solve, Stockton reiterated, is the tyranny of time and distance. The window to engage in serious life-saving activities following a large CBRN event is 72-96 hours. Domestically, the U.S. government has the capabilities to deploy response forces within the time frame needed to save lives on a large scale, and to provide search and rescue in a contaminated urban environment. Deploying those forces abroad, however, runs up against that 72-96 hour window. Stockton offered that there are valuable niche capabilities that can be rapidly deployed. In support of Operation Tomodachi in Japan, the U.S. government quickly sent teams to assist with characterizing the event and modeling the fallout plume. But in terms of life-saving capabilities, Stockton cautioned, there are limits to what a U.S. based force can accomplish internationally. A potential solution is to partner with foreign nations to build their capabilities and capacities.

Stockton recalled a recent statement by U.S. Defense Secretary Chuck Hagel that the U.S. military will retain vital capabilities, but at the same time the most sustainable and wisest approach to our security in the 21st century will be to help allies do more to contribute to their own security and our common interest. Stockton emphasized that this is especially true in the realm of CBRN response and preparedness, and suggested that the National Guard state partner program could be leveraged for this purpose; personnel from a given state could work with an international partner to help build that country’s capacity. Several states, such as Colorado, already engage in capacity building activities for CBRN response through their state partner programs. From Stockton’s perspective, these activities need to expand to more states and countries.

A second opportunity is training, Stockton continued. U.S. training and exercise activities could support partner nations who want to take advantage of U.S. expertise. Stockton underscored that joint training activities between foreign and U.S. forces would help meet the challenges of interoperability by providing a shared understanding of how the response to CBRN events can be successfully executed. An additional component to improve interoperability, he continued, is the development of common international decontamination and exposure standards.

Stockton stated that the open frontier in terms of CBRN response capability is developing partnerships with the private sector. The private sector in many cases has excellent preparation against natural hazards, he explained. Every big company and many medium and small-sized companies have plans for continuity of operations; for example, to protect critical infrastructure

and supply chains against earthquakes and other natural hazards. Many large companies maintain emergency operation centers. However, Stockton acknowledged, the private sector’s resilience to the emerging CBRN-type hazards needs strengthening. He added that adversaries that would launch a CBRN attack on the United States want to kill Americans, but their objectives are political and this means inflicting economic damage. Helping the private sector strengthen its continuity-of-operations plans for a CBRN event helps mitigate economic damage and makes launching an attack less attractive.

Stockton proposed that an additional opportunity to build private sector resilience to CBRN events is through the insurance industry. A properly structured insurance environment would allow policies to be made available to those companies that had taken the required steps to prepare for CBRN events. Stockton suggested that different premiums might depend on a company’s level of preparedness. Insurance for chemical, biological, radiological, and nuclear events does not currently exist, with rare exceptions and with good reason, he added. The difficulty in assessing the frequency and magnitude of the impacts from these events makes it nearly impossible to price insurance using the traditional actuarial approach. Stockton referred to the insurance market for explosive events, and suggested that it could be used as an example of how to provide insurance for CBRN events. He cited the Terrorism Risk Insurance Act (TRIA)³ that passed after the terrorist attacks on September 11, 2001. The enormous costs incurred following the 9/11 attacks caused insurance companies to be hesitant to offer coverage for a future event. Through TRIA legislation, the federal government ensured a backstop for coverage of losses under circumstances related to a terrorist act that allowed for the creation of an insurance market. Stockton envisioned that TRIA legislation, which expires in 2014, could be reauthorized and expanded to include all CBRN-related events.

Question and Answers

Lauren Alexander Augustine of the National Research Council asked why addressing CBRN events was important. Stockton advised that the CBRN threat was growing and required a better understanding of how to address the potential consequences. He cited the example of a long-term power outage on a power or nuclear facility, pointing to the cascading effects that would result on the nation and noting that current plans are targeted only for short and mid-length power outages. Long-term outages, whether due to a natural event such as the New Madrid Earthquake or a manmade threat such as a cyber attack on U.S. power infrastructure, would create a seriously disrupted environment for weeks or months. To be ready requires planning in advance.

A participant from the Oak Ridge National Laboratory suggested expanding partnerships beyond the private sector to include non-profits, non-governmental organizations (NGOs), and the community. Stockton agreed and pointed to an objective that FEMA Administrator Craig Fugate has often cited, to treat citizens not simply as passive victims of disasters, but as active contributors to their own resiliency. Stockton raised the recent Fukushima nuclear accident as an example, noting that the absence of information on whether to flee or shelter in place led to fear

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³ Terrorism Risk Insurance Act of 2002: http://www.gpo.gov/fdsys/pkg/PLAW-107publ297/html/PLAW107publ297.htm.

and confusion among Japanese citizens. Clear communication lines with the public help dissipate that fear, particularly for nuclear and radiological events. He added that working with partner nations to build that type of community resilience would be extremely valuable.

A question was asked about metrics for measuring success and the perception of what the United States can do in response to an international CBRN event compared to what the United States is actually able to accomplish. Stockton responded that, given limited resources, the federal government could only do so much in terms of building federal capacity, and pointed to the importance of the sub-IPC interagency process that is being directed by Major General Bentz. Stockton proposed that engaging more partners like the American and International Red Cross, United Way, and faith-based organizations is the best way to expand the resource base. For example, the U.S. government needs to support these types of organizations ability to operate in a contaminated environment, as CBRN disasters are very different events from which they traditionally prepare. A participant suggested leveraging connections with regional security organizations such as the African Union, Organization of American States, or the Organization for Security and Co-operation in Europe to further the conversation with private organizations in those regions. Another participant referred to a recent DOS workshop on corporate volunteerism that involved large corporations such as IBM, HP, and Citibank, suggesting that as another type of venue for expanding private partnerships in the CBRN arena.

A participant from the Israeli Home Front Command pointed out that because DOS is the lead agency on international CBRN event response, DOD has limited authority to engage in preevent planning to assist foreign partners in foreign consequence management. He asked if, given the tyranny of time and distance, there is a way forward that would give DOD and the National Guard enhanced authority to engage in activities that improve their ability to assist. Stockton responded that DOD has been comfortable supporting FEMA, the DOS, and other federal agencies in responding to a particular event. He acknowledged that, with international incidents, combatant commanders face additional concerns with requests for assistance, such as force protection issues. Although command and control might be better aligned with a request for assistance, Stockton advised that improved coordination efforts should be built into the current system.

A question was raised about the possibility of stockpiling antibiotics and other materials needed to respond to a large-scale biological attack in other countries so that the United States would not have to use its domestic supply to support foreign responses. Stockton replied that progress was being made to build a partnership approach to pandemics. Major General Bentz added that the White House is undertaking a big effort to apply lessons learned from the H1N1 outbreak to the current H7N9 coronavirus. A member of the steering committee offered that there is already an established system run by the United Nations Office for the Coordination of Humanitarian Affairs⁴ (UNOCHA) that addresses natural and manmade disasters, including biological events. It is highly developed, includes infrastructure in developing countries, and has been used hundreds of times in the past 25 years. He added that it is worth distinguishing nuclear and radiological events from biological events, but did not advise establishing parallel response systems. Instead, the existing system for responding to biological events, including decision-making processes and organizational structures could be expanded to include nuclear and radiological incidents. He cited a successful program run by USAID that trains first

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⁴United Nations Office for the Coordination of Humanitarian Affairs, http://www.unocha.org/.

responders in Latin America to bolster their effectiveness in responding to large disasters. As a result, USAID now only needs to provide assistance for very large disasters in Latin America.

A participant from the National Institute of Standards and Technology (NIST) asked what preparedness might look like in the future in terms of basic capabilities of a system overseas, whether it is a knowledge base, equipment base, or other. Stockton suggested that it would likely be an information base, pointing out that an established, carefully planned strategic communication agenda is necessary to provide reliable information during and after a CBRN event, and the only way to counter misinformation in the age of social media.

There are certain types of events that, while rooted in biology, do not fit the traditional pandemic model, posed another participant; for example, a massive area denial due to an anthrax incident would require the ability to operate in a contaminated environment. These are unique characteristics that put a biological event into a similar category as nuclear or radiological incidents. Stockton reiterated that standards are essential to determine an acceptable level of decontamination.

PANEL DISCUSSION

Capabilities Needed for Effective Response to an International CBRN Event

Moderator, Dr. Gerry Galloway, chair of the workshop steering committee, indicated that the panel would focus on capabilities needed for an effective response to an international CBRN event. The panel was framed around the following questions: (a) what capabilities are needed for effective response to a CBRN event? How are these different from responding to all hazards?, (b) from the U.S. government perspective, what capabilities are unique to responding to a CBRN event in a partner nation?, and (c) what are gaps in capabilities for coordinating CBRN response with partner nations? The panelists were Mr. Brian Lewis of the U.S. Department of State, Dr. Martin Cetron from the Centers for Disease Control and Prevention, and Mr. Chad Gorman from the Federal Emergency Management Agency.

Desired End States for an Effective CBRN Response Overseas

Brian Lewis, Deputy Director of Technical Programs at the Bureau of Counterterrorism for the U.S. Department of State (DOS) provided a strategic level perspective on outreach and preparation for responding to international CBRN events. He began with three components of an effective CBRN response. First, the local government needs the technical capability to rapidly identify a CBRN event has occurred, and then quickly communicate accurate information about the incident to the United States and other international partners; the faster the communication, the more lives can be saved. While natural hazards such as an earthquake, tsunami, or volcanic eruption are self evident, there may be no visual evidence of a CBRN event. If the local government does not declare an event has occurred, the United States may not detect it. The second component, Lewis indicated, is clear communication of needs by the local government; in the midst of a crisis, this can present a challenge. This means more than simply saying “send help” because it is difficult for outside governments to know how to respond. In the absence of clear communication, the U.S. government and other allies can only speculate on what is needed. Lastly, Lewis noted the importance of pre-identifying interagency CBRN response leadership

and subject matter experts. These three components or end states provide the foundation for an effective international CBRN response.

Lewis highlighted several unique attributes of a CBRN event as compared to a natural hazard. First, they are highly unlikely events and it is difficult to convince foreign nations to invest in preparation for a hazard they have never experienced. Second, it takes technical skill to identify a CBRN event. Third, characterizing the extent of a CBRN event, how far along a biological hazard has progressed or over how wide an area radiation has spread, is difficult for any government. The fourth difference, Lewis offered, is that CBRN events can linger. Natural hazards, such as an earthquake, have a definite end time, but it is much more difficult to know when, for example, anthrax deposition is done. Finally, fear and misunderstanding are common with CBRN events and it is difficult to reduce complex technical data into simple and effective messages that the layperson can understand. Lewis underscored that the singular nature of a CB-RN event means that a foreign government must be willing to receive technical expertise, equipment, and unique medical treatments as part of a response. From an organizational perspective, resources for CBRN response may not be located in the ministry or agency typically responsible for disasters.

Lewis offered that gaps remain in U.S. government coordination and decision making in regards to CBRN response; improving U.S. capabilities is an ongoing effort. Pre-determining CBRN technical expertise goes a long ways toward shortening U.S. response time, and DOS is constantly working to understand the distribution of expertise throughout U.S. embassies so that resources can be quickly mobilized when necessary. Finally, Lewis added, developing cohesive partnerships that support partner governments’ ability to prepare for different types of incidents needs to be improved. For example, the United States may practice decontamination activities with a given government, but lack training programs with that government for hazard detection. While the goal of engaging government partners throughout a region is a good one, he noted, to date the most effective relationships have been bi-lateral. Multi-lateral partnerships take more time to gain consensus, and tend to focus on the requirements of the least capable partner.

Global Challenges of Responding to CBRN Events

Dr. Martin Cetron, Director of Global Migration and Quarantine at the Centers for Disease Control (CDC), drew from over 20 years of experience in working with global health and infectious diseases to illustrate the capabilities needed for international response to biological incidents. He echoed earlier comments by Major General Bentz that the U.S. government response to biological threats has been improving due to experience gained in addressing infectious diseases and other health threats that initiate through natural processes. However, he cautioned that significant gaps in capabilities remain, particularly in the global arena.

Cetron pointed out that biological threats have unique factors that require a different set of considerations than a chemical or radiological event. First, he offered, the high speed and high volume of global air traffic is a game changer for the spread of communicable disease. People move around the world in 24-72 hours, which is faster than the incubation period for most infectious diseases. To illustrate this point, Cetron showed an image of the civil aviation traffic among the 500 largest international airports in over 100 countries (Figure 1.1). In terms of connectivity, he said, this is the world we live in. The second unique attribute is the progression

of a biological event through time. Cetron explained that unlike a chemical or radiological event, at ground zero a biological incident might not be immediately detected. If lucky, health providers will discover an epidemic before it starts to spread, as many biological threats grow exponentially with time. Considering the global interconnectedness of today’s world, he added, the designation of a global versus a local event quickly becomes meaningless; significant health threats can spread to multiple locations. Cetron cited the most recent major health threat, the Middle Eastern Respiratory Syndrome, a novel coronavirus that emerged in the Arabian Peninsula with the potential to become a global issue. He noted that the threat of spread was significantly heightened by the Hajj pilgrimage en masse in the region.

Figure 1.1: A geographical representation of the civil aviation traffic among the 500 largest international airports in more than 100 different countries. SOURCE: Modified and reprinted with permission from Hufnagel, L., D. Brockmann, and T. Geisel. et al. Copyright (2004). Forecast and control of epidemics in a globalized world. Proceedings of the National Academy of Sciences, U.S.A 101(42):15124-15129.

Cetron stated that emerging infectious diseases are on the rise with approximately 30 new epidemics in the past 30 years. The convergence of biologic, physical, and environmental, and social, political, and economic factors all play a role in the spread of disease. He added that health threats emerge under different circumstances, which is why Mother Nature is so successful in creating new diseases; the element of human intent poses additional challenges. Cetron identified several challenges and gaps that fall under the guise of the ability to ‘detect, respond, and prevent’. With detection, the major challenge is the predictability and detection of an unknown emergence. He indicated that it is not enough to have the capability to match an incident against biological threat agents that are known. In both clinical and environmental settings, diagnostic capacity and tools are required to diagnose a health threat that has not been previously observed, for example a disease that has mutated or been genetically modified to have

resistance to normal countermeasures. Another issue is the ability to determine thresholds for contamination and safety.

With response, the primary challenge is to define a problem quickly so that steps can be implemented to reduce risk factors and determine the pattern of transmission, for example, whether the threat is airborne, transferred via contact, or spread through the environment. Cetron cited the need to identify medical and non-medical countermeasures to contain an epidemic, as well as the need to develop global stockpiles of necessary medicines, which he said had improved but was not adequate. Within prevention, he indicated the need to mitigate the impact of an epidemic, to reduce the number of infections, the severity of the threat and number of deaths, and to protect new populations from exposure. Cetron said that technical capabilities and expertise are expanding around the world but also emphasized that much more is needed to improve global expertise.

Cetron turned to system-wide capabilities necessary for effective response. He cited the importance of infrastructure, expanding capability through training, and the need for multidisciplinary engagement to promote a whole of society response when an event occurs. He suggested a need to educate and engage the media as a source of support rather than as a source that expands the uncertainties around an event. He also pointed to the importance of establishing an international governance framework that promotes international health regulations and treaties; helps define government and intergovernmental norms around detection and reporting; and promotes collaboration during health investigations, for example with global specimen sharing and detection, and laboratory support. Cetron raised the concern countries have in regards to intellectual property and national pride around diagnosing and detecting threats in regional laboratories. Developing countries have raised the issue of specimen sharing and the need to reap the benefits from that information, for example if a vaccine is developed. Lastly, he revisited the need to stockpile countermeasures in multiple countries, not solely developed ones.

Cetron referred to the anthrax incidents that occurred after 9/11 (also called Amerithrax) to illustrate the challenges posed by a health threat that initiates through a nefarious act. The intentional use of anthrax changed how public health experts understood the implications of an infectious disease and altered the approach to the response. In these incidents, the disease presented itself differently than was previously known, causing meningitis, a poorly understood neurologic condition, and a different distribution of cutaneous lesions. He stressed how important it was to rapidly characterize the disease. Questions arose about whether the organism had been engineered for drug resistance and whether the usual antibiotics would successfully counter the symptoms. Cetron also cited the importance of effective communication. For example, during the Amerithrax incidents, misunderstanding about treatment approaches became an issue when exposed members of Congress and postal workers were treated with different drugs, even though the decision was based on sound biological reasons. Poor communication led one group to think they were being treated with second-class antibiotics. Another profound issue is the amount of disruption, uncertainty, and fear that a bio-event can generate; how can health infrastructure handle an epidemic where the amount of people infected is not clear and there is significant fear throughout a population. Clinicians need training to distinguish patients with common respiratory illness from those that show similar symptoms but have been infected by a potentially fatal disease. Lastly, Cetron cautioned against thinking we are more prepared to handle an incident than we are; health professionals cannot rely exclusively on their past experience but must be open to the uncertainty that can come with a biological incident.

Cetron highlighted the successes and challenges in addressing the 2003 SARS event, indicating that the global infrastructure for preparedness was significantly improved from lessons learned during the response. The disease was quickly characterized through effective global governance and laboratory collection. However, large economic losses, damage, and fear still resulted across the globe. Cetron reiterated several needs: (a) to communicate effectively, (b) to quickly understand how the epidemic is spreading, (c) to come together as a global health community to characterize the disease and develop diagnostics, and (d) to cooperate in developing and implementing medical countermeasures to the disease. Protection is also a major issue with a biological event Cetron indicated. During SARS, questions arose around protection of responders and people in infected zones, protective equipment, and how to adapt standards for personal protection from one environment to another. Lastly, he echoed earlier comments around issues of decontamination, and standards for “how clean is clean”.

Cetron noted that responding to certain types of epidemics may require difficult means for control and containment of the disease; SARS reintroduced the word quarantine to a 21st century public. He recalled his earlier discussion about the global air transportation network; with SARS this translated into strict measures enacted in various countries to try and protect their borders from incoming travelers. For example, thermal imaging was used at airports to identify people who had a fever. He cautioned that diagnosis through technology is susceptible to false negatives that can create additional problems, but countries such as China employ these types of techniques when new potential threats emerge. Cetron said that new evidence was emerging that point to screening for health conditions at the source of an epidemic as more effective than trying to control the illness at arrival points.

As part of the solution for filling in gaps in detection and response to biological threats, Cetron cited a new CDC project, BioMosaic that layers multiple types of data systems, including demographic, migration, health, and transportation patterns, to facilitate the movement of the health community from a reactive response to biohazards to more predictive capabilities. He envisions that these tools will help global health workers to visualize patterns of biothreats and provide more anticipatory capability to respond to fast moving pandemics.

A Domestic Perspective of CBRN Response Capabilities

Chad Gorman, Director of the Chemical, Biological, Radiological, Nuclear, and Explosives Office in the Response Directorate of the Federal Emergency Management Agency (FEMA) outlined how FEMA approaches CBRN preparedness and response from a domestic perspective, focusing on past efforts, the current approach, and the way forward. Gorman noted that examples of best practices learned in the United States could provide a helpful lens for response to international events; to illustrate this point he highlighted some domestic response approaches and activities.

Pre-2008, FEMA’s approach to planning and preparedness for a CBRN event was captured in the national planning scenarios defined in Homeland Security Presidential Directive 8 (HSPD-8) (White House and U.S. Department of Homeland Security, 2003). This outline provided 15 worst-case scenarios that would guide their response following a CBRN incident (Box 1.2). Gorman stated that from a planning perspective these scenarios presented several challenges that eventually led to a new approach: the scenarios did not offer the analytic depth to identify priorities over the time phase of an incident or provide information on how to make the

most effective use of limited resources to address those priorities. The use of one plan applied to one specific incident limited responders flexibility in dealing with a real event, and in creating one plan for each scenario it became apparent that many of the initial steps for response were the same for each hazard. What resulted, Gorman offered, was a de facto creation of an all hazards approach to planning.

In 2011, Presidential Policy Directive-8 (White House and U.S. Department of Homeland Security) defined an all hazards approach to preparedness from the level of capabilities down to planning, with the further direction that the needed capabilities should fit into a whole of community approach. Gorman recalled statements by FEMA Administrator Craig Fugate that people need to move away from the idea that governments are always in the lead following a disaster. Response efforts should not solely involve first responders. Federal and other responders should consider non-governmental organizations and people who live in the affected communities as a resource for response and recovery rather than a liability. Gorman cited the response to Hurricane Sandy in which the “first responders” were often neighbors, community members, and faith-based organizations. Using a whole of community mindset, FEMA’s current operation plans for all hazards are designed to address how to deliver core capabilities against perceived needs in many, if not all, scenarios. In considering the unique set of capabilities that a CBRN event may require, FEMA builds off the same all hazards approach, which provides 65-70 percent of the core capabilities. Annexes are then developed to address specific challenges

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⁵ FEMA National Planning Scenarios: http://emilms.fema.gov/IS800B/lesson5/NRF0105060.htm.

inherent to a C-B-RN incident, always with the goal of maximizing life-saving capabilities, and stabilizing infrastructure and ultimately the affected population.

In drilling down into capabilities specific to CBRN incidents, Gorman began by considering an act of nuclear terrorism. FEMA’s approach was to address the question of how to successfully respond following a nuclear attack or detonation. The DHS Strategy for Improving the National Response and Recovery from an IND Attack (Box 1.3) (U.S. Department of Homeland Security, 2010) was developed to outline high level capabilities required for response to an act of nuclear terrorism, such as managing a large, complex event; rapidly characterizing the incident; and using information about the hazard and the expected consequences of the event to inform decision making on priorities, incident objectives, and application of resources across the spectrum of emergency management. Gorman highlighted the ability to inform responders to make better decisions about mass evacuation, sheltering populations, enacting protective measures, medical triage and casualty care, controlling and stabilizing the affected area, and how to move from response into recovery operations. The document laid out the problem and identified what the delivery of capabilities might look like; what it did not do was offer a way to apply these capabilities in an actual emergency.

To address issues of implementation from the perspective of a local decision maker, emergency managers, and other responders, an earlier version of the Planning Guidance for Response to a Nuclear Detonation (v.2) (U.S. Department of Homeland Security, 2010) was revised. Gorman indicated that this document used the guidance on capabilities from the strategy report and framed it at the level of an actual event. The planning guidance sets priorities and describes ways to approach the application of the capabilities in the environment that exists following a nuclear event. Gorman added that this document was a huge milestone in addressing the response to a nuclear accident in that it took the view that, although catastrophic, an incident could be survivable. This was an important change in the discussion with local, state, and tribal partners, whose normal stance is that they do not possess the capacity to respond to a nuclear event and therefore all of the responsibility lies with the federal government. Through a sound basis in science and analysis of the evidence, the guidance demonstrated that employing preparedness efforts in advance could provide invaluable protection for the affected population such as communicating with the community to stay inside, facilitating better coordination with federal partners, and having a plan for allocating limited resources in a productive way.

Gorman added that the primary change in the revised version of the guidance was discussion that emerged around addressing risk communication to better prepare the public to respond to a nuclear event, and to facilitate a better understanding of what messages need to be quickly disseminated to help people save their own lives. Gorman noted that preparedness of the public was very important in the two terrorist attacks on the World Trade Center, 1993 and 2001. The 9/11 Commission Report (National Commission on Terrorist Attacks, 2004) analyzed how measures put in place by the Port Authority following the 1993 bombing affected how people in the Twin Towers responded on 9/11; measures included training and drills with the building population for preparedness and evacuation. They found that close to 95 percent of occupants below the impacted zone were able to save their own lives through knowing information about the location of exits, how to follow lighted arrow strips, and where to locate flashlights. Gorman stressed that this lesson learned was critical in developing new guidance.

This process led to a new document, IND Response and Recovery: Communicating in the Immediate Aftermath (Federal Emergency Management Agency, 2013), which provides guidance for public affairs professionals on how to communicate with the public following a nuclear incident. Risk communication experts were asked to draft likely questions that the public would have in the face of this type of event. The questions were matched with subject matter experts in the scientific community, national labs, and interagency partners to craft scientifically informed messages that could be used to fill an information gap very rapidly. These messages were tested in a focus group in Atlanta, Gorman explained, through a partnership between FEMA and the CDC. The focus group resulted in some interesting lessons learned; for instance, the wording of messages is important. Telling people to “shelter in place” did not resonate and the message was changed to “get inside”. Gorman posed a question of how all this information and data is integrated into building capabilities for planning, and identified a major gap in the ability to manage an incident as large as a nuclear event. A basic premise is that there needs to be a plan in place; he reiterated that FEMA’s new approach moves away from specific planning scenarios. Currently, FEMA is working with regions and states to develop a comprehensive approach for response, which includes matching science and analyzing capabilities to a city or region’s unique population densities, building types, weather patterns, and geography, i.e., challenges that could occur with a nuclear incident in a particular place. The first plan to be developed is in FEMA region V in the State of Illinois and City of Chicago.

Gorman concluded with suggestions of how the capabilities identified for nuclear events could be applied to chemical or biological incidents. In taking a high level approach, many of the same challenges and questions may characterize chemical and biological events. First, responders need to be able to manage the complexity of the challenges that are unique to the incident. Gorman highlighted the following questions as essential to the process a) what capabilities are needed and how are those capabilities delivered to meet specific needs; b) how is an incident characterized–what are you dealing with and where; c) what communication is needed with the public so they know what to do; and d) when to move on to recovery efforts. A framework designed to address these challenges could provide a useful approach to other CBRN events.

Question & Answers

Session moderator Galloway began with a question from an online participant who asked about how capabilities of U.S. federal agencies other than the military are leveraged during an international response. Lewis responded that DOS works across many agencies, including Health and Human Services (HHS), EPA, DOE, and DHS, in addition to DOD. They have identified resources and subject matter experts that would help to characterize the issues in the aftermath of an event and the U.S. support required to best meet those needs. Resources and support could come from DOD, but DOS works across the interagency landscape to find the best solution. Cetron offered the pandemic influenza as a good model for an intergovernmental preparedness initiative in the international arena. Difficult issues were raised in approaching the response to the pandemic, such as whether citizens should be repatriated versus stay in the affected country, and questions around the maintenance and use of global stockpiles of medicine. He noted that response frameworks already address infectious disease threats that occur from natural processes and globalize quickly, such as the Global and Response Network under the umbrella of the World Health Organization, which bring together international support based on capabilities to do rapid intervention and response. Lewis explained that coordination between counterparts in different countries, under bilateral or multilateral agreements, could be very effective, but that issues often arise when working between different ministries or agencies within the same country. These synergies are just now being coordinated within U.S. agencies and pose more challenges across international governance. Gorman agreed that an effective approach includes leveraging U.S. capabilities for domestic response to assist foreign partners. Lessons learned about how to coordinate the response to an incident in the United States from the local level through national structures, and how to move resources quickly to the incident command and location, could be applied internationally. Lewis added that the private sector could provide critical support in a local response overseas and domestically, but had not yet been effectively tapped into.

A workshop steering committee member commented that issues raised by Lewis would provide an excellent outline to scope future CBRN activities that might be undertaken by the National Academies, specifically:

• Lack of preparation for “unlikely” events
• Technical skills and equipment for detection and identification of the hazard
• Characterizing the extent of the problem
• “Lingering” and invisible hazards
• Fear/misunderstanding by the populace

In response, Lewis raised the challenge of managing expectations and narrowing the scope to what can realistically be done, adding that support from the academic community and private sector could provide invaluable assistance in improving U.S. response efforts.

Another participant asked how decision making in these situations could be streamlined. Lewis replied that the initial challenge is always to identify the problem, and then reach out to appropriate experts. The Fukushima accident was considered a nuclear problem that required a nuclear expert to coordinate the response. However, the solution went beyond nuclear experts, who fill one niche, and required assistance from the EPA, health communities, and many others. Lewis offered that the painful lessons learned through that experience helped to identify the

issues needed to improve decision making. He added that the interagency group being led by Major General Bentz is grappling with questions of which agency has the best capability, which agency is prepared to deploy to the location of the incident, and how to ensure that the appropriate resources are quickly dispensed to the site. This should help to avoid a knee jerk reaction, Lewis stated, which can result in the U.S. government sending every capability they have to offer, rather then focusing on what is essential. Cetron reiterated the need for federal agency partners to prepare and coordinate before an incident, particularly one that presents cross-sectoral challenges, so that required assets can be located quickly and deployed. He added that part of what is needed to improve decision making is to alter the mindset from whole of government to whole of society and work with people outside traditional silos. Gorman added that how we translate technical data to decision makers who are not experts in fields related to CBRN is critical, how we package information, describe information, and push information. An essential capability in supporting decision making is providing decision support, particularly in a high-paced, complex environment such as CBRN response.

Is the U.S. government preparation for domestic response to a chemical event robust enough that we are in a position to help another country, asked an online participant? Gorman drew upon FEMA’s strategy for nuclear response, explaining that FEMA is currently engaging in similar efforts to address the unique issues around chemical threats. Chemical incidents are fast paced, and first responders and HAZMAT teams are often the first to the scene. FEMA is analyzing what capabilities are needed from the federal agencies in support of a chemical incident, as well as the responsibility of the whole community. It is still a work in progress, he indicated, but appropriate steps are being taken to improve U.S. government response capabilities. Lewis added that, from an international perspective, preparation of partner nations is key to a chemical incident because of the rapid nature of a chemical event. The United States should work with partner nations before an incident to develop their capabilities for first response and help them empower their communities to take action.

Another participant offered that the grand challenge in CBRN events is a psychosocial one, challenging the panelists to think about the trusted messengers, both domestically and internationally, that could help the public get past the fears and trepidation of accepting messages like “stay inside” when they want to flee. The participant suggested that communicators should be identified across faith-based communities, media, and non-profit organizations in advance. Cetron agreed that the importance of communication could not be overemphasized, particularly with a whole of society approach, adding that it takes a unique skill set to garner the public trust and to be able to convey information succinctly and clearly. Cetron stressed that it takes different trusted opinion leaders to reach different communities. To promote outreach, the CDC started an education program for medical journalists focused on ways they could more effectively communicate important messages during a crisis. Lewis expressed two additional points, the importance of communication between the interagency counterparts and the challenge of translating information to partner governments. He indicated that some foreign governments are better at delivering messages rapidly to their populations using different media, while others have difficulty in identifying a credible spokesperson. As an example of effective communication using non-traditional messengers, Gorman drew on a major highway construction project that took place in Los Angeles, CA. To avoid a traffic disaster, the city enlisted celebrities with regular Twitter feeds to dispense the message to avoid the I-5 freeway at the day and time of the work; it resulted in complete success.

A question was asked about cultural capabilities necessary for international CBRN events that occur in complex societies, considering different gender roles, language, family structures, expectations of government, and values and risk perception regarding science. All of these attributes influence people’s behavior and ability to be resilient during and after an event. Cetron responded that this is a huge gap area that needs more attention, adding that even within the United States many different cultural communities are represented. CDC is working to design outreach that works over the vast cultural landscape of the United States; internationally, political structures can complicate the issue. For example some government leaders do not communicate information but rather tell their population “this is the way it is going to be”. There is also the challenge of countering misinformation; for example, during polio vaccination campaigns in some countries, certain groups spread misinformation that vaccination programs were a conspiracy to sterilize kids. Cetron suggested that the CDC’s bottom up approach to refugee resettlement represents a good model for communication. This approach identifies effective communicators within different communities and cultures, and creates an exchange of information between the CDC, who provides training on the message, and the community representative, who ensures that the message is delivered in a culturally appropriate way. Lewis agreed that local people have the understanding and knowledge of local requirements, adding that many response organizations link with local people to support their work in the field. He noted that it is often challenging to transfer messages and training designed for a particular place to another location, for example training for an incident in South Sudan may not apply in Southeast Asia.

Lewis was asked if there was a way to leverage the National Guard State Partnership Program, which has developed relationships with 65 countries, to address the need to connect subject matter experts in the United States with foreign partners. DOS and the National Guard Bureau work together at the headquarter level, responded Lewis. Partnerships between the U.S. National Guard and partner states tend to develop across military counterparts, which consider CBRN response as one niche capability. However, Lewis stated, these are military experts and they bring military capability and rule of law. From his perspective, the State Guard Bureaus have developed long-term partnerships between experts that have been successful in building capabilities and capacity, such as in the preparation for the Eurocup and the Illinois National Guard’s work with Poland. However, a challenge still exists of whether the receiving government has the leadership and organization to employ these capabilities.

A steering committee member asked about the U.S. government capabilities for modeling and simulation of an incident to provide partner countries and U.S. responders the necessary information to develop effective messages. Lewis re-emphasized that an affected country is responsible for determining the extent of the hazard and managing the response in their nation. If U.S. government response entities and the foreign government are sending different messages, there is a communication credibility issue. Many countries have the ability to model a situation or have detectors in place to measure the contaminant, which helps them to understand where the problem has spread and not just make predictions. He added that the United States would likely support a country’s effort to define the extent of the problem and work with the local government to verify or bolster their capacity to characterize the hazard. Cetron pointed out that asking the right questions could help a country understand whether they have determined the extent of the incident. International frameworks for response and governance, such as the International Health Regulations, have annexes designed to help countries determine their capacity to assess and respond. Normative standards can also be set out as part of a global governance process. Lewis

added that countries do not have to come to the United States but can receive assistance with predictive modeling through organizations such as NATO, ASEAN, or a bilateral agreement with a neighbor.

A participant from the FBI asked if the response would be different if an incident was caused by an intentional act. And, if so, what would be done in an international incident to determine the attribution? Cetron cited examples from the intentional anthrax incidents and indicated that there were many differences in the response. A lesson learned was that the FBI and law enforcement and the CDC both had an investigative role but with different purposes. This led to questions of how to coordinate an inquiry when there are overlapping needs that can impact each other’s investigation, such as both agencies needing to talk to the same people and communicate with the public. Since then, much has been done to strengthen the relationship between the FBI and CDC. Cetron posed that issues arise around the different chain of custody for evidence, moving specimens, and the ability to prosecute perpetrators and find attribution. Internationally, it is even more complicated due to politics, rules, and laws in different countries. Another difference is that when there is intent to do harm there is often a need to be ready for the unexpected. Cetron revisited unknowns associated with an intentional act, such as whether a strain of anthrax was bioengineered to be resistant or to evade detection and diagnostics. Intent also raises the level of fear and anxiety because that uncertainty creates more public panic. Gorman agreed, adding that FEMA’s perspective domestically is to always respond to the requirements of the incident and put capabilities against those requirements, be they naturally occurring, accidental, or manmade. For a CBRN threat, he added there is an opportunity within the Presidential Policy Directive-8 (White House and U.S. Department of Homeland Security, 2011) preparedness goal in the mission area for prevention (other mission areas are protection, mitigation, response, and recovery) to leverage intelligence indicators or information for terrorist acts. In the event that prevention fails, consequence management analysis could also be used to inform key decisions that buy down risk. Lewis stated that information from the intelligence community could be applied to an international CBRN event. The U.S. government is well organized to coordinate the response to an international terrorist act, including the delivery of health support, consequence management, and characterization of a site. The FBI and other intelligence agencies are key in identifying and ensuring proper collection of evidence, working with local government to investigate a crime against Americans or American interests abroad, and provide follow-on support for forensics and crime scene investigation. FBI attachés could work through an embassy to provide support for a local investigative authority. Lewis turned to the question of attribution, stating that identifying the perpetrator is likely a longer-term issue rather then part of the immediate response. The attribution piece requires detailed analysis and coordination within the U.S. government.

References

Environmental Protection Agency (EPA). 2013. PAG Manual: Protective Action Guides and Planning Guidance for Radiological Incidents. Draft for Interim Use and Public Comment, March 2013.

Federal Emergency Management Agency. 2013. IND Response and Recovery: Communicating in the Immediate Aftermath.

Hufnagel, L., D. Brockmann and T. Geisel, et al. 2004. Forecast and control of epidemics in a globalized world. Proceedings of the National Academy of Sciences. 101(42): 15124-15129.

National Commission on Terrorist Attacks upon the United States. (Philip Zelikow, Executive Director; Bonnie D. Jenkins, Counsel; Ernest R. May, Senior Advisor). 2004. The 9/11 Commission Report. New York. Available at http://www.9-11commission.gov.

U.S. Department of Homeland Security. (DHS). 2010. DHS Strategy for Improving the National Response and Recovery from an IND Attack.

White House and Department of Homeland Security (DHS). 2003. Homeland Security Presidential Directive 8 (HSPD-8): National Preparedness. Available at: http://www.fas.org/irp/offdocs/nspd/hspd8.html.

White House and Department of Homeland Security (DHS). 2011. Presidential Policy Directive-8. Available at http://www.dhs.gov/xlibrary/assets/presidential-policy-directive-8-national-preparedness.pdf.