6
Reflections
This chapter provides the key lessons from the 2 days of workshop discussion provided by three speakers from varying backgrounds and perspectives. It concludes with comments from the leadership of the Forum on Medical and Public Health Preparedness for Disasters and Emergencies on potential next steps and the important goals that can be prioritized in order to advance efforts toward improved outcomes for the future.
WORKSHOP LESSONS
John Armstrong, division director of the University of South Florida Morsani College of Medicine and member of the American College of Surgeons Committee on Trauma, posed the question, “What are we going to do next?” to speakers. He invited panelists to comment on what can be done to identify opportunities for improvement, specifically asking for three lessons from the workshop discussions.
Ending the Panic–Neglect Cycle
“The first thing that struck me,” said David Zonies, professor of surgery and associate chief medical officer for Critical Care, Oregon Health and Sciences University, “is that the next emergency cannot be a single use or individual response.” Prior to his time in Portland, he was in the military and watching the cyclical nature of how things worked: they would learn lessons during conflicts and make vast improvements before the next time. At the end of a conflict, he explained, the funding would dry up,
people would leave, training stopped, institutional knowledge was lost, and learning disappeared. Zonies’s comments echoed Lawler’s observations in Chapter 2, in that the same mistakes continue to be made. Zonies saw similarities in the preparedness-and-response workforce, in terms of funding the workforce as well as building institutional knowledge, and he was concerned about the current level of preparedness for the next emergency.
Importance of Data
Data were mentioned numerous times throughout the workshop, said Zonies. Specifically, that there is a lack of meaningful data, consensus on what the data should be, how the data should be used, how they should be shared, and how they can be sustainable while satisfying what is needed at the local, state, and national level. Reaffirming Zonies’s comments, Steven Mitchell, medical director for the Washington Medical Coordination Center, said that the importance of data has risen to the top of the discussion. The examples shared throughout the discussions demonstrate the need for integrating public health, acute care, and postacute care systems, as well as emergency medical services. We need to use our country’s strengths around data and data management, he said.
He was also stunned by the comment about how U.S. social vulnerabilities are also U.S. pandemic vulnerabilities. Moving forward, all of this work needs to be done using a lens of equity, he added. Any public health emergency will exacerbate the realities of people living in poverty with health disparities and inequities in access and care, Mitchell said, echoing comments by Bell on the importance of local accountability and local measurement (Chapter 2).
Removing Siloes
Looking to the future, we need to change this process happening in siloes, said Jeanne Benincasa Thorpe, Massachusetts undersecretary for homeland security and homeland security advisor to the governor at the Executive Office of Public Safety and Security. Even looking at this workshop, it is clear that work still remains in siloes, because everyone participating in this workshop has similar backgrounds, she said. She said the discussions are missing the people who will mobilize resources to communities, and that is what needs work. This is not something that public health should have to deal with on its own, she continued, but public health leaders should instead take advantage of agencies like the Federal Emergency Management Agency (FEMA) that can mobilize assets with emergency managers. “Did we have plans?” she asked. Yes, every state did, but they did not work, she replied. Echoing issues presented by Voelkel (Chapter 3), Thorpe emphasized that
preparedness plans were not practiced or exercised or did not involve the right agencies in a way that exposed weaknesses in response systems. Lastly, she argued, we have to think bigger and better about what is possible in terms of emergencies and disasters.
OPPORTUNITIES FOR ACTION
Considering these highlights and issues, Armstrong asked what it would take to advance issues, like data management, integrating public health, clinical care, and emergency management, and to take action on opportunities for improvement.
Planning for Change
Thorpe replied that while planning is important, having the right people at the table is more important. Plans can be written by one person, but if they do not have buy in, include people, make changes, and adapt where needed, the plan will not work. She advocated for continuing these discussions within the forum and writing down what is next, whether it is drafting legislation for states, proposing memorandums of understanding, or collating best practices from around the country.
Mitchell echoed Shah’s comments from Chapter 5 about potentially losing the opportunity to improve preparedness and response if next steps are not intentionally planned and carried out. Overall, he highlighted the need to invest in people and create stability within the workforce—across sectors of public health, acute care, postacute care, and emergency management. He also thought many solutions can be contained within the concept of the medical operations coordination cell (MOCC). We need to move in this direction as a country, he argued, to first build some basic standards and then have it grow and evolve with local context and solutions that have already been innovated.
Engaging Communities
Armstrong added that the public health workforce needs to get out of the public health departments and really become more embedded in the communities. We do not really know who is in our communities, he commented, and sometimes we also factor in indigenous tribes when in fact they are sovereign nations.
Sustaining Successful Change
Zonies reiterated comments from Dan Hanfling, vice president at In-Q-Tel, at the start of the workshop, saying, “We have a duty to plan, and no matter what we do, this is our solemn duty moving forward.” But we should also not break things that are working, he added. For example, Zonies said his health system launched a massive telehealth program for both acute and postacute care, and it was extremely well received by everyone from the patients to the health care workers. It would be a major mistake if it went away just because the emergency ended, he noted.
Thinking about vehicles for change, Armstrong said that some vehicles for change are controlled within professions and within executive agencies, while other vehicles for change are controlled by Congress or state legislatures. However, how these ideas can be taken and assigned to a vehicle so the work can move forward to achieve an end goal has yet to be determined, he said. Thorpe agreed that especially with the federal vehicle for funding, relevant agencies need to coordinate and develop criteria and priorities that the funding aims to solve. The return on investment for that funding should also be identified and monitored to measure preparedness, he said.
Engaging the Private Sector
To better engage the private sector, Thorpe said it boils down to inviting them to meetings, workshops, and conferences to start building relationships and familiarity. She highlighted the Boston Marathon that happens annually in April, but said their meetings start in September and are inclusive of government partners and the private sector. For the pandemic, she explained that they worked with all of the large venues, such as the Boston Red Sox and the New England Patriots, to help vaccinate the citizens of Massachusetts. Armstrong said his experience with the Chamber of Commerce is that they are interested in these conversations and want a healthy workforce, so they care about prevention. It became crystal clear with this emergency that a virus like COVID-19 can have a direct effect on the economy, so this is a good time to emphasize that with private-sector partners.
Summarizing, Armstrong said that there is clearly an enthusiasm for concepts related to the MOCCs and how to drive interest and implementation in scaling that concept more across the country. There is also a need to invite the private sector to meetings and discuss readiness, framing it in a way that is relevant and matters to them. Finally, he suggested more engagement on education and training with the public health workforce—starting with a needs assessment about where the gaps are and then engaging academia to build those skills into the curricula.
Mitchell echoed comments from James Lawler, executive director of International Programs and Innovation at the Global Center for Health Security at the University of Nebraska Medical Center, regarding Leadership in Energy and Environmental Design (LEED) certification and fire prevention standards becoming common and expected in new buildings, in addition to remarks on building economic incentives into health emergency preparedness (Chapter 2). We need to build a similar system to motivate private entities to invest in public health emergency preparedness, Mitchell said, as well as more effectively engage the Centers for Medicare & Medicaid Services (CMS) as a mechanism to bring change to the system.
OPPORTUNITIES FOR THE FORUM
“We have an opportunity; we cannot allow this conversation to be the end,” Armstrong stated. “This is a launch to move forward and make changes to save lives.” Richard Serino, distinguished senior fellow of the National Preparedness Leadership Initiative at the Harvard T.H. Chan School of Public Health, reflected concerns raised by Zink that some people are ready to move on to discussing the next pandemic despite long-term effects of the COVID-19 pandemic (Chapter 5). He emphasized the window of opportunity that is available to enact change and agreed that the window of opportunity is closing. But the opportunity cannot be wasted, he said. We need to train people to be leaders, he argued. We expect people to lead and communicate well, but we do not train them to do so, he said.
Hanfling concluded by outlining goals for the forum to translate discussions into next steps. First, he said, health equity issues need to be addressed, as they are truly at the root cause of the failures seen. This means addressing access to care, and lowering the barriers, which are also at the heart of health and economic security. Second, he called for a nonpartisan after-action review of the COVID-19 response, the same way that was done following the 9/11 attacks. This is important if we are to understand where we fell short and make the right improvements, he noted. Third, public health professionals need to focus on being nimble and proactive, recognizing that the role of public health leadership is now largely about communication. He also highlighted the goal of data modernization, saying it is about creating a data-enabled public health system that takes advantage of data that already exist. We need to be as specific as possible about what we mean when outlining this goal, he added. Lastly, recognizing that technology is not a universal solution but is critically important moving forward, Hanfling argued for investment in technologies to create the medical countermeasure enterprise and related entities that are required to meet the challenges of future pandemics or the next threats that emerge. This means better, faster genomic sequencing for early detection that is integrated so
it can be seen in real time, disease diagnostic platforms that can be easily pivoted, and vaccine development platforms that will be able to scale up vaccine production.
