Lessons learned from Katrina, 9/11, SARS, and other disasters
The panel included Dr. Ben DeBoisblanc, medical director of the intensive care unit at Charity Hospital in New Orleans; Dr. Walter Franz, a family medical physician who is part of Operation Minnesota Lifeline at the Mayo Clinic; Dr. Donald E. Low, microbiologist-in-chief at Mount Sinai Hospital in Toronto; former Health and Human Services Secretary Tommy Thompson, now with the Deloitte Center for Health Solutions at Deloitte & Touche; and Dr. Isaac Weisfuse, deputy commisioner of the division of disease control at the New York City Department of Health and Mental Hygiene. Nancy Shute, senior writer for U.S. News, moderated the panel.
SHUTE: I'm here to introduce four men who are the real deal. They've really been on the front lines of everything we are talking about as far as meeting the disaster, being challenged, and rising to meet an occasion that I think none of them frankly ever expected that they would be in, despite their extensive training.
In Washington we spend a lot of time talking about probabilities and possibilities instead of what is happening in the real world. These men saved desperately ill people from Charity Hospital in New Orleans, they treated wounded civilians in Iraq, they raced to discover the cause of a mysterious plague called SARS while patients and colleagues were dying in hospitals. They manned the front lines during 9/11, and are working to prepare for pandemic flu and whatever the next disaster is. Their reports from the front lines tell us how that hard-won knowledge might be used to save us when the next disasters arise.
Ben DuBoisblanc is the medical director of the medical intensive care unit at Charity Hospital, Medical Center of Louisiana in New Orleans. He and his staff evacuated 50 critical care patients to the roof of the parking garage and kept those patients alive, often by hand-squeezing air into their lungs.
He said at the time, "We were trusted with the lives of these people that we weren't sure were going to pull through. We didn't have the resources to protect their interests. We were very worried that some of them would die."
At one point in the five-day ordeal when they were trapped in Charity Hospital during Katrina, Dr. DuBoisblanc had to perform emergency surgery in the back of a truck on one young patient whose lung had collapsed. Using a flashlight, he used a knife to puncture the young man's chest, inserted a tube to reinflate his lung with anesthesia. It took four people to hold him down, but they saved his life.
Dr. Walter Franz is a family medicine physician and works with Operation Minnesota Lifeline for the Mayo Clinic. Dr. Franz has been a staff member there since 1982. He is also on the board of the American Refugee Committee and has worked with operations in Sarajevo and Albania to help evacuees.
Most recently he served as a colonel in the Army Reserve with the 416th Civil Affairs Battalion in Mosul, Iraq. In an earlier deployment to Jordan in 2002, his mission was to organize refugee operations. And last September he helped organize medical efforts to help evacuees during Katrina.
Dr. Donald Low is the microbiologist-in-chief in the Department of Microbiology at Mount Sinai Hospital in Toronto. He's a recognized authority in microbiology, infectious diseases, and has published more than 200 papers in peer-reviewed articles. His knowledge was tested when SARS broke loose in Toronto in 2003. During that outbreak, which has killed 774 people worldwide, he played a vital role in informing the general public about SARS, fighting its spread and working to discover effective treatment and control measures. He was also quarantined in his hospital, and saw his colleagues fall ill and die.
Dr. Isaac Weisfuse is deputy commissioner of health for the Division of Disease Control of the New York City Department of Health and Mental Hygiene. He has worked there on controlling infectious diseases, including AIDs, STDs and tuberculosis. He was in charge of emergency preparedness for the department since 1999 and served as an agency - (unintelligible) - commander during 9/11.
He was also involved in organizing the city's response to pandemic flu, and was awakened at 3 o'clock in the morning saying, yes, we found anthrax. So he'll tell us about that.
I'd like just to ask them a few questions about their experience so they can tell us, and welcome comments from them, and then we'll have time for questions at the end.
Dr. Ben, would you please tell us a little bit about what to you during Katrina?
DEBOISBLANC: Well, the first thing I want to state is a message that many of you have shared with me but I don't think has really received a lot of press, and that is what a privilege, a real honor it is to be a first responder. This was clearly the most triumphant experience as my life as a civilian.
We were in Charity Hospital, hunkered down for what we have done so many times over the last few decades – that's have our Hurricane Gray drill. We have practiced it and we have actually been confined to the hospital for a day or two at a time for previous hurricanes and tropical storms. I think all of us underestimated what was about to happen.
We first lost power. We had about 340 patients in the hospital, about 50 critically ill, and that's paring down. I think we recognized as a hospital that we were not going to close our doors, that over a hundred thousand people had chosen not to evacuate, could not evacuate, couldn't afford gasoline, had no place to go, and as you've heard this morning, during a natural disaster - during any disaster - that no matter how incapacitated you are as a hospital, people will turn to you as a place of sanctuary. And so we kept our doors open; indeed, we continued to accept patients until the very time of our evacuation.
The hurricane made landfall on Monday, and we lost power in one of our emergency generators right as the hurricane made landfall, but what was unexpected was that with 12 hours we would lose power from our second backup generator. You see, Charity Hospital was built in 1932, and the emergency generators were placed on the first floor.
And so for the next 4 1/2 days, we struggled to keep these patients alive without electricity, without water, and on the surface that sounds like, oh, not such a difficult thing to do, but not only do you not have monitors and ventilators, you don't have suction, you don't have X-ray, you don't have laboratory, you don't have toilets that flush. I don't know about you, but the first thing I do when the toilet no longer flushes is I run to the bathroom because I don't want to be the last guy in - (laughter) - and so we had a sanitation crisis that was evolving. And in the midst of all this there was all these reports coming over our little transistor radios that the city was in a state of lawlessness.
And the first thing I want to say is, I was there and I didn't see that. I think those images make great press, but that was one percent of the story. And what that did was two things: one - three things: made you afraid to come in, made us afraid to go out, and it killed our morale. And it wasn't until we thought that the only way we were going to get out was to get ourselves out - because we couldn't communicate with the outside world. Cell phones were useless. Regular telephones - we dialed every number we could think of - the police department, the fire department, the National Guard, FEMA. Only one guy picked up his phone, and that was Wolf Blitzer - and right to the Situation Room. And we started to say, hey, look, we're still here - because at that very moment that we - it crystallized in everyone's mind that, you know, we're waiting around to be rescued. We're waiting for somebody to help us. What a bad idea that is. It creates a sense of helplessness, and all it did was delay our evacuation. At that very moment it became clear that we had to get ourselves out. We had to be prepared to handle - take care of ourselves.
And so we started talking to Wolf on the phone - one of our residents. And a guy calls up on a phone - only phone that worked in the whole hospital. And he says, you know, I run an air ambulance in Little Rock, Arkansas, and I'll send you some helicopters if you can find a place for me to land them. And so with our Tulane colleagues having torn down light poles on top of their parking garage, we floated these patients over to the parking garage, set up a little mini ICU for about 2-1/2 days, and got these patients out one at a time.
The most remarkable thing of the experience was not the medical stories, but the stories of humanism - of unskilled, very young, very frightened doctors and nurses doing what they'd always wanted to do.
So for me it was a very triumphant experience. We ran on adrenaline for those five days. The tough part is what is happening now - is the city is very broken. It was a poor city in a poor state to start with, and now the whole healthcare infrastructure is broken, there's no schools, there's no churches, there's no - there's no social fabric. And so how do you rebuild the social and healthcare infrastructure to make people want to come back when there are no people there to use those resources. Would you build a hospital when there's nobody to use it?
So I think those are the challenges for us going forward.
SHUTE: Thank you.
Dr. Low, would you like to talk to us a little bit about when you first heard about SARS, you thought maybe you had avian influenza on your hand, I think.
LOW: Well, it was the week of – it would have been March 11th when we had a patient in hospital with an unusual disease that we couldn't diagnosed, and concerned that this might be influenza and possibly even avian influenza, and March 13 the WHO released their first announcement of the threat of a possible new cause of pneumonia, and we realized then that in fact that's what we had on our hands. This was the son of a woman who came back from Hong Kong, developed a respiratory illness and died, and her son shortly thereafter became ill and was admitted to a local hospital, to the emergency room where he was held for 12 hours and then admitted.
So by March 14th, we had called in all of the family members and realized they were all sick; they all had pneumonia. And initially this was really interesting. We had a new disease, we were one of the few places in the world that were experiencing it. We didn't realize the actual implication. And it wasn't until about a week later that we started to see healthcare workers come back to that same emergency room sick, and family members sick, and visitors sick, and physicians that had cared for these family members being sick. And it soon became evident that we not only had a new disease, but we were seeing transmission. And I think that it wasn't so much that it was a new disease that was important or being able to identify it, it was knowing how was this thing being transmitted because we didn't know if it was being transmitted by the air or was it person-to-person contact, but it clearly became evident that we were seeing transmission.
And do during those early days, we were watching what was unfolding in Hong Kong, which was essentially about two weeks ahead of us in the number of cases that they were reporting, hearing what was happening in Vietnam, and trying to really get your head around how to deal with this problem. And when we saw our colleagues and healthcare workers becoming sick, that was when we realized that we were really dealing with something new and something potentially very dangerous.
I remember – it was on March 23rd – we opened a hospital – an old hospital, a TB hospital that had been closed, and that Sunday night I admitted - with colleagues admitted 14 healthcare workers who came into that ward, all healthcare workers from Scarborough Grace Hospital. And the people that were caring for them were volunteers. These were people that agreed to come forward and to look after them.
And I'll always remember one of the nurses saying that, you know, I'm not so much concerned about myself, but I'm afraid if I'll take this home. She not only came down with the disease and died, but her husband, who was admitted to hospital the same day she was, and he also died, and that – those were the days when we just didn't understand just how infectious this was. Were we dealing with the next pandemic?
In hindsight, it was relatively easy to control. There was – looking back, it was a disease that, once you reimplemented public health measures, good infection control measures, we were able to control it, but a lot of tough lesson and a lot of concern before that actually happened.
SHUTE: Thank you.
Dr. Weisfuse, you've had some real experience in first responding; first with 9/11 then a month later to the day when you got the call about the first anthrax case in New York. Can you tell us about that?
WEISFUSE: Sure. I was at home in my home in the Bronx, and it was October 11, 2001. So that was a month after September 11th, and we in the health department, I think it's safe to say, were fairly exhausted. We had been following a woman who worked for Tom Brokaw of NBC News, who had a lesion that was clinically diagnosed at dermatologic anthrax. And she had described opening an envelope that had some powder, and we had gotten some of that powder from that envelope and tested in our lab, and in fact, it was not anthrax.
So at 11 that night, I got a phone call saying that that powder had been sent to CDC and had been tested and, again, it was not anthrax. I remember going to bed that night saying to myself, we finally caught a break. You don't get anthrax unless you're exposed to anthrax; this person was not exposed to anthrax, and finally, finally, finally, after our weekend, at least rest easy.
Unfortunately, around three or four in the morning, we got a phone call from the Centers for Disease Control where they had been looking at a slide of the woman's lesion and did identify anthrax, and when we were told of it around three or four in the morning, we activated our internal command system. We all - I remember basically saying, I can't believe it, about ten times - or muttering it to myself when I got the phone call because it just didn't, at that moment, make sense to me.
We had our initial meeting at – in our downtown offices at 6:30 in the morning. We ended – and it ended up being that day – October 12, which was a Friday, you know, was an incredibly remarkable day. So we started our day at three or four in the morning, met at 6:30 in the morning, got to NBC around 9:00, which we then discovered that there was a second envelope that she had opened that had a powder, that we located.
By that evening we found out there were four other media outlets in the city with highly suspicious cases - ABC, CBS, as well as the New York Post. By midnight, we had transported that envelope to our laboratory, where we then contaminated our laboratory, therefore knocking it out from doing any further anthrax testing, and two of three of our laboratorians, who were trained to do this testing, tested positive by nasal swab for bacillus anthracis. So we had quite a 24 hours.
SHUTE: Sounds like it.
Dr. Franz, tell me about how your experiences in Iraq, then, have helped you prepare for the kind of things you were trying to do for Katrina?
FRANZ: Well, I think the main lesson learned in Iraq was that the Iraqi healthcare system was mainly mandated to be a public-health-based system. There wasn't much curiosity in the minds of Iraqis that if they became ill, what their health system was. It was basically a state-mandated system.
And with all of the brokenness of that system and all of the difficulties that sometimes we might point to in terms of a government-mandated healthcare system, nevertheless there wasn't a whole lot of curiosity on any particular day how healthcare needs were going to be affected in Iraq.
My mission, as public health team leader with the Civil Affairs Battalion in Mosul, Nineveh Province, and Kurdistan, was to try to support and augment and reconstruct as necessary the healthcare system. But as large as that task would seem, I basically had one official I could go to who represented the needs of that – of the Nineveh Province, which is 5 1/2 million. There was a designated public health official. He had the mandate to come up with the plans, the missions, the decision making, and so there was a chain of command on the civilian side that we were trying to help, that we could do planning and business.
One of the difficulties – and this is nothing different in Region Four in Louisiana, where we primarily worked with Minnesota Lifeline, which is the – the headquarters was at Lafayette, or if we were in New Orleans, or if we were in Rochester, Minnesota where the Mayo Clinic is. Unfortunately, it's a fact of life – it's no criticism, but it's a fact of life that public health care services and public health infrastructure has been, to a large part, minimalized in our medical infrastructure.
In Minnesota, which statistically has the No. 1 or No. 2 public health infrastructure in the United States, I'm still not certain on any particular day what services I would get from the public health system if the traditional system, so to speak, would break down. And so I think that looking at the two experiences in Iraq, as we looked at reconstructing their healthcare system through all that they had been through, it was relatively focused on where the funding and where the help needed to go – to their public health system because that represented Iraqis.
What was difficult in this operation in Louisiana was certainly the fact that some of the – as wonderful as the healthcare facilities were and are in New Orleans, when they become affected directly by a disaster, the safety net under them in terms of a public health service, through no fault of their own, didn't exist. And our main mission, then, in Region Four, as we started our relief operations – went into Baton Rouge to speak with Dr. Aaron Brewer, who was the chief public health officer in command at the time, and she had been displaced from New Orleans – was to get from her what she felt was in the best interest of relief operations, and her suggestion to us and her mandate to us was to go to Region Four where there was a lot of displaced people and try to reconstruct and reopen public health facilities, which really had not been able to provide primary care services for over ten years. That was going to be our major mission. What it should look like at the end of our mission was that we had some viability to a public healthcare system that could start taking care of displaced people.
SHUTE: Thank you. I'm hearing you saying that you all lost major components of your healthcare system. Dr. Weisfuse, you lost your lab. Most of the hospitals in Toronto were shut down and not accepting new patients at that time. Maybe we can talk a little bit about what happens when you do lose a big chunk of your healthcare infrastructure and how you could see working around that the next time. Dr. Low?
LOW: Yeah, I mean, one of the early decisions made was to cancel all elective surgery, elective therapies, and diagnostic procedures, which in hindsight I think was a mistake. I mean, our outbreak lasted for over eight weeks, and it was difficult for people to come to grips with. It was fine to do that the first few days, but really coming to grips with what really is the risk to these patients, and they needed their chemotherapy, they needed their diagnostic tests, and some of them needed admission for surgery. And we just closed that down, and we were afraid to open it up, and it paralyzed the healthcare system. We had two hospitals in the first two weeks that closed completely to all admissions.
And this fear, this fear of the unknown and how is it being transmitted, and the fact is because at the end of the day half of our healthcare workers were the victims. We had only 380 cases, which doesn't sound much when we think about a pandemic, but half of those were healthcare workers, and so you can imagine how paralyzed you felt and the fear of trying to open this up and getting business back to normal. And I think that's – we had problems with surge capacity. We didn't have places to put patients, especially when we were closing hospitals.
And we had to deal with issues of quarantine, because was quarantine the right thing to do? And that took key people out of the equation. People like myself, and colleagues were put on quarantine for a total of ten days. And that meant we couldn't work. And a lot of healthcare workers were in the same situation. It almost paralyzed the government because early on some senior members in the government had been potentially exposed, which would have meant - because that was the policy at time - to have quarantine, and that they would have been put in quarantine.
So it's difficulty with surge capacity, identifying who is at risk, who had the disease, who didn't, and who should be put on quarantine if quarantine was going to work at all. And so as we look forward, these are all issues that we're trying to address as we look to the next pandemic.
SHUTE: Dr. Weisfuse, how about yourself? How did you work around this difficult -
WEISFUSE: Well, not only did we lose the lab for September 11th, we lost our main building, because we were only a few blocks from the World Trade Center. And so, we had to evacuate that building and were out for more than a month. And what we've dealt with since that time is trying to introduce redundancy into our system. So for example, we have another location in another borough of the city of New York where we can evacuate to if our building cannot be maintained. And we've actually drilled that where we've had to suddenly go to this other building and set up our health department and our emergency operations center in this other location.
We've also rebuilt our lab big time. We've opened up a 20,000 square foot BSL-3 facility in what was in our lab, which really has state-of-the-art technology. But we've also got agreements with other BSL-3 high level – Bio-Safety Level 3 – laboratories in the city that we can use their laboratories in case of a crisis where our laboratory is not available. So it's really emphasized our need to introduce redundancy facilities in as many of our operations as we can.
SHUTE: Thanks. Ben, what do you do when you lose half the hospitals in a city, including the one level-one trauma center?
DEBOISBLANC: I think Frank Peacock hit the nail on the head in the previous discussion; that is, we've got to be able to use resources outside of the city. There was absolutely no way that you could bring healthcare providers in to help us. There were no - you couldn't get into the city. The USS Comfort showed up five, six days after the event and by that time, the city was empty. It was a ghost town. The first four days were the critical days, and all we did was grab-and-go. It was an evacuation. And we needed a place to send those patients.
Baton Rouge took about 25,000 patients. They triaged at the Pete Maravich Assembly Center there, the largest field hospital in U.S. history. The Superdome housed some 30,000 of patients of lower acuity that being able to distribute these patients nationwide during the type of disaster that we experienced, I think, is critical. That's where we need to focus attention, because having neurosurgeons and trauma surgeons come to New Orleans would have been absolutely useless. They would have stood around, not been able to get in, and all the patients within three or four days would have been distributed outwards. So I think it's that evacuation that is key.
And along those lines, the first casualty of a disaster is always command-and-control communication. And without communication, all of these pyramid plans we have of how to disseminate information, how to control an evacuation are lost. World War II was one by sergeants; it wasn't won by generals. What you need are people in the trenches who are empowered to make decisions that will have a real effect on people's lives; that we haven't given a lot of attention to. We've set up these elaborate emergency preparedness algorithms, but we need to empower people at the lowest levels to make decisions that will have a real effect on how people receive care.
SHUTE: I don't know about you; I'm calling Wolf Blitzer. [Laughter.]
We have an Army colonel here who I think might be able to help us out on some of our command-and-control issues. Dr. Franz?
FRANZ: Well, exactly – and mirroring what Ben has said. And I wrote down quickly what would have been the ideal person for us to take with us to help out in Katrina. It would have been probably a former enlisted military because they know how to take orders. They'd have an MPH – so they'd know public health – background. They would be a social worker; they'd also be a chaplain because these are force-multiplier-type professions. They can talk to anybody, and they can help in any situation.
For the physicians in the audience, myself included, I apologize, but we're probably the least important - notwithstanding Ben's efforts on the top of a parking garage - because at the point of care in a critical situation, sometimes that's what you have to have. But without the infrastructure and command and control, and support mechanisms, you can't get to Ben, let alone evacuate the patient that he's taking care of. It becomes a non-sustainable mission.
So the point of command and control is that, yes, you do some things right in front of you in terms of delegate authority, but you're also looking ahead into the horizon, and your responsibility in command and control is to know the mission at least an echelon or so above you – what – in the case for us, it was what do the public health officials in Baton Rouge feel are the most important things for us to do and, as volunteers, where could we put our efforts after our initial boots-on-the-ground experience.
SHUTE: How would you improve that communication with the folks in Baton Rouge?
FRANZ: From the onset, I think always the most important thing is your first communication. We partnered. Our Minnesota lifeline effort was a coalition between the Mayo Clinic, the University of Minnesota, College of St. Katherine's, a Jewish relief organization called Nacama. And probably over all of that was the American Refugee Committee who had never done a domestic operation before. It's a non-governmental organization. And they had just come from tsunami relief and Darfur. They had the maturity to know, as they took a look at Katrina, that it was going to be more like an international, complex, humanitarian emergency than it was going to be a perhaps temporary relief operation. And as a result, the initial communication is most important, and by their rules of engagement, it's to go and find the most senior person in command, the most senior center of legitimacy, which was the senior public health official in Baton Rouge, and ask what can we do to help?
SHUTE: Dr. Low, what were the communications you saw when you were in the hospital, and how do you think those could be improved the next time around?
LOW: Well, the communications we had every day, we had a press conference that was held about 3:00, which included Toronto Public Health and representation from other public health units in the Greater Toronto Area. We had our chief medical officer of health, myself sort of representing the clinical side, and I think actually that worked pretty well. There was criticism about too many people, too many talking heads, and that it should have been one person that relayed the message and only one person, and that's what they did in Singapore. I would disagree with that. I think that people in Toronto were well informed. I think they felt a certain amount of reassurance that they were getting the facts. We didn't see people on the streets wearing masks. Tourism, of course, plummeted. But people who lived within the city really had, I think, a pretty good understanding of the disease and I think that's a direct effect of good communication, being available to the press, and just being accessible in sharing the information that you had at hand. And I felt that at the end of the day, I think that put us in good stead.
SHUTE: Thank you. Dr. Weisfuse, those of us who were covering the early days of the anthrax attacks just had a hair-tearing experience trying to get information out of CDC and some of the other agencies. You were on the other end trying to get information out to the people of New York. Tell us what worked for you and what didn't.
WEISFUSE: Well, you know, what worked for us was our mayor, Mayor Giuliani, who was very up front with going on the news with press conferences with our commissioner at the time, Dr. Neal Cohen, and explaining the situation. He did it as many times a day as needed, but certainly every day. And that was our major effort at getting out the word to people about what do to, what not to do, and what the update of the situation was. We also put a major effort in trying to relate and communicate with hospitals and medical providers in the city through what has become a health alert network, and something that we work very hard on, which is that connectivity with the medical community in the city so that they know what we're up to and what our recommendations are, and what the latest situation updates are.
SHUTE: I know you've also mentioned that you think that businesses, corporations, should be part of that health alert network. How do you think that's important?
WEISFUSE: Well, you know, we put a major effort in pandemic flu preparedness on talking to businesses in the city. And many large businesses that are located in the city have some occupational health infrastructure. And I tell them it is mandatory for your staff to be signed up for our health alert network. This is not a optional exercise. We're not going to be able to deal individually in terms of corporations in the midst of a crisis, with individual phone calls. It just is not going to work. But we will put our effort and our best information into these health alerts. And if you are signed up for it and use it and know how to use it, you'll get it and you'll get the latest information. We're not going to be able to realistically deal with individual phone calls on individual problems.
SHUTE: Thank you. If you had to fix one thing from the situation you went through, what would be at the top of your priority list, Ben?
DEBOISBLANC: That's an easy one – a satellite phone.
SHUTE: Okay, SAT phones for everybody. How about you, Dr. Franz?
FRANZ: It was to be able to have a very good idea of those who could take over for us at the end of a 60-day mission in terms of sustainability from a public health standard.
SHUTE: Did you have a sense of who those people should be or how did you leave it when you did leave?
FRANZ: No, we had worked starting day one of our mission, we worked for the instate of day 60, which was that the public health service who did come in as well as some displaced physicians and nurses as well as Louisiana State University at Lafayette, the medical center there, to take over for us. But as I mentioned, the public health services in Region Four had not had what I would call primary healthcare services come out of their public health clinics for over ten years. And again, it was no one's fault. It was just the way the system was. And so we had to start working on day one for a coalition at day 60 to take over for us. Otherwise, we would have been medical tourists, and not a group that came in to try to establish sustainability or something we could leave.
SHUTE: Dr. Low, what would you want to fix?
LOW: I think it would be leadership. We had responsibility divided between two individuals, and then, of course, federal government. But I think that we needed somebody outside of the chief medical officer of health or outside of emergency planning to be in charge of this outbreak and to have the resources to do what they had to do. We needed to be doing research. We needed to know what treatments worked and what didn't, and we could have done that very early on. We needed information about how was this thing being transmitted, what were going to be the rules regarding quarantine, who was going to go on quarantine, who didn't have to. These were things that just didn't happen, and I think mainly because of a lack of leadership and people trying to cover their own areas, making sure they didn't make mistakes, but not somebody to look at the big picture.
SHUTE: Where would you look for that kind of leadership? Would it be within public health? Would it be in a hospital? Would it be a politician? Where would you look?
LOW: It's the person. You just have to have somebody that you recognize in the community that is a good leader. It doesn't have to be someone who is an expert in the field, just a good leader. And I think we were able to identify, and we had long arguments over the phone about this late into the night, about trying to get the will to do that. And government wasn't willing to do it. I think it would have been losing face, and unfortunately it happened at a time when it looked like things were coming under control, not realizing we were making the biggest mistake of our lives in taking down our guard, because the thing just ramped right back up again. So I think that could have been overcome if we had had that proper leadership. So you've got to identify somebody in your community or somebody outside the community that comes in and takes that. And you have to put your trust in them.
SHUTE: Dr. Weisfuse, you had a great communicator, a great leader. What else would you like to have on your list?
WEISFUSE: Well, since both events were in New York City, I think peace on Earth would be a really good request.
You know, I think that the New York City Department of Health and Mental Hygiene is a very atypical local health department. We are very large. We cover a very large, complicated urban environment. But if you look around the country, many local health departments are tiny. I think the average number of employees in a health department around the country is about somewhere between thirteen and fifteen. And the idea that Secretary Leavitt really emphasized over and over again this morning about it's a local response, and you're going to put that kind of pressure on those thirteen or fifteen people to carry that load, I think the fix that not New York City needs, but that the country needs is sustained infrastructure building for public health at that county or city or village level.
SHUTE: I'm glad you brought up Secretary Leavitt, because first we heard from the head of HHS, who said don't look to us for help in pandemic flu; it's all local. Then we had the CEOs in major hospitals saying, wow, we're not ready. And then, it sounds like it is all devolving on folks like yourselves who are there on the front lines. What do you need besides more money?
WEISFUSE: Pandemic flu is a fascinating problem because it's not only a public health or medical problem; it's a societal problem, potentially a societal problem. So one thing we need that I think Secretary Leavitt pointed out is for everybody to take this seriously, but then realizing that there are some people who may want to take this seriously but can't or have difficulties. So I'm concerned about, for example, small business issues in New York City. I know the multinational corporations who are based in New York City have really been talking about this for a long time, and some of them have really extensive plans. But most business don't have that kind of resources behind them. And you know, issues around the vulnerable populations as we saw with Hurricane Katrina, I think we really need to move forward on that. So some of it is money; some of it is time and willpower and interest.
SHUTE: Dr. Low, you're doing a lot of work on trying to get Ontario ready for a pandemic flu. What sorts of things are you looking at there?
LOW: Well, one of the real benefits from SARS is that everybody has experienced a pandemic in Ontario, and really in Canada in some way, but especially in Ontario and especially in Toronto. And what we've seen as a result of SARS is the government's commitment to reinvest in public health, and they are doing that. In fact, legislation will be moving forward in May to create a public health agency in Ontario. There have been concerted efforts to hire staff in infection control roles within hospitals. When we do pandemic planning, people listen. We have no difficulty in having administrators listen and having people in government listen and participate, and are actually driving the process. And that is so refreshing that all of a sudden you have the ear of government. And it's not just the money, but also really the psychological support that they give you in planning like this. SARS has, I think, put us way ahead in pandemic planning and dealing with a lot of issues, because people say, you know, that's right. This is what happened to us when we had to restrict entrance to our hospitals; we had to redeploy staff; we had to close wards; we had to create isolation units. People have experience themselves, and so that has made planning much more efficient than I think it ever would have been.
SHUTE: Thank you. Ben, what do you see as a way to prepare for something that could be way more sustained than the five days you spent trapped in charity?
DEBOISBLANC: I think a lot of our emergency preparedness focuses on dropping back and entrenching. I've always thought that the best defense is a good offense and that in the case of Katrina, a stitch in time would have saved nine. It turns out that the cost of building levees was about one-tenth the cost of bailing out the city after the fact.
And as we look in retrospect at each one of these events, that there is something that could have been done to prevent them that would have been a lot less expensive, even in the case of avian flu, investing billions of dollars in finding preventions and treatment would be money well spent compared to the trillions of dollars that it will cost the globe if we do have a pandemic. We really, I think, need to refocus, because that entrenching philosophy is expensive and if it never happens because one is never aware of what one prevented, if it never happens, you really won't know whether your efforts were effective. So we really, I think, have to take a new focus here.
SHUTE: Secretary Leavitt was talking this morning about a pandemic flu could even be a crisis that will last a year. You're now almost eight months into the crisis in New Orleans with no end in sight. How are people handling it?
DEBOISBLANC: As I suggested in my opening remarks, this is the hard part. This is like watching grass grow. There were very few – amongst healthcare professionals – very few cases of post-traumatic stress disorder in the immediate aftermath, because I think it was a very – as I suggested – a very triumphant experience. But this part is really hard. Here, we not only are displaced as individuals, but our families are displaced. My children were in another state for six months while I was expected to try to rebuild the healthcare infrastructure in my own city. That wears on you after a time, and I think we also have to think about the morale issues amongst not just our first responders, but our second responders for events like this. And bird flu, an event that's likely to evolve over a year's period of time, is going to really test our resolve.
SHUTE: Thank you. Dr. Franz, you've looked at situations like this where people are displaced and the social fabric is tattered for years at a time. What would you say we need to start doing?
FRANZ: Right now, I would say certainly – and again, mirroring on some of Ben's comments – when I was in Iraq, I could focus on my mission because I knew someone was taking care of my family at home. Part of what I'm rehearsing in my mind since coming to this conference is what would I do if I had to go to work at Mayo and take care of people, but I'm worried about the health of my family. That's going to detract me possibly from my mission. It may change my viewpoint of going to work. I think the comments from Ms. Running were outstanding when she talked about you have to somehow generate an enthusiasm or a reason to come to work and to put your shoulder to the wheel.
One of the ways that I would look at it is what we do somewhat in the military. In times of crisis, in times of trouble, you rehearse and you desensitize so that you learn that maybe your basic fears somewhat are the old-fashioned fear of the unknown. And so, you rehearse it enough and you look at courses of action, and you develop a couple of things that maybe if you don't remember all ten points of what you're going to do in terms of crisis, you'll remember the first two because you've rehearsed it enough that you can find solace in that.
SHUTE: Thank you. And you mentioned earlier the enlisted personnel, and I think Vicki Running mentioned that you have to have your laundry workers and your kitchen workers prepared to come in a difficult situation.
FRANZ: And absolutely. And I think one of the things we learned in Minnesota Lifeline, as well it would work hopefully tomorrow as we have to look at things in Rochester, Minnesota is that you can't overestimate the power of your support people and also cross-training. Nothing might be more useless than a physician such as myself that doesn't know how to do basic sanitary duty if need be. Can I clean a floor? Can I process – take a patient someplace? Can I provide basic nursing care? We've become so very compartmentalized, myself included, in our medical care that I rely on a number of people to do other things as I go on to the next patient. In this type of environment that we may be facing, we may have to get out of our compartments and look at cross-training in the ability to be not the word multi-tasked, but multi-capable.
SHUTE: Ben, what did you see during the Charity crisis? Were people able to work outside of their traditional roles?
DEBOISBLANC: I think that during those first five days, you felt like you could walk on water, because it was just such an adrenaline rush for everyone. But it does call to mind the observation that much of what is now broken in the city of New Orleans are not physical plants. The buildings are still standing, if you haven't looked. They're still there. But the problem is there's nobody to work in them. We can't open restaurants in New Orleans, not because the restaurants in the French Quarter were flooded, but because there's nobody to bus the tables. And the same is true of our hospitals and all of our clinics is that the very people who provided that infrastructure have been displaced. And I would imagine that until we are able to create housing for those people to allow them to – to bring them back – that it's not going to be fixed.
SHUTE: Dr. Low, you probably came closest to anyone here as far as experiencing that where you had a really dangerous situation in your hospitals in the entire city. Did people come to work, and if not, how did you deal with that?
LOW: Well, it was surprising that people continued to come to work, despite hearing that their colleagues were coming down with disease. And one of the major concerns that they expressed again was they were willing to put themselves at risk, but they were afraid about taking it home to their families. And we had a particular situation at one of our hospitals where a physician that had SARS was being admitted to the ICU and a very difficult intubation that took a couple of hours actually and fifteen people were involved in that, and nine of them came down with SARS. Nine healthcare workers in the ICU, despite using what we told them were precautions that were going to protect them. And I remember that it was Good Friday evening. We had a conference call and we really thought on Monday morning that we would have no ICU staff across the city. And they showed up, and they continued to show up. We had transmission in our SARS unit in our hospital between a healthcare worker and one of the teacher educators. And having to go around that day personally and sit down with staff and say this is what happened; we're going to try to make it better; and we'll do all we can. And they continued to show up for work. So it just amazed me how resilient and willing to – you know, I mean, that's what they're doing. This is their job. And willing to do it was really exceptional.
SHUTE: What long-term effects have you seen from that experience?
LOW: There has been a lot of burnout, a lot of people that haven't gone back to – not an excessive number, but there has been – we've seen it. But fortunately, I think it's a small percentage, considering the number of people that either got sick or friends or colleagues that got sick that it is something that we've gotten over.
SHUTE: And Dr. Weisfuse, how about you with your double-whammy of 9/11 and then anthrax? How did your staff respond and did you have to take any special measures for them?
WEISFUSE: You know, I think one of the problems is that we tried to do a lot. We kept our basic public health clinics open throughout, so our TB clinics, our STD clinics, our restaurant inspections to some degree. So we kept a lot of balls in the air. I think there was, especially on the leadership perspective, a fair amount of burnout. Adrenaline will only get you so far, and I think we were sort of on the run for a couple months I think before we could sort of take a deep breath and try to get some perspective. But I want to talk a little bit about the hospital issue. I mean, one of the things that we've done in conjunction with Bellevue Hospital is actually set up a course on medical and hospital issues around terrorism. And it's really meant for, not necessarily for physicians but other folks in the hospital, in the hope that the more we can educate the people who run the cafeteria, the nurses, the orderlies, every level in the hospital, the more they are going to feel comfortable and understand what their duty is. So I am not as pessimistic as some about people not showing up. I think that that will happen, but I think there is a sense that people do come to the fore for an emergency as you saw in Toronto, New Orleans, and as happened in 9/11 – if they understand it, and they understand that people are trying to take whatever precautionary measures they can.
SHUTE: I know that in any kind of crisis, communications is a huge effort and there's been a big push and pull within HHS and some other public health organizations as far as how much to tell the public, particularly in preparing for a possible pandemic. What's New York City's policy on that?
WEISFUSE: Well, I think we've done a lot of work, you know, in terms of training on this concept called risk communication, which is how to get across these sometimes scary concepts in the most accurate way. So we've done a lot of internal work and discussion on that.
I think our approach is, you know, trying to strike that balance – you know, and it is difficult because New York City is well, larger of an environments - have tremendous other public health issues. We have a large HIV epidemic, we have obesity, diabetes, we have lots of issues and we can't lose track of those in our rush to prepare for pandemic flu. But that being said, I think that we want to get some common sense approaches across to the public about what a pandemic might mean for them, how they can protect themselves in terms of respiratory hygiene and perhaps other measures.
SHUTE: Thank you. I want to ask one more question of our panelists, and then we'll open the floor to questions, and I want to start with Dr. Franz because he came down to New Orleans really on a volunteer effort, and a great deal of the work you've done with refugees has been in a volunteer capacity. Are there ways that we could use volunteers better, either in a Katrina like situation or perhaps pandemic flu?
FRANZ: I think the – probably the most important thing you can always use volunteers but they can't be tourists. And I think the lesson learned is – and probably are – one of the most important aspects of our operation was to go through an organization who was used to dealing with volunteers and relief operations and they knew how to interface volunteers and efforts with those who needed it.
So yes, there's going to be a need for those efforts. You know, part of the issue is going to be the vetting. Unfortunately – and again, I'm part of the system so I guess I can criticize it - nobody ever taught me anything about handling human waste or a latrine until I was in the military; it's not part of my medical education. When I asked new generations of medical students, what would you do if our plumbing system broke down here? What would you do? They don't know. And it's not a criticism of them but it's a gap in their knowledge. But yet it's a basic thing.
So I think one of the lessons I took from this and looking at - is we educate volunteers for the future, in the healthcare sector because volunteers are going to be needed, as well as workers in healthcare area, again to be very well vetted and very well educated in basic public health principals.
SHUTE: What about you, Ben? Could you see putting volunteers to good work – good use now?
DEBOISBLANC: Well, as I think I commented earlier, there were so many people – thousands of people sent me emails in the one or two weeks after I got out of Charity, how can we help? We want to come down to help; we want to do something. And they were people with very technical skills who wanted to come down and set up a MASH unit somewhere. And there's a misconception that that's the real health crisis in the aftermath of an event like this. The real health crisis is people left their medications at home and that they don't have any insulin, and they don't have any blood pressure medications, and they don't know where to go if they have a health complaint.
So what we really need are people who are willing to do bread and butter types of volunteerism in community clinics set up in the region of a disaster - in the catchment area around a disaster. Those are people who could be - who could have highly technical skills but they have to understand the mission-at-hand, and the mission-at-hand is not to do neurosurgery. But we can also use a lot of civilians in that capacity with a minimum amount of training.
SHUTE: Thank you. Dr. Lowe, would there be a role for volunteers in a situation like SARS?
LOW: I think volunteers would be important. It would be important to identifying what skills they have so that you could utilize them. And sometimes that might be people that have either left the field and could come back or people that have retired and could come back, and we've thought about that, and are actually - that's part of our pandemic plan.
But we also have to be careful that in doing this we don't put them at risk because one of the big concerns we had – and as a result, we lost a huge labor force during SARS –was we didn't allow students to come into the hospital setting. We sent home volunteers because we were afraid of putting them at risk, and so we lost that resource and also lost the opportunity for them to learn from an experience like SARS. So it was unfortunate when we look back at it, and our attitude in the future is that we should not do that - that we should include them but we have to protect them.
SHUTE: Thank you. And how about you, Isaac? Volunteers?
WEISFUSE: We definitely believe in, you know, working with volunteers, but we want to set it up before hand so we have a medical reserve core with about 4,500 people enlisted who are ready to volunteer for New York City.
Just one example of where this is really critical – we know that during a pandemic, there will be more need for intensive care unit beds, more ventilators – we're going to need more respiratory therapists. We've actually targeted – trying to get respiratory therapists into our medical reserve corps. Hard to do; they're pretty much in shortage. And we've talked to the respiratory therapy deans in our local respiratory therapy schools. It's not easy to do that.
So we are aggressive on it, but clearly we need to do more and figure out some of the solutions to some of these basic healthcare manpower issues that are going to stymie us.
DEBOISBLANC: Nancy, if I could make a comment. I hadn't thought about this before Katrina, but one of the big issues we encountered was credentialing – that physicians came in and didn't have a license to practice medicine in the state of Louisiana; that a lot of hospitals that were receiving patients wanted to be able to use these medical staff but didn't know how to jump through all these medical-staff hoops to get emergency credentials.
I think some national database of pre-credentialed people that would be willing to respond to a disaster and the right legislation to make it transparent would have gone a long way to getting the resources to the point of care in an expeditious manner. Louisiana has enacted a good samaritan legislation that allows us to do that, but it ought to be a nationwide effort and there aught to be a database of people who've already gone through the credentialing process because God only knows we don't want people pretending to be doctors actually coming to practice medicine. But it's something that should be easy to do.
SHUTE: Thanks. That's a really good point. I think there has been some discussion about that on the national level and maybe there's somebody here in the room who could comment on that. I don't know - are we about ready to throw it open to questions? Questions from the room – if you could give your name and affiliation and if there's someone specific you want to address your questions to, please do.
Q: Are you prepared to ask one yourself? [Laughter.] Well, I'll throw one out. What about the military – the role of the military and in that sense, as far as volunteers go - a help? A hindrance? Different command and control structures? How does that marry with the civilian structure and was that a hindrance or a help?
DEBOISBLANC: I've thought a lot about this. There's one thing that the military does very well. They practice it every day and they practice it under duress and that is command and control.
I'm not sure we need boots on the ground. I'm not sure that the military would be better at responding to a humanitarian or a medical crisis than the people we have in this room. I'm sure that they wouldn't be.
But what they are very good at is command and control. Why not have the military assume the command and control structure? We'll do the – we'll put the boots on the ground; we'll do the footwork. But we need that coordination that only they can provide. The technology is already in place, they've rehearsed it every day. We ought to use it.
SHUTE: Colonel Franz? [Laughter.]
FRANZ: One of the interesting metrics now in the military is that, about 70 percent or more of healthcare for the military is by reservists. And so you have already civilians, for the most part, that are trained to be in uniform.
You also have – is a part of special operations – and now going over to the reserve side – civil affairs units, which basically more than 95 percent of civil affairs units in the U.S. military, whose primary job is to go with combat units, and under the directives of the Geneva Convention in terms of humanitarian response, are to mitigate the effect of warfare and disaster on civilians. That's a workforce that's there. They've already been federalized; in a way they've been trained, they've been standardized.
I certainly agree with the dictum that the military knows command and control well. There are, though, some euphemistic boots-on-ground services that are used to the command and control environment and that could help.
SHUTE: Dr. Weisfuse, does New York want the military to come in?
WEISFUSE: You know, I think that we – you know, we would coordinate with military if need be through our Office of Emergency Management – Emergency Operations Center where, if the military were in New York City, they would be stationed, as well as we would, in the hospital systems to coordinate. I don't think that we are necessarily looking for the boots-on-the-ground kind of help. We certainly are very appreciative of the help that we've gotten in 9/11 and anthrax from the Department of Defense on a lot of resource issues - notably, that's who bailed us out on our laboratory issues – as an example. So I think on certain issues we really could coordinate with them and work with them and we did during our crises.
SHUTE: And Dr. Low, you've got have a different military but would they have been useful for you?
LOW: All military. They were in Afghanistan so we didn't really have anyone to fall back on, because we talked about it, especially during the ICU crisis as a what-if – that the ICU support staff didn't show up on that Monday morning and could we turn to the military. And it would have been a real problem if that had happened.
SHUTE: How would that have been a problem? What would you see as -
LOW: Well, we had no military that every - most of the forces were in Afghanistan. So if they had of been present – yeah, I think it would have really been critical to have that ability.
WEISFUSE: I just wanted to make one more comment about the military. I think, aside from the, you know, coordination during a crisis, you know, we can learn a lot from the military in the hospital sector in the public health sector, and that really hasn't been taken advantage of in terms of some command and control issues and logistical issues, et cetera. They have a lot of expertise, and trying to figure out a way to share it with the public sector, public health, hospital sector – would be wonderful.
SHUTE: Great. Yeah.
Q: Yes. Nelson Jacobson. My question would be, isn't there a National Incident Command System – the NIMS – and that takes care of command and control? There's a presidential directive, PD5, that says all the first responders need to engage in first response using the NIM system. And has that been brought to your attention and are you guys coordinating with that?
WEISFUSE: I'll take a stab at it. Yes, we are very aware, well aware of NIMS – National Institute of Management System. So on paper these are all dealt with but the issue becomes - on the ground, you know. It's easy to say, yes, we follow NIMS, but – you know, New York City is a very complicated city. Multiple agencies would be on the ground. Does everybody know this, can act it out during a time of crisis? I mean, that's something we're working on, but having the document doesn't necessarily mean that it's going to work that way.
SHUTE: How useful is it as a framework?
WEISFUSE: Well, I think the Incident Command System is very useful as a framework. We've adopted it wholeheartedly because of some of the mistakes we made, you know, in emergency preparedness and some of the difficulties we've had. But, you know, command – I'm sure the military, with its sort of more regimented way of doing things, is a lot more able to effect these kinds of incident management or command and control protocols than the civilian sector, where everybody wants to do their thing, you know, you want to go to the site and do your neurosurgery or whatever it is. So I think the military certainly has advantages on it and I think the civilian sector needs to grow more into that kind of role.
SHUTE: Thank you. Next question?
DEBOISBLANC: Nancy, as a panelist, I would like to ask you a question. What is the – I know the answer, it's a rhetorical question but I want tohear you comment on it or I want to hear other people in the audience speak to the responsibility of the press to accurately report these events without inflaming the stories to capture ratings. That, in the immediate post-Katrina period, was a killer. That –
SHUTE: No, I think –
DEBOISBLANC: – there was a lot of reporting going around that turned out in retrospect – none of it was true. And I know that it's very difficult early on to validate a lot of those stories, but clearly as we try to do our jobs better, you've got to do your jobs better.
SHUTE: And I think you were listening just to local radio, wasn't that your source of news?I'm just trying to get out of this.
DEBOISBLANC: I appreciate it.
SHUTE: I'm happy to address that because I think it's a huge problem for those of us who are trying to cover these events as they happen. You know, I thought the Toronto folks really got on the ground fast and had a way for reporters – we all knew about the 3 p.m. press conference and so we weren't always trying to buy Dr. Low.
But with things like anthrax, it was excruciating trying to get accurate information about what was happening here in D.C., in our own city, let alone New York and Florida and some of the other locations. I do think systems with the agencies have improved so it's easier for us to get information. But I've got to tell you, from someone who's really, really trying hard to give level-headed, dispassionate advice, we have some photographers of ours sitting here in the room who went over to Brentwood, photographed, came back and then found out they've been contaminated with anthrax and were wondering what to do about their kids. That's a huge issue. We're all trying but we've got a long ways to go.
Another question?
Q: Hi. This is Ron Kahnfrom Boston again. I thought that some of the comments that Dr. DeBoisblanc made were very important and I wanted to follow up with both him and the rest of the panel about other issues that relate to people who are on medications or have medical problems.
So two things that haven't been addressed, and they're somewhat related, are what was your experience with medical records and what would be your recommendations about trying to help make medial records more available? And then I guess my second one, which is somewhat related – is related also, as I mentioned earlier in the earlier panel, to the health insurance industry, which once you get beyond that first few days of crisis, will also play a role in some decision making around healthcare in many places. I'd be happy for your thoughts and experience on this.
SHUTE: Okay. Who wants to try – tackle medical records? Any thoughts there?
DEBOISBLANC: I'll be happy to tell you what happened. I'm not sure I know what should happen, but for one time we were glad we didn't have an electronic medical record. We had a paper medical record in this old hospital and we were able - what we did is we taped some medical records – put them in a plastic bad and taped them to the forearm of our patients. So wherever they wound up, the medical records wound up with them. A national, electronic medical record would alleviate some of the problems of using an electronic medical record because I'm absolutely sure that if we had had one, we wouldn't been able to print a hard copy, and you wouldn't have been able to access that copy from outside, so we would have had nothing. But fortunately that didn't happen to us. I'd be interested to hear from some of the other hospitals in the region that did have electronic medical records and what they did.
SHUTE: And Isaac, do you have any plans or issues as far as electronic medical records in New York?
WEISFUSE: Well, you know, it's an issue that we are working on. We have a - it's not quite the same but we have a system that the New York State Department of Health has pioneered called HERDS, which allows us to look at hospital utilization and resources on a moment-to-moment basis to help us manage the healthcare system but that doesn't get to the individual level.
SHUTE: Okay. And I can say, just having been down to New Orleans, and talking to CEOs of the hospitals there, they are in a huge cash crunch right now. Each hospital is losing millions of dollars a month taking care of the uninsured and so far the dollars from state and federal sources are not flowing to them. So I can say they're definitely having a hard time down there. Thank you very much.