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The Big One?

November 18, 2009

Every couple of months, I get a copy of the magazine Emergency Management delivered to my inbox at work. Now, I’m not usually one for paper magazines, and I generally find the content of emergency management-type magazines to generally be lots of rah-rah and advertisement (bleh), but Emergency Management isn’t so bad. On top of that, they’ve got a robust website and have delved into social media pretty heavily (posting new stories to Twitter and curating an entire stable of blogs). And it’s free.

Anyways.

In this month’s edition, and online apparently, Valerie Lucus had a pretty interesting article on how H1N1 influenza forced UC Davis to rethink their pandemic plans. She brings up a point I’ve danced around for the last few months, but feel pretty strongly about:  our pandemic plans were not very well designed. They were written with H5N1 in mind, and tied almost exclusively to the WHO pandemic levels (some places, I’m sure, added the CDC’s Pandemic Severity Index, but probably not all).

Case in point, and one of Ms. Lucus’ examples; many places had plans to institute drastic social distancing measures when WHO raised the pandemic level to 5, like closing schools and canceling sporting events. The reality is that we hit level 5 with only a handful of cases in this country. I’ve talked about this before, back when we were just trying to figure things out, about the ineffectiveness of the pandemic level system.

This article, though, takes that thinking to the next level. It says that we planned for the worst possible situation, with the intention to “roll back” our response to match the pandemic (which in my mind is totally defensible). And planning for the worst case scenario is the easiest, in my mind. Give it everything, shut everything down, 12-hour shifts, activate volunteers, altered standards of care, the whole nine yards. Alternatively, we already knew the plan for a normal flu season–basically, do nothing.

The real tough decisions, though, were in the middle of those two. What do you do for a flu that’s spreading like wildfire…somewhere else? What do you for a flu that’s about the same as seasonal flu, but carries the weight of the pandemic moniker? If Houston and San Diego were closing schools, should we?

No one had talked about that before. Scratch that, no one I talked to talked about that. We all happily talked about how the government would shut everything down and save the world. Then it happened, and we were forced to make those critical decisions in the heat of the moment–which is EXACTLY what we were supposed to have avoided with all of that pre-planning.

Like I said above, though, everything we did was totally defensible. It was right at the time. The problem is that we’d never had to plan for a pandemic before. Thanks to CRI, we’re ready as all get-out for an anthrax attack (which, if you ask me, is why everyone’s first planning response was to set up PODs–when all you’ve got is a hammer, everything looks very much like a nail), but no one talked about how specifically we could roll back those bludgeoning 1918-like response plans. What were the triggers that should have kicked it into a higher level of response?

When everyone rewrites their pandemic plan this spring, remember these lessons. Planning for the worst case is the easiest; planning for the best case is next easiest; figuring out the middle is the really difficult part. With that in mind, write your plans from the bottom up. What constitutes the best case scenario? What triggers would cause you to respond more aggressively? Even more aggressively? Now, what does the worst case scenario look like? Build plans for each level of the response.

Sure it’s more writing and more exercising. But if we planned from the bottom up, instead of the top down, this spring might have been filled with fewer late night meetings and panicked conference calls.

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4 Comments leave one →
  1. November 18, 2009 11:17 pm

    Hello Jimmy … a good analysis … I think that something that emergency management professionals and even public health officials tend to overlook or underestimate, is the extent of “political considerations” that come into play. Not only in terms of electoral issues but also in terms of the understanding by elected officials and senior civil servants of the emerging issue.

    At the highest levels, plans are often a mere guide and are overlooked in favour of current considerations that may vary: public perception, key among them. In the end, public health officials often get caught up in these considerations as well, especially in situations where many jurisdictions are involved.

    To conclude, plans are essential but not the end-all … there’s an absolute need for public health officials and emergency managers to clearly understand the expectations of the political class and clearly communicate scientific and technical objectives. These are not always easy tasks.

  2. November 19, 2009 1:04 am

    Coming from a background in TV news, this is familiar territory. You plan for 45 minutes in an editorial meeting, and 15 minutes into the day you scrap it.

    The proper mindset is to never assume your plan will actually execute. In fact, I started a tradition of leaving the conference room loudly pronouncing “There goes Plan C.” Because if nothing else happens, we’ll have a plan to fill the newscasts — and once new events start chipping away at the Plan C resources, Plan B and Plan A start to reveal themselves.

    Fortunately, the exercise of building Plan C means you’ve already accounted for resources, and weighted the risks and rewards of the coming demands. The prioritization is done, and Plan B and Plan A don’t require as much deliberation. What they DO require is someone to take responsibility for making a judgment and living with it, instead of safely hiding behind that plan.

    With that in mind, we are overdue for an actual conversation…

  3. November 19, 2009 1:31 pm

    I would disagree that nobody was planning for the middle, at least at the local level. Many of the state and local planners I worked with when I was in MD at a local, as well as the major universities, were basing the operational activities in their plans on proximity of cases.

    I think the biggest weakness in the WHO phases (and the proximity triggers we worked on) was that they were based purely on the geographic spread of the illness and didn’t include a second axis for severity. Because we were all focused on H5N1 shifting its infectiousness we were prepared for a very severe illness spreading with increasing speed. Instead, we had a less severe illness that spread extremely fast where we needed to watch for increased virulence.

    The identification of triggers in your piece is the key thing for me. Plans that don’t have triggers for actions aren’t plans, they’re discussions of theory. Hopefully there will be a general overhaul of plans once things wind down, and we will shift over to more operational versions that include different courses of action based on specific triggers.

  4. FIREhat permalink
    November 19, 2009 1:43 pm

    I had this same discovery when I became the guy who dusted off my fire department’s pandemic plan this past spring. It was written in several years ago and was tied to the WHO levels. Among other things, it called for cancellation of leaves and non-emergency activities when we hit the levels we hit. Canceling leaves is a huge issue and ceasing non-emergency functions cripples the majority of our activities (training, fire prevention, public service).

    So we just had to ditch the plan and come up with one on the fly. It reminds me of what Eisenhower is reported to have said during the war: Plans are worthless but planning is indispensable.

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