receiving timely service when urgent or emergency care is required.1 Hospitals and healthcare systems have squeezed out all of their excess capacity for the purposes of efficiency and reduction of overhead. The way health care is financed has catalyzed these efficiencies so that cost-shifting to compensate for overhead to address non-income–producing services is virtually eliminated.

Hospitals manage “daily surge” in several ways; the predominant one is shared by every other industry with ebbs and flows in demand—increased wait times for service. A relatively steady state is therefore created, with predictable consequences. What is yet unmanaged is the unpredictable surge of patients that arises from infrequent, geographically scattered events, known as “disasters with medical consequences.” The issues dealing with large-scale catastrophic events are what seem unmanageable. Are the daily skills and accidents of the management of daily surge scalable for natural disasters or intentional catastrophic events? Clearly, the answer is “no.” This is not to say that the same capabilities needed to address daily surge are not applicable to disasters—they are. But it is the set of additional requirements to manage this rare circumstance that groups of experts gather and produce recommendations for catastrophic events. Due to the rarity of the events and the lack of a mechanism to gather data in real-time, this expertise is usually based on experience rather than the more normal evidence-based approaches to medical decision making.

The difficulty of designing a national strategy for medical surge capacity in disasters, much less the operational and tactical planning, is in evidence by the failure to produce such a strategy irrespective of the numbers of papers in the literature on the subject over this decade. Responsibility for developing such a strategy has been shunted off to states, the private sector, hospitals, think tanks, and professional associations. But it is difficult to ignore that one of the reasons for the formation of a federal government in the first place was to provide for the common defense. Medical response is an essential element of the common defense, and is therefore a responsibility of the federal government that must not be abrogated. Like the super majority of our critical infrastructures and key resources (CI/KR), the nation’s medical infrastructure is not owned or controlled by the government. Like much of the U.S. homeland security enterprise, the federal government has responsibility, but no control. Therefore, the way the federal government has asserted itself to achieve the goal of a common defense is through planning, controlling funding,



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