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Reflections on the Workshop and Opportunities for Moving Forward
Tener Veenema described the workshop as inspiring, informative, at times alarming, and powerful in highlighting the obstacles to mounting a systematic health care response to a nuclear incident. Jim Blumenstock summarized several of his key takeaways from the workshop, and Kevin Yeskey adjourned the meeting with closing remarks that reflected the Office of the Assistant Secretary for Preparedness and Response’s (ASPR’s) thoughts on the meeting and potential action items discussed.
BLUMENSTOCK’S KEY MESSAGES
The Reality of a Nuclear Threat
Blumenstock reinforced a point made evident at the beginning of the workshop: The possibility of a nuclear incident is real, and “an incident anywhere is an incident everywhere.” The magnitude of any type of nuclear assault, he said, would transcend geopolitical, or state, boundaries. Such an event would have significant second- and third-order consequences that would impact the nation as a whole and regions far from the blast site itself. “Clearly, the issue here is national,” Blumenstock said. “And the complacency that may exist in pockets of the country that it could never happen there or to them really needs to be addressed and neutralized because that is not a healthy planning mindset.”
Guidance Documents and Innovative Practices
Blumenstock was impressed by the wealth of relevant guidance documents discussed at the workshop; these included both planning and technical assistance documents as well as promising, innovative practices that have been made available by U.S. government agencies and other entities. He recalled, however, that all too often these types of products become the “best-kept secrets in the national capital region.” He called for an effort to create a compendium of these guidance documents and other resources to be reissued to the larger practice community to ensure that practitioners who ultimately are responsible for implementing these guidelines know that they exist. He suggested the National Alliance for Radiation Readiness could serve as a convener and distributor of the described resources.
All-Hazards Preparedness Versus Incident-Specific Response Planning
Blumenstock observed that all-hazards preparedness was mentioned several times over the course of the workshop and said that nuclear preparedness efforts benefit from the foundational elements provided through the paradigm. In his opinion, nuclear response planning must continue to leverage and capitalize on that approach. His one caution, however, was that the all-hazards approach does not address all elements of a potential nuclear incident response; he said that preparedness efforts need to strike the right balance between the all-hazards approach and planning for specific threats. “So how do you manage that message of reinforcing the importance of all-hazards preparedness,” he asked, while “also realizing that a nuclear incident-specific response has its own needs and capacity limitations and gaps that need to be filled?”
The Potential to Save Lives
Blumenstock said that several presenters emphasized that notwithstanding the consequences of a nuclear incident, lives can and will be saved through effective public education and by deploying a skilled, educated, and sufficiently resourced public health, health care, and first-responder workforce. “The response apparatus and the public must be motivated and driven by this positive outlook,” Blumenstock said, “and not be taking a fatalistic outlook that there is nothing we can do, so we shouldn’t prepare.”
Planning Assumptions
If such an incident were treated as an act of war, then military assets most likely would not be available to assist the civilian community in its
public health and medical response. Blumenstock pointed out that this in and of itself demands a significant shift from traditional planning regarding what federal, especially military, resources would be available within U.S. jurisdictions to assist civilian support. On a related issue, Blumenstock referred to the discussion around Emergency Management Assistance Compact (EMAC). While EMAC would certainly provide state-to-state support and assistance, given that the magnitude of a nuclear incident would be unprecedented, it is unclear how rich the available resource pool would be from state to state. This would be especially true in the early days of an incident, when multiple jurisdictions could be impacted and there would be uncertainty around the impact across the country.
International Assistance and the Global Health Emergency Workforce
Regarding international assistance in the event of a nuclear incident in the United States, Blumenstock mentioned concern voiced from the Pacific Rim regarding proximity to and reliance on other countries that may be closer logistically and from where it might be easier to provide support compared to Hawaii or the continental United States (see Chapter 3). This raises questions about what doctrines, policies, or procedures are in place to allow that to happen effectively and efficiently. Also during the workshop, there was some discussion about the World Health Organization’s global health emergency workforce and how it is expanding and how it may provide support and assistance if and when necessary.
Crisis Standards of Care
For Blumenstock, it was quite clear that a nuclear incident would trigger a scarce resource environment requiring a crisis standards of care posture. Implied in that statement, he said, are the following questions: At what point should a “playbook” of crisis standards of care for a nuclear scenario be developed? How well in advance can and should that be done—including using the playbook to conduct training and exercises—rather than waiting for an incident to happen and using it on a “just-in-time” basis?
Unique Needs of the Pediatric Population and Public Resilience
Blumenstock mentioned a recurring thread that emerged throughout the workshop: the unique and specific needs of the pediatric population in the event of a nuclear incident, ranging from communications and education through medical countermeasure availability and clinical care. Blumenstock also called for if not a national conversation, then a regional conversation around public resilience and nuclear preparedness. For him,
the public service announcements in Ventura County demonstrate that it is possible to do this (see Chapter 5). In his opinion, a nuclear incident should be considered part of the spectrum of threats and risks that the U.S. public is facing. In his opinion, the more it is talked about with appropriate information from credible sources, the more comfortable the public will be and the more focused on how to become better prepared.
Research Needs Moving Forward
Blumenstock highlighted several areas of potential research that would help advance preparedness and response for a potential nuclear incident. Specifically, he mentioned the need for more effective communication strategies, as discussed by Steven Becker and others. For example, he said, stakeholders could do more to understand the power of social media, both positive and negative, and its applications. In addition, he said, emerging technologies (such as wireless emergency alerts) could be pursued as a useful tool for successful public outreach and education. Separately, Blumenstock highlighted the clinical aspects of burn care as an additional research gap, especially around mortality associated with third-degree burns.
Workforce Needs and Collaboration
Blumenstock noted that workforce needs and gaps were discussed repeatedly throughout the workshop. In particular, he mentioned the importance of supporting nuclear response skills development, education, and training among current and future members of the public health and health care workforces; the challenge of addressing responders’ fears and discomforts regarding a nuclear incident; the role of volunteers and technology (e.g., telemedicine) as “force multipliers” during a response; and the need for specific training and medical curricula in areas such as medical toxicology and burn care to ensure that physicians, nurses, and support service staff are competent and comfortable handling complex and unfamiliar injuries. “We need to be much more serious and focused on teaching, training, and exercising against this type of scenario,” he said. Finally, Blumenstock mentioned the discussion toward the end of day 1 on partnerships and collaboration and how “we are all in it together” (see Chapter 6). Now is the time, he said, to clear silos away, whether those be among disciplines, jurisdictions, or just “turf and parochial” issues. He observed that even just having everyone here in the same room and engaging in conversation for 8 hours has led to a couple of courses of action, with people planning to get together to work through some of the barriers and gaps.
ASPR’S CLOSING REMARKS: CALL FOR AN ACTION PLAN
Yeskey recalled a past meeting with national experts in disaster response and emergency management and medical operations during which someone commented, “A disaster is just a hard day.”
“This scenario is not just a hard day,” Yeskey said of a nuclear incident scenario, echoing earlier workshop speakers. The standard strategies for triaging patients will not work, Yeskey said, if responders must account for both radiation and conventional injuries. He said there will be limited resources, limited countermeasures, and limited staff and personnel to take care of these patients, and if resources are not used effectively and efficiently, people who could survive will not. Responsible allocation of services and scarce resources will be critical, he noted. Ensuring that medical and public health personnel know how to use services and resources is critical to delivery, Yeskey said, and he referred to the list of countermeasures held in the Strategic National Stockpile and elsewhere. Most health care professionals are not familiar with the use of such particular medications, and he noted there may also be additional novel medications in use issued through emergency use authorizations. Ultimately, Yeskey said that crisis standards of care will be important following a nuclear incident, especially because the standards could remain in effect for a long time post-incident. “We don’t talk about that much in public,” he said. “Even in the medical community, we don’t spend a lot of time addressing crisis standards of care.” Yeskey described the response efforts after a potential nuclear incident as a shared responsibility. He called attention to the talent and expertise that the federal government brings to the table but asserted that no single entity can operate independently of others in this space. Governments, private industry, academia, and nongovernmental organizations all need to work together.
Emphasizing Preparedness
Typically, a national disaster comes with a warning. At the time of this workshop, for example, in preparation for a response to Hurricane Lane, ASPR had sent several disaster medical assistance teams to Hawaii and had already deployed a management team several days before. However, during a potential nuclear scenario, there would only be approximately 20 minutes to warn the public before a blast. “So what you have in your communities is what you have for a while,” Yeskey said. No-notice events are especially difficult, Yeskey commented. He compared a nuclear incident scenario to an earthquake scenario. “It’s going to happen, and it’s going to be bad very fast.” He stressed that support following a nuclear incident likely would not arrive quickly, so “if you are not ready and not prepared and you don’t
have those tools available,” he said, “you are going to be in a hole, and those are going to be hard to dig out of.” Thus, the real work, in his opinion, is preparing communities prior to an event. This includes educating practitioners and providers about the threat environment, ensuring community education and resiliency, and ensuring strong communication plans.
Windows of Opportunity for Medical Care
In response to a nuclear incident, Yeskey stated that stakeholders should consider the potential “windows of response” in relation to the likely patient populations that will emerge following an event: trauma patients, patients with acute radiation sickness (ARS), patients with burn injuries, patients with chronic injuries who require long-term rehabilitation, and patients with mental health issues, among others. During the initial response—only a few days—the focus should remain on traumatic injuries. In the following days and weeks, many will likely require attention for ARS. Yeskey also expressed concern for displaced populations, which could number upward of hundreds of thousands of people. Many in this group could rely on regular medication or suffer from chronic medical conditions, making long-term treatment—in shelters or other settings—difficult. Poor access to medications or care could create a larger burden on the health care system after it is already damaged and overwhelmed, Yeskey said.
Finally, the last window of opportunity is rehabilitation, Yeskey noted. He said this window is important and is often forgotten in planning and exercises. He posed several questions for consideration: What happens 1 year after a nuclear incident when people who suffered traumatic injuries require rehabilitation? How do these injuries increase the burden on recovering health care systems? How are these patients cared for? Yeskey also noted that while the risk of cancer from radiation is low, for those who do suffer that fate, it is a significant setback, and long-term recovery becomes all the more important.
Yeskey identified three crosscutting issues for the public health and health care communities to consider in response to a nuclear incident: mental health, audience-specific and age-specific communications strategies, and fatalities management. He noted that while fatalities management had not been discussed at the workshop, the topic warranted further attention as it is an inherently difficult issue (e.g., identifying human remains and matching loved ones with their families).
Windows of Opportunity for Communications
Yeskey stressed the initial message repeated throughout the workshop of “Get inside, stay inside, stay tuned.” “But then what?” Yeskey asked.
He encouraged the audience to imagine someone—hungry, thirsty, scared—sheltering for 2 days after an event. Naturally, he said, those sheltering will have questions: Is it safe to drink tap water? Is it safe to eat from canned food that has dust on top of it? Is it safe to eat vegetables that have been outside? These and other environmental and public health issues should be addressed in a consolidated message across jurisdictions, Yeskey said. Looking toward long-term recovery, Yeskey commented that many people would likely wonder when they could return to their homes and communities: When is it safe, and how “safe” is safe? How “clean” is clean? Yeskey noted that these are the types of questions often asked during recoveries from hurricanes and other disasters, and he suggested that lessons can be drawn from preexisting bioterrorism planning.
Developing an Action Plan
Lastly, Yeskey urged that the next step in nuclear preparedness be to consider an action plan by identifying priorities and delegating roles across stakeholders. He observed that there are numerous roles for ASPR based on the workshop discussions and noted that the government is well suited to delineating roles and designating funding. He reiterated, however, that this is a shared responsibility, and the private sector is absolutely better suited to performing certain tasks than the government. Looking ahead to the next 12 months and beyond, Yeskey said ASPR will engage organizations already working in this space, including the American Burn Association (ABA), the Association of State and Territorial Health Officials, the National Association of City & County Health Officials, and the Radiation Injury Treatment Network (RITN). ASPR’s Regional Disaster Health Response System will help to address some of the concerns brought up at the workshop, he said, but there is more work to be done and more partnerships to facilitate. He cited a budding partnership between ABA and RITN—“we need more of that kind of action.” As he adjourned the meeting, Yeskey commented that collective action can lead to solutions in this arena, but time is of the essence.
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