In the next panel session of the workshop, moderated by Roberta Lavin, executive associate dean and professor, College of Nursing, Univer-
sity of Tennessee, professionals representing state and local government agencies and related organizations were asked to consider the following: the current state of medical and public health preparedness for a nuclear incident; the relationship between current medical and public health preparedness and prior assumptions of the threat environment; possible changes to planning assumptions for nuclear incidents, with particular attention to the (re)emergence of state actor threats; and implications of these possible changes for nuclear incident prevention, planning, and response.
Patrick Lujan, emergency preparedness manager, Department of Public Health and Social Services, Guam, described the events of August 2017, when Guam made headlines worldwide following nuclear threats from North Korea. In October of that year, Guam was threatened again by North Korea. In response, Guam built up its research and planning for any future potential threats, Lujan explained. Lujan was followed by Michael “Mac” McClendon, director, Office of Public Health Preparedness and Response, Harris County Public Health. With its 33 cities, including Houston, Harris County is the third largest county in the United States. McClendon’s office is responsible for all-hazards response and recovery planning, and his remarks were also informed by his participation in the National Association of County & City Health Officials (NACCHO) Radiation Workgroup. The third panelist was Chris Williams, deputy director, Office of Radiation Protection, Washington Department of Health. Part of his role is to oversee the state’s Radiological Emergency Preparedness Program, which focuses primarily on radiation readiness for Columbia Generating Station, Hanford Nuclear Reservation, and Naval Base Kitsap. In addition, his office works with the Federal Bureau of Investigation and local fire and emergency medical services on radiological dispersal device (RDD) preparedness. Finally, Regina Hawkins, senior analyst, preparedness, Association of State and Territorial Health Officials (ASTHO), and co-lead, National Alliance for Radiation Readiness (NARR), offered an organization-level perspective as a convener of state and local health representatives.
Panelists discussed preparedness at several different levels, with Lujan describing Guam’s experience as a U.S. territory first. At 33 miles long and 7 miles wide, and with a population of 170,000, Guam is among the largest islands in the North Pacific. Nearby smaller islands look to it for guidance and leadership, Lujan explained. However, until the North Korean threat emerged in summer 2017, nuclear planning was “foreign” to Guam, despite ample public health preparedness planning more broadly, he said. Thus, Guam aggressively pursued a memorandum of agreement with the
U.S. Department of Defense (DoD) to address Guam’s response to this new threat, albeit with challenges. For example, the nearest Strategic National Stockpile cache is on the west coast of the continental United States, raising concerns about response time, Lujan said. In addition, Guam’s health care workforce is aging, which makes it difficult to build up a medical professional volunteer program. This is true not just on Guam, Lujan said, but also on the outer Pacific Islands. However, compared to the other islands, because of its unique territorial status, Guam is able to lean on DoD to provide resources.
At the state level, Williams explained that Washington’s Department of Health initiated its Radiological Emergency Preparedness Program in the 1970s because of the radiological hazards at the Columbia Generating Station, the Hanford plutonium development site, and the U.S. naval shipyards and submarine base. With the advent of public health emergency preparedness (PHEP) and the Office of the Assistant Secretary for Preparedness and Response (ASPR), U.S. Department of Health and Human Services, funding in 2002, the state began investing in public health preparedness on a broader scale. Although the PHEP- and ASPR-funded approach is an all-hazards one, the initial focus was on bioterrorism as directed from the federal government. In addition, the program also focused on threats that were specific to the state of Washington, including local disease threats, such as measles outbreaks, but also floods, wildfires, and other natural disasters, Williams said.
Nuclear incidents, including improvised nuclear devices (INDs) and other missile attacks, are not viewed as high-probability incidents, Williams said, and also a draft IND plan is in place. The radiological incidents are considered high probability to the extent that the state already deals with radiological hazards. Some of the PHEP and ASPR funding has gone into developing community reception centers close to Columbia Generating Station, Hanford, and in Kitsap County to offload the stress from hospitals in the event of an incident. Patients who might be impacted radiologically could then be sent to those centers. Ultimately, Williams said, threats are prioritized and addressed based on funding levels.
Williams said a key concern regarding nuclear threats is public perception. When the Fukushima incident occurred, Williams’s office took calls for several months from Washington residents who were concerned about an incident that had happened thousands of miles to the west, separated by an ocean. “The concern of the citizens really impacted our office in terms of the time spent trying to alleviate their fears,” he said. If an incident were to occur within Washington, self-evacuation would likely be a problem, with residents attempting to leave without understanding the magnitude of the threat. This, in turn, would impact people and hospitals outside of the impacted area, he said.
Addressing emergency support, Williams said the capacity of facilities in surrounding areas to handle the influx of patients from impacted areas and to treat those patients is a major challenge. Williams described an area of Seattle known as “Pill Hill,” where a large number of hospitals, including a Level 1 trauma center, are located. If that area were to be hit, those hospitals and that trauma center would be affected and possibly destroyed, in which case facilities outside of the impacted area would be dealing with issues for which they are unprepared. Williams concluded by noting that Emergency Support Function #8 partner coordination should become a higher priority.
McClendon described nuclear preparedness at the local level. Until recently, he said, Harris County’s nuclear preparedness efforts centered around transportation incidents related to shipping out of Port Houston or traveling to and from the port on the highway. Approximately 5 years ago, the Centers for Disease Control and Prevention (CDC) pulled McClendon and his colleagues into Atlanta for a 3-day summit on INDs, RDDs, and related threats, after which his office built and exercised plans, identified gaps, and developed about 25 partnerships across the county.
A key capacity-related challenge for a nuclear incident is derived from the county’s responsibility to plan megashelter (a shelter with more than 1,500 beds) operations throughout in the event of an emergency. For example, during Hurricane Harvey, Harris County operated two 10,000-bed megashelters, one at the NRG Center and another at the George R. Brown Convention Center. If the county is also responsible for screening people following a nuclear event, it has to be better prepared, McClendon asserted. Recent nuclear preparedness training exercises have gone well, McClendon said, with respect to the use of electronic and paper screening tools. However, it is unclear how prepared the county is for a larger, state-sponsored event. While the county continues to engage the private sector to support preparedness—including private health care systems, medical societies, and nongovernmental organizations—the private sector partners are not used to the typical government command and control structure, McClendon said.
Workforce issues pose another capacity-related challenge, as made evident during Hurricane Harvey. Harris County Public Health employs 700 people, but only 360 employees worked during the peak of the disaster, while the remaining employees were either unwilling to work or were affected by the hurricane themselves. McClendon described the county’s challenge in stressing to employees the importance of their role during an emergency response. “They do their day-to-day function,” he said, “but when we have a Type 1 event going on at the local level, they are reassigned, and that is problematic right now for us.” He called for refreshing the education and training of new employees so that they understand the importance of emergency response functions.
Regarding emergency management, McClendon hypothesized that if a state-sponsored event were to hit the city of Houston or Harris County, local responders would be on their own for the chaotic first 48 hours after the event, citing a period following Harvey during which entry into the county was exceedingly difficult. The experience led the county to preidentify employee needs during an emergency. Aside from broad all-hazards lessons in disaster preparedness, McClendon said that Harris County has not developed a response plan specifically for state-sponsored nuclear incidents.
Finally, Hawkins offered NARR’s perspective on nuclear preparedness, representing a broad coalition of state and local health partners. Regarding its strategic priorities, ASTHO assists its members in building resilient workforces, supports them through technical assistance, provides them with tools and also empowers jurisdictions to develop their own tools for radiation readiness, and helps to shape policy to ensure that the voice of public health is represented. Hawkins remarked that although most of its constituents have adopted an all-hazards planning and preparedness mentality over the years, there has been greater interest recently in preparedness specifically for a radiological or nuclear incident. Hawkins mentioned ASTHO’s participation in the Pacific Islands Preparedness and Emergency Response Summit and the sharing of federal (CDC, Environmental Protection Agency, etc.) materials and tools—including infographics and protective action guidelines—with Pacific Island members.
Turning to NARR, Hawkins has noticed growing interest among state and local public health practitioners through NARR’s webinars and traffic to other resources. The webinars allow for subject matter experts to discuss the newest tools and discoveries, and in May 2018, NARR released guidance for traveler screening at international ports of entry following a radiological incident; other tools are also in development, she said.
EMERGENCE OF STATE ACTOR THREATS: HAS IT CHANGED PREPAREDNESS PLANNING? HAS IT CHANGED WHO IS AT THE TABLE?
Lack of Nuclear Expertise at the Local Level
McClendon said that because of Harris County Public Health’s lack of expertise in radiation, it has entered into a memorandum of understanding with the University of Texas Health Science Center for health physics experts to advise and lead the county through a planning process. The county also leans on its state partners. In addition, the county maintains partnerships through health care coalitions and the private sector. As Houston is the “oil hub” of the United States, McClendon said, several oil corporations are headquartered there, with expertise in planning, responding, and recovering
from catastrophic emergencies. For the past 20 years, Harris County has been under either a federal or state disaster declaration response every 9 months (whether due to hurricanes, tropical storms, floods, or other disasters), and as a result there have been many opportunities to work with private sector partners. McClendon predicted that in the event of a state-sponsored nuclear incident, the county would likely lean heavily on the private sector until state and federal support arrive. Based on past experience with Type 1 incidents—the most complex incidents according to the Federal Emergency Management Agency’s emergency management grading scale—he described how local jurisdictions tend to scramble during the first few hours of a response, attempting to make sense of what is going on. He imagined that a state-sponsored nuclear incident would be so traumatic that it would stun them initially.
Williams agreed with McClendon that public health generally is not a radiation expert-oriented field. Although the state of Washington has an Office of Radiation Protection, there is no counterpart at the local public health level, Williams said, and Washington’s health care coalitions lack expertise in radiation-related issues. Although Williams’s office can provide that support, it has only seven staff, all of whom are dealing with other issues, primarily based on funding.
Nuclear Readiness at the Local Level: Calling for Support from Above
McClendon noted that further investment in nuclear preparedness will require further direction and funding from the federal government. The primary focus of Harris County Public Health right now is on day-to-day health promotion: obesity, smoking, other local health issues. When McClendon and colleagues approach the executive director about their planning process, the response is, “Where’s your capacity, and where are your dollars? That’s the bottom line,” McClendon said. Of nuclear incident preparedness, he said, “if it needs to be elevated, then it has to come elevated to us.”
Williams agreed with McClendon that an emphasis on nuclear readiness must come from higher level decision makers and be matched by adequate sources of funding. He reiterated that the focus is going to be on immediate, day-to-day issues unless a push is made from the sources that fund the state’s preparedness to be better prepared for a nuclear incident. PHEP and other federal sources of funding for state and local health often dictate priorities for these jurisdictions, Williams said.
Optimism: Nuclear Preparedness Is on the Docket
Hawkins offered what she described as “a little bit of a silver lining” in that much of the activity over the past year with respect to the threat of a
state-sponsored nuclear incident has acted as a catalyst. For her, one of her most important tasks with both ASTHO and NARR is the forging of very strong relationships with both members and federal partners. Over this past year, ASTHO’s federal partners have been reaching out directly and even using ASTHO as a conduit for reaching out indirectly to its members. In Hawkins’s opinion, ASPR has been mindful of state and local needs when making revisions to public health emergency preparedness planning. For example, she mentioned ASPR’s reaching out regarding the new Regional Disaster Health Response System (RDHRS) and reaching out for feedback and input.
A Role for International Assistance?
Because of its distance from the U.S. mainland, Guam has learned to “think outside the box,” Lujan said. Guam’s closest neighbors are Japan, Korea, the Philippines, and Australia. He mentioned having recently attended a biosecurity exercise on smallpox that was hosted by the University of New South Wales, Australia. Lujan expressed concern about current geopolitical tensions in the North Pacific and called for making necessary amends so that Guam can seek international assistance should a state-sponsored event occur.
Cham Dallas, university professor of health policy and management and director of the Institute for Disaster Management at the University of Georgia, also touched on the topic of international assistance. He mentioned the World Health Organization’s emergency medical teams and the discussions under way about extending the teams’ focus to cover thermonuclear threats (Ian Norton discussed this resource in greater detail later in the workshop; see Chapter 6). He too thought that cooperation with other nations was worth considering and wondered how feasible it would be, citing a recent example from his own work supporting Chinese officials working on nuclear preparedness.
Lavin, the moderator, asked panelists how preparedness efforts and plans at the state and local levels are relayed to hospitals, public health departments, and health care providers who are responsible for medical care in the event of a nuclear incident. In response, most of the panelists expressed concern about workforce turnover.
While McClendon commended ASPR’s development of RDHRS, he cautioned that the magnitude of people impacted by a state-sponsored nuclear event would require spending more money on training hospital
employees—the “boots on the ground” who do not worry about nuclear preparedness on a daily basis. Not only would the hospital employees need to be trained, but training efforts would also need to account for high staffing turnover at various levels, including nursing, and hospitals “have to start all over” 2 or 3 years after a previous training, McClendon said.
Radiation exposure treatment is unfamiliar even to some trauma physicians and providers, McClendon continued, and some providers do not maintain specialty skills across the course of their careers. He recalled how upon issuing a request through the Medical Reserve Corps for nurses to administer vaccines during an H1N1 epidemic, several of the nurses who responded had not administered a vaccine to a child in years. As a result, McClendon’s office was forced to offer just-in-time training to educate the nurses on the administration of vaccines for children ages 0–8. He emphasized the need for ongoing and systematic funding to ensure that more hospitals employ providers who can treat people in a nuclear trauma situation.
Williams agreed that staff turnover is a challenge and that maintaining boots on the ground readiness requires ongoing effort. When preparedness activities were still part of the Health Resources & Services Administration (prior to moving to ASPR), he noted, Washington State purchased large quantities of equipment for hospitals to prepare for all-hazards threats and offered annual training to hospital staff. Williams echoed McClendon and noted the frequent and noticeable staff turnover at the training sessions. Many employees in coordinating positions remained, but there was high turnover among hands-on providers.
Hawkins agreed with McClendon’s and Williams’s concerns about workforce turnover. She noted that NARR has experienced recent turnover due to retirement, and she emphasized the criticality of maintaining subject matter expertise in the area of nuclear preparedness and medical response.
Willingness to Work in the Event of a Nuclear Incident
In addition to expertise and training, Hawkins raised another issue that continually appeared throughout workshop discussions: responders’ willingness to work. She explained that there is a fear around radiological and nuclear preparedness even among those who are well educated and understand the risks of such an event.
Lacking in Resources But Strong in Networking: A Different Challenge
The situation in Guam is slightly different, Lujan explained. While the island lacks resources, networking is one of its strengths. Coordination is relatively smooth when an emergency occurs because the major decision makers in the police department, the fire department, hospitals, and other
important command centers already know one another, and when the resources arrive, “we just roll,” Lujan said.
Williams explained that in 2002, when he joined Washington State’s preparedness program, he had a conversation with his doctor about his work, and the doctor said, “That will never happen here,” referring to a potential bioterrorist attack. Williams suspected that conversation would have played out similarly if the topic had been nuclear events. Ultimately, he said, the threat of a nuclear event is not on the public’s radar, and people especially tend to avoid projecting the threat onto themselves directly.
McClendon agreed and added that even among local elected officials, the threat is not high on their radar. He suspected that Harris County could successfully draft and implement a plan as a receiver community in the event of a nuclear incident—if Harris County itself were not affected directly but took in displaced persons from the affected area. However, people do not want to project themselves as being the affected community, McClendon noted. Additionally, despite the possibilities for survival and recovery as described by Buddemeier, McClendon said that many officials have a fatalistic attitude toward a potential event. Thus, McClendon emphasized the need to educate even local officials about the threat environment, the realities for survival and recovery, and the need for preparedness planning (see Chapter 5 for additional discussion around communications tools and strategies).
Crisis Standards of Care
Jack Herrmann, deputy director, Office of Planning and Policy, ASPR, referred to Buddemeier’s description of the magnitude of the potential public health and medical impacts of a state-sponsored nuclear incident (see Chapter 2) and asked the panelists about efforts being made to address crisis standards of care: Are state, local, and territorial jurisdictions working with the health care sector to develop response plans to potential emergencies of this magnitude, during which there may be hundreds of thousands of people needing care?
Williams replied that in his prior role with Washington State’s Public Health Preparedness Program, he and colleagues developed a number of work groups to address crisis standards of care. However, groups focused primarily on pandemics and continuity of operations for situations during which, for example, there are more sick people than there are ventilators.
As far as he was aware, the state has not addressed crisis standards of care related to nuclear or radiological threats. McClendon described a similar situation for Harris County. There used to be a statewide crisis standards of care work group, but the effort stalled several years ago, and it has not been revived.
Preparedness for Ship and Sea-Related Delivery
David Winks, managing director, AcquSight, asked whether any of the jurisdictions represented on the panel had considered ships or submersibles being used to deliver an IND. Williams replied that Washington has a program whereby the state works with the U.S. Coast Guard and law enforcement officials to search for radiological sources on ships, particularly in the Puget Sound region. Trainings are conducted two or three times a year. In Texas, the Port of Houston Authority receives federal grant money to screen all containerized cargo that enters the port, McClendon explained. He said it is an active and well-supported program and that Port Authority is in constant communication with Harris County’s hazardous materials team and the U.S. Coast Guard; they also have the ability to screen on highways as well.
Concerns About Local Preparedness and Public Outreach
Raymond Puerini, senior program analyst, NACCHO, echoed panelists’ concerns about local preparedness and shared findings from NACCHO’s most recent annual preparedness profile assessment indicating a low level of concern regarding radiation issues. About 20 percent of respondents expressed concern about an accidental release, and only 16 percent reported feeling very prepared for an actual radiation emergency. In addition, 42 percent of respondents reported that they were not conducting any preparedness activities related to terrorist threats, and 35 percent reported that they were not conducting any activities related to CBRN (chemical, biological, radiological, and nuclear) threats.
Puerini said that NACCHO has also engaged stakeholders at both the local and state levels to understand gaps in preparedness, some of which are the same as those described by the panelists, including a lack of perceived risk of being affected by a nuclear incident and lack of outreach and public awareness. In addition, he said, stakeholders reported organizational silos and competing priorities that make it difficult for leadership to buy in to preparedness. Of these, lack of outreach and public awareness is the most profound gap, Puerini said.
Puerini asked Lujan about the strategies being deployed in Guam when facing threats from North Korea to engage the public and make people
feel safe and prepared. Lujan replied that the general strategy centered around CDC’s shelter in place message, and the territory worked with the Department of Homeland Security and DoD to spread it. In addition, they partnered with the University of Guam to hold live broadcasts.
Partnering with Vendors
In addition to the partnerships described by Hawkins, Kris Arnold of the American Red Cross Scientific Advisory Council suggested pursuing partnerships with hospital product vendors. She mentioned the increased use of advisory assistance in hospitals and projected that with these partnerships in place, hospital officials would be more easily able to efficiently disseminate (via electronic systems) current knowledge and instructions for handling radiation contamination and other CBRN problems.
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