9

Building Preparedness and Response Capability: Looking to the Future

During the workshop’s final panel, moderators from previous sessions were asked to share their reactions to workshop discussions and consider a path forward to achieving an appropriate state of readiness for nuclear incidents. Session moderator Laura Wolf, director, Division of Critical Infrastructure Protection, the Office of the Assistant Secretary for Preparedness and Response (ASPR), U.S. Department of Health and Human Services (HHS), also provided a brief overview of ASPR’s Division of Critical Infrastructure Protection as it connects to nuclear preparedness. This chapter summarizes her presentation, the moderators’ wrap-up, and the audience discussion that followed.

ASPR’S CRITICAL INFRASTRUCTURE PROTECTION PROGRAM

Critical infrastructure has four main components, which Wolf referred to as “the four ss”: staff, stuff, systems, and space. Wolf explained that the combination of properly trained staff, robust utility systems, access to necessary resources (e.g., pharmaceuticals, medical materiel), and resilient physical space can help the health care and public health sectors ensure resilience and risk mitigation. She emphasized that the Critical Infrastructure Protection Program (CIP), ASPR, considers infrastructure to go beyond simply hospitals; it also includes pharmacies, dialysis centers, health clinics, and other components of the broader health care system.

Wolf described the core functions of CIP. Because critical infrastructure is owned mostly by the private sector, CIP’s network of partners is critical to its success. Through the network, CIP supports private sector and other

stakeholder coordination of preparedness, response, and recovery efforts and supports insights-driven decision making through the connection and analysis of quantitative and qualitative data, Wolf said. CIP also supports risk management, and for the past 3 years, it has supported the development of a Health Care and Public Health Risk Identification and Site Criticality Toolkit,¹ which she described as an “objective, data-driven, all-hazards risk assessment” for partners. The toolkit will be released at the end of 2018, she said. In its role as a convener of diverse stakeholders, Wolf said that CIP maintains communications efforts between its stakeholders, leads Emergency Support Function #8 responsibilities for HHS, and has organized several working groups in cybersecurity, supply chain resilience, and biotechnology threats and opportunities.

MOVING FORWARD: PRIORITIES IDENTIFIED BY INDIVIDUALS ON THE REACTION PANEL

Wolf asked the panelists to reflect on priorities for moving forward that were identified and discussed throughout the course of the workshop.

Current State of Preparedness

Roberta Lavin, the moderator of Session 1 (summarized in Chapter 3), focused on the current state of preparedness for a nuclear incident. She prioritized the following:

• Lack of available expertise in radiation/nuclear science for state and local planners. Lavin reemphasized the lack of expertise in radiation and nuclear threats among state and local public health staff across the country. Other panel members agreed as well.
• Lack of funding to plan adequately for nuclear incidents.
• Confusion around crisis standards of care. Lavin expressed concern that state and local public health practitioners and health care partners do not understand how to implement crisis standards of care during a nuclear incident; several panelists noted that this issue has not been adequately addressed. Lavin pointed out that in large part because of complacency around the threat of a nuclear incident, the health care workforce is not being trained on the standards, accessing them, or using them.

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¹ See https://www.phe.gov/Preparedness/planning/RISC/Pages/default.aspx (accessed January 18, 2019).

• Constant change of personnel. Lavin summed up the concern of state and local staffing turnover: “Once you get people to know what they need to know, they leave,” she said.

Planning Assumptions

Cham Dallas, who moderated the second panel session on planning assumptions (summarized in Chapter 4), prioritized the following:

• New threats are changing planning assumptions. The possibility of a nuclear device much larger than 10 kilotons, Dallas said, completely upends previous planning efforts.
• Questions around what jurisdictions will “give up” in the event of a nuclear incident nearby or elsewhere. Touching on a point mentioned by James Young during his session, Dallas questioned how jurisdictions would support one another in the event of a nuclear incident given the sensitivity of resource sharing and allocation during such a deeply traumatic and potentially consuming event.
• Assumption that responders will show up in the event of a nuclear emergency. We cannot make assumptions that people will show up to work during a possible nuclear emergency, Dallas said. Many people inappropriately believe that the possibility of a nuclear incident is the most catastrophic threat. Even as knowledge is increasingly disseminated on this topic, fear and denial spreads easily, he said.
• Need for nonfinancial incentives. Dallas noted that ASPR and other federal entities already offer financial incentives to state and local jurisdictions to remain aware and prepared for nuclear threats, but he said he believes that nonfinancial incentives should be increasingly sought out.

Communication Challenges

Steven Becker, keynote speaker and moderator of the session on communications (summarized in Chapter 5), discussed the following takeaways from his panel:

• The importance of effective communication. Citing its emphasis and focus at this workshop, Becker noted the importance of effective communications as an emerging issue in nuclear preparedness (he mentioned the past 10 years as a particularly important period of development) and, more broadly, other disaster preparedness as well. He cited effective communication as an important tool for public readiness in the face of a horror scenario.

• Communication is inexpensive. Not only is effective communication one of the most important tools; it is also one of the least expensive intervention strategies, Becker said.
• Priority research gaps. Becker identified several research gaps in communications that he deemed to be high-priority issues: testing the effectiveness of pre-developed communications tools across demographic groups; research to inform the next stage of development on nuclear incidents, including addressing issues around stigma and new technologies such as wireless emergency alerts; and research to understand effective strategies, forms of outreach, and tools for first responders and health care workers.
• Importance of drills and exercises. Becker stressed the importance of testing new communications tools through drills and exercises, for nuclear incidents and other disaster planning. He suggested the development of an exercise guide or manual.
• Audience-appropriate communication materials. Becker suggested creating interdisciplinary work groups to inform the communication needs of several groups, including children and specialists who play important roles in a potential nuclear incident response.

Challenges to Building Capacity

Bruce Evans, moderator of the panel discussion on challenges to building capacity (summarized in Chapter 6), described priority areas from his panel discussion:

• The importance of buddy care
• The need for more burn care resources, including the workforce
• The need for high-fidelity simulation, including successful drills with distractors or additional stressors put on participants
• Encouragement of participation in international disaster response to build experience
• The likely shortage of bioassays during a response

Building Future Response Capacity

John Benitez, moderator of the panel discussion on building response capacity (summarized in Chapter 7), prioritized the following:

• Changing federal operating assumptions. Benitez noted that the operating assumptions of several federal organizations—including the Strategic National Stockpile, the Federal Emergency Management Agency, and the U.S. Department of Veterans Affairs—will

• continue to change, and it will be important to monitor to ensure readiness for a nuclear incident.

• The use of volunteers during a response. Benitez stressed that volunteers will likely be critical during a chaotic response to a nuclear incident, and he emphasized the importance of leveraging lay, professional, and just-in-time volunteers during a response.

Ensuring Workforce Readiness

Finally, John Koerner, who moderated the panel discussion on workforce readiness (summarized in Chapter 8), mentioned his takeaways from the panel:

• Criticality of developing metrics to quantify readiness. Koerner suggested the implementation and use of metrics to quantify levels of preparedness for nuclear events; currently, there are not enough data to understand readiness, he said. This includes understanding the availability of the workforce to surge up during an event for needs such as boots on the ground and lab work. Additionally, the workforce should partake in ethics training to ensure good care during an incident.
• Systems approach. Koerner suggested that stakeholders begin to frame the medical and public health systems as a “system of systems” in order to clarify how the various complex components, resources, and organizations fit together. He also mentioned the possibility of taking on a CONOPS (continuity of operations) approach to nuclear preparedness; he said the systematic linkages that such an approach would create between health care coalitions, other nontraditional resources, and the government would be useful during a potential response, especially in the context of a new regional framework.

Wolf ended the panel by analyzing several of the points made by speakers. Regarding communications, Wolf agreed that more research is needed and that findings from this arena should be translated appropriately into policy and action. She also emphasized the “bang for your buck” appeal of communications strategies, explaining that despite its low cost, successful communication has the potential to have a broad reach and impact in nuclear incident preparedness and response. She described updating planning assumptions around nuclear threats as another example of “low-hanging fruit” that has the potential to impact preparedness in important ways. Regarding professional response readiness, Wolf emphasized Koerner’s point about ethics training, noting that an understanding of the

interdependencies of crisis standards of care will prove critical during a potential nuclear incident.

ADDITIONAL TOPICS IDENTIFIED BY THE AUDIENCE

Following the panel discussion, Wolf solicited the audience for additional gaps and potential solutions in nuclear preparedness. Several audience members offered responses.

David Eisenman, associate professor, Geffen School of Medicine and Fielding School of Public Health, University of California, Los Angeles, mentioned willingness to respond as the key issue in his opinion. He noted that while it is important that medical professionals remain willing to respond, hospitals also cannot function without other staff support, including administration and maintenance. He noted that this problem is also connected to the interdependency of the health care workforce, as pediatrics, burn care, lab staff, and others will need to work in coordination to ensure a successful response. Eisenman also underscored the importance of communication with the public because ultimately, he said, community members are the first line of defense following a disaster.

Regarding workforce issues, Alan Siniscalchi of the Connecticut Department of Public Health and the Council on State and Territorial Epidemiologists called attention to the potential role that epidemiologists could play in a nuclear response, particularly with respect to data analysis. Art Cooper suggested an update to the “ready, willing, able” framework that would put “able” first; he suggested this because those who are able to respond appropriately are more likely to do so, he said. He also suggested creating a platform for just-in-time training for nuclear preparedness in order to make relevant material easier to teach, access, and update. Mary Casey-Lockyer suggested ramping up first aid training for volunteers because despite the possibility of radiation injuries, many individuals will require other first aid care following a nuclear incident. Lastly, Ann Knebel, deputy scientific director, Division of Pre-Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, emphasized the importance of engaging medical experts in areas addressed in less detail at the workshop—such as oncology—to ensure that a holistic approach is taken when managing thermonuclear patients and to ensure that radiation expertise is available.

Jessica Wieder emphasized a message from her presentation earlier in the workshop about the importance of teachable moments as a way to raise awareness about specific concerns. She noted, for example, that September 2018 was National Preparedness Month, a perfect time to spread messages about the causes discussed at the workshop. Wieder also mentioned the im-

portance of federal coordination for nuclear preparedness, and she said that entities should work to ensure that messaging is consistent across platforms.

Michael Consuelos stated that workshop participants should continue to pay attention to inevitable upcoming disasters in order to learn from them. In the next year and beyond, he said, other disasters will occur, and preparedness stakeholders should use those experiences to record lessons learned in real time and test new ideas to improve disaster preparedness and resilience.

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