By William T. Bowen, Commander (retired), Albany Police Department, New York; Health Policy Advisor, New York State Office of Homeland Security
hose who have worked in law enforcement for more than six years can recall when their duties were less complex and the term comprehensive referred only to a type of insurance coverage. Although the demands on law enforcement, like other first responders, were steadily increasing even before the terrorist attacks of September 11, 2001, they simply skyrocketed afterward.
In the past few years, the law enforcement vocabulary has expanded to include new terminology such as Homeland Security Presidential Directive (HSPD), National Incident Management System (NIMS), National Response Plan (NRP), critical infrastructure, unified command, all-hazards response, and comprehensive response protocols.
This change in vocabulary is indicative of the shifting focus of the role of law enforcement. One of the purposes of HSPD-8, issued in December 2003, is to outline actions to strengthen preparedness capabilities of federal, state, and local entities to respond to and recover from acts of terrorism, disasters, and other emergencies.1 Law enforcement professionals should therefore be meeting with other first responders to draw up comprehensive, all-encompassing response protocols.
Among other goals, HSPD-8 seeks to reassess the definition of first responder. When asked to identify first responders, most individuals familiar with this term choose the traditional ones: police, firefighters, and emergency medical services (EMS). Just as the vocabulary and duties of first responders have changed based on evolving preparedness needs, the definition itself of first responder must also change. It too has to be all-encompassing, like the response protocols currently being drafted. The first group that should be included in the expanded definition of first responder is public health departments—not the local health departments of days gone by, but those whose focus has shifted since September 11, 2001: hospitals, clinics, long-term care, nursing homes, and various health-care providers.
In fact, HSPD-8 reaches the same conclusion. However, this directive goes even further in defining first responders as “those individuals who in the early stages of an incident are responsible for the protection and preservation of life, property, evidence, and the environment, . . . as well as emergency management, public health, clinical care, public works, and other skilled support personnel (such as equipment operators) that provide immediate support services during prevention, response, and recovery operations.”2 For the purposes of this discussion, the focus will remain on public health and law enforcement.
Public Health As a First Responder
Like other first responders, the public health field has significantly redefined its role before, during, and after a disaster. As with the traditional first responders, public health officials are planning and preparing to accommodate a surge of victims needing or desiring medical treatment, as well as to protect the public from the spread of disease. Many public health preparedness plans include law enforcement—yet most law enforcement professionals are not aware of this and, more importantly, do not see a role for themselves in a public health crisis.
Disasters, whether natural or man made, cause large numbers of people to seek medical treatment. They also generate a significant amount of chaos. Law enforcement and public health officials should be planning for both. When reviewing recent disasters worldwide, it is easy to recognize that every disaster either starts as a public health crisis or becomes one in time.
Although it is hard to predict exactly what will happen in future disasters, we can rely on lessons learned to help shape our planning efforts. As observed during various disasters, on average, as many as 80 percent of those injured during the initial emergency bypass the EMS system and self-ambulate to the nearest emergency departments (EDs), hospitals, and clinics, seeking medical attention.3 For example, in the Tokyo subway sarin attack on March 20, 1995, 12 people were killed and more than 5,000 reported injured, of whom almost 700 were treated and transported by EMS. Since at least 4,000 victims are known to have received medical attention, more than 3,300 sought medical treatment on their own.4 The EDs, hospitals, and clinics to which victims self-ambulated were the first facilities to respond to the needs of these victims. In a very real sense, the staffs at these facilities were part of the community of first responders.
Public health is concerned with surge capacity during and after a disaster. Simply defined, surge capacity is the ability of a hospital to expand its services beyond normal operating levels to treat an atypically large influx of patients. Each hospital is planning for ways to accommodate this increased demand. Federal guidelines recommend 500 beds per 1 million population.
What does that mean on the local level? The bombing of the Murrah Federal Building in Oklahoma City on April 19, 1995, left 168 dead, destroyed or damaged over 300 buildings, and injured as many as 850 people.5 Those in charge of first responders should determine if their community has enough hospital beds (proportionally speaking) to handle that kind of demand. Recognizing limitations on local facilities, most hospitals are urged to plan for a surge on a regional basis, ignoring traditional hospital systems and normal geographic boundaries. All disaster planning should start at the local level but have the ability to expand to include regional resources and responses. Every disaster starts as a local emergency. Once it overwhelms the local resources, the emergency becomes a disaster; only through advance comprehensive response planning and developing memoranda of agreement (MOAs) can we properly respond to and begin recovering from the disaster. The National Response Plan uses the phrase “one team, one goal” in describing the appropriate attitude for collaboration on disaster response.6
The Law Enforcement Connection
What do self-ambulation and surge capacity have to do with law enforcement? They are clearly health issues. But when a hospital is forced to turn patients away, who will be called upon to provide security to protect the facility and secure the outside of the building from those who were unable to receive treatment? Hospital security personnel have limited response capabilities and generally operate inside the facility. Following the statistics given earlier and using the numbers from the Murrah Building bombing as an example—80 percent of 850 injured—imagine about 680 patients self-ambulating to a hospital. Add to that the number of “worried well”; the worried well are defined as people who visit a medical facility seeking treatment or reassurance, even though they have no real symptoms or injuries. The exact number of worried well is hard to predict, since the number is usually driven by the type of incident. More could be expected, for example, after a chemical, radiological, or biological incident. Hospitals would have to call upon local law enforcement personnel to provide assistance, secure the facility, and restore order.
Add to this the additional concern of people showing up for treatment following, say, an explosion or dispersal of an agent who have not been decontaminated because they bypassed the traditional first responders at the scene. In circumventing the normal first-response process, these people contaminate the facility they visit, forcing it to shut down. The contaminated facility has then become a second disaster site in need of response from an already overwhelmed community.
Citizens have come to expect a particular level of service and often anticipate immediate treatment when they are sick or injured. However, during a disaster, it may not be possible to triage patients in the normal fashion. With limited medical personnel and limited space, the most critical patients must be seen first. How will a mother respond when told her injured child will have to wait for treatment or return on another day because the child’s broken arm is not as critical as the injuries sustained by other trauma patients? Even worse, how would a father react when his child requires immediate medical attention to survive, but again, due to limited personnel and facilities and the demand of the surge, the child will not receive the heroic efforts typical of emergency departments under normal conditions? We need to plan for the backlash of angry victims and family members whose needs go unmet.
As mentioned earlier, public health crises can also start slowly, coming secondary to a disaster. As seen when New Orleans was struck by Hurricane Katrina in August 2005, an aftereffect of some storms is flooding; waters carrying sewage into streets and homes quickly becomes a public health crisis. If components of the critical infrastructure are damaged, the crisis could develop more slowly, but its effects could be even worse. For example, how many days can a community go without running water or electricity? Electricity powers traffic control devices, business alarms, heating and air conditioning systems, and gasoline pumps. Who will be called upon to direct traffic, prevent looting, and protect those housed in emergency shelters? Is there a contingency plan for providing fuel for emergency vehicles? There is no doubt that the resulting chaos in the community will demand a law enforcement response.
Public Health Concerns with Various Types of Disasters
When planning for responses to chemical, biological, radiological, nuclear, or explosive (CBRNE) incidents, decision makers need to acknowledge that each incident has the potential to create a public health crisis. Therefore, each incident could possibly involve law enforcement professionals and the other traditional first responders in previously unanticipated ways. Soon after two jets crashed into the World Trade Center, the public health concerns became evident: first responders had to be protected from the dust and debris; firefighters had to contend with the smoke and gases from underground fires; and decaying human remains had to be removed as quickly as possible to prevent the spread of disease. Over a period of time, subtle changes to the response itself were noticeable. Responders began wearing masks, helmets, gloves, goggles, and boots. With each new day, the response and recovery efforts became more complex, and the public health concerns farther-reaching. In fact, the full extent of long-term effects on public health from this tragedy may not be known for years. But because responders worked in partnership, the response and recovery efforts continued in what appeared to the public to be a seamless, well-choreographed effort. Public health responders protect not only the public but the first responders, second responders, and long-term responders as well.
It is possible that certain types of disasters may go unnoticed until discovered by public health responders. For example, if a biological weapon were to be deployed, it is most likely that victims would begin to seek medical treatment on their own in a variety of ways and settings. Unfortunately, many of the early symptoms associated with biological agents are similar to influenza symptoms; thus, victims might self-medicate before seeking professional medical intervention, thereby becoming sicker and exposing others to the agent for a longer period of time. As the number of victims begins to increase and testing confirms deployment of a biological weapon, the level of public chaos would rise accordingly. Unlike with an explosion or similar incident, there would be no clearly defined event or scene to manage. Tracking the origin of the agent and areas of potential exposure would be accomplished through a combined effort between law enforcement and public health officials conducting an epidemiological forensic investigation. Law enforcement and public health administrators share the common goal of maintaining public safety; this is a good reason to plan together.
The Pandemic Scenario
An area of current concern in public health is an influenza pandemic, which could start small but become a disaster as a result of travel patterns and human contact. Once the pandemic is identified, public health officials have plans to distribute mass prophylactic drugs or vaccinations to help treat or prevent the spread of disease. Plans call for the use of points of dispensing (PODs). The U.S. Centers for Disease Control and Prevention (CDC) have a program, known as the Strategic National Stockpile (SNS), in which stockpiles of pharmaceuticals and medical equipment have been strategically located throughout the United States for rapid deployment once requested by a state, within 12 hours of such a request. The state public health system receives the stockpile, called a push pack, consisting of eight truckloads of pharmaceuticals and equipment (if the entire push pack is requested). The state delivers the assets to local public health staging areas. The local public health departments then distribute them to the PODs. Law enforcement agencies play a vital role during receipt, distribution, and dispensing. The federal plan calls for mass prophylaxis of entire communities in 48 hours. Informing citizens of the plan, communicating specific instructions, and then managing the public response to a POD require law enforcement agencies to play a role. Some of the issues that should be anticipated are public panic and confusion, citizens demanding pharmaceuticals for homebound relatives, and separated families. Law enforcement agents will also be called upon to handle the logistics of parking and triage and to maintain order and security before, during, and after distribution and dispensing, among other activities.
Studies show that not all critical employees are willing to report for duty during emergencies and disasters out of concern for their loved ones. Health-care providers are developing plans to medicate their employees and their families. In some plans, employees report to work with their family, all receive the appropriate medication, and the employees stay at the facility to perform their duties. Many local health departments have similar plans that include law enforcement personnel and other first responders. However, the process must be properly communicated and explained before an incident to ensure maximum compliance. Communications regarding the level of risk must take place before, during, and after a disaster or public health crisis.
Some plans call for the use of isolation and quarantine—ranging in scope from “snow days,” where people are asked to stay home to help prevent the spread of the flu, to quarantine of an entire section of the community. Isolation and quarantine raise numerous legal and ethical issues that can be addressed only through mutual planning, exercising, and training. Law enforcement professionals must work hand in hand with public health officials to understand the legal and logistical difficulties involved in isolation and quarantine and the chaos that would surely accompany them. History has shown that resources may be needed far beyond the local, county, or even state level. Therefore, it is incumbent on first responders to open the lines of communications sooner rather than later during a local disaster. The NIMS and the NRP help all agencies speak the same language and better prepare themselves to accept support from state and federal resources.
Today’s challenges for all first responders, especially law enforcement, are much different from those of, say, thirty years ago. Just as the challenges have changed, so too must the approach taken to confront them. Years ago, law enforcement agencies worried mostly about preventing crime and responding to local emergencies. Today, there is a need for collaboration among the various types of responders, expanding planning efforts to include local, state, tribal, and federal governments; public health; and the private sector. These same challenges demand that law enforcement agencies use the Incident Command System, the NIMS, unified command, and the NRP to their fullest extent. They should be looked upon as tools to help law enforcement agencies respond to disasters—tools as important to law enforcement as those carried on the duty belt.
Through combining efforts and resources, first responders will all reap the collective benefits. They owe it to themselves, and more importantly to the communities they serve, to develop comprehensive response protocols and include everyone serving in the role of first responders at the planning table.■
|Commander William T. Bowen retired from the Albany, New York, Police Department after more than 25 years of service. He worked for the New York State Department of Health, managing hospital bioterrorism preparedness programs, including Chempack and the SNS. He currently serves as health policy advisor to the New York State Office of Homeland Security.|
1See “HSPD-8 Overview,” U.S. Department of Homeland Security Web site, http://www.ojp.usdoj.gov/odp/assessments/hspd8.htm (accessed June 29, 2007).
2“December 17, 2003 Homeland Security Presidential Directive/Hspd-8,” White House Web site, http://www.whitehouse.gov/news/releases/2003/12/20031217-6.html (accessed July 2, 2007).
31“Testimony of Dr. David Seaberg for House Homeland Security Hearing on Avian Influenza,” American College of Emergency Physicians Web site, http://www.acep.org/webportal/Advocacy/fed/testimony/020806.htm (accessed July 6, 2007).
4Richard C. Larson, Michael D. Metzger, and Michael F. Cahn, “Emergency Response for Homeland Security: Lessons Learned and the Need for Analysis,” Structured Decisions Corporation Web site, November 17, 2005, http://www.sdcorp.net/public/Pub_Emergency_Response_Homeland_Security.pdf (accessed July 9, 2007), 13.
5“Murrah Building Bombing—a Look at Numbers,” Oklahoma City National Memorial Web site, http://www.oklahomacitynationalmemorial.org/uploads/documents/Murrah%20Bldg%20Numbers.pdf (accessed July 6, 2007).
6“National Response Plan,” U.S. Department of Homeland Security Web site, http://www.dhs.gov/xprepresp/committees/editorial_0566.shtm (accessed June 29, 2007).