Still Vulnerable: Persistent Challenges for an Unprepared Nation Irwin Redlener, MD Director, National Center for Disaster Preparedness Professor of Clinical Population & Family Health Columbia University Mailman School of Public Health Trust for America’s Health Congressional Briefing Ready or Not? Protecting the Public’s Health from Disease, Disasters, and Bioterrorism February 3, 2012

Five Major Concerns

1. Haven’t defined/ benchmarked basic terms What is “prepared”? Who is “prepared”?

Goal: A disaster-prepared, less vulnerable population via reduced risk, increased resiliency and improved response and recovery

Vulnerable populations = Achilles’ heel(s) of disaster response

How Many? Children: 75 million > 65: 40 million Significant chronic illness: >120 m People with disabilities, 21 – 64: 22 m Living in poverty: 44 million Undocumented: > 11 million Prison population: > 2 million Nursing homes: 1.5 million …VI/Ps ? Probably > 50% of U.S.

2. Challenges of implementing national preparedness agenda in a federalist society

Random Acts of Preparedness 2001-Present

3. Growing deficiencies in public health emergency response workforce

The Workforce Gap 23,000 jobs at state and local public health agencies from ,000 fewer workers over the last 20 years 50% of workforce able to retire in % of public workers have not had formal training for their jobs A Mandate to Prepare As Resources Decline

4. Failure of imagination/ inability to think “at scale”

Concern is not about large emergencies or “small” disasters … These generally manageable by local or regional resources …issue is about prevention of and response to megadisasters

“Megadisaster” A catastrophic, high-consequence event, irrespective of etiology, that overwhelms or threatens to overwhelm local and regional response capacity. Indicators may include: Inability to manage immediate rescue of endangered survivors Significant backlog of victims unable to get appropriate medical care or other essential support Inability to protect vital infrastructure or prevent significant property destruction Uncontrolled societal breakdown

10 KT Nuclear detonation in NYC Living casualties Delayed 20% = 74,000 Immediate 20% = 64,000 Minimal 40% = 148,000 Expectant 20% = 74,000

< 40,000 Total hospital beds in NY State?

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Pandemic Flu in NYC: Assumptions Population of 8.2 million H5N1 attack rate: 30% Hospitalization rate: 10% Mortality rate: 2.5% of those infected Six month flu season

Potential Realities 2.4 million people sick (including 600,000 children) with avian flu 60,000 deaths (includes 15,000 children); 200,000 hospital admissions More than 300 deaths/ day Not enough: Vaccine, antiviral meds (tamiflu), hospital beds, ventilators, etc. …plus schools closed, many parents ill, potential quarantines, economy in trouble, little assistance from “the outside”, etc.

5. Growing – and dangerous – disparity between needs and resources (honey, I shrunk the preparedness budget…)

Preparedness Funding Crisis Preparedness and Response Funding at HHS and DHS fell 17% from FY10 to FY11, a drop of $900M from $5.3B to $4.4B -13% Public Health Emergency Preparedness Grants to State and Local Health Departments (HHS) -40% Academic Public Health Preparedness Centers (HHS) -11% Hospital Preparedness Programs –a 35% decrease over the last 5 years (HHS) -58% Regional Catastrophic Grant Preparedness Program (DHS) -75% Emergency Operations Center Grant Program (DHS) -28% Homeland Security Grant Program –the centerpiece of state and local homeland security funding (DHS)

Why? Recession  Austerity Deferring insurance/ “won’t happen on my watch…I hope” Extreme “silo-ization” Small, non-empowered constituency (who actually cares?)

What’s needed: Political Leadership and Investments Federal Budgets must reinvest and sustain funding at DHS and HHS Pass and fund PAHPA, HS Reauthorization Restore and expand funding to key regional programs like RCGP Restore and expand funding to key hospital and public health programs Adopt recommendations of National Commission on Children and Disasters Assume direct leadership for expanding medical counter-measure innovations Academic Partnerships Academia must provide training, research, and a new workforce Restore funding to Academic Public Health Preparedness Centers Invest in new Centers of Excellence Public Preparedness Individuals and families must be ready for disasters Make into law the recommendations of the NCCD Rethink public messaging

…or, roll the dice