The nation’s health care system is facing a growing number of actual and potential public health disasters, both manmade and natural, that require a coordinated federal, state, and local response. One of the people on the front line of anticipating and planning for these disasters is Robert Kadlec, MD, assistant secretary for preparedness and response (ASPR) at the U.S. Department of Health and Human Services (HHS).
Dr. Kadlec recently sat down with ACEP Now editorial board member Ricardo Martinez, MD, FACEP, chief medical officer for Adeptus Health in Irving, Texas, and assistant professor of emergency medicine at Emory University in Atlanta, to discuss his role at HHS and how emergency medicine can take an active role in disaster preparedness planning.
RM: Can you tell us about ASPR and how you arrived there?
RK: I guess I’ll start in the beginning. One of the hard lessons out of Katrina was the inability to mount an effective federal, medical, and public health response in support of the state of Louisiana as a result of that terrible storm. The health consequences were both direct and indirect. Direct to some people, but indirect to health care systems in Louisiana and the neighboring Gulf states.
My participation in the ASPR project began at that time when I was working for the chairman of the Subcommittee on Bioterrorism and Public Health Preparedness, Senator Richard Burr, who was a freshman senator from Northern Carolina. He was paired with one of the lions of the Senate, Ted Kennedy. You could say they made an odd couple, but they were both personally very committed to the concept of how do we provide better support to state and local authorities in the event of a disaster that overwhelms their means or their capabilities to help their community and their constituents.
The concept was really modeled after the Department of Defense and the Goldwater-Nichols Act in so far as saying someone needs to be in charge, and someone needs to lead an effort that is not only during the disaster, but well before the disaster to ensure that there’s advocacy for state and local authorities to get the resources they need to make sure that their public health systems and their health care systems are not only resilient but responsive and have capacity. Also, the goal was to ensure that the federal response in support of those state and local authorities is coherent, comprehensive, and coordinated. That is where I was personally involved. Then, as a consequence of my departure from the Senate, the bill was made law and the ASPR was created. It just was a coincidence that, 12 or 14 years later, I was asked to become the ASPR. As a result of the change in administration, I accepted the opportunity and went through Senate confirmation, and here I am.
RM: Tell us about your vision for regionalizing disaster response.
RK: Well, it was already visualized with the health care coalitions that have been funded in each state through federal grants. It was this idea that in very resilient communities, like in Texas, they had created a very capable coordinated local response; everything begins locally. As we saw in Houston and Beaumont, Texas, and as I saw in Miami as well as in the Tampa region, they had a pretty well established foundation for which they could mobilize their local and state capabilities. The idea then was coalesced with what was experienced in the Ebola event, which was something that was quite extraordinary. You could say predictable, but the impact on America and on the health care system was huge and disproportionate. What was created out of that was a national system with regional capabilities as it related to highly infectious diseases like Ebola.
The concept is really kind of like the Reese’s Peanut Butter Cup. We have the chocolate of the local health care coalitions, and we have the peanut butter of the Ebola experience, and how can you build on that to build a national system based on local health coalitions? The one thing I didn’t mention is where the trauma hospitals and the trauma system fits in. I believe that, quite frankly, the foundation of any kind of disaster system has to be made on what exists already with our local and the regional trauma systems. How do we build that out? Then, bake that cake and layer it with frosting that would be these highly specialized national capabilities like with infectious diseases or potential radiation or nuclear events. How do you build that national and regional expertise that would be supportive of the local trauma systems to respond to a variety of events?
RM: I like the idea of a regionalized disaster response, because centralizing often overwhelms a small group of resources. We’ve seen that with multiple events that have occurred. What’s interesting to me is that the infrastructure’s changing. Now we have a rapid growth of population-based resources that are distributed within the community, the urgent cares, the satellite emergency departments, and the emerging smart-sized hospitals. How would you best distribute those resources in a regionalized system?
RK: I think the key is that’s part of the coalition. That is really about integrating those kind of care systems as they evolve and as they mature to make sure they’re part of the conversation and part of the equation. When I was medical director in special operations down at Fort Bragg, I had 24 para-rescue men assigned to me. I was their medical director. What was transformational in their ability was not only their collaboration with their army and navy compatriots, but really the training and the opportunity for access to expert consultative support that took them to the next level.
How do we ensure that there’s training of our local providers? Emergency physicians’ educational role is vital in this thing, but what about the primary care physicians that are in that area? What about those other people who are very dependent on our emergency physicians, like our EMS providers, nurses, and physician assistants? There’s a great opportunity to provide training in disaster medical care that could be just-in-time or foundational. Those are the kinds of things that we’re looking to do that we think could be very transformational.
I’ll give you the example of Las Vegas. What was amazing was that in some circumstances the civilians were first responders, police were first responders, and fire and EMS were first responders. Many of the interventions they made at the point of injury, as we witnessed in the battlefields of Iraq and Afghanistan, were the difference between life and death for many of those people.
RM: What was interesting in Katrina was that many of the physician offices simply closed. It was the emergency physicians who stayed and manned their post for days at a time. How do you think emergency medicine can best support your vision?
RK: I think they need to be part of the conversation. What I described is kind of a work in progress, it is not finalized. I think we would be very interested to hear from your colleagues about not only how to create a system, but how to sustain it over time. One of the areas that we’re very interested in is, what are the reimbursement issues, the incentives that would work to make not only a trauma system but a disaster system sustainable over time. The second thing is what would be the role of your colleagues to do local outreach with community groups and others, like with “Stop the Bleed” or “Until Help Arrives.”
Obviously, EMS is another critical piece of this, and there’s no better group of individuals than your colleagues and your profession to intervene in this way to ensure that the tip of the spear for medical response is capable to respond to events that could involve chemical, biological, radiological, and nuclear threats, for example. How do we do that? Obviously, in the local health care coalitions, emergency departments play an essential role in terms of managing and coordinating care across hospital systems, as well as managing the flow and triaging where people need to go in a region.
RM: You made a great point about using all these different resources. The National Academy of Science is looking at integrating the private sector to be better responsive. One of the interesting examples was the role of the satellite emergency departments in response to Harvey where hospitals closed. The distributive nature of those satellite emergency departments allowed a lower staffed EMS unit to easily pick up patients, drop them off, and then get back into the community. After the first couple of hours, you start moving toward a search and rescue.
RK: The benefit of your satellite emergency departments is that you’re trained and equipped to do that, right? The question is how do we expand that capability to other places that are not naturally trained and equipped? Can you do it through just-in-time training? Probably not. I think that’s the opportunity. As people evaluate locally how their system is set up, they need the right kind of touch points, whether those are satellite emergency departments or neighborhood health clinics, because they can be vital in any disaster response.
Many times in these disasters it’s not only the direct effects of the disaster, but the indirect end of the disasters that relates to people’s chronic medical conditions that requires urgent care. How do you create a system to take care of people that, if you’re timely enough or provide the right intervention, keeps them out of the emergency department, keeps them out of the hospital, and out of the ICU?
RM: As you pointed out, the vast majority of resources are private, and yet this is a federal vision. What incentives do you see are important to ensure that private resources come together to support that vision?
RK: I think you touched on the idea that it’s a federal vision, but I think what we’re trying to do is a national vision, [building regionally into a national program]. I think your point is the right one. We’d like to create public-private partnerships. One of the things that the federal government has is a little bit of money—$250 million is a drop in the bucket in a $3 trillion industry. We understand that direct grants are not going to tip people over to join this endeavor. I think in some ways we look at the opportunity for CMS reimbursement to provide some marginal, incremental, above-the-top-line repayment as one possible strategy. There could be other tax incentives that could be identified. I think that’s part of the conversation we need to have with not only your association, but also with the hospital CEOs and others, such as health care insurers, to see what would make sense, because it’s not going to be one thing. As you pointed out, the health care system is diverse by definition, and in some ways you’re going to have to find different things that appeal to different parts of that system to participate and collaborate.
RM: One of the challenges has been that in the local markets, a lot of the health systems compete. Perhaps funding for some sort of care coordination center that’s used on a daily basis may be something that can then be the infrastructure that allows them to collaborate and coordinate when a bigger event occurs.
RK: I think that’s the basis or the logic that has been developed for the health care coalitions. You could say that we’ve not resourced it enough, and I won’t disagree. I think building something that has utility every day and that can expand to meet the extraordinary circumstances of a disaster of some sort, is the best way to make it. I think to build a parallel system, something separate, just break glass when something happens, is really not going to provide the benefit or is worth the investment that we need to make.
RM: You have really reached out and engaged a lot of different organizations, and I was very impressed with that. Are there any final comments you’d like to make to our colleagues about how they can help you move this vision forward?
RK: Well, I think first of all, we welcome their feedback and involvement. I think we’re better off, we’re more informed, we’re more capable, and we’ll have more likelihood of success if we work effectively with your organization as well as others to host those kinds of conversations to help define the vision together. My intent is to be somewhat of a catalyst for this all. We don’t have all the answers in Washington. The key is to ensure that, however we move forward, we move forward together with the commitment that in the end, we’ll not only be able to take care of patients better every day, but on the worst day for America or in a particular community or region, that we can provide the best care for all Americans.