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Public Health Update

Last year’s Pandemic thankfully was less deadly than originally forecast. The way it was handled has lessons to teach us about how to defend the homeland against naturally occurring health threats and man-made bioterror attacks.

In April of 2009 the United States first became exposed to what would ultimately become the latest Pandemic Influenza outbreak. It began with initial reports of citizens arriving back from trips to Mexico with a novel disease that was referred to at the time as Swine Flu. The swine flu had been circulating for the previous few months in parts of Mexico and was known to have infected humans; we were now seeing cases in the United States. The swine flu began spreading between family members and even to third parties who came into contact with infected people. The numbers of infected persons began to rise, the disease began to spread and with reports of similar infections from around the globe we faced the prospect of a pandemic.

In June of 2009 the WHO declared that the new disease, caused by the now re-named Swine-Origin H1N1 Influenza Virus (SOIV), officially was a pandemic. It met the all the criteria for a pandemic and this entirely novel virus was now active across the globe. In the eight years preceding the 2009 outbreak the NCCIA and a host of eminent researchers had expressed concerns about a pandemic episode.

The outbreaks of Bird Flu around the globe and the reported death rate of > 60% conjured images of the Great Influenza of 1918 and gave cause for concern to all who had studied that episode. Certainly, any repeat of a 1918-like outbreak was going to create a critical incident without immediate historical precedent. The work of the NCCIA with the National Governors Association and the conduct of pandemic preparedness exercises with all of the U.S. states and territories had demonstrated without doubt the extent to which an outbreak would test every facet of the national capability to withstand an entirely novel public health threat to the American population.

In March 2010 the CDC estimated that SOIV H1N1 had caused disease in 59 million Americans, hospitalized 265,000 and killed 12,000. A new disease strikes the U.S. it kills 12,000 it hospitalizes over a quarter of a million and it infects 1/6 of the population.

The NCCIA is currently studying what worked well in the effort to contain the disease and which successes appear to be random – due to the lower lethality of the disease than originally feared. The federal government relied on private doctors, nurses, hospitals as well as state and local public health agencies to do much of the actual work with individuals who were potentially or actually exposed to the disease. Much of the federal effort went into funding vaccine development. The plan was for widespread vaccination, something that was possible only with private sector cooperation. The federal government does not manufacture drugs so it turned to pharmaceutical companies. They were unable to meet the timetable that the federal government imposed. By the time the vaccine was in widespread use, the virus was proving to be less lethal than originally forecast. Fortunately, nature spared the nation a massive death toll.

In the future we cannot rely on good fortune. We are studying the response to the pandemic to learn how to be better prepared to deal with public health emergencies of all sorts in the future.


NCCIA Executive Director Suggests Ways to Share Public Health Information at National Governors Association Roundtable

On May 18 the National Governors association (NGA) held a roundtable meeting to examine the barriers to sharing public health information with state fusion centers and the greater homeland security community to identify best practices at the state level for facilitating the flow of that information. State and Federal participants who had direct experience and expert knowledge in public health, data fusion and intelligence, and the law attended the meeting.

Dr. Stephen Prior, our Executive Director, gave the luncheon speech in which he spoke about recent experiences in gathering, collating, analyzing and disseminating data surrounding the recent outbreak of Influenza A virus H1N1 – commonly referred to as Swine Flu.

Dr. Prior suggested that in sharing public health information we need to be cognizant of the inherent delays in data collection and analysis that generates the information that was the subject of the roundtable. In any emergent disease outbreak data is at a premium, information is scarce and frequently subject to revision as the disease state evolves. The present systems in public health are well versed in this and have at their core features that other more immediate data sources lack.

In the context of the new data sources, Prior noted that the Internet had generated new data sources, web-based applications, blogs and social networking, and, even web-based tools such as Google Flu-Tracker. All of these new sources could enhance the range of public health information but these sources lacked the features of traditional public health tools and were prone to such issues as information overload, false reports, lack of signal specificity and especially verification and validation.

Prior concluded by suggesting that the Federal government consider the funding of an ‘Epi-IMAAC’ – a public health version of the Interagency Modeling and Atmospheric Assessment Center. This would provide a single point for data collection, would be staffed by qualified experts, use a series of ‘approved’ modeling and simulation tools, and provide horizontal (across Federal agency) and vertical (Federal, state, local and tribal) integration of the information during an outbreak. This would ensure continuity in response and address some of the emergent concerns during the recent swine flu outbreak where, for example, schools closures within states and between neighboring states generated considerable debate and public anxiety.

The speech was very well received and provoked considerable discussion with the roundtable participants.

In an upcoming discussion paper NCCIA will further explore the Epi-IMAAC concept and its potential value to the public health responses by the nation.


Swine Flu Challenges Citizens to Act

By Ford Rowan
Chair, National Center for Critical Incident Analysis

The Obama Administration is walking a tightrope in public statements about swine flu. On one hand it wants to show that it is actively addressing the potential pandemic but it does not want to trigger panic.

The President’s first public statement (on April 27) suggested swine flu is a “cause for concern” and he added “but it’s not a cause of alarm.” The New York Times headlined the story “Obama seeks to ease fears on Swine Flu.”

The new administration is under pressure to show that it is moving aggressively to cope with the threat – and not just because of concerns about health or the economic harm that a pandemic would cause the nation.

The impulse to act fast can lead to problems. In 1976 President Gerald Ford faced a similar threat of a swine flu outbreak; he ordered mass vaccination to prevent the spread of that particular disease. It was a disaster of a decision that caused more people to die from the shot (25) than from the flu (one death). Hundreds more suffered from a nervous disease caused by the vaccine.

The hunt is on now for a vaccine that will stop the current virus. Estimates on availability vary but most agree that first shots will not be available before winter of 2009. A lot of virus will travel to many locations in the meantime.

Finding a safe and effective vaccine is important, but there are other non-medical aspects that need to be addressed. The social and psychological impact of public health emergencies can be enormous.

Direct action by state and local governments is crucial. Citizen involvement at the community level will be essential to coping with the spread of disease.

The anthrax cases in 2001 taught how easily the federal government can lose its credibility. Two months into that crisis a national poll for the Harvard School of Public Health showed that nearly twice as many people would trust state or local officials as would trust federal officials to tell them about the risks of anthrax. The “local fire chief” had almost twice the credibility as the director of Homeland Security. And the fire chief was trusted more than the director of the Centers for Disease Control and the US Surgeon General.

What could go wrong now? Here are lessons from three recent public health problems, the anthrax attacks, the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003 and the public health emergency in New Orleans after the levees failed in Hurricane Katrina in 2005.

  1. Avoid false assurances

    In the Anthrax case the federal government initially reassured the public that there was little to fear from the isolated cases. In the SARS outbreak foreign governments gave slow and low estimates of cases to protect their economies. In Katrina the federal government made promises of assistance that were not kept.

  2. Clarify rules and procedures

    In the Anthrax attack there was conflicting advice, particularly about the safety of the US Mail. In the SARS response in Toronto, public health trumped personal freedom of movement. In New Orleans after Katrina federal troops had to be sent in to stop looting, shooting, and chaos.

  3. Treat citizens equally

    In the Anthrax case postal workers (mostly black) received later and less costly health care than congressional workers (mostly white). In Toronto during SARS people of color were stigmatized because of concern the disease would be spread by Asians. In New Orleans the poor, the blacks and the elderly were the ones left behind to suffer the greatest problems from the flooding.

  4. Avoid governmental snafus

    In Anthrax the federal government provided inconsistent information to the public and initially silenced some of its experts, permitting falsehoods to proliferate. In Canada during SARS thousands of persons were unnecessarily told they were “voluntarily” quarantined. During Katrina as the floodwaters rose the relationship between federal, state and local government sank.

  5. Beware of media amplification of risk

    During the anthrax attack the media focused on the unfair treatment of postal workers who died and the risk to everyone who opened the mail. During SARS Asians and health care providers were portrayed as suspected carriers of the disease. During Katrina the media focused widespread disaster, drowning deaths, and despair when survivors were herded into confined spaces with little water, food or medical care. Outrageous problems do not mean that the risks are out of control.

  6. Don’t expect Washington to save you

    We all hope a vaccine is found, but until then the national scope of a pandemic would mean that people have to take care of themselves, their families and their neighbors. It’s not just a medical challenge. In all three of the earlier cases there were law enforcement issues, allegations of mistreatment of minorities, ethical controversies, uncertainty about the advice to give to the public most at risk, and decisions seemed to be made by the seat of the pants. In Katrina volunteers who wanted to help rescue people trapped by flood waters were turned away by federal authorities concerned about the risks. Many volunteers eluded roadblocks and the “Cajun Navy” managed to rescue many victims of the storm.

Encouraging volunteer activity in a nationwide pandemic would be crucial for providing care to persons sheltering in their homes. But little attention has been given about how it could be encouraged and – to the extent appropriate – coordinated on the community level. Most likely, people would self-organize activities and adapt to changing conditions. Such initiatives can pay big dividends but there are risks.

In most crises there are victims, survivors and rescuers. Curiously, the survivors sometimes think and act like victims. The transformation to a more productive outlook is facilitated when one becomes a rescuer. Helping others helps the one giving help. Those who recover from a bout with the flu will have lower risk of re-infection and can seize the opportunity to assist others.

There are potentially contentious ethical issues that could surface if swine flu becomes a pandemic. These issues include potential restrictions on travel, quarantine, triage standards for the rationing of medical care, ways to assure continuity of essential work without forcing employees to endanger their families’ health, ways to relieve economic disruption and provide food and supplies to homes. We will have to decide how we can help children continue to learn and the mentally ill to cope if the disease comes in wave after wave. How can we deter people from taking the law into their own hands to protect themselves?

President Obama correctly said on April 27 that swine flu is a cause for concern but not alarm. Mainly, however, it is cause for thoughtful action. Here’s a short to do list:

  • What should citizens do now to protect their families?
  • What should social groups, including businesses and faith communities do now to become more capable to help their neighbors in an emergency?
  • How can governments facilitate voluntary charitable acts by business and non-profit organizations?
  • How do we ensure the fair use of resources so that the poor, elderly, and minorities are not especially burdened?
  • Have we got a plan to avoid the stigmatization of ill persons?
  • How will we deal with potential civil unrest and criminal behavior?
  • How do we devise and explain medical triage so that it is fair and effective?
  • How can news organizations function when many journalists go from being spectators to being at risk themselves?
  • How do we empower people and help survivors of the flu become rescuers who care for their neighbors?
  • Are there steps that can be taken now to mitigate the economic impacts?
  • What can we do now that will help mitigate the psychosocial harm?

Some actionable advice is already out there on the websites of various government agencies. Beyond stockpiling food, social distancing and being prepared to shelter in place, citizens should take responsibility for their own safety. Elsewhere on this website is a summary of how people can maintain productive work and mitigate risk of disease.

There is much evidence that the federal government has learned from mistakes in past emergencies and that relations are healthy between Washington and state and local governmental agencies. But civic, business and religious organizations, as well as individual citizens will need to be active if a pandemic develops.

To get through a pandemic, we will need to help each other.


Public Health Agencies Respond to Swine Flu

Government officials are gathering information and monitoring surveillance data to assess the severity and spread of the new outbreak.

Please see the NCCIA advisory on how you can maintain economically productive activities and minimize risk in a pandemic flu emergency.

For more information please see the following sites:


NCCIA Authors Issue Pandemic Publication

NCCIA Chairman, Ford Rowan, and Executive Director, Stephen Prior, are two of the authors of a publication on Pandemic Influenza that was released by the National Defense University on January 26th 2007. The press release from NDU notes that the report is focused on ‘the broader aspect of maintaining social and economic viability by addressing the organizational readiness of society’s businesses and institutions.’ The document can be downloaded or print copies requested from NDU at the address on the press release.

Chairman Ford Rowan noted that ‘NCCIA is delighted to have contributed to the work at NDU and to have expanded our continuing contributions to the discussion of the responses to the urgent but uncertain threat posed by the H5N1 virus. We believe that the opportunity to act now, while we still have the luxury of time, is invaluable for planning and preparing for the possible future critical incident that a pandemic would represent ’.


Preparedness Workshops for State Officials

The National Center for Critical Incident Analysis conducted nine workshops to help state and local officials coordinate with federal officials and prepare for a pandemic or other health crisis. Stephen Prior, the NCCIA Executive Director, coordinated workshops for the National Governors Association. Ford Rowan and Barbara Monseu participated as speakers in the meetings. For an interim report on the workshops, click here..

A preliminary preparedness assessment concluded that there is raised awareness in state government of the problem and potential widespread impact of a pandemic. All states had significant and wideranging awareness of the threat, its origin, and its potential impacts. Additionally, all states were aware of the unique characteristics of a pandemic and the challenge posed for effective planning. But the interim assessment found some shortcomings.

Plans for response and recovery from a pandemic episode continue to have gaps. These shortcomings translate directly into areas in which the states and the federal government should next concentrate their efforts. For example:

  • States have not adequately considered how their individual decisions on school closure will impact other states, nor is there consensus among states on how to communicate with the public on this issue. Federal, state, and local authorities must clearly communicate with the public about the purpose and objective of closing schools or dismissing students. They also must recognize the potential impact of those decisions on the availability of workers in both the public and private sectors.
  • States do not adequately understand what federal capabilities might be expected at the state level and how federal agencies will engage with them during a pandemic. The presence at some of the regional meetings of the designated Principal Federal Official (PFO) for pandemic response offered the first opportunity for most states to interact with these potentially valuable federal liaisons, but the continued lack of clarity about federal roles and responsibilities—and the triggers for their engagement—contributed to an overall confusion about the federal response.
  • Prioritizing the order in which antiviral medications—for either treatment or prevention—are distributed to different groups continues to challenge states. Few clear examples were identified for either prioritization strategies or attendant public communication messages. Although this represents a “moving target” for most states as they continue to stockpile material, it is clearly an area that will generate significant public discussion and should be addressed in advance of any action during a pandemic episode.
  • The workshops revealed that informal contacts are in place among officials from states in each region. Those networks have proven effective for most past incidents, but they should be formalized and institutionalized because a pandemic has the potential to overwhelm informal links, particularly if key personnel become sick or are otherwise unavailable.
  • State plans rely heavily on the availability of privately held infrastructure, response by volunteer organizations, or actions by other organizations outside their immediate control. Yet the roles and responsibilities of those entities are not clearly defined in most state plans.
  • The awareness of potential shortages of critical goods and services was frequently cited as a challenge to the states. However, no solutions were provided for ensuring the availability of goods and services across state and national borders, and there appeared to be little coordination with the private sector in the development of state-based strategies.
  • Few states have conducted state-specific economic analyses of their economies under pandemic conditions, and no information was readily available during the workshops about the business of government (e.g., collection of taxes and fees or the potential effect on states’ ability to fund programs, pay vendors, or underwrite special prevention measures).


Recent Activity

  • NCCIA chairman Ford Rowan and Chair Emeritus Frank Ochberg have participated in two conferences in Turkey sponsored by the Psychopolitical Association. The purpose of the meetings is to consider ways to resolve conflicts between religious and political groups in the Middle East.
  • Workshops were conducted to assess the response to hurricane Katrina, to prepare for a possible pandemic, to assess the impact of a pandemic episode on schools and public safety.
  • Several articles have been published on the subject of pandemic influenza.
  • We have encouraged study and research on critical incidents and on development of models for the analysis of critical incidents.
  • We have collaborated with the federal & state agencies.
  • Our expertise has been recognized through the award of a major contract to conduct research and exercises for state officials.
  • We continue to work with the National Defense University and have extended our work to include the Dart Center and the Nieman Foundation.
  • We are expanding our outreach efforts and network partnerships.



  • Distributed Medical Intelligence Conference. New Orleans, LA. April 2006. Occupational Hazards: Business Sector Preparedness and Community Resilience.
  • Public Health Preparedness Summit. Washington DC. February 2006. Occupational Hazards: Business Sector Preparedness in Anthrax, Influenza, and Katrina Response.
  • Port of Mobile Continuity and Resiliency Advanced Regional Response Training - Community Response Module. Mobile, AL May 2006. (1) Identifying Critical Staffing and Modeling Absenteeism, (2) Identifying the Choke Points, & (3) Scoping Continuity Assessment.
  • Georgetown University. November 2005 National Capital Region Resilience Network. Avian Flu Preparedness.
  • Distributed Medical Intelligence Conference. New Orleans, LA. April 2006. Occupational Hazards: Business Sector Preparedness and Community Resilience.
  • Public Health Preparedness Summit. Washington DC. February 2006. Occupational Hazards: Business Sector Preparedness in Anthrax, Influenza, and Katrina Response.
  • Port of Mobile Continuity and Resiliency Advanced Regional Response Training - Community Response Module. Mobile, AL May 2006. (1) Identifying Critical Staffing and Modeling Absenteeism, (2) Identifying the Choke Points, & (3) Scoping Continuity Assessment.
  • Georgetown University. November 2005 National Capital Region Resilience Network. Avian Flu Preparedness.
  • American Board of Industrial Health, Denver, Colorado, October 2005. Building Trust: the Experience After Katrina.
  • International Center for Terrorism Studies and the International Law Institute, Washington, DC, November 2005, Homeland Security: Coping with Natural and Man-Made Disasters.
  • American Society of Safety Engineers, College Park, Maryland, November 2005. Applying the Lessons of Katrina to Prepare for a Pandemic Influenza.
  • Foundation for American Communication, Atlanta, Georgia, December 2005. News Reporting in a Crisis: Lessons from Katrina.
  • ORC Executive Business Forum, Fort Lauderdale, Florida, April 2006, From the Flood to the Flu: Learning from Disasters to Prepare for the Future.
  • International Center for Terrorism Studies and the Potomac Institute for Policy Studies, Arlington, VA, August 2006, The Middle East Conflict and the Media.
  • National Governors Association – Annual Policy Advisors Conference. Denver, CO. March 2006. Pandemic Influenza – Policies and Problems.
  • National Governors Association – Washington, DC. Pandemic Influenza – A Primer for State Officials.
  • League of Women Voters, Washington DC, April 2006. Homeland Security & Civil Liberties.
  • National Association of Public Information Officers, Washington DC. May 2006. Pandemic Influenza and Public Communication.
  • Spirit of Reconciliation Conference (DHHS/CDC), New Orleans, LA. From Flood to Flu. Western Governors Association, Annual Meeting, Sedona AZ. Pandemic Flu: Prepared or Panicked?



The National Center for Critical Incident Analysis is a privately funded, interdisciplinary effort by civilian experts in public health, national security, law enforcement, communications and social psychology dedicated to improving the public's ability to understand and cope with critical incidents, and the government's capacity to anticipate, prevent and manage these serious events.

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Conferences and Workshops

  • National Governors Association: Preparing for a Pandemic Influenza: A Primer for Governors & Senior State Officials.
  • Journal of Homeland Security & Emergency Management: Pandemic Influenza Preparedness: Adaptive Responses to an Evolving Challenge.
  • National Defense University: Weathering the Storm: Leading Your Organization in a Pandemic.