What Public Health Emergencies Can Teach Us About Climate Adaptation

We will be watching videos of life-threatening climate disasters every day on our phones until one day it’s our phone recording the next one.

Major environmental and health emergencies used to be rare, one-off occasions. Now being in a state of emergency is the new normal. Mega-hurricanes, massive floods, heat waves, inferno wildfires, even global pandemics, are now a regular part of our lives every year.

As the environment deteriorates, we will lurch from one emergency to another in a perpetual state of disaster response as the Earth becomes more and more uninhabitable every year. In order to survive humanity will have to both rely on and become our own emergency first responders.

Where we stand now is reason for pessimism. Even if we miraculously reduced all the world’s carbon emissions to zero by tomorrow we still couldn’t stop many of the environmental changes set in motion, only limit their worst effects. This is because more than 93% of the heat humans have generated is trapped in the oceans and atmosphere where it will linger for centuries.

The time for arguing about who is to blame is over. Now it’s time to figure out what happens when it’s our homes that are flooded, AC systems overwhelmed, or an even deadlier pandemic comes along.

For a few years I worked in the world of emergency response at the Centers for Disease Control (CDC). I witnessed the response to the Zika virus in the Americas, the Ebola virus in the Congo, Hurricane Maria in Puerto Rico, and most recently the COVID vaccine distribution.

In each of these emergencies, I’ve learned something new about how these shocks are handled by some of the largest public and private institutions tasked with responding. It’s this same networks of health partners and first responders who will be called upon week after week when the next disaster strikes.

This article/personal reflection is for anyone who is interested in learning more about the world of emergency response and wants tangible solutions to advocate for with their friends, family, and public officials to better prepare for humanity’s fight to survive climate change.

Lessons Learned

1. 2020 COVID – Computers call the shots.

2. 2019 Ebola – Assume people won’t listen to you.

3. 2017 Hurricane Maria – The money is there, if you know where to look.

4. 2016 Zika – Sometimes you have to make it up as you go.

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Lesson #1 – Computers call the shots.

In November 2020, the Pfizer and Moderna COVID vaccines neared the finish line for FDA emergency use authorization. In preparation for nationwide distribution, the U.S. Department of Health and Human Services formed a partnership with retail pharmacy chains to administer the vaccine. Drugstores like CVS, Walgreens, and Rite-Aid were to be the frontlines of the largest vaccination campaign in human history.

It was a simple and common-sense partnership. The federal government wanted to get the widest reach possible with the lowest effort. More than a third of Americans get their annual flu shot at a pharmacy and more than 80% of Americans live within 10 miles of a CVS or other community pharmacy.

For the pharmacies, the vaccine was to be provided at no cost to them and to be administered at no cost to the recipients. The pharmacies would benefit from increased traffic in their stores as well as positive PR on their vaccination efforts.

In order to become an approved pharmacy to receive the COVID vaccine they had a few rules they had to follow, namely how they would share data with the CDC on their vaccination efforts.

Every 24 hours, pharmacies had to submit data on things like how many people they vaccinated, the number of doses they ordered, and how many doses they had on hand in their inventory. This information would be fed into a larger system called Tiberius managed by Operation Warp Speed. In Tiberius, the federal government would allocate the scarce doses of the vaccine to each state based on demographics, demand, and availability.

This process working well had a lot riding on it. In December, the U.S. was in the midst of its deadliest month of the pandemic with the alpha variant from the U.K. rampantly hospitalizing and killing thousands of people every day.

Unfortunately, within the first few weeks of the vaccine rollout the wheels started to come off the track. States began complaining that the actual amount of vaccines they were allocated were far less than what they expected, in some cases more than 40% less. As a result, pharmacies and other vaccination sites in those states had to start cancelling thousands of appointments.

Our team in the CDC Vaccine Task Force was working with the pharmacies and needed to explain to them what was going on. This led us to wrapping our minds around the messy process that COVID data was coming into and out of the CDC.

The culprit was a faulty data synchronization between the CDC’s vaccine ordering system, VTrcks, and the allocation system Tiberius.

While vaccination providers were planning appointments based on what they ordered, it wasn’t until that information matched up with Tiberius that the right number of doses would arrive at their facility. The issue was diagnosed and fixed, but it held up vaccine distribution at a critical time.

Technology hurdles like this were one of many early missteps that were not only responsible for the U.S. ending 2020 nearly 18 million vaccinations behind schedule, but also resulted in failures to quickly identify hotspots and prevent outbreaks early in the pandemic.

The lesson is despite the best laid plans of mice and men, sometimes it’s the computers that are calling the shots. Literally. More than people agreeing on what needs to be done the harder work is ensuring that the information systems behind the scenes are also in agreement on what needs to be done. Getting the I.T. piece right can be in the biggest determinant on whether life-saving care can be administered in a timely way.

This is the largest and most important vaccine program that we have ever undertaken. We would have liked to have seen it run smoothly and have 20 million doses into people today, which was the projection. Obviously, it didn’t happen.

Dr. Anthony Fauci on the beginning of the COVID-19 vaccine rollout, December 31st, 2020

Things to advocate for:

Investing in standardized application programming interfaces (APIs) across healthcare and emergency response systems.

The two biggest challenges facing interoperability in our healthcare system today are data usability and public health data exchange delays. Health data right now are not readily available in a format that can be easily ingested and incorporated by different healthcare providers and public health systems.

More work and investment is needed in adopting the HHS Standardized application programming interface (API) for patient and population services across hospitals, laboratories, first responders, and meteorological services to make it easier for disparate systems to share information quickly in an emergency.

Development of a standardized “health passport” for individuals to manage, control, and protect their health data.

Do you know what you would do if you lost your paper vaccine card? Depending on where you live the process can be shockingly complicated to get physical or electronic proof of vaccination from your state immunization registry.

Imagine now that an immunocompromised person is brought to a large stadium for shelter after having their basement home flooded. One of more than 150 million people that will become climate refugees in the next 30 years. How will they attest to their exact prescriptions, vitals, and medical history with all their documentation under water?

Equipping individuals to have sovereignty over their own health information has been a challenge for years despite having the technology to do it in a way that protects privacy and ensures portability. Investing in a solution now that leverages advances in distributed data storage and biometrics will vastly improve healthcare in a rapid response setting.

Take Away
There will be no successful response to climate change without relying on technology. When it comes to quickly identifying and triaging an emergency situation our I.T. infrastructure needs to be nimble, portable, and interconnected – COVID has proved that it’s not there yet.

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Lesson #2 – Assume people won’t listen to you.

The Ebola virus flared back up in the Congo in 2019 prompting the WHO and CDC to rush medical personnel to contain the outbreak. They feared a repeat of the 2014 outbreak that spread across West Africa, then the largest Ebola outbreak in history.

As medical staff arrived and began treating and isolating patients, they faced a series of attacks by the hardest hit communities. People began throwing stones at doctors and burning down medical facilities. One day, two gunmen barged into a medical staff meeting and opened fire.

At the time, our team at the CDC’s Division of Emergency Operations was developing resource plans for the Ebola response. The deployments of CDC health workers being processed had to be immediately cancelled until the stronger security arrangements could be made. In total, there were 386 attacks against Ebola first responders in the Congo.

When asked why they were hostile to the medical workers, many responded by accusing the health workers of making up Ebola as a ruse to make money off the population. Some declared that it was a hoax perpetrated by the government to drum up foreign aid, cancel local elections and takeaway their rights. Religious officials and politicians stoked these fears.

Ebola doesn’t exist! You’ve invented the disease.

Gunman who fired on Ebola workers in the Congo

The skepticism and misinformation about Ebola bears obvious resemblance to COVID-19. Whether it was downplaying the threat of the virus, politicizing masks, watering down CDC recommendations, or letting unfounded fears of the vaccine abound, there was no shortage of conspiracies that undermined public health messaging.

The misinformation around COVID has similarly led to violence against healthcare workers and government officials. Most famously, the plot to kidnap Michigan governor Gretchen Witmer in retaliation for strict lockdown orders. Globally, hundreds of healthcare workers and contact tracers in the last year have been threatened and attacked.

This underlies a more fundamental issue with health emergencies, including climate change – successfully communicating science remains one of the most pressing challenges to overcome.

Many times, we assume that the compelling nature of scientific assessments – especially ones that are apparent right in front of our eyes – are sufficient to spur action.

It’s smarter to assume that there will always be some countervailing political, social, or economic force which will turn the public against you, even though you are trying to help them. The imperative must be on health authorities to be proactive rather than reactive and drive the message through diverse, independent, and non-partisan channels.

Ideas to advocate for:

Partner with singers, athletes, actors, and social media influencers across the political spectrum in unified messaging campaigns.

Celebrities have a tremendous influence on the information we retain, the attitudes we adopt, and the decisions we make, including those related to our health. This is a known fact, otherwise companies wouldn’t be paying them millions of dollars to be brand ambassadors. There is already evidence that celebrities have influenced our perceptions of climate change and have driven participation in climate activism.

In a health emergency, celebrity messages can be “especially important if trust in government/official sources is quite low,” according to Tracy Epton, a psychologist at the University of Manchester in Britain. Indeed, despite weeks of CDC warnings about the impending arrival of COVID early in 2020, the first real wakeup call for the public was when actor Tom Hanks and his wife Rita Wilson tested positive.

“Public health figures who have credibility must partner with social media influencers who have the reach. Harnessing the wide reach of local, regional and national influencers from a wide swath of sectors both within and outside of the public health community is necessary to counter the large volume of misinformation thrust into the information ecosystem.”

Dr. Amir Bagherpour and Dr. Ali Nouri – Fellow and President of the Federation of American Scientists

Response authorities should set standards on what constitutes false or misleading information in real-time, especially during a declared public health or disaster emergency.

There has been no greater driver of misinformation about scientific information than from social media. What many have called an “infodemic“, a deluge of fake news about the virus circulates on platforms like Facebook, WhatsApp, Twitter and YouTube at a dizzying velocity.

These companies are reactive rather than proactive and slow to flag or remove content before thousands have already seen them. Last April, 59% of posts about COVID rated as false by fact-checkers remained up on Twitter. On YouTube, 27% remained up and on Facebook 24% of false-rated content remained up without warning labels.

There is a strong association between the use of WhatsApp and Facebook and believing COVID misinformation.

September 2020 joint study from Harvard, Northwestern, Rutgers and Northeastern universities on COVID misinformation

Disaster response officials must form stronger partnerships with social media companies to identify common sources of misinformation and enable speedy removal. With the poor track record of tech companies being able to self-regulate, response authorities may need the power to remove content in real-time, especially at the early stages of an emergency.

Learn from the advertising industry on how to identify, engage, and influence the behavior of your target audience.

The ad industry is incredibly powerful because of its ability to understand the preferences of its audience and use them to subtly influence, even manipulate people into taking a desired decision. Credit their innovative use of behavioral economics, marketing analytics, and empowered creative departments.

While public health mass media campaigns have worked successfully on issues like reducing smoking, there is clearly much to be learned in terms of how to change individual behavior in the context of a health emergency. Recruiting from and partnering with the top advertising and public relations firms could provide some fresh thinking and new tools on better ways to win over the audience and nudge the public to prepare more proactively for climate change.

Take Away
Misinformation and conspiracies derail every public health emergency – science can’t be expected to be listened to on its own merits. For scientific guidance to be communicated more effectively there needs to be a re-thinking on the public faces of an emergency, the tactics to remove false information online, and how best to target and influence the average citizen.

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Lesson #3 – The money is there, if you know where to look.

On September 20th, 2017, a high-end Category 4 hurricane slammed into Puerto Rico. Hurricane Maria flattened entire neighborhoods causing unprecedented damage to structures, roads, the power grid, and healthcare facilities. The entire population of 3.7 million people was left without electricity overnight.

More than 100,000 Puerto Ricans did not have clean food, water, or reliable electricity for more than 6 months. It is considered the worst natural disaster in history to hit the island.

The response from the U.S. government was haphazard to say the least. Part of the reason was that this was the third consecutive mega-hurricane to hit the U.S. in a stretch of a few weeks: Hurricane Harvey, Irma, and now Maria. This precarious situation left FEMA, CDC, and other emergency response agencies even more strapped for resources.

The Trump administration was not only slow to take the crisis in Puerto Rico as seriously as the recovery efforts in Florida and Texas, but badly bungled the logistics and operations of getting relief to the island. This even prompted a personal feud between Trump himself and the mayor of San Juan.

Ultimately, Puerto Rico received 1/9th of the emergency meals, half the amount of water supplies, and 1/20th of the tarps provided during the responses to Harvey and Irma.

The Department of Homeland Security Office of Inspector General found that FEMA “lost visibility” or failed to fully track nearly 40% of shipments to Puerto Rico with a value of nearly $257 million in meals, water, blankets and other supplies.

ABC News

It was in this environment that our team at the CDC’s Office of Financial Resources was tasked to find money, wherever it may exist within the agency, to help fund the public health emergency response operation in Puerto Rico.

One thing I quickly learned on this fiscal hunting trip is how much government money goes unused every year. When federal agencies don’t spend the funds Congress appropriates to them within a specific timeframe, the funds are “cancelled” and returned to the U.S. Treasury Department General Account (known as the TGA).

Once funds are cancelled, they are legally not allowed to be used for anything else. According to a Government Accountability Office (GAO) study, roughly $24 billion dollars in government-wide budget authority is cancelled every year – enough to pay for an annual universal pre-K program.

The reasons for canceling government appropriations can vary. Sometimes agencies just run out of time to implement a program. Many times, they simply don’t have the capacity to effectively find organizations, projects, or things to buy to use up their appropriated funds.

Before having to cancel appropriated funds, some agencies have authority to redirect this money for other purposes – this is a process known as “re-programming”.

One specific spending mechanism we looked into for the possibility of reprogramming was “unliquidated obligations”. Basically, the government agreed to set aside money to pay for some purpose (obligation) but ended up not incurring any expenses for that purpose.

After diving deeper into the numbers, we uncovered $6 billion in unliquidated obligations on the CDC’s accounting books. Money that could be re-programmed not just for the response in Puerto Rico, but several other public health operations.

Ideas to advocate for:

Grant federal agencies more legal flexibility to re-direct appropriated funds when their original purpose can’t be fulfilled.

In a recent GAO study almost 70% of the agency officials interviewed reported that they ended up cancelling unused government funds because they could only be used for very specific purposes and did not have the legal authority to re-direct them to related/adjacent activities.

Rather than returning the money, agency officials need increased acquisition flexibilities, increases to warrant thresholds, new approving authorities, expansion to purchase card flexibilities, and the ability to use Inter-Departmental Delegation Authority (IDDA) and Inter-Agency Agreements (IAAs). These tools will give policymakers enhanced flexibility to respond to health emergencies in a forceful way.

Otherwise, agencies need to go through a process of review and congressional notification to take re-programming actions which can take several months. Because of the “use-it-or-lose-it” nature of these appropriations, a flurry of federal spending happens in the last week of the government fiscal year (last week of September) even if it results in lower quality projects or for issues that are not as urgent.

Federal agencies spend an average of 4.9 times more in the last week of their fiscal year than in a typical week during the rest of the year

National Bureau of Economic Research

Direct the Office of Management and Budget (OMB) to target undisbursed balances by streamlining the project closeout process.

Nearly a fifth of all government spending (~$800B) goes to disbursing grants. The very first work project I worked on was helping manage the Public Health Emergency Preparedness (PHEP) grant throughout all its phases: pre-award, award, implementation, and closeout.

The closeout portion of a grant’s lifecycle is where a lot of the hidden money may lie. Closeout procedures are designed to ensure that the grantee has satisfied the terms of the grant and submitted all required financial and performance reports to the awarding agency. In this process, money that was given to a grantee but was never actually used is often discovered. That’s not always the case though.

In 2011, the GAO identified that the total amount of unused grant money can represent anywhere from 2.7% to a jaw-dropping 34.8% of an agency’s or program’s grant funding. More than $794 million in funding remaining in expired grant accounts for just one agency. Stronger action to improve systems and policies for reconciling payment accounts and monitoring grantee spending can be critical to maximizing available dollars to respond to emergencies.

Take Away
Disasters and emergencies are the last time you want to be getting thrifty. Rather than asking “how are you going to pay for it?” realize that we probably have already paid for it! Millions of dollars are sitting in unused or expired accounts or are being returned to the government because of lack of capacity and poor management. Granting increased flexibility to use government funds and rooting out idling money during a project’s “closeout” phase can refill coffers when responding to multiple, concurrent emergencies.

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Lesson #4 – Sometimes you’re going to make it up as you go.

As the Zika virus began to spread across the Western Hemisphere in 2016 there was a scramble for reproductive health experts. Pregnant women infected with Zika were having babies born with deformed brains – a condition so terminal that women in South America were encouraged to postpone pregnancy for almost a year.

The CDC’s National Center of Birth Defects and Developmental Disabilities was called up to lead the emergency response at the agency. Unfortunately, most of the experts from the Center had no previous emergency response experience.

Early on epidemiologists were being asked to design communications flyers. Clinicians had figure out how to finance a laboratory task force. Unsurprisingly, things were delayed getting out the door to the populations that needed them most.

Staffing during an emergency response requires careful planning and tracking. But more often than not, at the beginning of a crisis an ad-hoc team of subject matter experts and support staff are pulled together, some of whom who may have never been trained for the unique environment of emergencies.

Because of the speed and voluntary nature of recruitment, skill sets are often misaligned or altogether missing for the precise needs of the response. This results in those on the frontline having to learn on the job at a time when inefficiencies and mistakes can have lethal consequences.

Ideas to advocate for:

Predict your needed workforce rather than reacting.

The U.S. has been in enough emergencies to know roughly what to expect whether it’s a domestic natural disaster or international pandemic response. By mining data from previous responses on information like: the number of people deployed, the roles needed, length of deployment, etc. agencies can create a predictive workforce based on specific emergency scenarios. This approach would not only enable more rapid identification of the right people when standing up a response but getting ahead of training those who have not been in a response before but have a frequently needed skillset.

Create a public health reserve – a gig workforce of dedicated emergency responders.

Disaster response agencies could develop a roster of response alumni and on-call workers that can be rapidly deployed without having to pull staff from other departments. This public health reserve would be similar to a “bench” in the management consulting industry but filled with government employees and volunteer citizens whose main role is to be emergency response specialists.

Versions of this exist currently in different cities known as a Medical Reserve Corp (MRC). MRCs were crucial in recruiting citizen volunteers to assist in COVID vaccination efforts. I was able to join the Fulton County MRC in Atlanta and assist in the logistics at Mercedes-Benz stadium (and luckily got my first dose out of it).

Make emergency exercise-based trainings mandatory for all health domains.

Many believe an emergency will not happen to them in their specific field and thus pass up the voluntary trainings on emergency operations. Zika struck reproductive health, COVID came for respiratory health, in which health domain will the next crisis strike? There’s no way to know, which is why these trainings should be mandatory and regularly exercised across health domains with an eye towards high priority scenarios, like:

• Pandemic influenza
• Vector-borne diseases (e.g., malaria, bubonic plague)
• Natural disasters (e.g., hurricanes, wildfires)
• Environmental hazards (e.g., chemical/oil spills, radiological incidents)

These trainings should be supplemented with YouTube-like clip series of short, discrete, actionable lessons would be designed to provide guidance and reinforce necessary skills in less than 5 minutes (e.g., how to use a test kit or fill out a report, etc.)

Take Away
Public health or medical expertise does not always translate to disaster response expertise. The most critical impact of inadequate training and staffing during an emergency response is that lives are at risk. Response staff needs access to the knowledge and support required to be prepared for their role and be able to deploy the necessary skills as soon as possible.

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Conclusion

While the world is still caught up in the COVID-19 pandemic, it’s critical that we do not view this in isolation of the larger ecological crisis at play between nature and humans.

While our imagination may be limited to floods and wildfires, mosquito-borne diseases like malaria and Zika will become more prevalent as the planet’s hot zone around the equator expands by 5.5 feet everyday. Pathogens, dormant for centuries in the Arctic permafrost, are being released as the ice melts.

Regardless of where the threat comes from, the lives of billions of people will be at the whim of how effectively their government can marshal the necessary resources to put out the next fire (in a very real sense).

When it comes to disaster and emergency response, most of us have no idea where to begin. And no, stop-drop-and-roll does not really count. For those on the front lines of responding, there is little time to look back – the next emergency is already upon them. The strain of a constant cycle of emergency activations and deployments have drained our public health and disaster response authorities. They need our help.

Responsible citizens have an opportunity and an obligation to demand action on the longstanding inefficiencies in our emergency response operations. If left unaddressed, they will continue to rear their head when the world can least afford them.

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