Bio threats - politics or preparation. A changing landscape


Preparing or Politics?

Proper preparation can prevent poor performance

Can the politics and the science surrounding Bio Threats ever be separated and progress made ? This is the important question that persisted, following the SDA Bio-preparedness debate held at the Solvay in Brussels.
A range of thoughtful, serious experts came together and shared their views on the level of the threats faced, and the measures in place and being planned to help combat any Bio-Threat events. 
The consensus of opinion from the report contributors and conference speakers made it crystal clear that Biological Threats were indeed very real from natural and also manmade sources. Although there was some divergence of opinion on the likely risks of a biological attack, it was interesting to note that such differences were focused more on the impact and type of attack, rather than its inherent probability.
What also became evident was that there was a disparity in interpretations, focus, even understanding of the essential factors that need to be addressed.  Consistent references were made on the need for more research, more surveillance, better resources and particularly better communication and co-operation, at all levels from the local through to the global and particularly between government agencies and those who would be part of the ‘response’ chain. 
In the expert submissions contained in this report, there is considerable commentary and recommendation for improvements and advances that can help; it was clear at the conference debate that a sense of frustration exists within the most expert of areas concerning the shortfalls of the current levels of preparedness.
If one was to summarise the impression created not just of member states and general EU planning but of global preparedness, it would have to be said that even through the rosiest of glasses it appears disjointed and partial at best; at worst confused and shortsighted.
Our experience at the Continuity Forum is that organisations and institutions seem to have a strong tendency to trivialise risks, even denying they exist until such time as they occur.  The attacks in London and Madrid, 9/11 and a host of other atrocities show the commitment of terrorists  to attack our communities as viciously as possible. Is it so unthinkable that these groups would use a Biological agent if they could?

Are these real threats?

In the last century, there were three pandemics that killed tens of millions, with Spanish Flu killing many more than the trenches of the Great War.  In a world with four times the population compared to 1918, and with that community now thoroughly integrated and intermingling in ways undreamt of ninety years ago, is it so unlikely that a virus will appear, spread and kill millions?
The evidence is that whilst catastrophic scenarios are not totally certain, they are far more than just remote statistical possibilities.  However, across the media, opinions and the message seems to swing from hype to hyperbole, affecting the ability to have a reasoned debate and engage on the issues sensibly with both policy makers and the public.
An examination of the history of recent major events shows that whilst each was foreseen by some, the majority were not considered a ‘serious’ risk until such time as it happened. The ensuing public enquiries have almost invariably found that numerous opportunities to avoid or mitigate the risks were either missed or more likely not taken.  This has been seen time after time and most often it’s not that the threats where not recognised or identified by experts far from it. Rather the risks where not taken seriously enough or other perceived ‘priorities’ took precedence over them for those with the capability, authority, resources  and indeed the responsibility to act.
A considerable part of the problem relates to the inherent uncertainty in dealing with Biological threats.  It is in the very nature of a virus to change, constantly altering its makeup as it replicates.  Each change brings with it the potential to become more or less virulent, increasing or decreasing the impact on us all at each iteration.
Already the H1N1 virus, usually described as mild in the media, has killed more than the 9/11, Madrid and London terrorist attacks combined, and experts agree that we are still in the early stages of the spread of this viruses.  Yet within a few months of outbreak, there was an almost palpable sense of relief from the world’s leading virologists that we were dealing with H1N1 and not the far more deadly H5N1 virus.
This sense of relief, along with the message that came from the media and the reassurances from governments, seemed to trigger a twisting of public perception, trivialising the risks and the impact of this event.

Is this justified? 

The H1N1 outbreak may well turnout to be a blessing in disguise, offering a warning shot of the difficulties and the general lack of capability across our organisations, businesses and societies to respond and cope with this type of health threat. 
To illustrate the point its useful to look at some background, taking experience that translates to the current situation and looking at some of the factors that a pandemic raises.

Understanding the system

In thinking of Pandemic threats, we first should understand that there appears to be a very different reaction from people generally to matters of health compared to, say, terrorism or accidents.  The human consciousness seems to far more readily accept the loss of life through illness, and there appears to be a greater tolerance to, or acceptance of, death when it is caused by health conditions, either in the individual or the community. This is not minimising the personal sense of loss or the follow on impact on the lives of the families involved, but as societies, a sudden or violent loss of life has a much greater impact on the national and even international zeitgeist, than the usually more disguised and significantly greater loss of life from healthcare issues. This is a complicated area and one that has a huge number of political and social considerations involved, all combining to create a framework that affects the judgements made by our politicians and media.

Most countries have Healthcare capability to a greater or lesser extent embedded in their national infrastructures.  There is a huge amount of money invested in this area, delivering care, and clearly value must be sought. This regularly entails balancing factors of treatment versus cost, and metering capability against capacity.  The reality is also that Countries are obliged to develop their Healthcare systems to match the social and economic situation; as a result there are limits. One of these limits is capacity.
Capacity is a vital function when it comes to management or mitigation in a pandemic situation.  It covers a number of areas such as medicines, professional care staff, space and resources, all of which will come under pressure as demand surges during a pandemic. During the current H1N1 outbreak, with relatively few infections and comparatively mild symptoms, we are seeing national healthcare systems coming under considerable strain, with intensive care resources being challenged by the numbers requiring them. 
Vaccine and Medicine availability is a vital consideration, especially bearing in mind the rapidity of spread we have had so clearly demonstrated by H1N1. Production takes time, and the development of an effective vaccine cannot be guaranteed to be available when needed. Technical factors then mean that even once vaccines become available, they have to be manufactured in vast quantities. They then have to be distributed and administered, again a mammoth logistical exercise that requires access to sufficient staff and syringes to cope. This connected chain is an essential component in an effective response, and one that has considerable challenges.
At all stages, starting with the primary research and surveillance levels, through testing and approval, to production and follow up, solid cooperation and clarity between the drugs companies and governments needs to be embedded, but these are areas where politics and business can collide. The investment required by individual companies can be huge, but offers no certainty of success.  Government needs the output from drugs companies to respond to outbreaks quickly, yet it appears it often lacks the capability or commitment to support this need, with some consideration of the costs to the companies involved. The result is that the stockpiles, often referred to as key to the response, aren’t actually widely enough available when, and importantly where, they are really needed.           
Compounding this problem is the capability of the Healthcare infrastructure to quickly reconfigure itself to cope with surge demand resulting from a Biohazard emerging forcibly.  Many of the usual operations of the Healthcare sector would have to be substantially reduced or even stopped, creating other pressures that cascade out into many of the other supporting structures, both in the social care environment and more widely in the community.
From the experience we have of working within this space over the past few years, we can see that whilst some limited progress has been made, generally the planning and its depth tends to be limited internationally.  Few Healthcare bodies have the resources, and in many cases lack the capability, to really develop the flexibility needed. Since March 2009, a huge amount of work has been undertaken to prepare for the effects of a pandemic, but this is missing the point. 
The threat of a Pandemic has been real and the subject of extensive thinking for the last seven to eight years.  Governments have reassured us that plans are in place, initially focused on H5N1, to cope, yet when the threat actually emerges the cracks are clearly there to be seen. 
International and National Strategic planning has little effect, other than politically, if the tactical capability is lacking - this appears to be very much the case across Europe and beyond.
The recent financial crisis has cost the world billions and affected most of us, however no immediate threat to life existed.  Trillions of dollars have been spent supporting the international financial system that needed help, yet a threat to millions of lives around the world is struggling to muster the resources needed to protect us.  Just a small percentage of the support given the financial sector would transform capability and earn the respect and thanks of a far larger part of the global community.

Connecting the planning 

Over the past decade a new management discipline has entered the world of organisational management, Business Continuity Management (BCM). It has arrived as the result of the distilled experience of a number of knowledge pools and enables organisations to cope during a crisis. BCM has had a rapid rise up the corporate and legislative agenda as more of its value is realised and the more our organisations become interlinked and entwined. The process is relatively strait-forward and is geared to help organisations work as normally as possible while their operations are being disrupted.
A vital lesson that comes from the world of BCM is just how interdependent systems and organisations are, one failure can quickly cause another in an apparently unconnected area. Further, BCM forcibly illustrates through many examples that for risks and their consequences to be effectively managed organisations have to thorough assess all the key steps in procedures processes and activities if plans are to deliver the desired resilience.
One key learning is that organisation plans have to be connected; Business and Public Sector have a shared need and benefit when plans connect well with both sectors having a part to play. In the face of large scale Pandemic risks it is shortsighted for government to ignore or limit the role that the business world could play in mitigating the overall risks and of specifically responding the diverse factors that emerge once a threat materialises.  
Business Continuity planning also has a significant role in establishing the core capability of Healthcare institutions to cope during a Bio-Health crisis. Just how well would the Healthcare response fare if nursing, medical and support staff fail to turn up for work.
At the start of the outbreak it was realised face masks were potentially in short supply, that stocks of syringes were needed and that proper policies were needed to win the confidence of workers who would be in the front lines of the fight, but be returning home potentially infected to their families. Looking further afield what kind of impact would energy or transport disruption have on the capability to respond?  What would the impact be for business and the economy.  Business Continuity Management has evolved to be far more than an IT tool and is now at the heart of enabling our national infrastructures to meet any disruptive threat.  
The beauty of the opportunity here though is it does not give just one benefit, investment is amplified, protecting and delivering resilience against a very wide range of other threats from the mundane to the serious, from terrorism to fire and it can be tailored to met the needs of all organisations large and small, public and private delivering flexibility and value consistently to adoptees.
Concern though should be expressed that fewer than 25% of our corporates have fully developed their plans and across international boundaries the total is far far lower.    

The Threat Perception

A considerable part of the reason much of the general situation concerning Pandemic and BioRisks exists comes from the mixed messages and perceptions communicated throughout our communities and societies.
We have already illustrated the different focus given to healthcare deaths, and adding to the problem is a general tendency to believe that risks are either overstated or simply not significant to individuals. 
Over the course of ten years, The Continuity Forum has researched thousands of organisations that have been hit by ‘disaster’ events, from floods through industrial accidents to terrorism. 
One point continues to  shine through for those worst affected ... They never though it would happen to them!
As stated earlier, in the last century there where three pandemics killing upward of 50 million people; climate change is producing an almost seasonal increase in flooding, and terrorism is an ever present and increasing threat for a substantial number of countries.  People, however, continue to think these factors won’t impinge on their lives or organisations.
This attitude materially affects and undermines our capability to build our knowledge, skills and capability, which must all combine to deliver resilience to these threats.  Presumed knowledge plays its part as people, and indeed organisations, enhance their denial of the threat with the notion that even if ‘something’ did happen then it ‘wouldn’t be too bad’ or that ‘somebody‘ would be able to fix it. 
In our experience, when one examines the history of a disaster and looks at the timeline, there are often frequent opportunities where intervention could have mitigated or even helped to completely avoid it. In most cases these opportunities are not taken. 
Our experience also shows we have a great capacity for deluding ourselves as to our real ability to cope during a crisis, and tend to underestimate the resources required, the impacts and stresses created; this is especially true in what what are often unpalatable situations. This factor applies just as much to governments and official bodies as to the individual. The result is often a retrospective reaction, a raft of updates, a public inquiry, a change in legislation or regulation, all aimed at building future capability for reoccurrence of a past event.  With a disappointing regularity, experts report the fact that warnings were given, yet unheeded, and consequentially the opportunities to influence the event scale and impact lost.
One other factor that has to be mentioned is our capability to forget. Lessons hard learnt become obscured by time, the remembrance of the difficulties and impacts diminishing until such time as they are revisited upon us.  
We have to learn from this experience and recognise that we do have the capacity and capability to prevent or substantially mitigate the worst of the threat before a price, potentially affecting millions, is paid.

Calculating the impact ... Changing the framework?      

In trying to illustrate the impact, we are trying to derive the unknowable from the unpredictable; herein lies the problem and the heart of the matter.  Most detailed predictions of the impact from either a Pandemic or a Biological attack are by their very nature flawed.
Often the range of impacts and the associated costs range too widely to be of much use to politicians and policy makers using a balance sheet or actuarial approach in their decision making.  In financial terms, this makes it a difficult process, with no clear demonstrable return on the investment achievable, to justify policy or change - hence real progress is limited.
We would contend that a different way of assessing this particular type of threat is needed; one that fundamentally accepts the unpredictability and uncertainty surrounding the issues, but also reemphasises the responsibility and commitment needed to protect the people both within and beyond borders. 
Much as the military provides security and is our shield against external threats of violence, our national and international healthcare agencies are at the forefront of a different but potentially greater campaign.. the War against disease.  By changing the framework against which we judge the value of our planning, we could and should develop a new level of ‘Health Security’, whose benefits could genuinely benefit the whole world.  
We would contend that this is going to be a developing theme for the 21st Century, and one which provides the opportunity for developed and emerging nations to collaborate in union against a common and shared threat. Disease knows no borders, and building adequate defences requires an ability to be agile and adaptive, to react quickly and contest the threat as it emerges - not allowing it time to build and grow in strength.  This approach has more than a passing similarity with military doctrine, and this comparison can be taken one step further.
The investment rationale for Military spending is fundamentally different to most government spending, and one that attracts a truly colossal amount of investment worldwide.  In thinking of the situation with regards to Pandemic and BioThreat, one point needs to be made. A significant novel virus outbreak, from either natural or manmade sources, could well cost tens of millions of lives, comparable to the losses seen during both World Wars. In addition, the economic impact would have the potential to run into trillions of dollars. 
Against this level of threat, surely the issues around Pandemic and BioThreat change, becoming very much more of a National Security challenge, and consequently becoming the clear moral duty of Politicians and Governments.     
Addressing the risks requires creative solutions that reach out globally to confront the full range of potential emerging health threats. A more engaged international community, addressing the topic of BioThreat, also has the opportunity to deliver complimentary support to less well resourced developing and emerging nations, helping transform access to healthcare around the world. 
We have a common interest in creating defences against viral threat and perhaps our current experience of H1N1 is highlighting the issues we have to address before it is too late. Perhaps by creating an international initiative that also knows no borders, that can create connections and amplified value through the sharing of knowledge and resources,  we can not just minimise or at very least substantially mitigate the risks to our own local countries and communities, but also create a beneficial relationship that points to the shared responsibility we have to each other in developing global access to Healthcare, as well as building effective ‘Health Security’. 
In closing we would remind readers of this report that if you try hard enough you can surely find reasons to doubt, disbelieve  procrastinate or ignore the threat we face, but we would ask that you consider these in light of the considerable evidence now assembled and balance it against the one reason we must act in union ... The price all our countries, communities and even families  would pay should we fail!


Russell Price is Chairman of the Continuity Forum
This article is extracted from the SDA Debates and reflects other submissions to the EU Commission on Bio-Threat. For more details please contact us directly.
You can download the SDA/Continuity Forum Solvay report below