For the reader's convenience, the President's National Strategy For Biosurveillance, signed 6 days ago, is attached at the end of this post. The background and operational experience of the author of this post may be found here.
Having reviewed the national strategies for bioterrorism / biosurveillance produced by the Clinton and Bush Administrations, the Obama National Strategy For Biosurveillance is the most polished to-date and addresses several key points our group has emphasized for several years now:
- that biosurveillance products are useless for the country if they are not shared in a timely fashion, particularly at the local level;
- that analogous to social behavior observed during crises and disasters, human beings tend not to follow pure command and control hierarchy- particularly when it comes to situational awareness; and specifically
- that "forecasting is a cognitive process informed by facts and models, and honed with experience" [emphasis by the author of this post]
Several refinements should be called out, keeping in mind the Strategy is very well-written:
- There is reference to Homeland Security Presidential Directive-21 (HSPD-21) as the guiding language, however precidence was achieved for HSPD-21 through the release of HSPD-7, -9, -10, National Security Presidential Directive-33, and (later) Public Law 110-53. This is an important historical point due to initial efforts to create a "Cheyenne Mountain" for infectious disease event forecast and warning, now known as the Department of Homeland Security's National Biosurveillance Integration Center (NBIC). The NBIC, however, has been rendered effectively impotent at the time of this post. The work of NBIC has been effectively farmed out to the National Laboratories for study, resulting in a ten year step backwards in attempting to meet the vision requested in the President's 120 day deadline. This massive regression in the thought process for national biosurveillance was directly observed by the author in several National Laboratory-sponsored conferences and in several senior level briefings in Washington.
- Although reference was made to forecasting (and specifically, weather forecasting), the inspiration missed the mark. Forecasting of impact after an event of concern has been recognized is certainly important. However, the full societal impact of converting this country's (and the world's) biosurveillance enterprise into one of comprehensive forecasting (i.e. the entire spectrum of hazard emergence to impact) was not mentioned. This was a crucial oversight of the grand psychosocial impact of creating and managing data sharing among a global network of infectious disease forecast stations in the spirit of the World Meteorological Organization. The analogy here is to think of the history of meteorology and how weather documentation preceded weather forecasting preceded tornado forecasting. The latter being an issue of national security interest in the 1950s due to the presence of our national deployable nuclear arsenal in tornado alley. The current National Strategy appears to emphasize tornado forecasting above and beyond forecasting routine, daily infectious disease activity. Local communities 'wired' to expect infectious disease forecasts as a part of their daily lives represent communities exhibiting adaptive fitness- increased resilience over time. If the Administration does not make biosurveillance relevant to the average citizen conducting their routine activities of daily living and the healthcare professionals who take care of that citizen, sustainability will be in question. One only needs to look at the entire national biodefense enterprise writ large to see that persistent challenge.
- Promotion of distributive, local level community resilience within the United States is key, and the National Strategy does acknowledge this. However, experience by this author suggests that a significant hurdle remains within the bureaucratic substrata tasked to implement this Strategy: the so-called "Rice Bowl" phenomenon. As has been the case since our country was born, there is a tendency to support initiatives that feed the federal engine: the "self-licking ice cream cone", and the interagency fight to maintain this status quo cannot be underestimated. It is realized within the Strategy that social media now destabilizes any effort to silo, close/hold, or sequester information- especially in the context of a rapidly evolving crisis. However old habits die very, very hard in the world of biosurveillance, and the bureaucratic substrata deserves the closest of scrutiny during the implementation process.
- Warning failure was not mentioned in the National Strategy, probably because of the negative connotation associated with failure of process. But this simply cannot be ignored. Both of the specific events mentioned in the Strategy- SARS and H1N1 pandemic influenza were associated with significant errors in signature recognition, issuance of warning, and information sharing. While it is acknowledged in the Strategy that uncertainty in the context of a crisis confounds decision makers, this uncertainty cannot be a further impediment to biosurveillance operations. Elected officials (and public health officials that answer to them) are highly reluctant of uncertain situations, preferring to have the facts confirmed as much as possible prior to dissemination. History has shown us over and again this mindset does not work in biosurveillance. SARS and H1N1 are not the sole events where warning failures have occurred. The introductions of HIV/AIDS, West Nile virus, and Asian soybean rust are several poignant examples.
- The National Strategy heavily emphasizes concern about intentional threat, however as mentioned above, the biosurveillance community writ large has performed inadequately when it comes to the recognition of concerning signature patterns and the timely issuance of warning for naturally emerging infectious disease events- events that have severely challenged our national public health infrastructure (i.e. HIV/AIDS). The Strategy acknowledges this concept in several places, however we must draw upon prior experience with other national security initiatives such as satellite imagery, the national highway system, and meteorology- that to keep sustainable funding and support from the tax base, one must derive daily relevance from these activities. Hence, we certainly should give homage to intentional threat, but we also must answer the "so what" of the taxpayer.
The author of this post is aware of several highly expensive (either in terms of funding or investment in human capital) key national biosurveillance programs that have been rendered impotent or deactivated. In this economically austere environment, there yet remains significant social resistance from within to exhibit fearless leadership and innovation as this country once saw with other national efforts that inspired the National Strategy- efforts that utterly changed our society.
The Vision here, in 120 days, should achieve nothing less.
James M. Wilson V, M.D.
Chief of Station
Western Slope, Colorado