Disaster Would Overwhelm Hospitals, Author Warns
Disaster Would Overwhelm Hospitals, Author Warns
The third of a three-part series.
'The Edge of Disaster'
Stephen Flynn, former Coast Guard commander and author of The Edge of Disaster, says that the United States medical system is unprepared to handle a catastrophic emergency such as a flu pandemic or a major terrorist attack.
The problem, Flynn says, is that hospitals have been trying to cut costs.
"The medical community has been moving in the direction of much of our economy," he says, "which is wringing out the extra capacity in order to essentially focus on the bottom line."
Each year, more than 300,000 people are treated in U.S. hospitals for the flu. The common flu is dangerous; more than 30,000 Americans die from it every year. But Flynn is even more concerned by the prospect of pandemic flu, such as the outbreak that occurred in 1918.
Flynn estimates that a pandemic flu outbreak today would result in 80 million infected Americans. If the death rate were similar to that of the 1918 flu, then a current flu pandemic could result in 800,000 deaths in the United States.
There are only 970,000 hospital beds in the entire country, says Flynn, "so clearly we'd have to find a much different way to provide emergency care for people outside of our hospital settings."
Flynn says the United States lacks the federal leadership necessary to organize state and local efforts.
Flynn worries that a medical system that can barely meet day-to-day demands will be caught unprepared by an onslaught of emergency cases.
"We're going to have incidents whether by acts of God or acts of man that are going to place a lot of people in desperate need for emergency care," Flynn says. "And it will be life and death whether or not they receive it."
He says that investing in a medical system that can handle a potential surge is "something that we can't afford not to do."
Flynn endorses alternative solutions that will enforce the medical system without tremendous expense. He says much more can be done to reach out to retired doctors and nurses who could serve as a rank of reserves for medical professionals.
There are also programs that give citizens basic training so that they can assist medical professionals in the event of an emergency.
To inspire such change, Flynn thinks the United States needs to realize that the medical system is moving in the wrong direction.
"The efforts to essentially try to keep costs down and to ultimately make... our medical care system as efficient as possible," he says, "stands in opposition to the need to have surge capacity when things go very wrong."
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Excerpt: 'The Edge of Disaster'
Chapter 1: A Brittle Nation
The United States has become a brittle superpower. We are the world's economic and cultural 900-pound gorilla and spend more on our military muscle than the rest of the world combined. Yet we increasingly behave like the occupants of a grand old mansion who have given up on investing in its upkeep. We depend on complex infrastructure built by the hard labor, capital, and ingenuity of our forbears, but we seem oblivious to the fact that it is aging and not very gracefully. Bridges are outfitted with the civil engineering equivalent of a diaper. Public works departments construct "temporary" patches for dams that leave those living downstream one major storm away from waking up to a wall of water rolling through their living rooms. Our electricity comes to us via a decades-old system of power generators, transformers, and transmission lines that have utility executives holding their breath on every hot day in July or August.
It is not just modernity's hardware that is being neglected. Two decades of taxpayer rebellion have stripped away the means for emergency workers to help us when we need them. Today, most city and state public health departments are not adequately funded to manage their routine work. A flu pandemic would completely overwhelm them. A growing number of firehouses have been shuttered in recent years, and firefighters must make due with radios that often are unable to support communications with neighboring departments. In many cities across the country there are fewer police officers on the streets today than there were in 2001, and those still on the beat have only limited access to the kind of protective equipment that would allow them to operate in a contaminated environment. Emergency room services have been a major casualty of medical care belt-tightening, forcing ambulances to routinely engage in countywide scavenger hunts for a place to bring their patients. Federal agencies such as the Coast Guard operate with a rickety fleet of aged ships and aircraft that routinely break down during patrols. In short, on any given day, our first responders are barely treading water. That means that there is little to no capability to deal with large-scale disasters such as major hurricanes, terrorist attacks, and disease outbreak.
Like the spoiled offspring of well-off parents, we seem blissfully ignorant of what is required to sustain the quality of our daily lives. Washington has shown little interest in challenging this national state of complacency. Rather than address the myriad soft targets within the U.S. border, the White House has defined the war on terrorism as something to be managed by actions beyond our shores. The rallying cry of the Bush administration and its allies on Capitol Hill has been "We must fight terrorists over there so we don't have to fight them here." What this ignores is that terrorists can still come here—and, worse yet, are being made here. When it comes to natural disasters, both ends of Pennsylvania Avenue rationalize their passivity by citing deference to governors and mayors and the private-sector. With the exception of the nation's capital and military bases, our national infrastructure lies within the jurisdictions of individual states and cities and is largely owned and operated by private entities. And emergency response has traditionally been a local responsibility.
The most compelling lesson we should have learned on 9/11 is that our borders are unable to provide an effective barrier against the modern terrorist threat. The al-Qaeda operatives who carried out the attacks on New York and Washington had been residing in the United States. They did not strike us with weapons of mass destruction provided by a rogue state but turned four domestic airliners into their equivalents. The Madrid train attacks in March 2004, the suicide bombings of the London Underground in July 2005, the June 2006 arrests of seventeen radicalized Canadians in Toronto, and the August 2006 arrests of two dozen British citizens intent on bombing U.S.-bound flights from London all highlight the growing reality that advanced democratic societies are not immune to incubating the homegrown terrorist threat.
The central lesson to be learned from Hurricanes Katrina and Rita is that major natural disasters are likely to overwhelm states' and localities' capacity to respond. Those two storms caused damage to more than 90,000 square miles of land and destroyed 360,000 households Washington's exhortations to governors and mayors to do more will not alter documented reality. In a report on disaster preparedness released in June 2006, the U.S. Department of Homeland Security found that only one quarter of state emergency operations plans and 10 percent of municipal plans are sufficient to cope with a natural disaster or terrorist attack. The majority of plans "cannot be characterized as fully adequate, feasible or acceptable to manage catastrophic events."
Denial and a fatalistic sense of resignation seem to be conspiring to immobilize us. Superficially, on an individual level there is an underlying logic to our inertia. Most of us will not be in the wrong place at the wrong time when terrorists attack, the earth rumbles, the tsunami hits, or the hurricane makes landfall. Of course, there will be victims, but odds are that individually we will not be counted among them. On the flip side, if fate does place us directly in the crosshairs of a disaster, anything we may have done in advance to protect ourselves is likely to be overwhelmed by the destructive forces aligned against us. So why worry about forces that lie beyond our control?
But this kind of rationalization is silly and irresponsible. Anyone who has ever prepared for a camping trip or gone to sea on a small vessel knows that having plans for coping with emergencies does not rob these activities of their enjoyment. However, not having plans could eat away at your peace of mind and put lives needlessly at risk should misfortune strike. We rightfully condemn as a fool anyone who marches off into the wilderness or leaves shore without the basic survival skills and tools for coping when things go wrong.
The fact is that we are living in increasingly complicated and perilous times and we have to stop pretending that disasters are extremely rare and unforeseeable. Even if we personally are usually lucky enough to be outside the primary strike zone, we are unlikely to escape the fallout. The things we depend on are becoming more and more interconnected and interdependent. A disruption of pipelines and refineries on the Gulf Coast means that gasoline quickly becomes in short supply everywhere. The closure of a major seaport such as Los Angeles means a nationwide shortage of the things that retailers and manufacturers—and ultimately consumers—need to keep operating. And in an age when long daily commutes and frequent air travel are facts of life, there is little hope that the rapid spread of a contagious disease can be contained by a simple quarantine.
The danger from man-made attacks is growing despite the more then five-year reprieve the United States has enjoyed since 9/11. We have been hedging most of our security bets on open-ended military campaigns to combat terrorism overseas, a gamble that appears to have worsening odds. When we were focused on containing the Soviet Union during the Cold War, relying on the projection of our military power beyond our shores made sense. However, today, we are seeing that the far-flung radical jihadist threat cannot be encircled by deploying our armed forces to the Middle East and Central Asia. Indeed, those efforts have had the unintended consequence of attracting more recruits, including "self-starter" groups of first- and second-generation Muslim immigrants in advanced democratic societies such as the Netherlands, the United Kingdom, and Canada. The use of sabotage by insurgents in Iraq has also helped to proliferate the number of individuals who possess the skills and technology to target critical facilities such as refineries, pipelines, water management systems, power generators, and electrical transformers. Whatever the long-term prospects for a more peaceful Middle East, and they do not look good, for the foreseeable future the global terrorist risk is going to get worse before it gets better. It is simply a matter of time before the United States is attacked again.
Compounding the risk is that we are living our lives in ways that increasingly tempt both fate and our enemies. At the micro level, most of us are blithely depleting the reservoir of self-sufficiency that once got us through emergencies. Our just-in-time lifestyles rely on ATM machines to provide us with cash when we need it and twenty-four hour stores to provide us with food and gas on demand. When the power goes out and these modern conveniences fail, we quickly become incapacitated. Within hours after storms hit, thousands of people end up standing in line for clean water, a hot meal, and basic shelter. Then we are dismayed to find that the public safety and public health sectors that we have been starving of resources during the good times are unable to help us when the times get bad.
We have raised our exposure to harm in other ways as well. For one thing, we have been unwilling to invest in the infrastructure that supports our lives. In 2005, the American Society of Civil Engineers assigned grades to fifteen categories of infrastructure based on a review of hundreds of studies and reports and a survey of more than two thousand engineers. Grades were assigned on the basis of condition and capacity, and funding versus need. It was not the kind of report card you would have wanted to bring home to your parents: four Cs, ten Ds, and one incomplete. The narrative reads like a survey that might have been conducted on the eve of the collapse of the Roman Empire. Roads, dams, water purification facilities, the power grid, canal locks, roads, and wastewater management systems have gone from very bad to worse in the past four years. More than 3,500 dams around the country are unsafe and many pose a direct risk to human life should they fail. The nation's inland waterway system is literally falling apart, which is especially bad news for Midwesterners, who depend upon it to move agricultural exports, bring coal to power plants, and transport chemicals and other bulk commodities. Nearly one half of its 257 locks are functionally obsolete, and that number is projected to rise to 80 percent by 2020. The report also documents that while the U.S. power system is in urgent need of modernization, maintenance expenditures have been dropping by 1 percent per year since 1992.
Demographic trends are also contributing to our growing fragility. Over the past two decades, Americans have been moving to coastal cities and communities in growing numbers. Half of the U.S. population currently lives within fifty miles of the coast just as scientists are predicting that we are at the start of a cycle of severe weather that promises more frequent, and probably more dangerous storms. Hurricanes Katrina and Rita highlighted a fact that we should already have known: the poorest and neediest among us are especially vulnerable in these areas. Those who cannot afford to own cars may be stranded in homes that lie in flood zones or are easily damaged by high winds.
The stakes transcend the unnecessary loss of innocent lives and the risk of major disruptions to our economy and our society. Our elected leaders' failure to provide meaningful leadership in addressing America's gravest vulnerabilities endangers the durability of the social contract between the governed and the government. The poststorm collapse of the New Orleans levee system showed that government at all levels was unwilling to undertake prudent measures to protect us in the face of a foreseeable and inevitable threat. Increased public cynicism has been the inevitable by-product. A poll conducted on the eve of the first anniversary of the Katrina disaster found that 57 percent of Americans feel the country is ill prepared for a disaster. After the next major terrorist attack on U.S. soil, the post-9/11 homeland security efforts will again be placed under a blistering spotlight. Americans will then painfully discover that our elected and private-sector leaders have been barely going through the motions. Beyond passenger airline security, few meaningful measures have been put into place to construct a credible counterterrorism deterrent at home or to ensure that the emergency plans laid out on paper could actually be carried out in reality.
Thinking about and preparing for when things can go very wrong need not be about becoming a nation of Chicken Littles. It is foolish and self-destructive to oscillate between immobilizing fear, on the one hand, and blithely going about our lives playing a societal version of Russian roulette, on the other. Natural disasters will happen, and not all terrorist attacks can be prevented. However, what is preventable is the cascading effects that flow from these disasters and attacks. The loss of life and economic fallout that disasters reap will always be magnified by our lack of preparedness to manage the risk actively and to respond effectively when things go wrong.
As a stepping-off point, we must be open to rethinking how the business of national security and emergency preparedness is done.
On the home front, we continue to leave it up to city and state governments to manage natural disasters, with Washington admonishing mayors and governors that in case of a disaster they will be on their own for at least seventy two hours. In an earlier era, relying almost exclusively on local means to deal with calamities was the only real option, given the substantial barriers that geographic distance presented to effective communication and transportation. But today assistance from afar can be just a few hours away. Within twenty four hours after Katrina made landfall, the perennially underfunded and undermanned Coast Guard managed to get one third of its aviation assets, some from as far away as Alaska, operating within the Gulf Coast area. By the time the 82nd Airborne arrived in New Orleans six days later, Coast Guard men and women had already rescued more than 33,000 people trapped in the floodwaters. The service never waited for direction from above. On its own initiative it brought in resources from around the country, locating and assisting Americans who were in need. Other elements of the federal government, including the Pentagon, could potentially have responded as the Coast Guard did. That they did not and do not has been a matter of choice, largely having to do with resources and who will pay for them. If the American people would choose to invest in a more active federal capability to help us in times of need, we could have one.
While the Bush administration has assigned the federal government a decidedly back seat role in dealing with natural disasters, it has undertaken an essentially "go-it-alone" approach to the war on terrorism. The White House has not mobilized the nation to wage this war, only our national security establishment, on which the administration is willing to spend freely. In 2007, the defense budget is over half a trillion dollars which accounts for more than 50 percent of the federal government's budget for discretionary spending. Not only are we spending this extraordinary amount so that our military can wage the war on terror, but the Pentagon has also asked for and received $16.5 billion to protect itself from terrorist attacks.
This is insane. The Department of Defense is spending twenty-five times more protecting its own military bases, naval ships, and barracks, two thirds of which are located inside the United States, than the federal government is spending to help local governments protect our major cities. The U.S. Navy is bankrolling a Coast Guard force to protect its vessels moving into and out of Puget Sound that is several times larger than the entire Seattle port police force, which is responsible for protecting that city's long waterfront. Any objective analysis would conclude that terrorists would be more interested in targeting civilian infrastructure on U.S. soil than taking on the U.S. military. Yet Washington sees no imbalance in providing billions of dollars to the Pentagon to protect its hardware while providing a paltry $710 million for cities around the country to use to safeguard critical and largely unprotected infrastructures. Since the White House has chosen to combat terrorism as essentially a military and intelligence activity, it treats homeland security as a decidedly second-rate priority. The job of everyday citizens is to just go about their lives, shopping and traveling, while the Pentagon, Central Intelligence Agency, and National Security Agency wage the war.
In short, we have a war on terrorism that is being waged almost entirely by our armed forces and intelligence community, and we have a disaster management system where the bulk of the burden falls on local and state shoulders. What we actually need is an approach to both these imperatives that will engage all levels of government to a far greater extent.
But our most important and largely untapped national assets are everyday citizens and the private-sector that powers our economy. On December 9, 1941, two days after the Japanese attacked Pearl Harbor, President Franklin Roosevelt said to the American people:
We are now in this war. We are all in it, all the way. Every single man, woman, and child is a partner in the most tremendous undertaking of our American history. We must share together the bad news and the good news, the defeats and the victories, the changing fortunes of war.
Company executives traded in their pinstripe suits for uniforms and led the effort to adapt America's industrial base to support the war effort. Women left their homes to work in factories, while neighbors and grandparents provided childcare. Americans grew "Victory Gardens" and volunteered to be air wardens.
Americans have not lost their willingness to give of themselves. Many of the rescues made in the aftermath of Hurricane Katrina were done by good Samaritans. Volunteers have helped to rebuild churches and homes. People opened up their purses and wallets and donated to charities in record numbers. What has been missing is the kind of leadership that Lincoln and Roosevelt exemplified when the nation faced its darkest hours.
The presidential scholar James MacGregor Burns has said that transformational leaders are always "relentlessly optimistic." Even when circumstances seem grim and the hurdles for achieving progress appear insurmountable, a leader retains his faith that change for the better is not only possible, but inevitable. This does not mean that leaders must be starry-eyed idealists. Just the opposite is the case; few followers are willing to hitch their fate to someone who is not grounded in their current reality. So leadership must always start from a clear-eyed view of how things really are. Only then can we begin to address how we can get from where we are to where we need to be. That is the aim of this book: to create a more resilient nation.
Excerpted from The Edge of Disaster: Rebuilding a Resilient Nation by Stephen Flynn Copyright © 2007 by Stephen Flynn. Excerpted by permission of Random House, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.