The 4S’s of surge capacity

By Mary Odum

Welcome to the arcane and short-sighted world of public health strategic planning. This post introduces the term surge capacity, a term we will hear often in the coming months of this growing Ebola (EVD) epidemic. Surge capacity is the ability to manage sudden or prolonged increases in overall healthcare demand, and the key components are the 4 S’s of staff, stuff, structure and systems, for hospital and community preparedness (Adams, 2009). During a pandemic, lack of surge capacity in all four of these areas become key limiting factors:  hospital isolation beds (structure), healthcare providers (HCP-staff), isolation gear (stuff), and an efficient, just-in-time, high-transformity system, which is an obstacle to resilience. 

Did you think that this was the growth curve for EVD? Exponential curves look similar whether in global population or pandemic cases!

Pandemics and wars serve as economic equalizers to reorganize the global landscape into units appropriate to available resources. Historically, wars have served to reorganize boundaries of areas of territories based on power and influence. Regions were also affected by pestilence—successful regions had adequate resources and avoided pestilence by remaining in balance with their environment and other regions. The littlest viruses can serve as the greatest equalizers in an inequitable system. As fossil fuels wane, functional low-energy economies will require less disparity between the haves and have-nots, and a much smaller population, in order to exist within ecological limits in their environment. The fact that this virus is emerging now as a global pandemic is no accident.

 Can a pandemic come to the US, and how would it behave?

Watching this disease spread is like watching a slow motion train wreck, or, as an editorial in the journal Economist  suggested, like chasing a rolling snowball.The idea that the virus will somehow stop at 20,000 cases, as initially suggested by WHO, or 550,000 as some models predict, or even one million cases, is a hopeful idea which is not backed by logic so much as the need to not look too far into the future. The more this virus spreads, the more ability it has to spread, as it creates disorder and loss of control. The virus could either come directly from West Africa by boat or plane, or indirectly from another affected large country such as India or China as time goes on, as they are likely candidates for pandemic due to their population size and poverty. “Will” notes that “people from all over the world will be going to circumambulate the Kaaba in Mecca for the Hajj (and to kiss the Black Stone there) October 2nd to 7th this year.” The timing couldn’t be worse.

Disordering Pulse in Society Odum, Zygon, vol. 12, no. 2 (June 1977)
Disordering Pulse in Society Odum, Zygon, vol. 12, no. 2 (June 1977)

This epidemic is being spread in West Africa by transmission within an overwhelmed healthcare system and spread in the community by contamination and spread by family caregivers without options. Denial by governments is resulting in delayed or inadequate policies, while citizen distrust of government is also aiding in the spread. There are no real barriers to stop EVD, as the global mandate for economic growth and national policies are fixated on maintaining global trade by whatever means. Communication is essential for vigilant surveillance of public health. While media hype about isolated suspected cases is not constructive, the opposite reaction, where government attempts to suppress communication about outbreaks can result in deadly delays of action. Optimistic media stories about supposed cures may lower the guard of the public and perhaps interfere with public health attempts to quarantine, by creating a populace that feels invincible. There are times when pessimism and an abundance of caution become protective mechanisms, but American society has had caution bred out of us through coddling by our successful fossil fuel based system. We expect safety, security, and rescue by technology. Fossil fuels have allowed us to exert an excess of control and create a complex order, which a virus now proposes to disrupt.

dods-organizational-involvement-in-global-healthThis week’s brief EVD news was buried on page F6 of my Sunday newspaper, at the back of the business section. Can the media change its tune from growth pumping through celebrity culture to a more precautionary stance, where we look at issues and look for solutions? Will the ubiquitous nature of social media aid the spread of the virus or help control it? Perhaps both—the power of social media is a new factor that may have unforseen consequences in this epidemic in both helpful spread of information but also detrimental spread of paranoid rumors. The same distrust of the government that the media is describing in West Africa can also be seen in the US now in the #Ebola Twitter feed. Crises trigger paranoid ideas: that the outbreak originated through bioterrorism, or suspicion that this is a plot to instigate martial law or take over Africa’s resources. There has been a big outcry against the sending of troops to West Africa to build field clinics, but many Americans don’t realize that the Department of Defense budget and organization for medical management of infectious diseases is extensive. The same distrust of the government that is present in West Africa is also present in the US, even before a crisis complicates the matter.

If the EVD does reach the US, our capitalist, highly mobile economy will add to our containment woes, as the mandate to keep the economy humming may keep employees working, students in schools, children in daycare, and people shopping in malls and other mingling places in this country where diseases are traditionally spread. A large jail and nursing home/retirement village population might also be sources of spread.

TSAGuidanceIn an outbreak, entertainment, tourism, and large gatherings would need to be curtailed. Would US leaders be able to take the political actions required to control the disease at the outset to prevent pandemic spread?  The idea of quarantine is in direct opposition to the dominant economic paradigm of growth. A quarantine would damage the systemic structure, rules, and feedback mechanisms that promote growth. The absence of discussion of screening at ports on our political agenda in the US suggests that our leaders are still in denial. Perhaps we won’t institute any controls or safeguards on borders and travel until it is too late. WHO just issued interim guidance for airports and for airlines, which suggests that TSA will need to assess and diagnose travelers, and develop some hyper-vigilant cleanliness. Is TSA up to the task?

Some cautious citizens would undertake self-imposed reverse quarantine (SIRQ) in a pandemic. But SIRQ would also add to further economic collapse, beyond what is already occurring. I think that further economic contraction and de-globalization of trade as a result of EVD is a given, and a pandemic would be the coup de grâce for many businesses in the US that are grimly hanging in there now. Eventually, but too late, quarantines would be imposed, and the economy would stall further anyway. We have a catch-22; if we don’t isolate, the epidemic becomes a pandemic and the economy contracts. If we isolate and quarantine, the economy contracts, and a pandemic could occur anyway, in spite of quarantines.

Transmission-infectious versus contagious
Boone & Gerba, AEM, 2007 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1828811/
Boone & Gerba, AEM, 2007 Factors affecting fomite transmission

While the mainstream media jumps to the extreme case question of whether the EVD can become airborne, a more mundane possibility is that EVD becomes or has become more contagious through indirect transmission. EVD is highly infectious, requiring very few virions to transmit the disease. But it is not considered to be highly contagious, since it is transmitted via body fluids. There is a diversity of opinion of how contagious this disease is on surfaces (fomites), which is an important topic to be studied further, with CDC guidelines bearing the label “Interim.” There is also the question of how this already extremely infectious virus might behave in colder, darker climates. EVD appears to prefer cooler temperatures and high humidity. One study found that the Ebola virus lasts longer on fomites at low temperatures and dark conditions, but the science on fomite transmission and infection control is complex and incomplete. How would EVD behave in wintertime, in modern, closed office buildings full of people in first world settings? We don’t really know, since our only science is based on Ebola in rural, isolated African villages.

The urban spread of EVD in West Africa has caught experts by surprise, as the experts believed in limited contagiousness and transmissibility. Once EVD gained an urban foothold, the epidemic’s growth became exponential. Cities concentrate energy, materials, and people, so perhaps the explanation is as simple as concentrated viral loads with humans in close contact. Human behavior in cities is different too, which may be a factor. Which factors are more important in behavior of the virus–cultural or genetic? We have not learned everything we need to know about this disease.

Small, isolated outbreaks in the US could and would be handled swiftly and capably by our healthcare system. But what about patients who avoid the healthcare system due to lack of insurance? The pool of unemployed and uninsured people could create outbreaks through informal community vectors, especially given the sad state of funding for public health departments in the US, whose role is community surveillance. If or when an outbreak gained a foothold, our healthcare system, which has little resilience in excess staff and bed capacity, would also become overwhelmed, setting up the same dynamics as are presently occurring in West Africa, with overload of the healthcare system, and transmission through caregivers at home in the community. The overload of the healthcare system would be magnified by the need to treat any generic fever or flu-like symptoms with caution and isolation, due to the infectious nature of the disease.  If caregivers do not use universal precautions and scrupulous isolation techniques, caregivers become the mode of transmission and not isolators of this deadly disease.

As the pandemic grows, the routes of international transmission will expand. More outbreaks could occur through freighters, air travel, or immigration of those fleeing hot zones. The long incubation period will aid this, as travelers can move a long distance in the incubation period of 2 to 21 days with modern travel. If it does arrive in the US, it could potentially hit the population harder than populations in Africa, as there may be some native immunity in Africa due to fruit bat saliva exposure, and Africans may have a fitter population and genetic base as there is less medical rescue and less immunosuppression. Or the disease could become less lethal or infectious, or our public health system could win the day—we can hope.

Surge capacity in hospitals

In the 1990s in the US, community hospitals were sold to corporations, and medical models of care were traded for business-oriented, profit-making models. Modern hospitals have since adopted an efficient system that operates at or near capacity most of the time, resulting in routine reductions in hospital staff to improve profits. This profit-making model defeats any public health attempts to plan for surge capacity. “Health Resources and Services Administration (HRSA) has attempted to describe surge capacity [goals] in terms of numeric benchmarks; it has defined regional surge capacity as the ability to triage, treat, or reach a disposition of 500 cases per million for infectious diseases” (Adams, 2009). HRSA’s vision for surge capacity appears limited to a specific act of bioterrorism or other short-term, localized event, but the vision is in no way grand enough for a growing pandemic, as we are seeing in West Africa–perhaps because it is not achievable given recent exponential growth of the population. Our high-transformity healthcare system has little resilience or slack, although socialized healthcare systems are similarly unprepared. Because of the complex demands of high-transformity (high-tech healthcare), care of patients with deadly and highly infectious disease becomes a “logistics nightmare” for all aspects of treatment.

AmbulatoryCareIsolationroomEVD could spread most easily to other countries when patients are cared for in communities without quarantine.  Control of this disease works until patients either avoid hospitals or can’t get into hospitals because they’re full, or aren’t diagnosed properly. Hospitals can become centers for transmission if they’re overloaded, lack proper isolation beds or PPE, or have inadequate infection control. Isolation beds are already a constraining factor sometimes in routine hospital care in the US, with limited surge capacity. Proper isolation rooms include anterooms for isolation gowning, degowning and handwashing, and sealed surfaces to allow cleaning (and no carpets!). Modern hospitals typically have less than two of these isolation rooms per unit, while doctors’ offices typically don’t have any. Modern hospital care is also reliant now on alcohol handrub as a shortcut for handwashing. Is alcohol handrub effective with EVD? I don’t think we know. While pandemics appear to be an unthinkable and unplannable horizon for HRSA, HRSA has established a bioterrorism goal of “one regional healthcare facility, in each awardee defined region, that is able to support the initial evaluation and treatment of at least 10 adult and pediatric patients at a time in negative pressure isolation within 3 hours post-event.”

Logan, 1998-Model flu epidemic treatment rates and failures
Odum [Logan], 1998-Model flu epidemic treatment rates and failures
Those goals are meager considering the potential growth rate of a pandemic. The problems that arose in hospitals during Superstorm Sandy, a local disaster, also show large problems with readiness. All of this suggests that we are in no way ready for a pandemic. It is too late to prepare the additional surge bed capacity in hospitals for this or any pandemic–a better plan might be to try to create a community-based surge capacity plan, that trains community workers and provides caregivers in the home adequate training and supplies.

Surge capacity for healthcare providers

As Dawson at Reuters pointed out yesterday, the new Ebola clinics slated for West Africa are useless without staff.

 “Each 100-bed Ebola treatment center under construction needs 230 trained staff, including 12 medical experts, to operate, U.S. officials said. That would mean nearly 4,000 personnel for the Liberian facilities due to start opening in October, and it is unclear where they will come from. ‘Building hospitals and equipping them is great. But unless you have trained personnel to work in them, that is not going to help,’ said Rabih Torbay, senior vice president at the global healthcare nonprofit International Medical Corps (IMC). ‘Seventeen thousand beds, but who is going to staff them?’ asked Torbay, who leads IMC’s Ebola response. . . . . Nancy Lindborg, USAID assistant administrator, said international agencies have drawn up a detailed matrix, specifying what each country and organization can contribute to addressing the Ebola crisis. ‘Health workers is the key gap,’ she said.” (Reuters, 9/20/14).

The 4,000 HCP needed for October 2014 in West Africa dwarf HRSA’s targeted, regional surge capacity plan for the US, which calls for 250 more HCP as a surge response in urban areas, and 125 more HCP in rural areas. An exponentially-growing pandemic that affected the US would quickly outpace strategic responses of the US healthcare system, which would be linear. Medical training has a long lag time, and volunteerism may be limited with this deadly disease. Nurses in particular may be in short supply, as many older nurses have delayed retirement due to the poor economy and poor or no pensions. The average age of a registered nurse is 47, with 55% of the US RN workforce 50 years old or more. Approximately one third of the entire workforce is due to retire in the next decade. How would a long-term endemic or pandemic EVD impact an aging workforce that is already anticipated to be in a significant shortage as baby boomers age and health care demands increase? I’m not sure we want to find out.

Logan, 1998-Model of hospital and insurance impacts of a flu epidemic--profit-making saps resilience from the system
Odum [Logan], 1998-Model of hospital and insurance impacts of a flu epidemic. Profit-making saps resilience from the system.
Enough HCP is the biggest bottleneck in a pandemic in either hospital or community-based care. Watching the EVD epidemic grow provides the US with an opportunity to make systemic changes to an inadequate healthcare system, if policy makers are willing to face the issues. But creating resilience in our healthcare system is constrained by an expensive, dysfunctional, for-profit system that is wedded to the insurance industry (also for profit) and also dependent on full-time employment linked to the success of corporations. The coming disorder inherent in this epidemic is an opportunity to face our global population problem and reorder our healthcare systems, as we face the beginning of increasing mortality during energy descent. We are completely unprepared for the certainty of a future pandemic, whether it is Ebola now, or something else that comes fast on its heels. It is time to face our biggest problems.