It couldn't happen here. Before 9/11, that's what we used to think. We've known better for two years. Yet America remains unprepared to deal with disaster, experts say.
A big part of the problem is that hospital emergency departments already run at -- and over -- full capacity. Even a relatively modest disaster would overwhelm most cities' public health systems. This problem started before 9/11 -- and is getting worse, not better.
Why aren't things going according to plan? Because there is no plan, says Irwin Redlener, MD, director of the newly-created National Center for Disaster Preparedness at Columbia University's Mailman School of Public Health.
"This is a national crisis," Redlener tells WebMD. "I am very dismayed about where things stand at this time. We are telling the health-care system to get ready for bioterror, for example. But we are not telling them exactly what that means. And we are not giving them sufficient money or guidance. ... It is absurd to the point of lunacy."
A Chorus of Concern
Redlener isn't the only expert raising the alarm. Here's Arthur Kellermann, MD, MPH, chair of Emory University's emergency medicine department, a member of the board of the American College of Emergency Physicians, and a member of the National Institute of Medicine.
"This is a nationwide crisis and nobody wants deal with it," Kellermann tells WebMD. "Nothing has been done to address the problem of emergency room overcrowding and too little hospital capacity. Nothing -- capital N-O-T-H-I-N-G -- is being done on a national level."
And meet Emanuel Rivers, MD, MPH, director of emergency medicine research at Detroit's Henry Ford Hospital.
"Without a doubt we are going in the wrong direction," Rivers tells WebMD. "Increasing emergency room overcrowding is a very significant weakness in our ability to respond to any crisis. Look at the general deterioration of capacity in hospitals around the country. If we had a national crisis, we would have a much worse problem today than we would have had in 2001."
James Bentley, PhD, is the American Hospital Association's senior vice president for strategic policy planning. He says individual and regional hospitals have made huge improvements in disaster preparedness since 9/11. But he, too, says the lack of a national strategy creates problems.
"There is a lot of frustration in whatever state you look at, because the federal government is unwilling to say, 'OK, here is what we plan for,'" Bentley tells WebMD. "So Georgia could plan for one thing, and South Carolina and Alabama plan for something quite different."
Disaster Waiting to Happen
In a recent article in Emergency Medicine Journal, Rivers and co-author Stephen Trzeciak, MD, note that hospital emergency departments are America's safety net. But that net is dangerously frayed.
"The number of emergency room visits have gone up by 10 million to more than 100 million per year -- yet there has been a 20% decrease in number of emergency departments," Rivers says. "That translates into overcrowding. And a number of hospitals are downsizing, so fewer beds are available. With less money coming in, hospitals have lowered their capacity. Supply and demand have disassociated."
It's been going on for a long time before supply catches up with demand. Bentley says hospitals are caught between two opposing forces. On one hand, government and private insurers are cutting down on how much they'll pay for hospital services. That means hospitals take in less money. In response, they become more efficient. This means cutting back on empty beds.
On the other hand, disaster preparedness asks hospitals to keep a lot of spare beds around. But hospitals can't afford to do this.
"For a decade we have been squeezing hospitals like crazy in terms of cutting costs, releasing unused facilities, reducing capacity, and at the same time we are seeing reimbursement rates slow and drop. Hospitals are in a horrible fiscal situation," Redlener says. "If part of preparedness is having hospital surge capacity, we have been working in the exact opposite direction for years. Now we are in trouble. We don't have the comfort zone in hospital budgets that we need for preparedness."
The numbers are stark. According to a 2002 Advancing Health in America survey, 62% of all hospital emergency departments now say they are at -- or over -- their capacity to treat patients. In the cities, it's even worse: Three out of four emergency departments are at or over capacity. One in eight urban hospitals actually turn away ambulances 20% of the time. And this is business as usual, not a national emergency.
It's a dilemma with national security implications. Yet, Rivers and Kellermann assert, it's being ignored.
"Most hospitals in the country aren't sure how to handle tonight's 911 calls, much less a drastic terrorist attack," Kellermann says. "I am frankly baffled as to why individuals trusted with national security and public health aren't engaged in addressing this issue. There hasn't even been a meeting of key players. There have been no discussions of how do we handle a major, mass casualty attack or mass epidemic or bioterror incident."
Preparing for the Next 9/11
Redlener says that there's no scientific way to know exactly what hospitals should prepare for. So he's calling for a major, national effort to agree on what preparedness should look like.
"In my 30 years in health care, this is probably the most crucial, most critical agenda I have had the opportunity to work on," he says. "I am very, very worried. We don't have to be this unprepared. It is fixable. It is not as though we have a huge asteroid on a fixed path to hit the earth. We can prepare for disasters, whether it's terrorism or an industrial accident or a natural event. We now have an opportunity --- and an obligation -- to prepare."
Kellermann has worked out a detailed action plan. In a nutshell, the plan is to convene, reform, and re-engineer:
- Convene: This calls for a high-profile meeting of federal and state officials and representatives of hospital and medical associations to identify what each player can do.
- Reform: These are things that cost little to do. Most involve tweaking regulations and reimbursement formulas to give hospitals a financial incentive to prepare for disasters.
- Re-engineer: This means targeted investments in emergency medicine and disaster preparedness. It also means training more emergency medicine doctors, nurses, and emergency medical technicians.
"My watch reads Sept. 4," Kellermann says. "In a week it will be Sept. 11. We don't have a lot of time left before something happens again, and wakes us up to these issues. But that is a hell of a way to run health policy in this country."