Is your health department running?

An Osterholmian analogy…

It occurs to me that your health department is a lot like your refrigerator. If you live in an area of the United States that pays for a state or local health department that has “the prevention and control of foodborne/infectious/communicable disease outbreaks” in its mission statement, then you are investing in both to keep your food choices safe.

Would you buy a refrigerator that determines its own performance level, not necessarily with the goal of maintaining a temperature that keeps food safe?

Would you buy a refrigerator with no thermostat and that continues to operate when the door is left open?

Would you buy a refrigerator that does both of the above, but only between 8am-5pm Monday-Friday?

Would you trust this refrigerator to keep your food safe?

Now,

Would you buy a health department that investigates outbreaks at its leisure instead of in response to public demand?

Would you buy a health department that does not advocate for improved surveillance laws and that does not measure and manage its own performance during outbreak investigations?

Would you buy a health department that can only work 8am-5pm Monday-Friday, even during large outbreaks (emergencies) that sicken hundreds of people?

Would you trust this health department to give you the information you need to make safe food choices?

We ALL do to some extent.

But,

I have to admit it’s getting better, a little better all the time. (It can’t get no worse)

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Reflecting on CSTE’s 2010 Food Safety Epidemiology Capacity Report

Today the CDC MMWR published Food Safety Epidemiology Capacity in State Health Departments — United States, 2010. The report details the results of a survey sent to state and local health departments meant “to count and characterize the food safety workforce in local, regional, and state health departments and to measure and evaluate core capacity to detect, investigate, and respond to foodborne diseases and outbreaks.”

This research fascinates me and I tip my hat to the authors for a job well done. While I’ve not seen the questionnaire used in this survey, and I believe that some of the statistics are very difficult to interpret without more information, a few things do concern me, and should concern anyone interested in public health accountability and effectiveness.

  • 27 states do not prioritize foodborne disease outbreak investigations. How many of those 27 states have foodborne disease surveillance programs? What is contained in the mission statements of those programs? (It is the promise they make to the tax-paying public) How many of these states want more epidemiologists to reach full capacity?
  • 20 states do not have laws that allow them to pay epidemiologists overtime during investigations. Are these public health authorities relentlessly lobbying to have those laws changed? Do states restrict police and firefighters to responding to disasters between 8-5 Monday-Friday? No, because if they did, police and firefighters could not meet the needs of the tax-paying public. Foodborne outbreaks are similar to disasters with tremendous costs to the public’s health and the industry, however they are not typically thought of as disasters because they are geographically and temporally dispersed, and the responders are not from the emergency management discipline. How many of these 20 states reported they needed more epidemiologists to reach full capacity? Do we need more people to work 8-5 or do we need to be able to pay experts to work overtime when appropriate?
  • Only 27% of departments plan to implement the CIFOR guidelines to improve foodborne outbreak responses. How many departments that do not plan to vigorously review and implement the CIFOR guidelines, as well as other continuous quality improvement activities, report that they need more epidemiologists in order to reach full capacity? Do we need more people to do an inefficient process, or do we need to define an efficient process and plan for surge capacity?
  • Finally, how does reported capacity to investigate correlate with actual program timeliness and effectiveness outcomes and program quality as perceived by the tax-paying public?

I personally believe that foodborne disease surveillance programs exist, at the very least, to provide accurate and timely risk information to consumers in real time, not just to crank out annual summaries of data. If our nation’s foodborne surveillance authorities are divided about the importance of participating in outbreak investigations and informing the public, then public health is absolutely failing in it’s promise to the American people. In order to solve multi-state outbreaks in a timely and accurate manner, we absolutely need a shared understanding of the urgency of these outbreaks. We also need a shared understanding of how to investigate. The public relies on the efficient cooperation of state and local health departments and the CDC for actionable risk information. When our system’s vision is fragmented, our performance in terms of timeliness and accuracy will likely suffer! (See my latest post about Adm Thad Allen, USCG (Ret.))

I ask fellow public health professionals: Are we a service organization or a summary organization? Do we answer to the needs of the tax payers and other partners, or are we above public accountability because we believe deep in our hearts we are doing the right thing? Do we share information and provide services that meet the needs of the people that keep us in business?

Admiral Thad Allen, USCG (Ret.): Multistate Foodborne Outbreak Guru?

For those of you who don’t know me personally, read my blog or follow me on twitter, I have two great passions in life: emergency responses, especially to foodborne disease outbreaks, and leadership. I recently came across a Harvard Business Review interview with Admiral Thad Allen, USCG (Ret.) in which the Admiral reflects upon his leadership during the federal emergency responses to 9/11, Hurricane Katrina, the earthquakes in Haiti, and the Deepwater Horizon oil spill. His response to the first question in the audio interview posted on HBR.com reflects on the complexity of leading through complex disaster responses involving several agencies, and it should weigh heavily on foodborne disease outbreak leaders in government, industry, academia, and consumer groups. My complete thoughts on the brief quote below:

Admiral, facing such a big, complicated crisis, how do you start? Do you approach this like a military operation?

“…When you move into what I’m going to call a whole-of-government response, and this is a hurricane response, an oil spill, doesn’t matter what it is, you’re really not talking about unity of command at that point you’re really talking about unity of effort. Because what you have is a number of cabinet officer, cabinet agencies, that have different jurisdictions, responsibilities, all of which come to bear on the problem, all of which can be used to address the problem, but also carry with it responsibilities for them to actually do their jobs.”

Coordinated investigations of foodborne disease outbreaks are also complex in that they require the coordination of dozens of state and local health departments, CDC OutbreakNet and PulseNet, FDA, USDA, potentially DHS (Department of Homeland Security), and one if not dozens of food producers, manufacturers, distributors. Typically the governmental investigation process is coordinated by CDC OutbreakNet leaders who coordinate information sharing, hypothesis generation, and continuous cooperation with federal regulatory agencies responsible for contacting food companies and state and local health departments responsible for interviewing outbreak cases. Often an Epidemic Intelligence Service (EIS) Officer will lead the response by compiling state epidemiological data, facilitating conference calls, and interacting with federal regulatory agencies. The ability to communicate a sense of urgency in the investigation, empower partners, and manage extreme complexity are leadership talents that could increase the performance of cooperating partners and the timeliness of the response system as a whole.

“So the number one issue in my mind is creating unity of effort. And creating unity of effort will vary with the specific incident you’re involved in, having been involved in several recently including 9/11, the Haitian earthquake response, Katrina, and the oil spill, how you achieve unity of effort is slightly different in each case based on the demands of the situation and the effects you’re trying to achieve but overall what you’re trying to do is aggregate everybody’s capabilities, competencies and capacities to achieve a single purpose, still taking into account the fact that they have individual authorities and responsibilities.”

Foodborne disease epidemiologists are aware of variability in the epidemiological presentations of outbreaks and its impact on the course of outbreak investigations. Depending on the supply-chain complexity of the food item that is causing a cluster of human illnesses (One brand of melons vs. one peanut paste present in 2,000 commercially available products), an outbreak investigation could require months of epidemiological interviews, dozens of product tracebacks, and interaction with hundreds of food companies. Creating a unity of effort (and thus achieving desired effects) during a multistate foodborne outbreak investigation requires talent proportional to the complexity of the outbreak.

Undoubtedly the course of the investigation can have consequences on the unity of effort. During the 2008 outbreak of Salmonella Saintpaul associated with Jalapeno and Serrano peppers, a long and difficult outbreak investigation and an ultimately erroneous public health advisory created doubt in governmental credibility and competency during the latter days of the outbreak. Similarly the long, difficult, and confusing investigation of E. coli O104 associated with fenugreek sprouts in Europe drew criticism from experts from across the world. These effects can create challenges for leaders who must achieve unity of effort to identify the cause of the outbreak and take public health action if necessary. (Which poses the question, can a unity of effort be achieved if Fresh Del Monte is ever again circumstantially involved in outbreak investigation leadership? Despite a recent major lapse of professional trust I trust that the answer is yes.)

“That makes it a much more complex matrix to manage and it makes it a much more complex management challenge, but it’s a feature of our democratic government and its one of those things where we need to start raising leaders that have the capability to do that.”

Which brings us to how we train leaders for foodborne disease outbreak investigation and control. Leaders include environmental health specialists and epidemiologists in state and local health departments, CDC OutbreakNet and PulseNet leadership, inter-agency liaisons, regulatory agency leadership, and food industry senior leadership, all of which manage complexity on some scale during their participation in a multistate investigation. What is required in an outbreak investigation leader, and how much of what is required can be trained? With a background in organizational culture, one could hypothesize that an experienced, well-known and influential leader in a central role such as OutbreakNet would be more able to create unity of effort early in a multistate outbreak investigation than a rookie, given an intimate knowledge of the system, acquired experience from past outbreak investigations of varying complexity, and long-standing relationships with leadership in cooperating agencies.

However upon first examination it appears that our current system of multistate foodborne disease outbreak investigation coordination at CDC is not utilizing leaders with extensive experience in foodborne disease outbreak investigation. EIS Officers, who rotate in OutbreakNet for two years gain tremendously-specialized leadership skills, yet usually leave OutbreakNet for a higher-paying position in CDC. I don’t question the value of the experience to EIS Officers, but from an emergency management perspective, do they have the acquired experience and influence to lead a national emergency response? It’s not just EIS officers, it’s everyone working their way up the ladder in the federal agencies. Unless employees are passionate about their work, they are able to apply for unrelated, higher-paying jobs in different areas of the federal government.  The actual pay structure of federal agencies provides an incentive for employee turnover, which may be counterproductive to achieving institutional memory, a unified culture of outbreak leaders, and unity of effort in times of crisis.

Does this really matter? Does the system need to change? Do we need to stop relying on EIS Officers as outbreak investigation leaders? Do we need to incentivize career-specialization in foodborne disease outbreak response in relevant federal agencies? A giant leap forward in public health workforce development, knowledge management, and performance evaluation informatics could provide an evidence base for any decisions about restructuring federal food safety responses, although it seems such a breakthrough is years into the future. For the time being it seems the system works somewhat efficiently most of the time, thanks in large part to foodborne outbreak responders like Dr. Ian Williams, long-standing Chief of the Outbreak Response and Prevention Branch at CDC who works closely with EIS Officers in OutbreakNet during multistate investigations. His extensive experience in multistate investigations and relationships with partners bolsters the culture of multistate outbreak responders. But perhaps we should be mindful of the potential importance of leadership in determining multistate outbreak investigation performance in the future and how our current system develops those leaders. Developing a unified sense of urgency and a culture of performance across the federal, state, and local outbreak response system will be a challenge because of the variation in state and local public health laws and the lack of central management of the workforce. Individual leaders of outbreak response agencies should strive to create and support cultures of best practice in order to ensure and improve the overall timeliness of public health action during multistate (and local) foodborne disease outbreak investigations.

A disaster drill pays off at the Monticello Nuclear Generating Plant in Monticello, MN

The Monticello Nuclear Generating Plant (Photo from XcelEnergy.com)

The main goal of the U-SEEE research project that I work on is to determine how emergency responder training histories and work experience contribute to performance in response to actual disasters. What I have heard from many responders throughout the project is that sometimes emergency responses are hindered by impossible logistics, lack of equipment, and malfunctioning equipment – no amount of prior training or experience could have prevented some aspects of the emergency response.

I was reminded of this as I read in today’s Star Tribune that an emergency preparedness drill conducted at Xcel Energy’s Monticello Nuclear Generating Plant in Monticello, MN had detected a defunct sprinkler system in one of the plant’s buildings. While the sprinkler system was not in a reactor building, this discovery reminds us of the need to conduct emergency preparedness drills and exercises, not only to test and train our brave emergency responders, but also to ensure the proper functioning of equipment that can dramatically influence the outcome of a disaster response.

Welcome to An Edible Disaster

Hey, I’m Evan. Welcome to An Edible Disaster. In this blog I’ll share some interesting food safety news and views as well as comment on my research and life as a Public Health PhD candidate.

I chose the name “An Edible Disaster” for this blog because I study public health emergency preparedness. My main interest is in food safety and foodborne disease. While it may not be mainstream, I view foodborne disease outbreaks as disasters – to be taken as seriously as any other natural or manmade disaster. They constantly recur, and like other disasters they are handled by a set of emergency responders – usually environmental health professionals, epidemiologists, laboratorians, and regulators in government agencies (See the “Team Diarrhea” video below). The field of emergency preparedness has learned and improved much from past emergency responses, however I do not see the same progress in foodborne disease outbreak preparedness. Thus, my goal with this blog is to comment on public health preparedness research and practice, often as it relates to foodborne disease outbreaks.

Just to give you an idea of exactly where I’m coming from, allow me to introduce to you Team Diarrhea. Team Diarrhea (aka Team D) is a group of epidemiologists, laboratorians, and graduate public health students who work in foodborne disease surveillance at the Minnesota Department of Health in St. Paul, MN. The group works with physicians from around Minnesota and the CDC to detect cases of foodborne disease, identify which foods the unfortunate cases ate before their illnesses, and to end “clusters” or outbreaks of foodborne diseases when a specific food is making many people sick. (Full disclosure: I was previously a student worker on Team D)

These are the emergency responders responsible for identifying foods that are contaminated with dangerous bacteria like E. coli and removing them from the market before they cause hundreds or thousands of severe illnesses. These are the disasters I want to improve our ability to respond to.

I’ll have plenty more to write about Team D in the future, but for now I’ll leave you with some entertaining video. Sit back and enjoy some high-quality diarrhea theatre!

See Also:

http://www.kval.com/news/39335972.html?embed