Monday, August 31, 2009

Power: a true test of character

As I mentioned in a previous post, the Department of Health and Human Services has contracted with the American Association for Respiratory Care to do a count of ventilators available in the US hospitals. This step is necessary in order to understand the capacity for accommodating the potential 300,000 victims of H1N1-induced acute respiratory failure. The AARC web site gives this interesting disclaimer:
"The U.S. Department of Health and Human Services further secures the privacy of your institution’s data through participation in the Protected Critical Infrastructure Information (PCII) program administered by the U.S. Department of Homeland Security. Resulting from the Critical Infrastructure Information Act (CII) of 2002, the PCII program protects voluntarily submitted critical infrastructure information from public release through Freedom of Information Act (FOIA), state and local disclosure laws, and use in civil litigation. Additionally, PCII can not be used for regulatory purposes. Institutions and facilities sending important data into the Federal government can be assured of the highest commitment to confidentiality and security of their data."

Why might the AARC feel the need to include it in order to conduct a legitimately needed survey? Clearly, they must feel that the responders would be reluctant to disclose publicly their vent numbers. Should the number of available ventilators really represent classified information under the current circumstances? How much more difficult does such secrecy make the already Sisyphean task of preparing our nation for what may be coming? It is like preparing for a war without knowing the number of rifles available to the army. And if it is this difficult to get a vent count, how impossible is it then to come up with an integrated triage plan? If the CEOs do not want known the number of shovels they can contribute to this sandbox, I hardly think they are running to volunteer the information on more advanced equipment (bulldozers, e.g.) or personnel to any foreman. Yet this is a very complicated sand castle construction, with many turrets, moats and portcullises, which without central oversight could do a lot of damage if not put together properly.

Having exhausted the sandbox metaphor, I will move on to several other, equally over-used ones. It is obvious that there are all-out preparations underway at the state, county and municipality levels. Further, hospitals are working hard as well to make sure they can provide best care possible to the greatest number of people. And the DHHS is working tirelessly to keep abreast of all the current developments to have mitigation measures in place. Unfortunately, all of the parties are brilliant musicians playing at the same time without a conductor. Federal regulators are constrained by state laws, regional agencies are confined to their own regions, and single institutions are ultimately driven by what is in their best interest; and besides, they are also beholden to the anti-trust laws!

Thus, suggestions (they are called "recommendations") are made, but there is currently no mandate that they be followed. It is like a surgeon suggesting that anesthesia be given to the patient before the first cut -- it may or may not happen. The President's advisers recommended in their report that he appoint an H1N1 Czar to oversee our preparedness efforts. But what is a Czar without the power to demand accountability, but a deposed monarch?

To me this fragmentation of effort falls in line with the mounting public paranoia that the government is using H1N1 as an excuse for a wholesale take over of the healthcare system, described nicely in a recent musing by Dr. Rob Lamberts, one of the top medical bloggers. In reality this is about turf battles and assertion of powers more than it is about any real threats to them. I know I keep referring to the NEJM piece that I reviewed a few days ago comparing Israel's state of medical preparedness to ours. I do not have to tell you that Israel has one of the most effective crisis mitigation systems in the world. Their healthcare system has to be ready for a mass casualty situation at a moment's notice. One of the central differences between them and us is competition between hospitals (they don't have it, we do). In the current instance, this competitiveness may be getting in the way of even the most rudimentary efforts at readiness. Hospitals already stand naked before a firing squad, having to report errors and other quality measures. What's the big deal about quantifying preparedness?

Abraham Lincoln once said "Nearly all men can stand adversity, but if you want to test a man's character, give him power." Let's look at this as an opportunity to show off our character, and share the power for the greater good.

No comments:

Post a Comment