Previous IFPA-Fletcher Conferences

National Security Strategy and Policy:
Planning for and Responding to Threats to the U.S. Homeland

October 28-29, 2004
Ronald Reagan Building
and International Trade Center
Washington, D.C.

Dr. Ivan C.A. Walks
CEO, Ivan Walks and Associates
Senior Medical Advisor, E Team
and former Chief Health Officer for the District of Columbia

Introduction By: Dr. Charles M. Perry

Dr. Ivan C.A. Walks: Good morning everyone. They gave us those big, comfortable chairs; it was kind of hard to jump up as quickly as I needed to.

Just a little bit of clarification. I'm CEO of Ivan Walks and Associates and E-Team is an association I've worked with; I'm not an E-Team employee. So that means I can say good and bad things about them, or about anyone else.

What I really want to talk about today is how all of the things that we have to do kind of fit in with the people that we have to do them with and, in some cases, do them to. This era that we’re in, from September 11 on forward, and I was the health officer here in Washington, DC during September 11, and then subsequently during the anthrax attacks, and was the Incident Commander for our response here in DC for that, and so had an opportunity to work very closely with the some of the folks on the panel here. I think Jim Hughes and I spent a couple of days together, to put it mildly.

It’s been a very interesting time over the last couple of years, and currently doing work now on projects for the Centers for Disease Control, the Department of Homeland Security and other private, as well as public folks. I call this the preparedness era, and I think when we talk about preparedness-- One hint I’ll give you, when I was in college, they told me that anything that’s underlined on a slide, that’s what you have to remember; the rest of the stuff you can ignore. So I tried to underline the important words or important concepts here. I'm going to assume everyone here can read, so I will not read these slides. I've got about 12 minutes left out of my 15, so I'm going to go a little bit quickly and try to hit the highlights.

I think that when you think about preparedness, you think about response, continuity is what people really want to know. If I can get up and take my kids to school today-- I remember on September 11, trying to worry about our-- we have young children, and about those children being in school, in DC, and how we can get to them. And then when do they go back to school? When can we get our lives back in order? So continuity is going to be an issue.

Also, one of the things we tend to forget is that we work within communities at some point during a crisis, and usually very early these become community issues, and there are community opportunities that we miss and community challenges that we have to address.

I was with a group over at Georgetown and we were talking about something called MIPS, medically idiopathic physical symptoms; sometimes MUPS, medically unexplained physical symptoms. Bottom line is that for every time someone is injured during some sort of attack, there are a lot of psychological consequences. I'm currently serving on something called the September 11 Oversight Commission. The Board of Governors of the American Red Cross asked five of us to sit and oversee the spending of the more than $1 billion they collected post-September 11, and what we’re finding now, a few years out, is that people still have needs, but all of the bones have healed, all of the burns have been treated, and what we’re dealing with now are the psychological consequences. Still, also, Hurricane Andrew, years ago; Oklahoma City, years ago; folks still needing to deal with those sorts of issues.

And if you look at what’s actually happened with bioterrorism over the last several years, and though in Washington, DC we did lose Mr. Morris and Mr. Curseen, two US Postal employees during the anthrax attacks, most of what we do in terms of response to stuff is we worry about important things, like negative pressure, isolation rooms, and that kind of thing, and we don’t think enough, I think, about the mental health infrastructure and the focus on mental health needs that we’re going to have to address short-term as well as medium- and long-term, if we’re going to really want to focus on continuity and having our communities continue to function after some sort of a crisis.

By the way, I'm the only person I know that’s ever been testifying in court and have the court reporter actually stop the proceedings and ask me to speak more slowly. So I apologize for that; it is a character flaw, one of many. Hopefully, it’s the only one you’ll see this morning.

This is taken from the HHS Risk Communication pamphlet, an excellent document if you don’t have it. Really, when you talk about risk communication, it ultimately is, again, really underlined, an exchange of information and opinion in an unstable information environment. That, I think, is a critical piece of what we need to think about. When you don’t have all the information, you still have to be able to communicate, and you still have to try to communicate in a way that maintains your credibility because, I will submit to you, credibility is your most important commodity during a time of crisis when you have to interact with the public.

Now, we talk about the public like it’s one person, and I do, like most of us do, I get up and I talk to myself. I am most comfortable talking to people that are educated and got a bunch of initials after their names and still remember the ‘60s as opposed to having read about them. A lot of good folks were born back in the ‘50s. But that’s not our population in America, and our population is extremely diverse, and when we think about and we plan for and we try to respond to incidents that happen in our communities, all of these things become relevant.

The second-to-the-last bullet, the second-to-the-last word is “historically”; an historically diverse population is something I'm going to get back to; all the rest of this, I think, is pretty self-explanatory.

I call these hallmark psychosocial events because that’s indeed what they are, they are psychosocial events. On the left you see people appropriately running when the Towers come down in New York City. The picture on the right was taken on the streets of Washington, DC as people were driving by and looking at this, and I don’t know about the rest of you, but where I come from, if I see two people putting on something like this, there’s only one thought that comes to my mind -- no, not that there’s a disaster; no, not that something contagious might be going on -- the first thing I think about is, where the hell is my suit? [Laughter] And I would submit that if you give it any thought, that’s probably your first question as well, because I'm not as polite as many other people. I want to know, if people are dressed like this, where is my suit.

This is the kind of thing we have to think about when we look at how people in our communities are going to respond to us, those who they trust in many ways to help keep them safe.

Now, information dissemination is a critical part of any planning, and the bottom line is you’ve got to coordinate information dissemination. Those bullets are pretty self-explanatory. A unified message throughout the region; you notice it doesn’t say throughout the city, doesn’t say throughout the state, doesn’t say throughout the country, because if you think back to West Nile virus and its sojourn down the East Coast, it was a New York problem initially. Then it became a New Jersey problem, and it crept down the Coast, I was the health officer here in DC, and my good friend, Georges Benjamin, who now runs the American Public Health Association, was in Maryland, and we could not figure out why those darn mosquitoes couldn’t understand when they had crossed a border, because it would make our lives a lot easier. And I would submit that any sort of a cloud that’s being disseminated, any sort of an illness, whether it's flu or anything else, you need to think regionally, and all those manmade borders are pretty irrelevant during a time of crisis.

This is a pretty scary picture for me. That’s me with my mouth open, not a surprise to anyone. The friendly gentleman behind me was my boss at the time, who’s the Mayor of Washington, DC, and the scariest thing probably for Dr. Hughes and the infectious disease community is, what the heck happened to that microphone right in front of me before it got to me? There are a couple of chunks bitten out of it, et cetera. But I use this slide because it’s important to count the number of microphones and think about how many different kinds of people you're talking to. If you're in Los Angeles, for example, how many different television stations just broadcast in the Spanish language? If you're in Washington, DC, how many languages are spoken here? I think like 70 or 80. In LA, it’s over 100. And you need to think about the fact that you're speaking to a diverse public and to a diverse media.

Which forces us to look at a couple of things. When we’re doing all of our good cross-jurisdictional system design and the most difficult thing to do, but one of the most important, is cross-jurisdictional procurement. I know that’s an oxymoron and actual blasphemy to talk about stuff like that, but if you want to work cross-jurisdictionally, think about cross-jurisdictional procurement. And then most importantly, I think, think about measuring the value of the dollars that you've spent and think about measuring the efficiency of what you’ve done. I used to work in the managed care community, and one of the saying from managed care is “In God we trust; all others bring data.” Another saying is “What can’t be measured can’t be valued.” I think that both of those are relevant sayings to keep in mind as you're doing planning for continuity of operations, and as you're doing preparedness planning.

We’re here to talk about terrorism and terrorist events, but I submit to you that terrorists don’t really have to sneak in with anything that’s really dangerous. They can just show up and use what we leave lying around. I don’t think we learn enough from the normal things that happen to us, things like West Nile, things like the flu. Last year, many of you may remember that national news was made when a child at one of the high schools here in DC was playing with some mercury. The school had to be shut down, the apartment building was shut down, folks were housed in hotels, kids were bused to the Convention Center to go to school. Now, many of you, like me, are old enough to remember that mercury used to be something we played with in school. You’d push the little bubbles together and watch them come together; is there any reason now to have mercury in a high school? No. I can’t think of one. So why is it still there? Why do we have things lying around that are that dangerous, that are that disruptive to the continuity of the lifestyles in our community.

Then one of the issues I want to spend a couple of minutes on is this whole issue of credibility and the history, the historic diversity of the populations that we serve. There was another national story here in DC this year about lead in the drinking water and the water supply, and then the story of the 2004 flu shots. I just on the local morning news here yesterday talking about the whole issue of flu shots, and as a health officer it was always, “everybody get your flu shot, get your flu shot, get your flu shot,” and now what we find is that with all the times we’ve been told things-- Back with the anthrax attacks, there were stories in the Washington Post about the Tuskegee experiment, and why the white people didn’t die and the black people did, and the folks on Capitol Hill got this, and the ones that weren’t on Capitol Hill got that, and you kind of want to dismiss those things, because we all want to move forward in our communities but here, again, with the flu vaccine, we have the same kinds of issues come up -- why is there flu vaccine on Capitol Hill and why isn't there flu vaccine in the nursing home in our community?

We need to think about those issues and think about the credibility challenges it makes for us during a time of crisis. This is part of the history in our communities that you can date back to things like the nasal swabs during the anthrax attacks that came up, the change from Cipro to doxycycline during that time, and further back to a lot of other incidents where people, rightfully or not, have believed there was some discrepancy in who was important to protect and who wasn’t important to protect. If you’ve ever stood in front of a bank of microphones trying to talk to the public during a crisis, this is one of those things that you have to consider.

On that oversight committee on which I sit, we cover every single thing that someone could have had a problem with during the September 11 tragedies, except one. I’ll give you one guess what it is. Respiratory. I don’t know why. I heard an answer, and the answer is that the respiratory illnesses should be covered at the government level, or the public sector level should cover that. But we all remember, those of us in public health, looking at these pictures and thinking, what are those folks breathing, and we heard the official word was “don’t worry.” Then we heard later that, yeah, it is an opportunity for worry.

It's that kind of, if you don’t know, say you don’t know; if you do know, tell the truth; and if you can’t tell the truth say “I can’t tell because of an investigation,” or something, but you do not ever tell people things that are not true, because this first bullet, the underlined word, “safety of responders,” we had folks respond to New York City on September 11 from all over the world. People came to try to help, and we are now providing services through the Red Cross for folks in Canada and many other different areas. We need to make sure that our responders are safe. We have to be honest with them about the risk.

One little, quick story. When I was going through my training in the Air Force many, many years ago, they taught us the ABCs -- airway, breathing, circulation. Something bad happens, you come to the person, that’s the first thing you do, you establish an airway and establish breathing, and then you worry about bleeding. And on the test, the question was, “When you get to an incident, what’s the first thing you do?” Most of us wrote down, “ABCs,” because that was the right answer. That was the wrong answer. First thing you do when you come to someone who needs help is find out why the heck they need help, because if you walk up to that person and say “Are you okay,” you may be the next person who gets with a brick of the back of your head because somebody’s throwing bricks and you didn’t take the time to look and assess your environment, and you didn’t worry about the safety of the responders. That’s a real issue, and it’s one that I think we don’t think as much about as we need to.

The other thing, and I think you’ll hear a lot more about this, is having secure information and knowledge management. A lot of our systems are not as secure as they need to be, and it’s a tragedy when you get up and tell people, confidently, what you think to be true, and find out that someone has messed with your data.

There are a lot of challenges in bioterrorism preparedness. I'm going to try to finish in the next minute here. A lot of these issues, the last one-- typically we get funding in the public sector for a reason, and so sometimes that funding can lead to additional stovepipes. I think that we need to think about healthcare intelligence, think about automated disease surveillance objectives, and make sure that when we’re building stuff that we have GIS capability. One of the things that I began to say after the anthrax attacks here in DC is that a picture is worth a thousand lives. Very hard to translate some things. It’s a lot easier to get folks to look at a map and see a diagram of where the safe and unsafe area is, and help people understand why they have to go in one direction or another.

So these kinds of new systems that are being developed need to have the kinds of general standards that allow the systems to be useful in the ways that we know they should. All of the things listed here are things that I think are relevant when we are designing these sorts of surveillance systems.

One of my clients is Oracle Corporation, and they do a lot of the real fancy high-tech stuff that I, frankly, don’t understand, but when they come to me and say “Does this make any sense,” I can tell them in a public health setting this will work or this won’t work, and people will know how to use it or they won’t know how to use it.

Some take-home lessons. I think the first one’s obvious. The second one is a little bit less obvious. Flexible implementation is critical, because when you plan to do something, other folks may know your plan, and so you need to be able to implement differently.

Quick last story. During the anthrax attacks, we needed to set up to give a lot of folks antibiotics, and our plan was we would use the DC General campus here in DC, about 70 acres, a subway station, bus lines right there. Great location, great idea. Unfortunately, the day we needed to start setting up, right next door at RFK Stadium, some guy named Michael Jackson and a group called the Back Street Boys were having a concert to raise money for the Pentagon victims. Can you imagine Dr. Walks standing there saying, “Those of you here for the concert, please go to the left; those of you here for your anthrax treatment, please go to the right.” We needed to set up some place else.

So the most important person on the response team that day was not the police chief, not the health officer, not the fire chief; it was the officer in charge of property management, who was able to tell us “We’ve got another building not too far away that’s also on a subway stop, that’s got a big enough room to accommodate what you need to do.” That sort of implementation planning ahead of time, with the right partners on the team, can make all the difference.

And my very last comment is the last bullet. When things speed up, it’s important to take a breath and slow down. I speak very, very quickly most of the time. Hopefully, I think, clearly and quickly most of the time, but one of the things I learned from my mom is only fools rush in, and it doesn’t take a lot more time to take a deep breath during a time of crisis, think about the action that you're going to take, and think about what you're going to say. When you say something, once it comes out of your mouth, it never gets to go back in. You just have to watch the news to know how many people don’t take some time and look at this last bullet. They get up, they say what they think needs to be said, very, very quickly, and then spend the rest of the time trying to spin it or trying to correct it.

I think it's an important comment to make to an organization like this, to a group like this: When things speed up, take a minute, slow down. Think about the consequences of your actions. Think about the diversity of the population you're probably talking to. Think about the historic diversity and what these people have heard before, and how they may be forced to hear what you're saying. And then take a thoughtful action, take a caring action, and remember everything that you do is going to have a consequence for all of the other things that come afterward in all the other disasters.

That’s it. Thank you very much. [Applause]

Questions and Answers

JIM DOWNEY: Jim Downey at the Army War College. Back in the Cold War days, there were a lot of civil defense education projects and films, and thankfully I'm young enough to have not experienced a whole lot of that, but it seems like the focus of communications now is on when an event is occurring or after. Should we be doing something nationally to continually educate people about possibilities like you’ve described well in advance?

DR. WALKS: First of all, absolutely, and I am old enough to remember the old “get underneath your desk and put your head between your knees” kind of stuff when I was in school. I also remember when I was a kid, I grew up in Southern California, in earthquake country, and in many of the schools, kids on the first day of school brought to school a shoebox, and that shoebox would contain their favorite non-perishable food and a note from Mom and Dad that would say something like, “Ivan, this is Mom and Dad, stay at school with your teacher and don’t worry, we love you and we’ll come to get you as soon as we can.”

That kind of planning, giving folks something to do, having that comfort food there for the child, and enlisting all of the organizations that already exist-- my first slide, I think the last bullet talked about community resources, and helping-- one of the projects we’re working on is a project with the National Urban League and HHS, and it’s just incredible to me the existing resource there with the Urban League there in 34 states. They serve million of folks every year. They communicate with these folks routinely. Why not integrate them into any sort of a plan you have and link folks ahead of time, make sure there are ways that information flows out to the community so that during a time of crisis it’s not the first time that you know who the public health director is, or the first time you understand how homeland security is relevant to the community, where the shelters are, where food is going to be distributed.

All of those kinds of things should be done, and could be done, because you're right, we do have some history, but I think most importantly during a crisis is not only telling folks what not to do, but telling them what to do, some positive instruction about what you do. I don’t know if it helped to be under the desk, but at least it allowed them to count us quickly because we weren't all running around and screaming down the hallway.

WALT BUSBY: Walt Busby, Computer Sciences Corporation. I just want to make a comment, and then hopefully leave the question for other panelists for address. I'd like to commend Dr. Walks. He was the voice of reason and reassurance during those trying times when others were up ranting and raving about weapons of anthrax and other scare tactics, and things that weren't necessarily true.

Get to the point; yesterday we heard that a nuclear bomb in a suitcase, a nuclear bomb in a sea/land container, a cruise missile coming from a ship transiting, and Baltimore Harbor was the greatest threat. We are very, very scared, as we should be. But as professionals, how do we deal with the issue of integrating technology, the medical surveillance capabilities in order to be able to do what we need to do to better educate the public, and in order to be able to respond better and save lives when that event occurs. Thank you very for your service.

DR. WALKS: Thank you for your comment. In the interest of time, I'm going to ask the other panelists, who I'm sure will be able to address that in much more detail.

RICHARD HARRISON: Richard Harrison with US Pacific Fleet. When I saw your slide up there, the two people in the chem/bio hazard suits, I thought back to yesterday’s suggestion that maybe we should, as a deterrence measure, put troops in the street and subways and other things like that to deter terrorists from taking any action. I would think that troops in the street in response to a disaster might create a feeling of security, but what are your thoughts on troops in the street in advance of a tragedy or incident as a deterrence measure against terrorists? Does that help, or in the public view would increase the fear level?

DR. WALKS: I don’t know enough about that to speak as an informed professional, and I think it’s important to say what you don’t know. I can speak to that question as someone who has traveled to a couple of different countries in Africa, and has been in South America, and in the Caribbean, and having been in some places where either troops or law enforcement carry automatic weapons and walk through the streets armed, and having talked to folks who live in countries where there is terrorism. I don’t know and I don’t have the data to know whether it helps to deter terrorists, or whether it helps to deter things. I do know that in many of the communities across America, there is not always a sense of security when people come into those communities in uniform, are armed, et cetera. I think that it would be important to, if something like that were going to happen, absolutely you would have to get all of the relevant community-based and religious organizations to come together to help people understand, to help educate the public about exactly what it is you are trying to do, because absence that, troops just showing up in neighborhoods, I'm not sure what kind of effect that would have, but my first reaction is I don’t think it would be a positive one, without doing the homework first.

Thank you all very much. I appreciate my panelists giving me a little bit of lead way here. Hopefully, all my old friends are still friends on the panel. [Applause]