Materials Distribution in a Public Health Crisis

In the so-called Dark Ages, “emergency plans” focused on keeping invaders – Vikings, Visigoths, and Vandals, for example – or political enemies out of one’s own fort, and on maintaining life for those within the fort. Much of what is now called emergency management focused, therefore, on management of the food supplies and other materials required to ensure self-sufficiency. Much has changed in the many centuries that have passed since then, but those are still among the essential goals of emergency management in today’s world.

In recent years, particularly since the 9/11 terrorist attacks, there have been several federal programs initiated that involve the distribution of materials during and/or immediately after a public health emergency. In addition, and as a logical follow-on, many local, state, and county-level planning efforts have been geared to provide a suitable framework for the delivery of those materials during and/or after a terrorist attack. Among the most important of these efforts has been creation of the Strategic National Stockpile (SNS) program initiated by the Centers for Disease Control CDCs and a closely related subprogram called Chempack.

All of these efforts are or should be developed in accordance with certain basic concepts, one of the most important of which is called generalization. In any plan (developed for any task or situation) there are always a number of tasks that have to be carried out. Generalization is simply the common-sense recognition that the step-by-step process developed to carry out one plan, or one step in a plan, should ideally be applicable to as many other steps, or plans, as possible.

A second basic concept, also of the common-sense variety, requires using resources that already are available for everyday tasks to carry out other tasks that might develop during a crisis. One garden-variety example might be using a hose normally used to wash the car or water the lawn to put out a fire in the tool shed.

Tools, Skill Sets, and Competency Levels

In theory, every planning effort might usefully be considered to be a tool R&D (research and development) program. In many if not quite all situations the planning for the task determines the size and design of the tool. For example, the SNS program requires that specific localities develop their own plans for moving materials from a county-level site to individual clinic sites. That task might be broken down into several steps or components. It is how those components are viewed that determines how well (or how poorly) local planners apply the generalization concept.

The first step is to define each component in the general terms needed to accomplish the task at hand. In the SNS example, medical supplies would be delivered by the state to a county-level staging area. An inventory system would then be used to keep track of the supplies. By tapping into the system, clinical sites throughout the state would be able to request the specific supplies they need. By defining each step, without reference to the SNS or to any specific type of materials (medical supplies, in this example), planners can apply the same plan to the receipt, inventory, and supply chain of any type of materials required by any end user in the state.

All offices and agencies at every level of government carry out certain tasks specifically assigned to those offices and agencies. Assuming that the personnel at those agencies are competent at their jobs the public has a right to expect that those jobs will be done correctly. The level of competency is likely to vary considerably, however, from job to job and from person to person. Any public health nurse, though, should possess a certain set of skills suited to the work he or she routinely does. In this case, his or her skill set probably would include varying levels of medical education, the knowledge needed to carry out pre-vaccine evaluations, and the ability to administer vaccines and/or medications of various types. Other government employees would not usually possess the same skill set. Nor would all other nurses, for that matter, because many nursing skill sets require licensure and/or board certification, but others do not.

Different jobs obviously require different skill sets. For that reason, even though the public health nurse might be the staff member best qualified to be in charge of patient education, he or she might not be the staff’s best forklift operator. Recognition that blue-collar non-medical staff members possess their own valuable, and often unique, skill sets is not only an important lesson for planners but also a helpful intangible in building teamwork.

Ideally, staff members should perform the same tasks during an emergency that they do every day—using the same tools, and following the same work practices. That way, even the staff members who might be overwhelmed by the emergency per se can step back into the refuge of the familiar. The previously mentioned forklift operator, moreover, would probably do his or her everyday job not only better but also more safely than another person assigned to the job just for the emergency.

Specific Accountability for Everyday Tasks

There are several efficiencies that result from applying a “normal” everyday mechanism of government or business to a medical crisis or other emergency. Among the most obvious benefits is that the use of normal processes and staff personnel already in place eliminates, or at least significantly reduces, the need for any special training. Again, the SNS process helps to illustrate this point. Typically, the CDC will ship the materials needed to the state or states immediately affected by a public-health crisis or similar emergency. It will be the job of the individual states to break down the materials into the smaller quantities needed to supply the counties or cities within the state. The CDC, of course, requires that an accountability system be maintained that can show where specific materials have been delivered after they have been received by the state.

Because the process described involves public health, it frequently happens that state health departments are assigned the responsibility for distribution and inventory control. Here, the first step in the process is to unload the materials received from the CDC and transfer them to local facilities, maintaining a strict inventory control at all times.

All states have their own support and supply departments (by whatever name), the functions and responsibilities of which are similar to those of the federal General Services Administration. Most if not all of those departments have branches or divisions responsible for warehouses where state supplies – paper goods of various types, for example – are unloaded, counted into inventory, and later withdrawn from inventory for delivery to wherever they are needed.

The same warehouses, and the same inventory-control systems, can be used during public health emergencies. The receipt, storage, inventory-control, and delivery tasks are carried out efficiently and safely because those performing the tasks are familiar with the work from carrying out their day-to-day jobs. It should be obvious that the first time a person operates a forklift should not be during an emergency.

Effective emergency management means, among other things, that – rather than designing new forms and/or creating a separate inventory-control system to deal with a public health crisis – it is both less costly and less complicated to use the warehouse staff and other people involved in a crisis situation by assigning them, insofar as possible, to the same jobs they do every day.

The tasks involved have changed considerably, but whether the goal is to distribute medical kits to a smallpox clinic or lay in the supplies needed to withstand a Viking attack, the basic principles are the same: Plans should be generally focused, and day-to-day resources and processes already in place should be used to get the job done.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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