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The Sum of All Parts

Hopkins takes an enterprise-wide approach to planning for disasters no one believed in a year ago.

In an APL "war room," Hopkins leaders have simulated a worldwide flu epidemic, a dirty bomb and other high-impact incidents. Local, state and federal officials have joined in the exercises.

Before 9/11, Gabe Kelen could enjoy a thick page-turner about international intrigue. Now, his spare-time reading is an unrelenting diet of world news, federal budgets and "any chatter I can pick up between government agencies."

Not that Hopkins' director of emergency medicine has spare time.

After last year's terrorist attacks, Kelen emerged as the logical choice to chair a mass casualty task force created at the urging of University President William Brody. Envisioned as a temporary group, the idea almost immediately outgrew itself. "It quickly became apparent this wasn't a task-force issue," says Kelen. "Terrorism wasn't going to go away any time soon, perhaps for as long as a generation or more."

Furthermore, just as the anthrax outbreak revealed confusion between the law enforcement mission of the FBI and the public health mission of the Centers for Disease Control and Prevention, Kelen and others realized that Hopkins' numerous components also needed to get in step with each other.

"People were going in disparate directions," says Kelen. "and there was a lot of confusion about who was speaking for whom. At the same time, I became the de facto clearinghouse. People from all over were asking, What should our policy be? What equipment should we buy? They just assumed they needed approval from the task force."

By December, Kelen had the solution: Make the task force a permanent body that could tap every asset of the Hopkins enterprise and have the authority to speak on behalf of all. On July 1, with Kelen at its helm, CEPAR (for Critical Event Preparedness and Response) was officially launched--the first office ever charged with planning for and coordinating Hopkins' overall response during a catastrophe.

The idea, though, isn't to craft a one-size-fits-all approach. Each component of Hopkins Medicine has its own disaster plan (see story below). CEPAR will step in only if an event overwhelms one entity, or involves two or more (such as the need to close one of Hopkins' three hospitals). In that case, explains Kelen, CEPAR will set priorities for the entire enterprise, and if the disaster is large enough, may help manage it.

"CEPAR will have authority over other entities," he says, "but we're not going to operate as cowboys. We'll be there to help bring resources back and forth so that each entity doesn't have to make its own contacts with government authorities."

CEPAR has two boards that together include the top decision makers of the University, the schools of Medicine and Public Health, and Johns Hopkins Medicine. External advisors--policy makers at public health agencies, government experts and community leaders--also will contribute.

"CEPAR is two-way communication," says Ronald Peterson, president of Hopkins Hospital and Health System and executive vice president of Johns Hopkins Medicine. "Gabe is not going into a back room and coming out with a plan by himself. He realizes how many resources he has at his disposal, and he's making sure his oversight goes beyond his own area of expertise."

Peterson points out Hopkins is unique in its collection of assets: hospitals, home care group and community physicians, schools of Medicine, Nursing and Public Health, international affairs experts at the University, and an ace in the hole--the Applied Physics Laboratory.

While CEPAR was still on the drawing board, APL began hosting top-level Hopkins meetings that at first made participants think they'd dropped into a Tom Clancy movie. In its Warfare Analysis Laboratory (WAL), conducting the same kinds of exercises (WALEX) they use to help military planners think through their concept of operations (CONOPS), APL facilitators have been guiding discussions among the people who could have to steer Hopkins through disasters that no longer seem farfetched. "Once the sexiness wears off," says Peterson, "you get down to business. It is not a novel."

What APL brings to the undertaking is a chin-deep pool of engineering experts with well-established links to government and military organizations. One issue that emerged during the first WALEX was the need to back up and secure communications. "If communication goes down," says Kelen, "that's what's called a showstopper."

Fortunately, says mathematician Robert Stewart, that's where APL excels-along with other projects like helping the nation develop biosurveillance sensors that can detect and track the release of biological warfare agents.

Still, says Stewart, whose niche at APL is computer-modeled decision support, the over-arching goal is coordinating on a big scale, when the number of patients "would not be tens and fifteens, but hundreds and thousands. There's a difference between the first response to a disaster and managing the consequences of large numbers of casualties over a long period of time. Our job is helping people make decisions in extreme circumstances."

Kelen says most communities can respond to attacks like those that occurred at the World Trade Center and the Pentagon. "In this region, we could handle 3,000 injured patients in a heartbeat. But we've generally never prepared for a 'slow-cook' disaster--smallpox, a new strain of flu, a dirty bomb--that poses things we've never been tested on. That's why we need CEPAR. I believe in my heart and soul we need to give it this level of attention.

"If something happened tomorrow, we could deal with it, maybe not perfectly, but we could do it. If there's one thing we're good at at Hopkins, it's rising to the occasion."

-Mary Ann Ayd



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