Situation Awareness in Public Health
By: Dale A. RosePosted in Uncategorized on July 19th, 2009
The recent H1N1 outbreak has been fertile ground for discussion on this site and elsewhere. Borrowing a term that Stephen once brought onto this blog, there is a veritable “smorgasbord” of objects, concepts, strategies and technologies to examine and reflect upon as the world comes to grips with a bona fide pandemic event (I’ll save for Carlo to verify this claim). One such first-order concept which I would like to introduce today is “situation awareness.” The term has bubbled up a great deal lately in discussions around H1N1, especially within the various operational structures and organizations, such as HHS and CDC, taking the lead on the response side of things.
At its core, situation awareness, or SA, basically describes knowing the right information, at the right time, in the right way and in the right amount, in order to make the right decisions to improve or protect health. Although it is ostensibly applicable across all domains of public health, as a concept it is usually associated – or in any event, it eventually ties itself back to – public health emergency preparedness and response. To give an example from H1N1, response has been very much guided by demands for information that go beyond what we might call “traditional” public health surveillance and epidemiological investigation. Certain disease detection and surveillance technologies have been employed in tracking the disease, but the sources of information are disparate and varied, requiring a great deal of filtering and integration to paint a meaningful picture. From aggregate disease reporting to case level data; media and internet search term tracking to hospital bed and patient tracking; virologic surveillance to border surveillance, the array of data being produced across heterogeneous sites that constitute an increasingly global health security apparatus is staggering. Contrast these information needs with the 1976 Swine Flu event, and one begins to see a stark shift in terms of the kinds of techniques brought to bear in developing useful information for response.
Many of us blogging on VSS are familiar with various public health capabilities in the context of preparedness and response. Community mitigation strategies, countermeasure delivery, mass prophylaxis and vaccination – these are just some of the capabilities to which public health is held accountable in carrying out its preparedness and response functions. More to the point, knowledge about the state of readiness and performance of these various capabilities is also very much at the core of situation awareness. Think of knowledge about capabilities as something like the second half of a feedback loop in the production of situation awareness, the first half of which is information gleaned from signals (like flu surveillance, or internet search term use, or BioSense, etc.) in the external environment. In theory, marrying these two produces a picture not just of a health threat in near real-time, it also produces a picture of what can be done about it – what resources can be brought to bear – in like time, suggesting what likely outcomes will be. This, in turn, can suggest future states, with future interventions and future outcomes, etc etc.
For students of public health, this is a far cry from the kind of rationality that has governed public health surveillance historically: namely, a focus on the aggregation of a variety of population-level data to determine risk factors (and interventions) associated with health outcomes. I would like to suggest that public health’s traditional techniques – surveillance, epidemiological investigations, laboratory testing, etc.- are, at least at certain sites and in certain contexts, being marshaled and modified in service to the emergent need (rationality?) for situation awareness. My core argument, which I’d like to test out in this forum, is that situation awareness embodies the demand for a new kind of knowledge, one premised less on the need for ever greater quantities of data, per se, and more on the need for timely, actionable information. Again turning to H1N1, this may account for the seemingly odd development that public health officials are no longer concerned, per se, with the accuracy of aggregate case counts. Generating that information is extremely resource-intensive and, to the point I am trying to make, not all that useful for public health decision-making. At the level of actual practice, this number, the all-important “numerator” in calculating disease incidence, and “denominator” in calculating case fatality ratios – and the very core of traditional epidemiological techniques – has been backgrounded in favor of additional types of information: characteristics in severe cases, transmissibility in specific settings, such as schools and hospitals, utility of community mitigation strategies such as school closures (VERY controversial, for about a thousand reasons), and viral susceptibility to treatment and prophylaxis.
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How has situation awareness emerged? What problems does it seek to address? What are its techniques? Its boundaries? What configuration of practices and knowledge arose to form it? What demands does it place on individuals? On other assemblages and apparatuses? These are complex questions worthy, I think, of further pursuit. Lyle, of course, has done a stellar job of getting at many of these issues in his discussion of BioSense and syndromics, and I should very much like to see continued discussion of, for example, the employment (failure?) of real-time disease detection technologies in the context of H1N1. A broader investigation tracing back the concept may prove fruitful. A cursory look shows situation awareness to have a very extensive history in military applications, notably around operator performance of a variety of technologies, including aircraft and other combat vehicles. (Good) pilots have, in fact, been held as exemplars in the field, having been very heavily scrutinized for how they are able to make sense of, and inject order into, a vast amount of very disparate and very quickly changing information in a high-stress environment – and achieve desired outcomes on top of that. Tracing back contemporary public health situation awareness across its various lineages in aviation, psychology, operations research and the military, could prove a very informative project.