The U.S. health system isn’t prepared for the kind of massive disasters that the 21st century could bring, such as pandemics, international terrorism, cyberwarfare or climate change.
A logical first step to address the issue would be to begin to develop collaborative, regional projects, focused on specific areas such as large-scale trauma, burns and infectious disease outbreaks, two top U.S. health officials wrote.
To get it done, they said, those efforts should provide some incentives for hospitals to participate and find ways to build on public-private partnerships.
“We don’t want to scare people, but we do hope this work can be taken seriously and plans and actions will be put into place,” said Dr. Donald Berwick, president emeritus and senior fellow with the Institute for Healthcare Improvement and a co-author of the opinion piece published this month in the Journal of the American Medical Association.
The University of Nebraska Medical Center and clinical partner Nebraska Medicine already are involved in several such efforts, two of which are mentioned in the piece as examples of how such an approach could work.
It’s also the type of approach UNMC and Nebraska Medicine are hoping to expand upon in their massive, $2.6 billion proposal to transform the campus. The proposed NeXT project, with its 1,000- to 1,200-bed complex of high rises, would combine a state-of-the-art teaching hospital and federally funded wings designed to enhance the nation’s ability to respond to a variety of hazards, from natural disasters to environmental accidents and highly contagious diseases.
The project would rely on the same kind of public-private partnerships used to build the $370 million Fred & Pamela Buffett Cancer Center, with a mix of federal, state and private funds.
The piece also comes as UNMC and Nebraska Medicine again are in the spotlight for their role in assisting in an international health emergency. Thirteen Americans evacuated from a cruise ship docked off the coast of Japan currently are under quarantine on the campus for the novel coronavirus.
They are being monitored either in the Nebraska Biocontainment Unit, completed in 2004 and funded by the State Health Department, or the newly opened National Quarantine Unit, part of the federally funded National Training, Simulation and Quarantine Center. The quarantine unit is the only one of its kind in the country.
The medical center also was involved in monitoring 57 Americans who returned from the Wuhan area of China, epicenter of the novel coronavirus outbreak. The last of the 57 flew out with a clean bill of health Friday after completing a mandatory 14-day federal quarantine.
Dr. Jeffrey Gold, UNMC’s chancellor, said the unprecedented nature of the outbreak — with tens of thousands ill, more in quarantine and China scrambling to build temporary hospitals — reinforces the need to build surge capacity and resilience in order to protect the nation’s health security.
Workshops that the JAMA piece drew on were aimed at identifying ways to strengthen health care preparedness. Also on the to-do list was finding ways to create incentives for the health care sector to expand preparedness and to involve private-sector supporters.
Dr. Kenneth Shine, former president of the Institute of Medicine, now the National Academy of Medicine, and the piece’s other co-author, said hospitals’ ability to deal with individual, localized disasters has markedly improved since 9/11. Boston-area hospitals’ effective response to the Boston Marathon bombing in 2013 is a good example.
“What we’re talking about, and this was before coronavirus, is where the scale is substantially greater,” Shine said. “And that, we’re not prepared for.”
Nebraska has been a leader in such efforts. But it also has gotten some funding to help. Shine said Gold has been a leader in advocating to increase the amount of federal funding available, emphasizing the need for seed money to help health systems launch such programs.
Most hospitals, Shine said, operate on relatively narrow margins. They first have to devote resources to preparing for local priorities. Getting them to spend time and money to prepare for something that for them may be a rare event is a significant challenge. And if they’re challenged with preparing on a national level, the scope can look overwhelming.
That’s why regional responses, focused on specific threats, have been recommended. One example is the National Ebola Education and Training Center, which is made up of 10 regional training centers, led by UNMC, Emory University in Atlanta and Bellevue Hospital in New York, all of which successfully treated Ebola patients in 2014.
For regional responses to work, however, health systems must work together. That takes planning and collaboration, including determining how to share information about available beds and equipment in an emergency.
Nebraska Medicine and Massachusetts General Hospital in Boston are developing regional response systems that provide a template for others. Each received a $3 million federal grant for the work in 2018. Nebraska’s plan is expected to bring together a wide variety of health care entities, from emergency medical services to public health labs, and pull together communities across the state.
Berwick said there wasn’t any disagreement during the workshops, which were hosted by the National Academies of Sciences, Engineering and Medicine. “Hopefully now there will be a more concerted response over time,” he said.
The good news, Berwick said, is that such approaches also stand to affect health care quality.
Shine said the communications systems in place in a New England initiative, for instance, mean a physician in rural Massachusetts can now get information about resources available in Boston.
Said Berwick, “It’s unlikely these threats will materialize. But it also goes to how to build preparedness to also strengthen health care systems overall so care gets better, people have better access and greater cooperation occurs. So it’s seeking a win-win.”
ATLANTA — In the predawn, long before getting to her job as a Marietta teacher, Emily Willard, 28, hits the gym.
A couple of times a week — as well as some weekends and school holidays — she's at Total Row in Buckhead, getting a bit of a workout, sure, but that's not why she's there. She's a trainer, leading a group of early morning rowers in their huffing and puffing so she can pick up some extra coin.
"It is nice to have money on the side," Willard said.
In Atlanta and nationally, the unemployment rate is plumbing historic lows. Most people looking for a job can find one. But for some, one job isn't enough.
One thing that hasn't changed amid an unprecedented decade of economic growth: About 5% of American workers still have at least one side hustle, according to government statistics, although researchers believe the actual number is higher.
For some it's a choice, but for others it's a necessity. During and after the Great Recession, inflation-adjusted wages fell for several years and they've been up and down since. Last year, wage gains barely outstripped inflation.
Among people with multiple jobs, there's also been a marked increase in the share of people with no full-time work — just part-time jobs stitched together, said Anne Polivka, a research chief at the Bureau of Labor Statistics.
And no matter how low the unemployment rate goes, the juggling of jobs is likely here to stay as "gig economy" work like ride-sharing and dog-walking gain traction.
Young people are more likely than old to have an extra job, with young women more likely than men.
Cahara Murray, 25, is among those working two jobs to make ends meet.
"It's a hassle," she said. "It's a second time of day that I have to commute. I would love to have just one job."
Murray works about 45 hours a week at a university, then spends up to 20 hours a week at a business-to-business marketing company.
"I do it because I'm a millennial and I'm poor," she said. "Almost all of my friends have some kind of side hustle."
DATA SUGGEST NO SPIKE IN JOB JUGGLING, DESPITE GIG ECONOMY TALK
Since 2010, the number of jobs in Georgia has risen 21.1%, while the number of people employed is up 18.6%. The mismatch means many are doing more than one job, adding up nationally to about 8.06 million workers, according to the Bureau of Labor Statistics.
But despite the hype about the "gig economy," there just isn't proof of a massive shift in how most Americans work, said economist Andrew Garin of the University of Illinois at Urbana-Champaign, who has sifted tax data in search of clues.
"This isn't to say the number is low. But people have been struggling to make ends meet in one job for a long time," he said.
An estimated 5.2% of workers had more than one job in 2008, and last year it was 5.1%, according to federal statistics. Researchers acknowledge the actual share is probably higher because the estimates are based on surveys that may miss many people, especially younger workers more likely to have side hustles.
It's definitely higher among millennials. Among workers 20 to 24, the share is 5.4% — but 6.8% for women. Among all women, it's 5.6%, and among those who have been widowed or divorced, it's 6.5%.
Younger workers could be juggling more jobs because they haven't had much time to build savings — or pay off their student debts. The most recent data from the New York Federal Reserve Bank puts outstanding student loan debt at $1.48 trillion.
While the growing economy has created jobs, many don't pay well, said Lawrence Mishel, distinguished fellow at the Economic Policy Institute.
The success of Lyft and Uber is an indicator, he said, because the companies are constantly losing drivers and signing up more, signaling a reservoir of people who need money.
"It is evidence that the regular job isn't so good," said Mishel.
Half of U.S. workers did not see any salary increase in the last year, estimated Bankrate, which advises consumers on their finances.
CHOICE OR NECESSITY?
It is not only millennials who are hustling.
Jackson Faw, 59, runs an Airbnb, drives for ride-hailing companies and has a side hustle to his side hustle contracting directly to drive for some clients.
"When I am asked how many jobs I have, I say, about a dozen," he said. "The dirty little secret is that it's hard to make a living just by driving. I have to work about 60 hours a week. I work every day. Every single day."
He is looking for a lower-stress way to "blend" his various jobs. But he doesn't think he's returning to the corporate world he left when he was laid off five years ago — he has grown accustomed to flexibility. "I would likely not take a job, a traditional job where I'd have to show up in an office."
Gabriella Mooney, 33, also said she is choosing to work more than one job.
The East Point resident spends up to 30 hours a week helping to run a company that rents production equipment. She also works 25 hours or more as a personal assistant. And she occasionally does contract work as a graphic designer, small-business consultant and gardener.
She's getting divorced, which makes her a single mother of a 2-year-old.
"If I could live off less, I would, but I have to take care of my son, and I have to feed myself," Mooney said.
Still, it's not just about the money, she said. "I could easily get a job with a corporation and make a ton of money, but I could hate my life."
Others, though, said they have no choice.
Dylan Loope works at Buckhead's Total Row. He teaches about a dozen classes a week, but at several studios. The 25-year-old is always looking for more classes to pick up, "so I can fill the gaps without having to struggle through."
Asif Lakhani, 29, wishes his work situation were a bit more straightforward.
"I would like to have one job, if I could get the job I want — a job where I wouldn't have to worry about making ends meet every month," he said.
The Roswell resident works about 30 hours a week at a marketing job, does freelance writing and occasionally drives for Lyft.
Lakhani also appears in clubs as a stand-up comic — a gig that, at this point at least, is far from a living wage.
"Sometimes you get a free beer," he said. "Sometimes you work for free."
Six Monroe Middle School boys stop talking about basketball, homework and what they’re having for lunch so they can listen to Galat Toang.
Sitting in a conference room, the tall 26-year-old reads them a letter he wrote to the rapper T.I. after hearing his new album.
“It made me think about life and being an African American,” Toang said, reading the letter. “I’ve always enjoyed your music since coming to America in 2004 while learning English.”
One of the boys in the group looks like Toang, who is from South Sudan. The boy doesn’t say much during the 30-minute discussion, but he laughs at jokes and soaks up Toang’s words.
The boy and others like him are why Toang has his job.
Toang was hired in December by the Omaha Police Department as a gang prevention specialist. His goal is to help Sudanese and other immigrant groups with struggles they may be facing.
Like the department’s other three gang specialists, Toang acts as a role model to all youths and works to encourage kids to take a positive path in life.
The Police Department has noted a rise in Sudanese gang members over the past two decades as thousands of Sudanese refugees have resettled in the Omaha metro area. The two largest Sudanese gangs in the area are Trip Set and African Pride, but gang members of Sudanese descent also are in other neighborhood gangs.
Gang involvement has a direct link to poverty, said Omaha Police Capt. Thomas Shaffer of the gang unit. Youths are attracted by the promise of quick money while their parents work two jobs to get by.
The gang members are a tiny percentage of the otherwise thriving 10,000-plus Sudanese refugees who now live in Omaha, which is thought to have the largest Sudanese refugee community in the nation.
Police leaders wanted to have someone in their corner who could speak directly to young immigrants about adjusting to the stark cultural changes that Sudanese people experience — and to do so without turning to criminal activity.
“Living in America is not easy. There are ups and downs,” Toang said. “Coming to America, being able to follow a decent lifestyle, not follow the crowd and be able to make something out of myself — that shows a lot, and hopefully other kids can follow the example that I’m trying to lead them to.”
Police had a difficult time filling the gang prevention specialist position, which was publicly announced in April 2019, Shaffer said. Toang was ready to join the U.S. military until “the job found him” and he was asked to interview.
Since starting the work, Toang has been “like a sponge,” Shaffer said. Toang speaks to kids at Monroe, McMillan Magnet Middle School, Indian Hills Elementary School and at Boys and Girls Clubs of the Midlands, which helps pay the gang specialists. He also talks with kids at the Douglas County Youth Center, conducts home visits for at-risk kids and meets with other refugee groups. Two weeks ago, for example, he spoke with about 20 Karen refugees.
“We all came through that same struggle, and to be able to have someone who went through that same experience as you, it makes a difference,” he said. “They can see that you’ve walked it.”
Toang and his family arrived in the United States on March 24, 2004, when Toang was 10 years old. They settled in Des Moines, where he graduated from high school. He then attended a junior college in Illinois for a year on a basketball scholarship. He returned home because he needed surgery for a groin injury. He then played for three years at Grace University in Omaha. When the college closed, he transferred to Bellevue University, where he graduated.
He didn’t know English when he arrived, but now speaks it perfectly, with no accent. Like most of the Omaha Sudanese population, Toang is from the Nuer Tribe, and he still speaks the Nuer language fluently.
South Sudan has roughly 64 tribes, Toang said, but tribal differences don’t matter to him in Omaha.
“I’m not just helping a tribe, I’m helping a community,” he said.
Toang attended a discussion among Sudanese leaders and residents in mid-February that addressed youth violence. Several Omaha police officers took part in the talk, which was hosted by New Life Family Alliance, an organization started by Sudanese people that helps other refugees from South Sudan adapt to American life.
Sudanese leaders expressed frustration and questioned why some youths looked up to gang members and disobeyed their parents.
Officer Dave Ullery, an Omaha police gang intelligence detective, has been studying refugee gangs for about five years. He explained that the African gangs started out of a need for protection against other gangs who lived in South Omaha public housing.
Most of the gang members are Americanized and don’t know or remember much about their South Sudanese culture, Ullery said.
“They do not respect their families, they do not respect their elders,” Ullery said. “There’s tension in the family and cultural differences within their own family.”
Some of the gang members are stealing cars from Sarpy and Washington Counties, maxing out stolen credit cards, getting access to guns and dealing drugs such as Xanax, fentanyl and marijuana, Ullery said. A group of Trip Set members who live in Washington, where marijuana is legal, ships weed to Omaha, where it then is distributed to cities across Nebraska and Iowa, he said.
Officials hope violence among Sudanese gangs and the public doesn’t worsen. In June, 24-year-old Jal Dak Kun was fatally shot, and 23-year-old Bol Kueth is awaiting trial on a first-degree murder charge. Ullery said the motive for the shooting was tribal conflicts between groups in Des Moines and Omaha.
In April, 11 Trip Set gang members were arrested in connection with gun and drug charges. The U.S. Attorney’s Office said the Trip Set gang had become more active in Omaha over the past three years, with about 150 gang members and associates.
But gang life has plagued several other ethnic groups — it’s not a problem unique to the Sudanese, said gang unit Officer Tony Espejo.
“These problems that we’re talking about ... it doesn’t just happen to South Sudanese kids,” he told the Sudanese group. “It’s happened to Latino kids, African American kids, white kids, Polish, Irish, any immigrant group that’s ever come to the United States of America.”
Espejo, who runs the Police Athletics for Community Engagement free sports league coached by officers, hopes to start up basketball leagues with help from the Sudanese community. Membership in PACE has skyrocketed in the past few years and is an indicator that prevention and outreach programs are working, despite gang membership staying relatively steady in the past few years.
The efforts are hard to quantify, but Shaffer said it’s the individual successes that matter. For as much as gang unit officers enforce laws and make arrests, they’re also working hard to interact with the community in order to keep youths away from a life of crime.
Officers work to engage with late elementary school or middle school students who may be at risk for gang membership — the youths could have an older sibling who is a part of a gang or come from a family that has been involved in criminal activity. The department also is helping older former gang members get driver’s licenses and pay court fees — barriers that can prevent them from gaining employment.
“We’re not trying to limit the gang population by incarceration,” Shaffer said. “Obviously, that takes people out of society, but it doesn’t stop new membership. That’s where prevention comes in.”
The majority of the Sudanese refugees who resettle in Omaha find stable employment, said Jmaleldinn Adame, the senior manager of programs at Omaha’s Refugee Empowerment Center. The organization helps refugees with a long to-do list of items, such as doctor’s appointments, housing, language classes and employment, then follows up with families about six months to a year after they arrive.
“They’re doing the best they can,” Adame said.
Sudanese refugees started coming to Omaha about 20 years ago, but federal policies have become more restrictive over the past few years and haven’t allowed for any new arrivals, said Adame and Tut Keat, who is Sudanese and founded New Life Family Alliance.
Years ago, Keat spoke to Sudanese youths and told them that they were a part of the Omaha community and therefore could and should contribute through public service jobs at City Hall or in the Fire or Police Departments.
Toang is the second person from South Sudan to join the Omaha Police Department. Omaha’s first Sudanese police officer, Muorter Majok, graduated from the police academy in March 2019. Shaffer hopes Toang applies to be an officer and one day wears a badge, too.
Keat said with Toang and Majok, his dream came true. Representation matters, he said, so seeing a Sudanese officer makes a difference.
“Now when (youths) see those people succeed ... years from now, more young people will join,” Keat said.
Police Department officials say they are pleased with Toang’s progress.
“Galat brings a unique perspective to kids,” said Sgt. Jon Waller. “He’s definitely a motivated, dedicated person that wants to give back to the community. We’re lucky to have him.”
The number of children ingesting rare-earth magnets — powerful tiny balls that are a popular desk toy and can shred a child's intestines — has skyrocketed in the three years since courts blocked the efforts of federal regulators to force changes to the industry, which largely holds the power to regulate itself.
The nation's poison control centers were on track to record six times more magnet ingestions — totaling nearly 1,600 cases — in 2019 than in 2016, when a federal court first sided with industry to lift the Consumer Product Safety Commission's four-year ban on the product. Medical researchers say the only explanation for the spike is the return of these unusually strong magnets to the market after the court ruling.
Now, with the consumer safety agency largely sidelined, magnet industry officials have launched a new effort to prevent product injuries and deaths through voluntary safety standards. Used for thousands of consumer products, these voluntary standards are supposed to reflect a balance between business and safety interests.
But during the creation of voluntary standards for magnets, the priorities of safety groups and regulators have been drowned out by the desires of manufacturers, who often decide which safety options are considered and hold an advantage in voting on which rules will take effect, according to a Washington Post review that included listening to hours of public standard-setting meetings and obtaining emails about the process, along with interviews and documents.
Problems with voluntary safety standards extend beyond magnets, critics say, to other children's products, including infant inclined sleepers, crib bumpers and furniture at risk of toppling over. In many cases, the product safety agency can't act until the voluntary standards have proved inadequate.
"It makes our jobs harder to have to defer by law to an extremely inefficient and industry-focused process," said Elliot Kaye, a product safety commissioner and former agency chairman. The voluntary standards process, he said, "has cost lives."
In the magnets case, which played out over recent weeks, manufacturers drew clear limits on how far they were willing to go for safety. They would consider only standards that "don't change the utility, functionality and desirability of the product for adults," Craig Zucker, who runs a magnet company, said in an email to others on the committee deciding the proposed safety rules.
But safety advocates said that the committee should look at anything that might avoid accidents. Otherwise, Don Huber, director of product safety for Consumer Reports, said in an email to the committee, "I am struggling to see how it will be anything beyond a marginal improvement."
The magnet makers wanted to rely on written warnings and packaging designs to curb accidental ingestions, according to emails and committee conference calls.
Safety advocates said that wasn't enough. They wanted the magnets either to be too big to swallow or too weak to cause organ damage. The magnets commonly found in desk toys are made up of sometimes hundreds of magnetic balls, and swallowing just two is a medical emergency, doctors say.
Why not try making them too big to swallow? asked pediatric gastroenterologist Bryan Rudolph during a Nov. 21 call to discuss the standard.
"Because nobody would follow it," Zucker replied.
Other products that pose dangers to children have highlighted the limits of the voluntary standards process. Before being recalled this year because they were associated with the deaths of dozens of children, inclined sleepers had been covered by a voluntary standard that pediatricians argued failed to follow established guidelines for safe sleep.
"It's a flawed process," said Nancy Cowles, who sits on several voluntary standard committees as executive director of the advocacy group Kids in Danger. "There are times when it works. But it often feels like we are only slowing down the process."
Rare-earth magnets are unusually dangerous because they are often 10 times stronger than the ordinary magnets used to hold a shopping list to a refrigerator. If multiple rare-earth magnets — each the size of a BB pellet — are swallowed, they can pull together inside the intestines, potentially causing life-threatening holes and blockages. Emergency surgery is the usual result.
"This is one of the most dangerous products on the market," Rudolph said.
Julie Brown, a pediatric emergency room doctor, said she sees on average one case a month at her hospital, Seattle Children's.
"They can make kids very sick," Brown said.
Accidental ingestion of high-powered magnets emerged as a problem in 2005. The magnets were breaking free from toys. Magnetic construction sets soon were blamed for at least one death and dozens of intestinal injuries.
In response, a voluntary safety standard was created in 2007 to limit the power of loose magnets in toys and to require powerful magnets to be permanently connected so they can't be swallowed.
The problem subsided. But sales of high-powered magnet sets exploded two years later. This time, the magnets were found in desk toys and changeable sculptures. They were not covered by the toy safety standard because they were not meant for children.
In 2011, the safety agency warned about the magnets, and it essentially banned them the next year. Two firms refused to stop selling them. One of the companies persuaded a federal judge to overturn the agency's ban.
So in late 2016, for the first time in four years, rare-earth magnets were legal to sell.
That ended what appeared to be a successful experiment in injury prevention: Magnet ingestions had fallen by almost half during the four-year timeout, from an estimated 3,617 emergency room visits in 2012 to 1,907 visits three years later.