You’re Wrong About Narcan

Some background: there are programs the give away free narcan (generic name naloxone) to the public. Naloxone is a drug which temporarily reverses the effects of an opioid overdose. 

This seems like a good thing right? Get a life saving drug into the hands of people who need? Wrong. There has been near constant debate about this issue for years now. Some people (I hope merely a vocal minority) hate this idea. Lest you think I’m straw-manning you, here are some real Facebook statuses I found about narcan (excuse the spelling- these are copied verbatim) 

  • Giving away free narcan so where do I pick up my free epi-pen that Ineed to save my life…. such BS
  • As a retired police officer I’m appalled at the use of tax dollars to supply narcan to drug users…
  • Yep, let’s shoot up, I got the free Narcan….tax payers footing the bill for people who have a blatant disregard for their own lives…
  • This is a JOKE to me! Free Narcan and I’m struggling to figure out how to get insulin cause I’m type1 diabetic!!!!!! I kno I’m goin to catch flack for this but ppl CHOOSE to do drugs, I didnt CHOOSE to be a diabetic!!!!

I have been involved in several arguments about naloxone now. I think people who are criticizing these programs are incredibly wrong headed about the whole issue. What follows is my answers to the most common objections to giving away naloxone. 

“We should implement a three-strikes system: three narcans then you die”

There is no practical way to implement a ‘3-strikes’ policy or any strikes policy. There’s no central database of such things, and even if there was, it wouldn’t be set up for anyone to quickly query “how many doses of naloxone has John Smith had in the past 12 months?”. Even if there were- most narcan administrations (including by PD or EMS) will happen before they even know the patient’s name- let alone DOB and social and input it into the MDT. In the case of an overdose, most of the initial care will be done prior to even knowing who the patient is. When you roll up to an unresponsive the first priority is not getting the patients social and typing it into the computer.

The transition to electronic medical records started over a decade ago and there’s still no reliable way to transmit records between different hospital systems, ems agencies, etc in a single county let alone a state. When you move a patient between healthcare facilities the most common way of moving the records is sending them with a folder full of paper copies. Further police records are on an entirely different system than any medical records.

“But I don’t think it’s fair that addicts are getting free Narcan”

Naloxone is not and was never “free” if it’s administered in a hospital or by EMS. The cost of naloxone is billed to the patient’s insurance the same as any other medicine or treatment. The “free” naloxone is either naloxone that’s being given away to the public as part of a public outreach program or sometimes naloxone that’s administered by a police officer.

“Why don’t we give away epi pens for free? Or insulin for diabetics? Or Chemo?”

First, people with epi pens and people who are insulin dependent self-administer. This means that the only person who needs to have an epi-pen or insulin syringe is them. Narcan is different. It can’t be self-administered because someone who is having an OD is by definition not going to be able to administer Narcan on themselves. So an effective public access Narcan program needs to saturate society with people who have Narcan, in hopes that during and overdose somebody near or the first first responder on scene will have naloxone and will act.

Second, Narcan is more or less harmless. If you administered it to me now, it wouldn’t do anything. You can however hurt or even kill someone with insulin or epinephrine. So you can’t just hand out epi-pens willy-nilly. It makes more sense to think of Narcan as like an AED for overdoses, as opposed to like insulin.

But cost cost cost the refrain continues. Can we really afford to save all these people? As it happens, the answer is yes. Naloxone as a drug is so cheap it’s basically free. Below is a table comparing the cost of naloxone to Humalog (a common insulin brand) and Epi-Pens.

DrugPriceSource
Humalog Pen$34/mlMedicaid (NADAC)
Naloxone Syringe$15/mlMedicaid (NADAC)
Epi-Pen$143/eaMedicaid (NADAC)
Naloxone Nasal Spray$63/eaMedicaid (NADAC)

So why not epi-pens? (a) Epi is 2x-3x more expensive than narcan. (b) there also isn’t an epidemic of people with severe allergies dying because they don’t have epi pens. (c) epinephrine incorrectly administered can hurt or kill people. (d) epi-pen users can self-administer. (d) Many police officers also carry epi pens in their cruisers (and all ambulances do).

Why not insulin? (a) insulin is 2x as expensive as Narcan. (b) there isn’t an epidemic of diabetics dying from lack of insulin. (c) the dosage on insulin is important, so you can’t just hand out standard doses to people. (d) insulin users can self-administer. (e) insulin is not an emergency medication. People who are dependent on insulin need multiple doses on a regular basis in perpetuity.

And why not chemo? Well that’s such a dumb comparison I’m not even going to address it. But you could start by googling “average cost of chemo” and then comparing that number to the prices above.

“Yeah but still. Narcan is expensive, and these addicts did this to themselves”

The option you seem to be suggesting as an alternative to narcan administration is “everyone stands around and watches the overdose victim die then calls the coroner.” This is just never going to happen, not least of all it would be illegal for EMS providers to do that, and grossly immoral for anyone to do that. You could I suppose refuse to give police or the public narcan, but you don’t technically need naloxone to treat an overdose. Overdoses can often be treated by breathing for the victim for several hours until the drugs they took wear off. The killer during overdoses is respiratory arrest followed by cardiac arrest followed by death.

Since most police officers and bystanders are neither equipped nor trained to deliver effective rescue breaths, in many (most?) cases the victim will have stopped breathing, their heart will have stopped, and their brain will be being slowly choked of oxygen by the time the ambulance arrives. This means that the paramedics and EMTs will be walking into a full blown code.

So, what does working a code mean? Upon arrival, the EMS team will start doing CPR. While CPR is happening one of the members of the team will attach a set of EKG leads ($20) and a pair of defibrillation pads ($60-100). They will establish a line using an I/O needle ($90). At the very least push epinephrine ($40) and normal saline ($30). This will all be done whether the patient lives or dies.

And, if they live, what then? This would likely mean that upon arriving at the hospital the they would need to be placed on a mechanical ventilator (retailing for $5,000-10,000+) and be sent to the ICU ($600-1,500/day ). In 2015 the average total cost of an overdose admitted to the ICU was $92,408 .

This could have all been prevented by a police officer or member of the public administering a $60 dose of narcan before they went into full arrest. Some quick math tells me that for everyone OD narcan prevents from being sent to the ICU, we could buy about 1,600 more doses of naloxone. Seems like a stupid good deal for the taxpayers and the healthcare system to me.

Narcan is also the cheapest option for dealing with an overdose. Well, not the cheapest. The strictly cheapest option would be to let the victim die on the ground while everyone watched. But in limiting ourselves to options which are not grossly immoral and callous, Narcan is the most cost effective option. The cost of the pre-hospital supplies alone $230. This is 1500% more expensive than delivering a single syringe of naloxone, or 380% more expensive than delivering on nasal spray of naloxone. That’s the costs before the patient is even admitted to the hospital.

“But a lot of addicts don’t have insurance and won’t pay their bills.”

Correct, many victims of overdoses are people who do not have any kind of insurance or the money to pay out of pocket for expensive medical treatment. So a large portion of the cost of treating overdoses is going to be eaten by the agencies/hospitals who provide that care. We, society as a whole, are at the end of the day eating the cost of treating many overdoses.

From a purely economic perspective, would you rather pay for:

  1. A single syringe of naloxone that costs $15 which will likely save a person’s life and give them the opportunity to fight their addiction or
  2. Thousands of dollars of pre-hospital care and tens of thousands of dollars of in-hospital care, where the patient may come out with brain damage or not come out at all.

“But I heard my police department is having trouble paying for Narcan.”

Yes. To the extent the there is a legitimate cost problem, it’s at the police department level. Police departments, especially small departments, may have trouble paying for naloxone kits & training for their officers. Across a small department serving a jurisdiction with a lot of overdose cases, the costs can certainly add up very quickly. Since police generally cannot bill (charge insurers) for medical care they provide, the town or city government has to pay all the costs of the naloxone.

But this is not a reason to not give police and the public naloxone. This is a reason to develop some mechanism by which police agencies and non-profits can share in the immense society benefits of police having naloxone. If police administering a $60 nasal spray when they arrive at an overdose is potentially preventing nearly $100,000 in hospital and pre-hospital medical costs per patient and hundreds or thousands of deaths, then it would seem to be in everyone’s interest to make sure all police officers have as much naloxone as the need. By ‘everyone’ I mean- hospitals, EMS agencies, insurance companies, Medicare, Medicaid, and then just all of us in the public.

If the hurdle is getting the necessary money to police departments and non-profits to purchase naloxone, then we can undoubtedly find a way to get either the naloxone or the money for naloxone to them. Maybe this means hospitals purchase naloxone in bulk and donate it to the police department(s) which serve the area they’re in. Maybe it means some cost sharing agreement where EMS agencies and hospitals will reimburse police agencies for doses that their officers deliver on scene. Maybe it means city governments move money from a public health, homeless assistance, or EMS agency fund to purchase naloxone for police officers, because police officers having naloxone will serve the purpose of those other funds.
But the “problem” is not being able to afford to get naloxone to police officer, the “problem” is connecting the wires across a complex society so that enough of the million of dollars in cost savings from naloxone end up getting naloxone to the people who need it.

“Yeah but even if they’re saved- there are still other costs at the hospital, and the success rates on resuscitation attempts on ODs is so low.”

Yes. The success rate on all resuscitation attempts are very low (though improving)- but the expenditure of EMS resources is going to happen in the process of the attempt. If they make it to the hospital, there will be more costs, and admitted to the ICU more costs, all regardless of what the outcome is. The total cost to the healthcare system will always be cheaper if there was an early narcan administration, just like the cost is always cheaper on a cardiac arrest if there was early CPR & defibrillation.

If there’s early administration and they’re conscious: they spend the night on a naloxone drip and can be discharged. Unless the victim is cold; there’s almost always going to be a resuscitation attempt on-scene- which is still more expensive than naloxone.

“Right, Drug abusers are already very expensive for society- the cost of incarcerating, the cost of crime- even without the medical costs should we really be paying for Narcan when addicts already cost so much money?”

A good first step if you’re worried about cost would be not incarcerating them in the first place. That’d save a lot of money right there. But that’s controversial. There are also options which would eliminate the need for addicts to commit crimes to either get their drugs or get money for their drugs, but those, likewise, are controversial, since they involve giving drugs or money for drugs to addicts. Starting with something cheap and non-controversial is a good place to start.

“Okay, but what we really need are treatment programs- people to come out of the shadows and get help- giving away free Narcan is just enabling them.”

About 85% of opioid addicts will relapse at least once in the process of getting clean . Due to the fact that a user’s opioid tolerance is a moving target (especially if you’re trying to kick it- your tolerance will change significantly) and the strength of available street drugs is likewise a moving target, the people who are most at risk for ODs are those who are trying to get clean and relapse. Daily users will be much more familiar with their tolerance and the strength of whatever they’re buying on the street than someone who was clean for eight months than slipped. So, there’s no practical or pragmatic justification for being opposed to narcan access programs. You’re going to end up letting a lot of people who are trying to get clean die.

If you want to stick with the “they made their choices” line you are going to be doing that at:

  • Great financial cost to society,
  • The cost of less people getting clean and surviving their addiction, and finally
  • The great moral cost of the tens of thousands of dead who could have been saved with a $60 medication (which in terms of medications, is so cheap it’s basically free)

“Yeah but come on- if you OD three times, that’s your fault at that point, I mean three times? Come on.”

An overdose is often the impetus for someone to seek treatment in the first place. So if they don’t survive their first overdose, they’re not going to get treatment. If they don’t survive a second overdose when they relapse, then they’re never going to complete their treatment program.

And what if someone overdoses three, four, five, six, seven, ten times- but after the eleventh time they get clean for good? At which overdose have they used up their chances? Where do you draw that line, and why? How many doses of a $15 medication is their life worth? How many shots at rehab? If we can’t put a price on human life then why are we putting artificial limits on how many times someone can OD before they’re irredeemable?

ODs are usually freak accidents, your dealer gave you fentanyl which was cut incorrectly, or you pushed a little too much because you have the shakes and don’t know what you’re doing with a syringe.

There is no moral quality the differentiates someone who ODs because of an unhappy accident and someone popping oxy every day, only that the person popping oxy hasn’t OD’ed and they can afford oxy. If you use long enough it will happen to everyone.

“Yeah but Narcan isn’t a solution, at best it’s just a band-aid”

Nobody is saying it’s a solution. It’s the cheapest and most effective intervention to both save lives and contain the social costs of addition. It should be non-controversial. Cheap noncontroversial interventions are a good place to start.

Band-aid, but band-aid are good things. Especially when they prevent death. A multi-trillion dollar investment into residential treatment programs and research into addiction is a little bit harder to sell than spending a couple thousand dollars to give police Narcan.

“Yeah but…”

Look, I guess if you want to leave addicts out to dry that’s your prerogative. But there is no financial or pragmatic justification for this. In fact, your position is more expensive and less effective than naloxone programs. If your twisted moral worldview makes you think that addicts don’t deserve to live, then say that but stop trying to hide behind just trying to be ‘fiscally responsible’. Say that you don’t think someone who overdosed isn’t entitled to the same level of emergency care we offer every member of our society.

Uninformed or Misinformed? The Media on Naloxone

A headline from USA Today came across my desk today “Drug company raised price of life-saving opioid overdose antidote more than 600 percent ” with the simple comment “this is evil” from the person who shared it. My ears immediately perked up, because ‘pharmaceutical pricing’ regularly falls into the category of things the news media is seemingly incapable of reporting on accurately. I was not disappointed.

The story (which has generated all manner of hate-click headlines this morning), is about a company Kaleo implementing a significant (600%) price increase on one of their products, Evizo, two years ago. Evizo is a naloxone autoinjector, which means that it’s essentially an epi-pen for opiate overdoses. It’s a pre-dosed, self-sheathing syringe that delivers naloxone, which is an opiate reversal agent.

Naloxone, patented in 1961, is far outside of any patent protection, which means it’s available from several different manufacturers in both branded (like Evizo and Narcan) and generic variants. Naloxone is sold in a variety of forms, most notably: vials for intravenous administration in hospitals (~$25/dose), and pre-dosed intramuscular autoinjectors (like Evizo), and pre-dosed nasal sprays (like Narcan, ~$125/dose). The pre-dosed auto-injectors and pre-dosed nasal sprays are what is used by police officers, EMTs, and lay-people.

The thing that makes Evizo different from its competition is that the autoinjector pack speaks to the person using it, giving them instructions for administration much like modern AEDs do. This, to begin with, made it a niche luxury product. Even before the price increase, when it was launched at $575, it was still some 300% more expensive than the brand-name naloxone nasal spray Narcan ($125).

I was among the first groups of EMTs to be trained to administer naloxone in NJ in 2014-15. We were trained on the nasal spray. Everywhere I’ve subsequently worked and every public-access program I’ve ever participated in has trained people exclusively on the nasal spray. This is of course anecdotal, but I’ve never seen a naloxone autoinjector in the field.

Which brings me to my gripe with this USA Today article, and most of the news coverage of this price hike today. What people think when they read a headline like the USA Today headline is that “those evil pharmaceutical companies raised the prices again, now it’s going to be impossible to afford the drug that saves peoples lives during ODs” which is not what happened. But USA Today knows that people will think that, and get angry, and share the article.

What happened is that one of at least six companies which manufacture naloxone raised its prices two years ago. This is not like if the only electricity provider where you live decided to triple its prices, this is like if Apple decided its new iPhone was going to cost $6,000. Weird move from a business perspective, but there are still a lot of other options for high-quality phones that don’t cost $6,000.

The Apple comparison isn’t even a particularly good one because unlike Apple, Kaleo represents a very, very, small market share. The latest information I could find was from 2015, but as you can see in the figure below, Kaleo’s market share was that black sliver highlighted in 2014-2015.

So what, exactly, is happening here? Kaleo is a private company, but it appears to have been struggling. A 3rd party audit available from the SEC shows Kaleo was bleeding money between 2014-2016 , posting an average net loss of $32m for the three years.

The price increases were likely a gamut by Kaleo to get pharmacy benefit managers, insurers, and government healthcare programs to pay more for Evizo. A hundred page congressional report on this saga indicates this is the case. This one in particular seem to have ended up being a way of getting Medicare to reimburse thousands of dollars for Evizo while private insurers negotiated lower prices or dropped coverage of Evizo entirely. However, despite the pricing games and seeing some growth in sales, per the report, Kaleo has never turned a profit on Evizo.

This is an important point of clarification to remember any time you see a media report on drug prices: people, individuals, almost never pay the ‘sticker prices’ (also known as the wholesale acquisition cost or WAC). Low-effort ‘news stories’ can get millions of hate-clicks and shares because the American public does not generally understand this. When these stories get reported, the prices quoted are the prices that pharmaceutical companies are charging your insurer for your prescription, it’s not the price you pay at the register in the pharmacy.

The price you pay at the pharmacy is based on your plan, what your insurer covers, how much they cover, and contracts with the drug companies. Especially in a case like naloxone where there are other options, Kaleo’s pricing did not have the overall effect on the price of naloxone that the headlines for this story would imply.

I wrote this little overgrown Facebook comment up during my lunch break and tidied it up after work, I am not a journalist, I do not have an editor. Yet, I was able to find some important clarifications. Reporters, editors, and headline writers: be better. I understand the economics of journalism are a little wonky right now. That said it’d be better if you published nothing rather than put out stories like this that obscure an issue more than explain it.

You know you are misleading people when you say: Drug company raised price of life-saving opioid overdose antidote more than 600 percent. You’re not strictly lying, but you know that that headline will give most people who see it the wrong impression.

You know that people are not going to look at that headline and think “one of a half dozen manufacturers, this one manufacturing a specialty product, raised their prices two years ago”. You know that thousands of people will share the article angry or scared without even reading the article, and even those who skim the article may come away with the wrong impression. Be better. I don’t know how you expect anyone to trust your name or your brand if your headlines are misleading and your articles require additional research to have a full picture of the story.

All Bleeding Stops Eventually

Responding to the Criticism of Stop the Bleed Training

The Department of Homeland Security is pushing a new public awareness program called ‘Stop the Bleed’ which is trying to train as many citizens as possible in basic bleeding control techniques. This is partially in response to the mass shootings we’ve been having. A lot of the casualties from these events are the result of blood loss. Many lives could have potentially been saved if the victim’s bleeding had been controlled earlier. In the first minutes of an active shooter situation, the police will be entirely concerned with neutralizing the shooters. It will likely be five to ten minutes (at least) after the initial police response before medical personnel move in to start treating victims. For many this will be too late. If more people were trained in bleeding control, they could potentially save their own lives or that of those around them.

The criticism of these programs is always the same. That training like this ‘is turning our schools into war zones’, that this is ‘normalizing mass shootings’, or that this will somehow preclude whatever your preferred action on gun control is because we’ve ‘accepted mass shootings as part of life.’ Frankly, I don’t understand this view. When I say I don’t understand, I mean I have difficulty comprehending how any adult can seriously hold this view. But it’s clear that that is more about the limits of my own imagination or capacity for empathy since many serious people do seem to genuinely hold that view, so let me explain myself.

I do this (emergency preparedness and emergency training) professionally. I run CPR and bleeding control courses at work on a semi-regular basis. I participate in creating emergency plans and procedures. In the event of a crisis or emergency, I would be part of the response. My department is tasked broadly with preparing the organization for an emergency.

The fundamental reality of my field is that we cannot eliminate all risk to everyone at all times. It’s simply not possible. We cannot offer complete protection or complete safety. Public safety typically has extremely constrained resources & budgets, especially when, like me, you are one operational department in a large organization. I serve approximately 19,000 students, faculty, and staff across more than two dozen campuses. My colleagues and I have to decide how best to allocate departmental resources in order to maximize safety and preparedness.

Armed guards (instead of unarmed) are a regular suggestion, even from the political right, in lieu of something like active shooter training or stop the bleed training. So, let’s dig into that. In Manhattan, the going rate for an armed guard is $24 an hour. I teach bleeding control courses, they take about an hour, and if I’m giving away tourniquets to the participants, the cost is around $25 per student. For those who are ahead of me, one-year of 24/7 coverage from one armed guard at one campus would cost $105k. If we had a $105k excess budget (we don’t but a guy can dream) which of these would provide a larger benefit to my organization and the population I serve?

  1. Employing one armed guard at one campus for one year
  2. My department training an average of 12 people a day for a full calendar year (4,380 people) in basic bleeding control and hands-only CPR, and giving them all a tourniquet

Which of those would provide the largest net-positive? I know which one I would go for. We train 4,380 people, say the training sticks with 60% (2,628 people), who will hopefully be with our organization for years to come. Those 2,628 will also be out walking around, living their lives, with that lifesaving training in their heads. It seems like a no-brainer compared to sinking $100k into a single point of armed security for one year.

This is obviously bar-napkin math, but you begin to see why people who do what I do often pursue what to the public may seem like counterintuitive aims. “Why are we spending all this money on training when we could invest it in armed guards to keep people safe?”. Mass-training programs, like the now decades-long push to teach the public CPR, provide a lot of benefits compared to the relatively modest investment required.

The connected criticism, which comes especially frequently when this training is done at schools, is about not burdening ‘children’ with such things, about it triggering anxiety. As a physician said to me on twitter criticizing bleeding control training being given to high school students: “A child should never have to worry about trying to save another child. A child should never be in that situation in the first place.”

Leaving aside the question of if high school students are “children”, I agree with the impulse. It is important not to unnecessarily terrorize people, especially children, with things (like mass shootings or cardiac arrests) which are very unlikely. I should differentiate between “mass shooter training” and bleeding control training. Mass shooter training (if a shooter comes into the school this is what we’ll do) is something which I do not believe we should be doing with young school children. It effectively terrorizes children over something that is extraordinarily unlikely, creating a fear that need not exist. It’d be like doing home invasion drills with your children, why would you want to put that thought in their heads before they are old enough to process the probability of ever being a victim of a home invasion?

But to teach someone a skill is not to terrorize them. Teaching someone a skill, showing them how to fix something, is empowering. Every child (and certainly every adult) should know how to use a tourniquet and do CPR from the point they’re physically strong enough to do those skills. It’s not ‘normalizing’ violence or injury, it is empowering people to be masters of their own fate.

The conflict here is between normative and descriptive ways of engaging with the world. “There should be no mass shootings” is a normative claim, “but there are mass shootings” is a descriptive one. We must, at this level, engage with the world on a descriptive basis. We must engage with the world as it is, not as we wish it to be. This is what people in my field do. We are given limited resources and an impossible goal. We take honest stock of the world as it exists, and work backward towards what we can do to make a positive impact in it.

I do not have the luxury of saying in response to mass shootings “well there shouldn’t be shootings” or “we should ban guns” or any such macro-level political ‘solutions.’ I am tasked with doing something productive for the population I serve in the face of this risk. Calls for mental health funding, red flag laws, media reform, or various flavors of gun control are all well and good but are part of a separate discussion. Those long-term systemic policy discussions are not going to help the victim of a shooting who’s bleeding out on the ground while the police are searching for the shooter. But bystander or self-intervention to stop the bleeding could.

This is empowering. We live in a political environment where millions of Americans feel impotent and helpless to be able to effect change around these systemic problems. But this is something you, or anyone, can do to have a positive effect on the world. Anyone can learn to use a tourniquet or pack a wound from YouTube videos (if you’re in NYC I’ll be more than happy to teach you how in person over lunch). This is something everyone can do today to mitigate the tragedy of mass shootings and violence or injury of all kinds. Regardless of what our politicians do or don’t do, all of us citizens can grab this bull by the horns and say “I am going to learn how to do this, and I may someday save a life with this knowledge, I am going to take this step to reduce the amount of tragedy in the world.”

The final criticism, which often comes from professionals, is that we can’t expect “lay people” or “civilians” to do these things, let alone do them correctly. They, rightly, point out that out of people who learn CPR, only a percentage of them will actually perform CPR if the time comes, and only a small percentage of that group will do it correctly. This is true, but it is all the more reason to give better training to more people to increase the numbers of people who know these skills, choose to do them when needed, and do them correctly.

Even professionals fumble and make mistakes, or freeze entirely, especially the first time they do something in the field. This is why medical training consists of repeated simulation practice and then graduated, supervised, practice in real life. Further, it’s worth noting a lot of physicians and medical professionals are spectacularly bad at skills they rarely or never use in their practice. A dermatologist, despite his MD, is not going to necessarily be any better at using a tourniquet than a janitor who went through a stop the bleed seminar. A veteran nurse who works in a pediatrician’s office is not necessarily going to be any better at CPR than one of the college students I trained this fall.

Mark Bennett said succinctly in a discussion on twitter “If we are certain we will attack, we may attack. If we think we will run, we will certainly run.” It is not about getting 100% of the training to stick with 100% of the people. This is about increasing the probability that if I find myself bleeding out on the floor of Penn Station during rush hour there will be someone in the crowd who knows how to control bleeding and jumps into action. The fact of the matter is there will not always be a professional present. There will not always be an EMT or a Police Officer there when you need them. Sometimes, it will be up to you, the person going about their day who is all of a sudden tossed into chaos. Massive bleeding and cardiac arrest are two situations were seconds count, and the victim won’t have minutes to wait for an EMS response.

If professionals like me go into this exercise thinking “regular people will never do this”, then regular people certainly will not. If we breed helplessness, and tell people there’s nothing they can do, just wait for help, then helplessness is what we’ll get. However,if we go into this thinking “this is a skill regular people can master and will use in an emergency, and save lives” then there is a chance they will, and that, is a chance I am willing to take.

You can find this post cross-posted on my LinkedIn

Do We Owe Them Nothing?

Something I’ve been musing about recently, which I would write an essay about but I am far too lazy and far too busy to do anything of that nature, so I’m going to fire off some thoughts here

I wonder, what do we as a polity owe one another? When I go back to visit Bethlehem PA where I went to college, and I see the abandoned steel stacks towering over an entire city built, by the, now defunct, Bethlehem Steel. And I wonder, what do I, or people like me, owe the people who worked there?

Famously the ‘white working class’ quote unquote revolted and delivered us, Trump. We’ve talked a lot as a nation about those who’ve been ‘left behind’ by globalization. My great-grandfather worked on the railroad, but since then I have no direct connection to heavy industry. It’s easy for someone like me to look at the steel & coal towns throughout America and murmur incantations about ’employment trends’ ‘retraining’ ‘structural shifts’ and ‘cyclical unemployment.’

In economics we talk about friction, meaning anything that prevents markets from operating at optimal efficiency. Mass changes in the labor market cause ‘friction’ for instance. Friction while we transition for an economy based on physical, muscular jobs, to an economy of knowledge workers in cubicles.

The aggregate statistics, in this case, lose a reality. That the ‘friction’ is people, Americans. The ‘friction’ is waiting for a 22-year-old college grad to take the place in the labor market of a 45-year-old steelworker who was laid off and will never work again. Middle-aged steelworkers were not being re-trained to be accountants or computer programmers.

Steel is an interesting case to me because it’s one of the industries that didn’t need to go away. There is no economic law that dictated America needed to outsource steel production. The death of American steel was the result of a trade policy pursued by the American government. It was not an unfortunate accident, it was a deliberate choice.

The situation as I see it is this. America in the post-war order pursued a set of economic and trade policies. These policies benefitted the country (and world) as a whole. Yet the brunt of the cost, almost all the downside, was borne by a minority of our citizens. Do we owe them nothing? A pink slip & well wishes? Destroying American steel made America rich, but made American steelworkers poor.

At this point, some tech-utopia libertarian going to stick his head into the conversation. He’ll say ‘well they should have followed employment trend, learned how to code, transitioned to another industry!’ Which I have two objections to.

First, on learning to code. A 45-year-old man who spent his entire life as a steelworker is not just going to up and learn to code and get a software dev job. Some will and can, most won’t and can’t. It’s not realistic as a broad solution. Especially if that 45-year-old man was, until he lost his job, supporting an entire family on his income and relying on a now nonexistent pension for his retirement.

Second, that recommendation, in general, doesn’t scale. That advice works if you have a friend who is in x industry which is going to go away soon. It does not work for an entire industry of workers. Why? Because we needed the steelworkers, right up until the moment we didn’t. It was the steel industry that made the materials for the tanks, airplanes, and ships the won WWII and the rebar that built our cities. If everyone took the advice of leaving for greener pastures when the writing was on the wall, we would have been in a pickle.

Take trucking. Trucking is going away as a profession in the next decade. But, up until the very second that we turn trucking over to autonomous vehicles, we need truckers. They’re the engine of our economy, getting almost everything we use from the docks to us.

Do we owe them nothing? People doing the equivalent of going down with the ship so that the economy can still function and we can live comfortable lives while we make their industry & jobs obsolete? I think we owe them something. I don’t know what, but we can do better than snide slogan about ‘learn to code’ and a half-hearted ‘job retraining’ program that doesn’t work.

Is This a Real Plan or Just a Fantasy? Five Characteristics of Fantasy Documents

In a previous post, we spoke briefly about fantasy documents a term coined by Lee Clarke of Rutgers. In this post, I wanted to dive a little deeper into this concept. There are, I think, five characteristics[1] of a fantasy document as described by Clarke.

Characteristics of Fantasy Documents:

  1. A fantasy document tells the reader a story rather than describing reality[2]
  2. A fantasy document plans by simile[3]
  3. A fantasy document calls for actions which have never been done successfully and/or are not seriously prepared for operationally[4]
  4. A fantasy document (tries to) protect a system or organization from criticism and scrutiny[5]
  5. A fantasy document never admits a risk is unassessable or uncontrollable, rather asserts that every risk is not only understood but controlled[6]

Fantasy documents follow a story-like structure. They read like a script for everyone to follow, cleanly denoting timelines, designating actions to be taken, communication lines to be established, supplies to be requisitioned, and actions to be taken. In all reality, a true plan at scale would have to work something like a choose your own adventure novel; except it would fill bookcases upon bookcases trying to account for every any eventuality or combination of events. These plans would swell to the size of the reality they inhabit, like Borges’ unconscionable maps, making them exact, but functionally useless.

Fantasy documents don’t take that multi-path procedural tact. Instead, they lay out a narrative. ‘In the case of [x], we will do [y], within [h] hours we will do [z], within [d] days we will do [a]. Himself a perpetuator of his own fantasy documents, nuclear strategist Herman Khan mocked early nuclear war plans of the US. He said in On Thermonuclear War that the Army’s plans to, immediately after a nuclear exchange, begin embarking state-side units to sail overseas and fight a land war with the enemy, were patently absurd.

Khan, likely rightly, observed that in the event of general nuclear war what was left of domestic military formations would be immediately engaged in reconstruction & keeping domestic order, they would not be embarking to fight a land war in Europe. But the story of sneak attack followed by an extended land & sea battle is a story policymakers and civilians alike were familiar with.

In service of the story, fantasy documents plan by simile. [x] event which we’ve previously dealt with is like [y] event which we’re trying to plan for. Nuclear war is like conventional war but with bigger bombs. A big oil spill is like a little oil spill[7], we just need more response vessels. The evacuation of Long Island during a nuclear reactor meltdown is like the daily Long Island – NYC commute. Responding to a radiological emergency is like responding to a fire[8]. They often presume that a small emergency response will linearly scale to a large one.

These similes often lead to fantasy documents specifying actions to be taken which, would be impossible or nearly impossible to undertake, and are never seriously prepared for operationally. One clear example is civil defense plans in America. One of the plot points in the stories told by civil defense planners was the evacuation of urban areas if the government believed nuclear war was imminent. This would, planners thought, serve two purposes, first to get civilians out of harm’s way and second to put the United States on more secure footing to fight a win a nuclear war.

Never mind that the total evacuation of New York is something that had never been done before. Never mind that the millions of evacuees could be easily seen and then targeted by bombers. Simply envision for a moment the logistical challenges of moving the entire population of New York City out of New York City. Then the challenges of housing them somewhere far enough from Manhattan to be safe from a nuclear attack. This alone would stretch the resources of the government to the breaking point. Now imagine doing that simultaneously with the 10 largest American metro areas under a condition of imminent nuclear war. It simply strains credulity that urban evacuation could have ever been considered a serious policy, but it nonetheless was.

Khan, a physicist by training, was frustrated nearly to the point of rage over what he saw as unrealistic and ineffectual civil & military planning in the early cold war. In one famous incident during a meeting in the Pentagon, Khan slammed the table saying in extreme frustration “Gentlemen, you do not have a war plan. You have a Wargasm!”[9] referring to the military’s doctrine at the time of massive retaliation. But by looking at the plans in Clarke’s framing as fantasy documents instead of Khan’s framing as ‘plans which should guide operations,’ they begin to make more sense.

The actual function of a fantasy document is often not to plan for anything, but rather, in part, to shield an organizations or institution from criticism. Oil spill containment plans assure the public & environmental groups that the oil company is in fact prepared to respond to, contain, and resolve even a massive spill. Civil defense plans assure the public that their government is ready and able to protect them in the case of a nuclear war. The story that nuclear war plans tell is that the government or the military stands ready an able to not only fight, but win a nuclear war.

As Clarke details at length, the United States government claimed to be able to protect 80% of the American population in the event of nuclear war, a number which, as near as could be determined, had no basis in reality[10]. It was stated in a single report and then repeated as fact for years.

Fantasy documents never admit an inability to control risk. The reality was, most likely, that the potential damage from a nuclear exchange was completely unbounded, and there was little to nothing the United States government could do to control that risk other than trying to prevent nuclear war to begin with through deterrence. The risks involved in a nuclear exchange were unassessable and uncontrollable.

The reality was, that in the event of a 200,000 barrel oil spill neither the oil company nor the government would have the ability to contain the oil or prevent ecological damage. The very act of shipping oil by supertanker had created an uncontrollable risk. How could planners admit that to themselves let alone the public at large? A fantasy document wouldn’t be fantasy if it didn’t purport the ability to control the uncontrollable.

Now that we have a good background on what a fantasy document is, next up we’ll talk about some uses of fantasy documents and why writing them may not be as bad as it seems.

Footnotes

  • [1] I should emphasize these are drawn from my reading Clarke’s work but this is not a set of criteria he explicitly lays out anywhere in his book. I have tried to include robust page references so that a reader can follow where I’m drawing from.
  • [2] Clarke, Lee. Mission Improbable: Using Fantasy Document to Tame Disaster. 16
  • [3] Clarke. 74
  • [4] Clarke. 39; Clarke p.78
  • [5] Clarke. 41
  • [6] Clarke. 142
  • [7] Clarke. 78
  • [8] Clarke. 89
  • [9] Kaplan, Fred. The Wizards of Armageddon. 222-223
  • [10] Clarke. 35-38

Emergency Planning: Foresight or Folly?

Anyone who has ever filled an admin role in emergency services or emergency management is familiar with the veritable binders of plans, procedures, and guidelines for obscure & unlikely events that exist in most organizations.

My own experience is that more often than not when one of those binders gets pulled off the shelf in the midst of an emergency, what is contained in those pages is usually not particularly helpful, and often gets ignored entirely.

It is remarkably unhelpful in that often in organizations I’ve worked for, the only people who’ve read those plans are the people who wrote them heavens knows when and the people responsible for updating them every x many years. If the operations personnel, the people on the ground doing the response, have never seen the organization’s plan, one might wonder what the purpose of having the plans at all is.

However, maybe the purpose of these plans was never to guide operations, but they served another purpose. Shedding light on this question, J. Anderson writes in the Journal of Homeland Security Affairs;

These are what Lee Clarke has called “fantasy documents,” that is, documents that do not actually guide operations, but rather serve as reassurances that the organization has taken the problem seriously and stands ready to deliver… Schemes of prediction and preparation fall short of reality. Reflecting on the response to Hurricane Sandy, FEMA Administrator Fugate wrote, “We still plan for what we are capable of doing. We still train and exercise for what we can manage. We must plan, train, and exercise even bigger to fracture the traditional mindset.[1]

In my current job, where I do in-house emergency planning for a private organization, I think about this a lot. What exactly is the purpose of these documents I’m writing? Do they serve an operational purpose? Are they primarily for a regulatory or legal compliance? Are they merely an insurance policy to point to amorphous plans when asked by stakeholders or the public how we will respond to one thing or another? Are they an exercise in thinking through contingencies? A receipt that we have certain data on file?

I should add, I don’t think any of those functions are prima facie illegitimate pursuits. Though I do think that those of us commissioning, writing, and approving plans should have a clearheaded approach to what we’re doing. As such, the normative and descriptive functions of our plans (what the plans or documents should do vs. what the plans or documents actually do) is a topic which deserves some examination and discussion.

So given that, what should a plan be? Should we be writing much more detailed plans, trying to address every possible contingency with careful step by step procedures? Or should our plans be walked back to be much more general heuristics guiding response?

Is it legitimate for a plan to have little operational value and primarily be an exercise in thinking about possible contingencies and taking them seriously? Or does a plan need to guide operations?

Should we abandon the ‘planning’ enterprise entirely and instead direct resources towards excising & training the field staff in hopes that with a highly trained & experienced staff the spontaneous response will be better than any plan a schmuck like me can write parked behind a computer for weeks on end could be?

I don’t have full answers, but I have some ideas that may illuminate the planning process, which I intend to share over the coming weeks in (hopefully) bite-sized chunks as I have time to write about them. I’m hoping that by sharing some of what I’ve been thinking about, I can get some input from others with different perspectives & experiences.

[1] https://www.hsaj.org/articles/10661

Citizen App Review

BLUF: Citizen is an app that gives users real-time information on crimes & emergencies near them. The app is well designed for the average citizen but isn’t ideal for professionals in public safety or emergency response. Citizen’s information on incidents comes from scanner feeds.

About the Author: I am an Emergency Manager at a Manhattan-based University System. I have a professional background in EMS and an academic background in security policy.

Recently on twitter, I was made aware of an app called Citizen which provides real-time crime reports to users based on geo-location and allows them to stream live video of the incident. I’ll do a quick tour of the app and then share some thoughts.

screenshot_2018-05-22-14-18-59.png

Citizen is currently available in the New York and San Francisco metropolitan areas. The UI is slick and will feel familiar to users of Facebook & Instagram. On load, you see “Stories” across the top which are like small news packages Citizen produces summarizing previous events. Below that is the map, with red dots marking recent incidents, and in the lower half of the screen is a list of incidents.
Screenshot_2018-05-22-14-19-24

Pressing on an incident opens up a new screen with details. There is a timeline of the incident with updates and clarifications. There is also a set of four buttons, allowing you to react, share, contribute media, and ‘warn’ your contacts.

Starting from the left-hand side, React does more or less what you’d expect. Share opens up the OS sharing interface and allows you to post or send a link to the incident in question. The link resolves to a web page with basic details on the incident and a prompt for the visitor to download the app. Example here.

The Record functionality allows you to live stream through the app if (a) the incident is active and (b) you are close enough to the incident. This footage is then marked a ‘verified.’ Other users can watch your live stream as it happens as well as a recording of it afterward.

Screenshot_2018-05-22-16-42-50The Warn button seems to act like the share button. It allows you to send a ‘warning’ SMS message to people in your contacts list. The text includes a short default message and a link to the incident.

screenshot_2018-05-22-16-42-03.pngOn each incident, there is also a chat section, in which users can discuss the incident.

There is no search or filter function within the app. The list of incidents is generated based on what part of the map you’re focused on. For instance, if I zoom all the way into where I am, I see only two incidents. The ‘Recent’ events list is generated based on incidents which occurred within the past seven days in the area of the map you’re focused on. A partial selection of older incidents appear in the ‘Trending’ list.

Citizen’s website says it sends out notifications when an incident occurs near you, but having had this app for several days in Manhattan, I’ve never gotten one notification. That may have been serendipity, but I’m not sure. There are no settings of any kind in the app, let alone notification settings.

Screenshot_2018-05-22-14-20-44Screenshot_20180522-170344This leads me to one of my general frustrations with this app and apps like it. Slightly ironically an app designed to increase transparency is in and of itself quite opaque. The Citizen ecosystem is nearly hermetically sealed. There is no way I can find to get videos of incidents out of the app or to view them at all without having the app installed.

Citizen is not explicit about where it gets the information it pushes to the app and how it chooses what information to publish. My guess based on intuition, their FAQ section, and a job posting is that they have employees monitoring scanner feeds and typing up dispatch information.

Their website indicates that their operations team makes some editorial decisions in what they put on the app, saying quote;

Incidents discussed on emergency communications channels are vetted by our central operations team – a group of analysts with backgrounds in public safety, writing and other relevant fields. Our team is trained to make on-the-fly decisions about what goes into the app based on complex criteria and supplementary research.

They go on to say,

Citizen excludes vague complaints of ‘suspicious persons’ or ‘suspicious behavior,’ in order to avoid instances of racial profiling. Our operations team also removes any non-pertinent descriptions of suspects, when those details are irrelevant to the incident.

Which is certainly their prerogative, but it’s worth noting that what you’re getting is not an unfiltered write-up of scanner traffic.

One of the things that make Citizen different than other similar services (I’m thinking here of Breaking News Network) is that Citizen is much more restrictive with user contribution. Citizen, as the name suggests, is designed for regular people as opposed to professionals. Breaking News Network encourages any user to “report” incidents, which are vetted and supplemented by a small staff of dispatchers. While the BNN user interface is undoubtedly less user-friendly, it offers a much higher level of functionality.

For Citizen, I don’t see its current iteration as being particularly useful to me. If I could speak to the Citizen team, my feature wish-list would be as follows;

  • Open up the ecosystem. If I can’t share an incident quickly with colleagues who don’t have the app, its usefulness is severely limited. Links shared out of the app should ideally resolve to a web page with all the incident information.
  • A greater suite of notification options. As an emergency manager for a university, I would like to get push notifications for anything that happens within in a specified radius of one of our campuses not just wherever I happen to be standing.
  • Search functionality within the app. Filtering incidents via zooming & scrolling on the map isn’t ideal, and there’s quite a bit of lag in getting the incident list to update.
  • Give me some mechanism to save or flag incidents, so I can go back and look at them again later
  • A web/desktop interface

That said, my impression from Citizen’s website is that they are not aiming their product at users like me. The feature set I want may not be what their broader user base needs or wants.

I’m not clear on the what Citizen’s business strategy is. Paying to monitor scanner feeds 24/7 is not an inexpensive endeavor. At least right now I don’t see how Citizen is bringing in any revenue. Something the Citizen team may want to consider is creating a sister product for people like me. My organization may be willing to pay for a version of Citizen with the feature set I listed above.

Despite my gripes with the app, Citizen’s incident reporting is excellent. The best I’ve seen recently available to the general public for free. For the average person in Manhattan or San Francisco, it’s excellent. For the private sector professional, with some added functionality, it would be a valuable addition to your OSINT resources.

Screenshot_2018-05-23-11-56-35Update (05/23/2018)- This morning I received my first push notification from the Citizen App since installing it. The incident was a reported bank robbery approximately a mile from my

current location. I received the notification about five minutes after the incident was first reported, when the police were canvasing for the suspect.

Interestingly, I did not receive a notification for an earlier reported assault that was much closer to me.Capture+_2018-05-23-11-58-04