Hospital in a bunker

On being prepared as history refuses to end

Over the last few years, I’ve been thinking more about the idea of readiness, especially in a healthcare context.

After all, just three years ago we ran a nationwide simulation of what it would look like to have a simultaneous pandemic and supply chain shortages originating in China, and we failed. Hospitals struggled to have even latex gloves on hand, cancer treatments were delayed because of capacity issues and lack of contingency plans, rapid Covid tests were largely unavailable and the vaccine development was miraculous but the rollout was a mess (I ran out of words to link to, but I wrote about the production and supply chain issues a bunch of times in different publications).

At the same time, we all know the challenges confronting American healthcare and that keep us from being ready. The software is outdated and siloed, the providers are burned out, each health system is a fiefdom unto itself, responsible for maintaining its own supplies (this does not always work).

At the national level, we have some systems in place to backstop states and localities, primarily in the form of the Strategic National Supply. I’ve been researching the SNS with an eye to writing a comprehensive piece, and, while it’s ready for a variety of short-term situations to happen on a locality level,¹ it’s not intended to be a medium- to long-term supply in case of a conflict.

Which brings me to fellow a16z-er David Ulevitch’s tweet on Monday about the ongoing Israel conflict, and where they thrive: 

https://twitter.com/davidu/status/1711605938078318885?s=20

With all this in mind, I was particularly struck by the news that Israel is opening their 2,000 bed, 3 story, underground hospital. Their what??

Located in northern Israel, near the border with Lebanon, the Rambam Medical Center was particularly affected by the Second Lebanon War in 2006, which saw missiles landing close to the hospital. The hospital, one of the largest in the country, decided to prepare for future conflict by building a massive underground structure that could serve as a wartime hospital. 

During peacetime, the underground structure serves as a parking garage. During wartime, it can be converted within 72 hours into a space with operating rooms, delivery rooms, an ICU, and a decontamination center following non-conventional attacks. In case of biological or chemical attacks, it can be sealed off and self-sustaining with food, water, and electricity for three days.

I’m aware that this isn’t exactly a top priority for US hospitals, many of which are struggling by on razor-thin margins (and others of which are investing billions of dollars in capital projects that may or may not serve patients directly but which are definitely not underground bunker hospitals). And, at the same time, Israel has a National Health Insurance program, and many (but not all) of its hospitals are run by the Ministry of Health. Also, after decades of conflict, Israel is particularly motivated to be ready. 

But it’s interesting to think about in a US context. If there were a national emergency, another pandemic, or a prolonged attack on US soil, I’m not sure what our hospitals would do. 

Having been interested in this topic since I was a freshman in college, I once participated in a small, rural Pennsylvania hospital’s readiness drill. I was assigned to pretend that I both (a) had a broken leg, and (b) was possibly contaminated with nuclear fallout. The hospital staff rushed me into a decontamination station (only bumping my “broken” leg into the wall a few times) and that was that. But they only had a few students participating, and the assumption was not that we were under continued attack. It was fun but not particularly reassuring.

It’s not all bad. Many cities have readiness plans, including plans to convert existing infrastructure (hotels, a stadium) into decontamination centers or hospital wards. And when the Boston marathon bombing took place in 2013, Boston’s hospitals responded smoothly and admirably. As Dr. Atul Gawande wrote in the New Yorker a short time later,

At my hospital, Stanley Ashley, a general surgeon and our chief medical officer, was that person. I talked to him after the event—I had been out of the city at the time of the explosions—and he told me that no sooner had he set up his command post and begun making phone calls then the first wave of victims arrived. Everything happened too fast for any ritualized plan to accommodate.

So what did you do, I asked him.

“I mostly let people do their jobs,” he said.

That’s the real miracle of healthcare, period. The providers jumped into the fray and relied on their decades of training to save a remarkable number of victims. But as we saw with Covid, a medium- to long-term situation requires more than relying on the goodness of our medical professionals. It also requires readiness. 

How does that happen in the US? I don’t know. Maybe AI will save us by predicted shortages in advance. Maybe policymakers can incentivize hospitals by tying Medicare funding to maintaining a supply stockpile and extra beds (withholding national funds in a quid pro quo is one of my favorite historical legislative cudgels). Maybe we have to wait for a conflict and suffer for a few years before everyone realizes that we need to be able to make our own medications (while there are task forces, it is unclear what they are currently doing).

But if you’re interested in healthcare readiness, let me know. I’m obsessed with this topic and can’t find enough people who are also into it.

This information shouldn’t be taken as investment advice (obviously), and the opinions expressed are entirely my own, not representative of my employer or anyone else.

Please also see a16z.com/disclosures for additional relevant disclosures.

1. And only a few localities, at that. A 2021 New York Times article about the Covid vaccine rollout also discussed the supply of 75 million doses of anthrax vaccine held in the SNS. Why 75 million? The reporter asked Dr. Kenneth Bernard, a Bush advisor, who recalled a meeting after 9/11. “A bunch of people, including myself, were sitting in a room and asking what kind of attack might happen,” he said. “And somebody said, ‘Well, I can’t imagine anyone attacking more than three cities at once.’ So we took the population of a major U.S. city and multiplied by three.”