The key is to gather the right information ( but not too much), being able to objectively analyze it, and make projections based on the analysis. It means being able to do something useful with the information.

In any event, I think Lyle’s point regarding health behaviors and their effects in the context of emergent events is well-taken and, I might suggest perhaps in response to Carlo’s point, distinctly “new” as a type of salient information that public health is increasingly regarding as relevant to its mission. This is not to say there are not tensions here. I spoke with a senior epidemiologist recently about the social effects / impact of school closures on communities (e.g., strain on parents’ & work schedules, consequences for student education if prolonged closure, etc.), and his reply was basically to dismiss the notion that public health should either collect data about those things, or take into consideration those sorts of effects when making decisions. This view may be held more by epidemiologists than senior leadership, who are more sensitive (and vulnerable) to the political implications of mitigation measures (and their “social” effects) of this type.

Two more points in reply. First, again to Carlo’s question about what is new here. This is a very good question and, in fact, I wrestled with it in an early draft of my initial post. I think it is fair to say that much of what has and is transpiring with respect to H1N1 is familiar. At its core, the response revolves around traditional public health capabilities like laboratory services, surveillance and epi investigations, not to mention interventions like mass vaccination, which falls directly under the purview of public health. My sense, though, is that situation awareness and its attendant “inputs” – like the relatively recently formulated notion and set of practices that constitute “biosurveillance” – move substantially past these traditional orientations and activities. I’ll mention just two aspects that differentiate it from traditional public health.

Briefly, I think situation awareness demands the kind of aggregation, filtering and integration of information that is light years different than prior configurations of public health information needs or data collection and analytic practices. What technologies are new? What relationships are forged across sectors (and apparatuses)? Several come to mind: global disease surveillance systems that work to forge new relationships with historically volatile political jurisdictions and shape the behavior of life scientists, such as now occurs in the middle east and the former Soviet Union; ties to private industries and retailers that sell over-the-counter medicines and equipment for early warning purposes; an increasing trend to self-report, blog and inquire about health-related issues, some of which is monitored and analyzed utilizing quite complex algorithms to detect search and reporting trends and the like. This list goes on. Mind you, I’m not taking the position that this is the inevitable march of progress; I’m taking the position that these are incontrovertibly different in their configuration and effects than traditional “core” public health techniques and rationalities.

The second aspect to SA to mention here is early warning and detection. Lyle noted in his response that these aims have fallen somewhat by the wayside; I might qualify this statement by suggesting that this is still (very much) an aim of syndromics and BioSense – and therefore SA – especially at the federal level. The recently published National Biosurveillance Strategy for Human Health makes very clear that early warning and detection are (still) central to thinking around situation awareness. There seems, however, to be a general sense that achievement of this aim was elusive in the H1N1 case and, to Lyle’s point again, he is exactly right in saying that syndromic technologies provided something more akin to supplemental information for decision-makers than anything approaching an early sign of trouble. On the flip side, I suspect that some days were shaved off of the date of detection of the outbreak by virtue of very specific technologies (successfully used to detect H1N1 cases #1 and 2), which were deployed to enhance surveillance coverage and the timeliness of lab reporting in very specific contexts – in other words, to enhance situation awareness.

Is SA a buzzword, the concept du jour in a field that perennially reinvents itself? Maybe. But we should be cautious in dismissing it if it is: the transience of a term is not a correlate of its novelty in practice, and should not imply that it has no effects. There are real strategies being developed, incorporating real technologies, integrating disparate sources and types of real information, which are collectively reformulating and reconfiguring institutional relations between domains and shaping expectations of behavior among the lay public and across myriad occupational groups in ways that are unfamiliar in the history of even recent public health. But this is not a monolithic movement; it is advancing at some sites of practice, and remains virtually unheard of in others. Where, how and under what conditions the concept is being implemented is, to me, a question of primary importance (I’m constantly reminded that a case of measles will activate an entire health department’s public health outbreak management machinery; multiple cases of norovirus in a nursing home may not raise an eyebrow).

In any event, there is a lot to mull over here, but also a lot more that can be said. I would welcome a further round of exchange if any points we have raised merit additional consideration.

As to syndromic surveillance and H1N1, I wonder how good an example it really is: If this is the main contribution of syndromic surveillance to the mission of public health, it is a rather modest one. What physician working in an ER could miss the fact that they are suddenly overrun by worried ill cases? And what epidemiologist working at the NYC Department of Health would be surprised to get a phone call from that physician? In other words: an event like this is entirely predictable and hard to miss once it occurs. It seems as if this technology is still searching for a unique problem to which it can provide a unique solution (and thus legitimize itself).

I first encountered the term situation awareness (or situational awareness) at the 2006 Syndromic Surveillance Conference. A woman from CDC described how BioSense was being shifted from an “early warning” to an “situational awareness” system. In fact, real-time health surveillance in general has increasingly abandoned the goal of early warning or event detection in favor of some kind of ‘situation awareness’ in the course of an event. Where are cases increasing most rapidly? Which hospitals are in danger of being overwhelmed? How are public health announcements and interventions impacting the epidemic spread?

The current H1N1 outbreak is a good example. The recognition of an ‘event’ had much more to do with diagnostic and particularly laboratory surveillance than any ‘real-time’ surveillance system. However, New York City heavily used syndromic surveillance during the course of the outbreak there. One of the key insights it provided was that ‘worried ill’ (those with ailments which were probably not H1N1, and were certainly not serious) were flooding the emergency room. This led them to the health departments to make pubic announcements discouraging visiting the ER except in case of severe symptoms. What is interesting about this is that syndromic surveillance in this case was not revealing anything about the actual epidemic of disease but about the behavior that accompanied the outbreak. However, for public health today I would suggest that such behavioral effects are as significant as biological effects in the management of an epidemic event.

One note of hesitation: I wonder if the term ‘situation awareness’ actually is covering up the concrete shifts or lines of mutation going on here. It seems a little like a buzzword the way it is used in some preparedness circles, and while I think significant changes are at stake, the relation between this term and the concepts and practices we are following is I think worth keeping in question.