Domani Spero
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Yahoo News reported on September 9 that “an undisclosed number of people who’ve been exposed to the Ebola virus — not just the four patients publicly identified with diagnosed cases — have been evacuated to the U.S. by an air ambulance company contracted by the State Department.” The report identified Phoenix Air Group as the provider of the air ambulance services. The VP of the company said medical privacy laws and his company’s contract with the State Department prevented him from revealing how many exposed patients have been flown from West Africa to the U.S. He did tell the reported that Phoenix Air has flown 10 Ebola-related missions in the past six weeks. The report also says that the State Department confirmed the four known Ebola patient transports but couldn’t provide details on any exposure evacuations to the United States. An unnamed State Department official told Yahoo News that “every precaution is taken to move the patient safely and securely, to provide critical care en route, and to maintain strict isolation upon arrival in the United States.”(See Ebola evacuations to US greater than previously known).
Public records indicate that the State Department awarded the air ambulance contract on August 18, 2014. The sole source contract was awarded to Phoenix Air for a period of six (6) months at an estimated cost of $4,900,000.00 under FAR 6.302-2 for “unusual and compelling urgency.” The services include among others, air ambulance evacuation, a dedicated on-call aircraft and flight crew, an aero-biological containment system, and emergency recall and mission preparedness:
This requirement is in response to Department of State’s diplomatic mission overseas to provide movement of emergency response personnel into and out of hazardous/non-permissive environments and medical evacuation of critically ill/injured patients, including those infected with unique and high contagious pathogens. This is an immediate response to the Ebola Virus Crisis.
The contract justification says that the movement of patients infected with highly contagious pathogens, as with the current Ebola Virus epidemic, requires the use of an air-transportable biocontainment unit. A unit was designed and built by the Center for Disease Control in 2006 in collaboration with the Phoenix Air Group in Cartersville, GA. The Aeromedical Biological Containment Shelter (ABCS) is the only contagious patient airborne transportation system in the world which allows attending medical personnel to enter the containment vessel in-flight to attend to the patient, thus allowing emergency medical intervention such as new IV lines, intubation, etc.
Yes, the Pentagon has a transport tube but —
“The U.S. Department of Defense has a transport “tube” which a patient is placed into, but once sealed inside the patient is isolated from medical care. It is admittedly (by the DOD) more designed for battlefield causalities than live human transport, especially over long distances. It is also only certified for DOD aircraft and not by the FAA for commercial aircraft which makes this capability not feasible in meeting the Department’s urgent need for the capability to transport contagious patients world-wide.”
Why is this a sole-sourced contract?
Below is part of the justification statement extracted from publicly available documents:
As a matter of standard business practice, Phoenix Air Group does not provide chartered transport of highly contagious patients outside of a standing government contract. As the only vendor with this unique capability, Phoenix Air Group has never offered this service on a one-off basis to private of government entities. The capability was developed on a multi-year contract with the CDC (2006-2011). When the CDC could no longer to afford to maintain the stand-by capability, the equipment was warehoused. While it is technically true that the movement of two American citizens in late July, 2014, was a private transaction, those missions were conducted after the Department requested that PAG consider a break in their standard business practice on a humanitarian basis, with the assurance that the USG would make all necessary arrangements for landing clearances, public health integration, decontamination, and provide press guidance. Simply put, the transportation of this type of patient requires too much international and inter-agency coordination, and incurs too much corporate risk, for PAG to provide the service outside the protection of a federal contract to do so.
The U.S. Department of State has always been responsible for the medical evacuation of official Americans overseas, regardless of their USG agency affiliation. Because of the unique severity and scope of the current Ebola outbreak, and the complete lack of host nation infrastructure to support victims of EVD infection, the international community is finding recruitment of professional staff very difficult without being able to articulate a sound medical evacuation plan. To that end, the Governments of Mexico, Japan, the United Kingdom, Canada, and the United Arab Emirates, as well as the World Health Organization and the United Nations, have separately approached PAG to establish exclusive contracts for this limited resource. Had the Department not moved very quickly to establish its own exclusive use contract, our negotiating position would have shifted, placing USG personnel and private citizens at significant risk.
The availability of the PAG resource is thus a foreign policy issue, placing the U.S. Department of State as the logical arbiter of international agreements to assure equitable coverage while protecting U.S. national interests. The Department is moving to establish Title 607 agreements with these and other eligible entities, allowing coordinated sharing of the resource on a cost-reimbursable basis under 22 U SC 2357 authorities.
Private American citizens responding to this crisis would lack the resources to privately contract for this service, even if it were available on the open market. By establishing the contract through the Department, additional options are provided to American Citizen Services, allowing them to structure the funding as a form of repatriation loan. This would be very difficult to do if not for a Department-level contract; by bringing the resource in-house, the money flow remains within the Department, spreading the financial risk across a much larger budgeting pool. Foreign governments are being encouraged to take similar steps with their own private citizens through high level dialogue that is only possible when the Department is in the lead on this issue.
Given recent CDC guidelines for the movement of asymptomatic contacts, an unprecedented level of control and coordination is necessary to move these individuals that, despite not being contagious or even clearly infected, are nonetheless quarantined. The USG is left with only two options in supporting a CDC scientist that has a high risk exposure to an EVD patient — use the PAG capability to fly the person back to the US for observation and optimum care should disease develop, or leave the person in place where no care is available if the disease develops. The question, then, is not how many EVD patients will be moved, but rather how many contacts and EVD patients will be moved across the entire international response population (as many as three per month). Finally, from a pragmatic stand point, given the limited options for movement of even asymptomatic contacts, it has become clear that an international response to this crisis will not proceed if a reliable mechanism for patient movement cannot be established and centrally managed.
The “special missions” G-111 aircraft, what is it?
The ABCS was certified by the Federal Air Administration (FAA) under a Supplemental Type Certification (STC) for use in an aircraft. The STC further lists only two (2) air- craft by serial number as approved for the installation and operation of the ABCS. Both aircraft are owned and operated by Phoenix Air.
The two aircraft listed by serial number in the STC are “special missions” Gulfstream G-III jets owned and operated by Phoenix Air. There are only three “special missions” G-111 aircraft in the world and Phoenix Air owns and operates all three. These are unique aircraft converted in the Gulfstream Aerospace factory during the original manufacturing assembly line from standard “executive” aircraft to “special missions” aircraft which includes a large cargo door forward of the wing measuring 81.5” wide X 61” high thus allowing the large components of the ABCS to be installed in the aircraft and post-flight decontamination to be performed, each aircraft has a heavy duty cargo floor allowing the ABCS floor attachment system to be installed, and each aircraft is certified at the factory for passenger, cargo or air ambulance operations.
Phoenix Air holds various DOD Civil Aircraft Landing Permits (CALP’s) from all U.S DOD service branches allowing its aircraft to land at all U.S. military bases and facilities worldwide. For security reasons, all medical evacuations of patients with highly contagious pathogens must land at military airfields. Recent experience reinforces the importance of using military airfields, especially OCONUS where the host nation governments have refused to allow the aircraft access to civil airports in the Azores, but have conceded to allow the aircraft to refuel on USMIL airfields in their country.
All Phoenix Air flight and medical personnel have the Commission on Accreditation of Medical Transport Systems (CAMTS) required accreditation and CDC recommended inoculations for air ambulance missions as well as missions into disease~prone areas around the world providing DOS a unique capability that may not be available with other aviation vendors.
Unlike the outbreak of the highly pathogenic avian influenza (H5N1) virus and fears of a pandemic in 2007, one thing we haven’t heard this time is “shelter-in-place.” Back then, Americans abroad were advised to identify local sources of healthcare and prepare to “shelter-in-place” if necessary. “In those areas with potentially limited water and food availability, Americans living abroad are encouraged to maintain supplies of food and water to last at least two and as long as 12 weeks.” We remember thinking then about the embassy swimming pool and wondering how long it would last if city water runs out. Or what happens if a mob comes into the compound in search of food and water.
That does not seem to be the case here. At least, this time, there will be an air ambulance equipped to evacuate Americans back home should it come to that. Note that the justification statement does not include details of how much of the cost will be accounted for as part of the repatriation loan program (pdf) for private Americans.
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![U.S. Ambassador to the United Nations Samantha Power, second from right, receives a briefing from Rear Admiral Scott Giberson, far right, who is the Acting Deputy Surgeon General and Director of the Commissioned Corps of the U.S. Public Health Service, about the Monrovia Medical Unit (MMU), a 25-bed field hospital that will be used to treat Ebola-infected health care workers, on October 28, 2014. The MMU is expected to open soon, and will be staffed by members of the U.S. Public Health Service Commissioned Corps. Also pictured, from left to right, are: Liberia’s Foreign Minister Augustine Ngafuan, USAID/OFDA Director Jeremy Konyndyk, U.S. Ambassador to Liberia Deborah Malac, and Disaster Assistance Response Team (DART) Leader Bill Berger. USUN Ambassador Power is in Liberia to see firsthand the impact of the Ebola epidemic and to press for a more robust response from the international community. [State Department photo/ Public Domain]](https://i0.wp.com/diplopundit.net/wp-content/uploads/2014/10/15653354652_f153d97915_z.jpg?resize=500%2C332&ssl=1)
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