Read: “Challenges," July 2016 edition of DomPrep Journal
On 7 June 2016, the DomPrep team convened 14 subject matter experts from various disciplines to address issues surrounding community resilience and public health. The purpose of the roundtable was to align the missions andentify action items to create synergy among various community stakeholders. This article summarizes the key takeaways from the roundtable participants.
Oscar Alleyne, senior advisor for Public Health Programs for the National Association of County and City Health Officials (NACCHO) moderated the discussion, beginning with a summary of the highlights of the 2016 Preparedness Summit, which focused on “Planning Today for Rebuilding Tomorrow: Resiliency and Recovery in the 21st Century.” By examining the disaster lifecycle, the Summit addressed the need to push science into the recovery and resilience stages, including but not limited to: unique partnerships; disaster risk reduction; and behavioral health recovery. This is in line with the efforts of the Rockefeller Foundation’s 100 Resilient Cities initiative.
Sustaining Healthy, Resilient Communities
The June DomPrep roundtable took the Summit discussion a step further to address gaps that exist between public health and other sectors, which could hinder resilience and recovery efforts. The public health sector must infuse disaster risk reduction into currently existing disaster preparedness and recovery plans – and to some extent a jurisdiction’s overall community health assessment planning initiative – and distill this information into tactical actions. The National Academies of Science, Engineering, and Medicine released a report in April 2015 with recommendations pointing to the importance of integrating disaster recovery planning into currently existing community-based planning efforts in order to build communities that are better, stronger, and healthier.
As an outgrowth of that report, the Academies is working on a toolkit aimed to translate this 504-page report into an actionable, adaptable community tool, including: suggestions for engaging politicians and other community leaders;eas for expanding engagement beyond traditional planning stakeholders; inventory tools; and a facilitation guide to include exercises and worksheets to aid in planning. Participants described the outcome product as not a standalone process, but rather a “plug-and-play” module with appropriate choices of processes to diverse community needs and requirements.
Participants agree that conversations must move away from the “what ifs” to address community events that are already occurring. By building resilience to health events based on scientific and policy principles, communities can slowly transition to disaster planning that involves a public health component. As groups meet to discuss resilience, one participant warned not to lump every project into the resilience theme. Resilience for public health has a different meaning than resilience in other sectors. The challenge is to prioritize the needs of the community versus public health resilience, which may be at the bottom of these priorities. Disparities and inequity can be significant, but translating the science and asking communities about their concerns can build a stronger foundation to ensure that needs are met. Also suggested is the importance of conveying public messages that are digestible and actionable, as well as determining which innovative programs are not being integrated and why.
A digital dashboard was suggested as a capability that could provide a visual depiction of the various interagency connections. For example, first responders and public safety partners regularly acquire data that should be passed on for public health analysis. They are able to more readilyentify when something is atypical, so public health agencies can leverage this information. Unfortunately, some disaster plans and policies are not scientifically supported and not addressed with programs to best facilitate actions.
As one participant noted, “We cannot respond ourselves out of all disasters that are coming.” Resilience and risk reduction address underlying vulnerabilities, ways to reduce exposures, and capacity to cope with disaster. Public health agencies need to leverage infrastructures such as pharmacies, which are often trusted within the community and canentify vulnerable populations. Resilience should be community-led rather than entity-led. Preparedness tends to be about preparing for a response, whereas resilience requires looking at trends (e.g., in healthcare) and bringing people into a neutral space to better “sell” the concept of resilience on a national platform, incentivize risk reduction, and organize around a multisector platform. Although such platforms exist, participants noted that they are not well-funded or balanced between response and resilience.
The fire service is a successful example of changing community cultures, processes, and requirements to promote prevention and reduce risk. For many years, the fire community at large has leveraged existing community networks and infrastructures to create broad and well-received risk and preparedness campaigns. It has collaborated with standards bodies for the development and implementation of wide-ranging product and service enhancements, with the indemnification community to reward compliance (e.g., the 1973 America Burning Report).
However, as noted by a representative from the fire service, such successful campaigns changed some of the core missions of firefighters and, in some, reducing the need for or eliminating some jobs. Successful communities break resilience into day-to-day steps (but with a long-term mindset) and utilize tools that already exist. Difficult choices need to be made, so sectors need to recognize the choices and evaluate the acceptable and unacceptable risks, as well as analyze the innovations and barriers to innovations or operations when they are encountered. By siloing public health authorities, it is difficult to see the full picture.
One participant cautioned that, when making efforts to reduce risk, not to rely on past incidents and practices for current solutions because the environment is constantly changing and the results could be significantly different under different conditions. With uncertainty in the climate, economy, and infrastructure, it is critical to move forward with the appropriate partners and the right tools, actions, and leadership. Otherwise, the opportunity may be missed. Community-led participatory preparedness is the key to gaining broad stakeholder involvement.
Much more work is needed to increase community involvement in health resilience efforts – at the individual, family, organizational, community, and national levels. Participants suggested that a near-term strategic accomplishment would be as simple as getting sectors to understand public health community’s core and secondary mission-critical capabilities, key assets and capabilities they have at their disposal, and how to more effectively integrate them at the community level. In order to affect change, all stakeholders must be on a level playing field. Participants agree that strategic communication on mission and messaging need to become ubiquitous and communicate it in a simple format that could even fit on a bumper sticker or tweet.
Unfortunately, it can be difficult to persuade people unless either the task is easy or they are financially motivated or mandated. Roundtable participants mentioned four key individual motivators: (a) personal experience with past disasters; (b) system changes being nonexistent; (c) personal calling/altruism to make a difference; and (d) frustration with progression. In essence, the motivations vary, but they share a common theme and ultimate goal.
Practical Applications of the National Health Security Strategy
The public health community needs to define its role in (and support of) resilience and ways in which it can build relationships and trust. Some roundtable participants expressed frustration with how public health is progressing. Although resilience is not a new concept, they noticed that not much has changed in the public health system. One example cited was that mental health response teams were onsite during the Paris-Brussels attacks, but they did not provide services for the firefighters. The gravity of the response and timeframe of government response is not in line with long-term recovery, especially for behavioral and mental health concerns.
Such health concerns usually cannot be cured, but instead must be mitigated. In most cases, eradication should not be used as a measure of success. In fact, defining success can be hindered by various factors, including: federal regulations; credentialing roadblocks; simultaneous incentives and disincentives; and frustration at higher levels. Changing the way the government works and changing the way people think are two very different issues. Therefore, what is needed to prepare versus what is needed to truly recover are not in accord. There needs to be a better way of quantifying and qualifying mental health to effectively apply disaster risk reduction strategies to health concerns.
Although some may think that particular interventions work, the outcomes do not always provide adequate proof. The science behind public health needs to improve. For example, health personnel canentify a significant amount of people who are likely to develop mental illnesses, but disaster behavioral health needs to better describe how stress risk manifests. In short, mental health is a health risk with economic consequences.
Another hurdle mentioned is that improvement plans are sometimes never finished or adopted (or health is not a component). Completing the disaster lifecycle is predicated on having adequate time and space between disasters. If lessons learned are not integrated into an after action report and/or performance improvement plan, then they are not useful for subsequent incidents. For example, the 2009-2010 H1N1 pandemic lessons still have not been integrated into a newer improved plan, and subsequent disasters continually push integration lower on the priority list. When working with multiple sectors and agencies, an agency may choose to write the plan, but there is often no specific entity assigned to the task. Such ambiguity needs to be avoided.
Behavioral health systems are another sector that are already overwhelmed. It is necessary that the health systems perspective examines how many people will recover, benefit, and have behavioral health problems. Physical illnesses are studied after a disaster, but studies on behavioral and mental health issues are equally needed. Possible solutions to minimize the “worried well” (i.e., people reporting to hospitals who do not need medical attention) include behavioral health personnel managing fear by better explaining the disease, by better quantifying the issue, and by engaging the whole community. Discovering existing root causes and spending pre-disaster time with credible and trusted sources could avoid some exposure.
All of the above require some form of funding, but there was consensus that there needs to be a shift from dependence on federal dollars toward new public-private partnerships. Unfortunately, a single lump sum of money will not fix the issues at hand. Leveraging funds that force the recipient to rethink how they will be used could incentivize sustainable outcomes at the local level. Possible solutions are social impact bonds and other value-added benefits for private sector investors. Of course, no single investor can sustain or be responsible to fund a never-ending expense.
In public-private partnerships and collaborative efforts, both trust and value are critical. If the private sector does not feel that what it is doing is valuable or profitable, then it has no incentive to assist. As such, the public health sector needs to translate the National Health Security Strategy in a way that speaks to the potential investors. Indicators thatentify data elements and strategies to help drive the dialog are needed. An illustrative example shared by one participant was that, if 30 percent of the population contracts influenza at the same time, the food supply would shut down. The facts must be put in place.
Healthcare has undoubtedly become a huge industry, which is why it needs to be integrated in all preparedness and resilience efforts. Better planning would help the public health sector better integrate into communities and assist all sectors in creating more surge capacity and mutual aid agreements to support coordinated activities and to share resources, facilities, services, and other support required during emergency response.
In This Issue
Emily Lord leads this July 2016 edition of the DomPrep Journal with an article on the preparedness gap that persist across the country. Changes are needed to better prepare for and address current and emerging public health threats. This change is critical because, according to Robert Hutchinson, public health threats are evolving at a faster rate than the efforts to prepare for them.
Justin Snair and Megan Reeve Snair then discuss social impact bonds, which may enable communities to not only prepare better, but also to reduce costs. Collaborative efforts using a whole community approach would enable communities to expand their abilities to plan for, respond to, and recover from health threats, as described in Thomas Russo’s article.
George Morgan shares information on the benefits of employing the National Incident Management System during the response phase, when an incident cannot be avoided. The next phase of a disaster is recovery, which may not be easy, but Natalie Grant offers some advice to tackle this complex process. In Baltimore, Kathleen Goodwin, Leana Wen, and Jennifer Martin use Baltimore’s Health Department as an example of how public health practices can be integrated to assist all stakeholders in making critical decisions.
Rounding out the issue is a follow on to last month’s issue on “Risk” and long-term power grid failure. According to J. Michael Barrett, the electrical grid is not ready for communities’ constantly growing power needs. Good decisions now that incorporate actionable research will better prepare all sectors for an imminent or future short-term or long-term threat.
Special thanks go to the many people who contributed to this edition of the DomPrep Journal:
E. Oscar Alleyne, Senior Advisor for Public Health Program, NACCHO
J. Michael Barrett, Director of the Center for Homeland Security & Resilience
Laura Biesiadecki, Senior Director for Preparedness, Response, and Recovery, NACCHO
Darrin Donato, Resilience Policy Coordinator, DHHS ASPR
Kathleen E. Goodwin, Special Assistant to the Commissioner, Baltimore City Health Department
Natalie N. Grant, Program Analyst, U.S. DHHS/ASPR/OEM/Recovery
Regina Hawkins, Intern, NACCHO
Jack Herrmann, Senior Program Officer, National Academies of Sciences, Engineering, and Medicine
Robert C. Hutchinson, Deputy Special Agent in Charge, U.S. Department of Homeland Security, U.S. Immigration and Customs Enforcement’s Homeland Security Investigations
James J. James, M.D., Dr.P.H., M.H.A., Executive Director Society for Disaster Medicine and Public Health
Thomas Lockwood, Former Member of U.S. Department of Homeland Security's Senior Leadership Team
Emily Lord, Executive Director, Healthcare Ready
Nicolette Louissaint, Director of Programming, Healthcare Ready
Jennifer L. Martin, J.D. M.A., Director, Office of Public Health Preparedness and Response (OPHPR), Baltimore City Health Department
George A. Morgan, Battalion Fire/EMS Chief, Hagerstown
Patrick Rose, former Director for Pandemic and Catastrophic Preparedness, NACCHO
Laura Runnels, NACCHO
Thomas (Tom) P. Russo, MA, CEM, Faculty Member in the Emergency Management Program, Columbia College, South Carolina
Justin Snair, Program Officer, National Academies of Sciences, Engineering, and Medicine
Leana S. Wen, M.D. M.Sc. FAAEM, Commissioner of Health, Baltimore City