The Changing Role of Public Health The Changing Role of Public Health in Disaster Responsein Disaster Response

What does it mean to be a public What does it mean to be a public health first responder?health first responder?

Nancy VanDevanter DrPH*Nancy VanDevanter DrPH*David Abramson PhD**David Abramson PhD**

Perri Leviss***Perri Leviss***Joyce Moon Howard**Joyce Moon Howard**

Peggy Honore ****Peggy Honore ****

*New York University College of Nursing*New York University College of Nursing**Columbia University Mailman School of Public **Columbia University Mailman School of Public HealthHealth***Consultant***Consultant****US Department of Health and Human ****US Department of Health and Human ServicesServices

“ “ I am hopeful this was a once in a lifetime I am hopeful this was a once in a lifetime event. I am hoping that all the lessons we event. I am hoping that all the lessons we learned from this are chronicled and put into learned from this are chronicled and put into a book for the next generation, and that I a book for the next generation, and that I never have to pull the book out and look for never have to pull the book out and look for those answers. So, and I think, how do you those answers. So, and I think, how do you train staff for the worst National natural train staff for the worst National natural disaster we have ever seen in this country? disaster we have ever seen in this country? How does anyone wrap their mind around How does anyone wrap their mind around getting ready for that?”getting ready for that?”

AcknowledgementsAcknowledgements

• We would like to thank the leadership and We would like to thank the leadership and staff of the Louisiana State Department of staff of the Louisiana State Department of Health and Hospitals, the City of New Orleans Health and Hospitals, the City of New Orleans Department of Health and the Mississippi Department of Health and the Mississippi State Department of Health for sharing their State Department of Health for sharing their extraordinary experiences and insights.extraordinary experiences and insights.

• The Robert Wood Johnson Foundation who The Robert Wood Johnson Foundation who funded the study.funded the study.

How the study was How the study was conductedconducted

• A purposive sample of 50 key informants A purposive sample of 50 key informants identified by leadership of the three identified by leadership of the three participating health departments were invited participating health departments were invited to participate in the Katrina Oral History to participate in the Katrina Oral History Project.Project.

• Individuals were identified on the basis of their Individuals were identified on the basis of their disaster related responsibilities and included disaster related responsibilities and included both organizational leaders and a smaller both organizational leaders and a smaller number of line staff.number of line staff.

How the study was conducted How the study was conducted (cont)(cont)

• The study was described to potential The study was described to potential participants as an Oral History being participants as an Oral History being conducted to better understand the role conducted to better understand the role of public health in responding to disaster of public health in responding to disaster and a permanent record of these and a permanent record of these historical events that would be available historical events that would be available in local universities for future study.in local universities for future study.

• 44/50 key informants were interviewed. 44/50 key informants were interviewed.

How the study was conducted How the study was conducted (cont)(cont)• In-depth qualitative interviews 1 ½- 2 hrsIn-depth qualitative interviews 1 ½- 2 hrs

9-13 months post disaster9-13 months post disaster• Interviews audio taped and transcribedInterviews audio taped and transcribed• Transcripts returned to interviewee for Transcripts returned to interviewee for

review and correction review and correction • Thematic analysis was conducted by the Thematic analysis was conducted by the

research team who developed a code bookresearch team who developed a code book• Data was coded by 2 independent coders Data was coded by 2 independent coders

and entered into Atlas ti (kappa .85) for and entered into Atlas ti (kappa .85) for further analysis.further analysis.

Oral History as Tool in Public Oral History as Tool in Public Health Systems ResearchHealth Systems Research

• Provide personal accounts and Provide personal accounts and observations of historical events by observations of historical events by participantsparticipants

• Allow researchers to document events and Allow researchers to document events and identify themes as they emerge naturally identify themes as they emerge naturally from the datafrom the data

• Provide opportunities to examine Provide opportunities to examine interfaces between organizational and interfaces between organizational and environmental issuesenvironmental issues

• Allow for historical data to be gathered for Allow for historical data to be gathered for future researchfuture research

Main Themes: 1Main Themes: 1

• Expectations for public health Expectations for public health disaster preparedness have greatly disaster preparedness have greatly increased since 9/11 with the increased since 9/11 with the increase in funding to provide increase in funding to provide leadership and workforce training.leadership and workforce training.

““Public Health, is not used to being a Public Health, is not used to being a

response system, it’s used to being a Public response system, it’s used to being a Public

Health System. Well, the incidents of 9/11 and Health System. Well, the incidents of 9/11 and

Katrina and the threat of bio-terrorism and Katrina and the threat of bio-terrorism and

chemical terrorism and agro terrorism and all chemical terrorism and agro terrorism and all

this has made, really, Public Health has had to this has made, really, Public Health has had to

shift gears and become a response agency.shift gears and become a response agency. “ “

Main Themes: 2Main Themes: 2

• Public Health leadership has a responded Public Health leadership has a responded to it’s new responsibilities in disaster to it’s new responsibilities in disaster response utilizing the following strategies:response utilizing the following strategies:1.1. Training public health staff in Training public health staff in emergency emergency responseresponse2.2. Recruitment of emergency response Recruitment of emergency response

personnelpersonnel3.3. Capacity building through strategic Capacity building through strategic partnerships with community agenciespartnerships with community agencies

Challenges in implementing Challenges in implementing these strategies: these strategies: PH employee PH employee trainingtraining• Skills necessary to carry out PH functions Skills necessary to carry out PH functions

differ significantly from emergency differ significantly from emergency response skills.response skills.

• Aging PH workforce may not be able to Aging PH workforce may not be able to function as first responders due to family function as first responders due to family responsibilities and physical limitations.responsibilities and physical limitations.

• Identification with traditional public health Identification with traditional public health role may create barriers to adoption of role may create barriers to adoption of new role.new role.

““Emergency response staff are a certain type of Emergency response staff are a certain type of people. Public Health people are a certain type people. Public Health people are a certain type of people. And they’ve been able to come to the of people. And they’ve been able to come to the table, but when you look at this kind of table, but when you look at this kind of disaster, all right, you need EMS, you need disaster, all right, you need EMS, you need first responder kind of people, you need very first responder kind of people, you need very dynamic people who can, and I’m not saying that dynamic people who can, and I’m not saying that Public Health don’t have those kind of people, Public Health don’t have those kind of people, but that’s not what they’re used to doing.”but that’s not what they’re used to doing.”

““You know, our workforce is an You know, our workforce is an

aging workforce and I think the mindset of our aging workforce and I think the mindset of our

older nurses was like-OK this is enough for me-older nurses was like-OK this is enough for me-

and this was the final straw that broke the and this was the final straw that broke the

camel’s back. And that was…we’ll call it quits camel’s back. And that was…we’ll call it quits

after this. And so we’ve had a lot of our older after this. And so we’ve had a lot of our older

workforce to early retirement.” workforce to early retirement.”

Challenges in implementing Challenges in implementing these strategies: these strategies: Hiring Hiring Emergency Responder ExpertsEmergency Responder Experts

• Difficultly integrating into public Difficultly integrating into public health culture.health culture.

• Lack of public health experience.Lack of public health experience.

• Risk of having parallel versus Risk of having parallel versus integrated workforce. integrated workforce.

“…“…in most every state the lead coordinating in most every state the lead coordinating agency (for emergency response) is the agency (for emergency response) is the Public Health Department. The problem of Public Health Department. The problem of that is the most emergent need for Public that is the most emergent need for Public Health and Medical is not Public Health, it’s Health and Medical is not Public Health, it’s the medical, the hospitals, the Community the medical, the hospitals, the Community Health Centers, the Emergency Medical Health Centers, the Emergency Medical Services, and in most cases, Public Health as Services, and in most cases, Public Health as an entity, no matter how well trained, versed an entity, no matter how well trained, versed and experienced they are, don’t have that and experienced they are, don’t have that expertise within their realm.” expertise within their realm.”

“ “ The federal government, even police, The federal government, even police, firefighter, all of these first responder firefighter, all of these first responder kind of people that think that Public kind of people that think that Public Health is ‘touchy feely’ ….”Health is ‘touchy feely’ ….”

Challenges in implementing Challenges in implementing strategies: strategies: Building community Building community capacity through partnership capacity through partnership developmentdevelopment

• Public health workers were not Public health workers were not historically trained in capacity historically trained in capacity building and community partnership building and community partnership development. development.

““How would we train our public health How would we train our public health professionals in leadership? So we started professionals in leadership? So we started developing things like the Public Health developing things like the Public Health Leadership Institute and training our Leadership Institute and training our managers in how to lead folks into the new managers in how to lead folks into the new millennium to have different skill sets and millennium to have different skill sets and to be able to be more involved with their to be able to be more involved with their community and community decisions and community and community decisions and change the culture of being a state change the culture of being a state employee that they would work 8-4:30 to employee that they would work 8-4:30 to 24/7. “24/7. “

Findings from 9-11/Anthrax Findings from 9-11/Anthrax Oral HistoryOral History

• ““Historically there have been Historically there have been significant challenges to integrating the significant challenges to integrating the cultures of public health with that of cultures of public health with that of the OEM. These result from the nature the OEM. These result from the nature of the mission of each agency. Public of the mission of each agency. Public health must always be focused on the health must always be focused on the larger population issues while larger population issues while emergency responders are concerned emergency responders are concerned with the health and safety of the with the health and safety of the individual.”individual.”

ConclusionsConclusions

• There are inherent tensions to the integration of first There are inherent tensions to the integration of first responder and public health roles that should be responder and public health roles that should be acknowledged.acknowledged.

• Traditional public health workers need clear guidelines and Traditional public health workers need clear guidelines and expectations for their emergency response roles that are expectations for their emergency response roles that are consistent with their skills and training.consistent with their skills and training.

• Emergency response staff need to recognize the public Emergency response staff need to recognize the public health environment and it’s primary mission. health environment and it’s primary mission.

• Because the demands on public health in emergency Because the demands on public health in emergency response are likely to far exceed the resources available it response are likely to far exceed the resources available it is essential to build strategic community partnerships that is essential to build strategic community partnerships that can fill some of those gaps.can fill some of those gaps.