From Flu Wiki 2

Forum: Building Resilient Communities

24 May 2006

Peter Carpenter – at 12:48

Community Planning & Individual Responsibility Putting the Public back into Public Health

Peter F. Carpenter Pandemic Summit 19 May 2006

Our current disaster preparedness system is built on the basis of mutual aid. When one community has an extraordinary event then mutual aid is the perfect solution because it allows other nearby communities who are not experiencing the same event to contribute resources. However, when there is an area or nation or worldwide disaster (a Pandisaster) then mutual aid will no longer be a viable solution since there will be no available resources from neighboring communities. We must therefore develop truly Resilient Communities — communities that have planned, prepared and tested the capacity to take care of themselves in the event of a Pandisaster.

Designing and implementing a Resilient Community will not be an easy task. It will require ‘civilianizing’ our current disaster preparedness and response model with our current emergency responders becoming the teachers rather than the doers. It will require the development of a community ethic of individual preparedness rather than the current 911 mentality. It will require the mobilization of schools, business, social groups, service organizations and churches in totally new ways. And it will require periodic testing to ensure that we have actually created Resilient Communities.

We have to put the Public back into Public Health. What has been accomplished

Greater awareness amongst the already well informed

Some very good, but totally vertical, planning

Thanks to all those public health professionals whom have both done competent planning and been honest with the public about the limits of their abilities to do anything if a pandemic occurs.

Progress on new vaccine development and production techniques

Greatly improved, but still spotty, surveillance

But the virus has also made progress – As of 12 May — 208 human cases and 115 deaths And infected 16 mammalian species

What are some of the problems

We must mobilize the American public if we are to have any hope of successfully coping with a true pandemic. That mobilization must be based on scientifically sound facts, clear and honest communication of those facts and specific guidance on what each individual, business, school and neighborhood organization must do to be prepared

This week’s Lancet’s editorial states this clearly:

“Avian influenza is not a challenge. It is a predicament of extraordinary proportions. Doctors must say this loudly and repeatedly. Presently, we are largely silent. As The Lancet wrote after the 1918 influenza pandemic, if only we had acted earlier with a “collective health conscience”, many millions of lives could have been saved. Today, we are repeating the same mistakes of a century ago.”

Civilization has ‘progressed’ to the point that: - we all have specialized skills and tasks (but we retain few generalized skills) - supply chains are just in time - there is no excess capacity in any institution - we no longer ‘need’ to store food etc. to survive from one planting season to the next or to withstand a failed crop

water – municipal systems – just in time electricity – public utilities – just in time natural gas – public utility – just in time food – purchased 3–4 times a week – avg reserve w/o elec is 1 week sewage – public utility – just in time fire – public agency – on call estimated that less that 5% of the nation’s homes have fire extinguishers. refuse removal – public utility – weekly

Government at all levels has also become highly specialized and just in time (cities, fire districts, water districts, school districts, hospital districts, harbor districts. etc.) Each government agency does its own thing and no one has the responsibility for bringing the pieces together. There is very little horizontal communication and almost no horizontal coordination

Therefore, everything works well and efficiently under normal circumstances,

However, for these very same reasons, we have no ability or capacity as a society, community or individuals to perform under extraordinary circumstances.

The California Little Hoover Commission made the distinction between high frequency emergencies, which can be handled with mutual aid, and disasters, which overwhelm the existing system.

World Trade Center and Katrina both were relatively small-scale disasters that exemplify this, particularly in the recovery phase.

A Flu Pandemic would overwhelm the current system and our existing health care resources – either we develop resilient communities or tens of thousands will die who might be saved

Lots of unanswered questions

1 – how should firefighters or police respond to a call from a quarantined home?

2 – will people in quarantine be allowed to starve? If not, who will feed them? One County plan clearly states: “Residents will be required to stay in their homes for a significant period during an influenza pandemic; thus, residents will need public information, education and tools so they are prepared to take responsibility for basic needs (food, water, prescription medications, over-the-counter medications, etc.).”

Here the public health officials make it clear that they intend to impose quarantine but that it is the responsibility of those quarantined to then take care of their basic needs.

Is it ethically correct and/or sound public policy for public health officials to exercise their authority to impose quarantine without also assuming responsibility for the effects of such a quarantine order?

The Canadians have made a point of stressing ‘reciprocity’: that is, for that which government asks of its citizens, there is in turn an obligation to those citizens. For example:

“When public health trumps civil liberties: the ethics of quarantine

There are times when the interests of protecting public health override some individual rights, such as freedom of movement. At such times, society has a duty to inform people of the nature of the threat, be open in explaining the reasons for over-riding individual freedoms and do as much as possible to assist those whose rights are being infringed.

Reciprocity. Society has a duty to see that those quarantined receive adequate care, are not kept in quarantine for excessively long periods, and are not abandoned or psychosocially isolated. There may also be a need to eliminate economic barriers, such as loss of income, which would otherwise prevent someone from obeying a quarantine order.3”

Communities controlled by quarantine under command and control systems alone are likely to be quite brittle and dysfunctional under pandemic conditions that are already national and global in scope. Whereas networks of resilient communities optimized for situational awareness based upon a common operating picture and collaborative strategic actions to address mission critical gaps would be quite flexible and effective.”

Quarantine and medical resource rationing are not only medical decisions but they are also political decisions. Recall the issue of bath house closures in the early days of AIDS in SF. What you perceive as medical correct may not be politically acceptable and what is deemed to be politically necessary may not be medically correct. Look how long it has taken for AIDS to become both a routinely tested for and reportable disease.

There is a big difference between being an appointed official and being an elected official. Do not confuse having the legal authority to do something with having a mandate from the people – the two are very different and neither is sufficient alone.

Appointed officials are accountable only to their boss, elected officials are accountable to the public – a very big difference

3 – who will help the at-risk/special needs populations prepare for a pandemic? Who will help them during a pandemic?

4 – How and who will ration non-medical resources such as food and fuel?

5 – How will school closings be coordinated with childcare responsibilities and leave from work?

6 – Why are different jurisdictions using different planning assumptions ? This will confuse the public and reduce their confidence in those making the predictions.

7 – Who will protect health care facilities, pharmacies and food stores from rioters?

The veneer of civilization is very thin – how we will deal with panic followed by looting followed by riots? Particularly when we will have so few law enforcement personnel available for duty.

8 – what exactly should an individual do to be prepared? - what supplies and for how long 3/7/30 days ??? - training

9 – What is the role of pharmacies???

10 - How to integrate the business sector

A recent National Journal article talked about Wal-Mart’s response during Katrina that illustrates the vertical silo problem in government and business plans:

America’s giant corporations have their own emergency-management systems, separate from and parallel to the government’s. They cannot afford not to: These businesses have billions in assets — facilities, goods, and personnel – to protect. And if those private assets survive intact, they can help fill a tremendous public need during disaster-recovery efforts, if the private and public sectors can bridge their differences and work together.

No company demonstrates more clearly how much can be done — and how much is still to be done — than Wal-Mart. With its facilities concentrated in the storm-prone Southeastern states, the Bentonville, Ark.-based retailer had hurricane plans in place long before Katrina…In the first three weeks after Katrina, Wal-Mart sent almost 2,500 truckloads of supplies to the stricken states … the company sometimes struggled to coordinate with the Louisiana National Guard and other government agencies about what to send, how to dispense it, and what to charge. Shipments were held up needlessly, turned back at checkpoints, or delivered without clear agreement on whether the supplies were to be given away or sold. … it turned out that the planning on both sides had a blind spot big enough for a hurricane to swirl through. The Guard had rehearsed its role in a disaster; Wal-Mart had refined its checklists to secure its stores; but neither had thought through how to work with the other. As organized as Wal-Mart was internally, its cooperation with the government was often “totally off-the-cuff,”. …. So in the first, desperate days after Katrina slammed ashore, corporate officials and public servants had to improvise ways of working together, based on personal connections and fortunate coincidences. At the point where all procedures failed, people, regardless of whom they reported to, just banded together to save lives as best they could. What needs to be done

1. Preparedness will require coordination among federal, state and local government and partners in the private sector.

2. An informed and responsive public is essential to minimizing the health effects of a pandemic and the resulting consequences to society.

3. We have to start thinking in new ways — and the public health people have to take the lead if the health and survival of the public is your mission.

4. Communication

The public health professionals CANNOT prepare our communities for a pandemic without the full participation and support of the public. And that participation and support must be courted, earned and respected. Without the public you will fail and if you fail we will all suffer and many will die.

A story: It was 1971 and inflation was out of control. President Nixon had just imposed a wage and price freeze and closed the gold window. A small group of us were given the task of creating a totally new organization, the Price Commission, which would control the entire US economy. We had just 16 days to hire 600 people and write the rules and regulation to control the prices for practically everything sold in the US. And when the freeze was lifted and we began to operate on the 17th day our basic principle was that we could not succeed without the support of the American public.

The Chairman of the Price Commission established our credo People will support what they understand.

To reach the American public we had a news conference every day and we gave employee badges to all the media covering the Price Commission – they could talk to any member of the staff – something unheard of in Washington DC. The bottom line is that the American public and we stopped inflation in its tracks. The Price Commission was abolished 18 months later and replaced by a more flexible transition back to a totally free market in which substantial changes had been made by the leadership that we provided on increasing productivity as the essential means of curbing inflation. I had the privilege of serving as the Deputy Executive Director of the Price Commission from the very beginning until we had accomplished our mission.

This week’s WHO Perspectives has a superb article by Sandman and Lanard that states:

“Communication wouldn’t be such a problem if it were possible to get ready for the next pandemic without talking to the public. It isn’t.

Health authorities want the public to be aware of this grave threat for three fundamental reasons: so people will prepare themselves emotionally and logistically; so people will help their schools, businesses, hospitals, and other organizations prepare; and so people will support the preparedness efforts of their governments. And there’s a fourth reason: If and when a pandemic begins, people who have had time to get used to the idea are likelier to understand their risks, follow official advice, and take an active role in protecting themselves.” Sandman and Lanard state: “that motivating people to start taking bird flu seriously should be a top priority for government health departments, and that risk communication principles provide the best guidance on how to do so.”

“Start where your audience starts

Don’t be afraid to frighten people

Acknowledge uncertainty

Share dilemmas

Give people things to do

Aim for total candor and transparency” - Sandman and Lanard

5. Who and how are we pulling all the pieces together? No one is doing horizontal and integrated pandemic planning. Government is planning for government and business is planning for business etc but no one is looking across the board horizontally. Those businesses which will probably shut down their normal operations because of a pandemic, like restaurants, movie theatres and health clubs, represent an incredibly valuable resource for use as treatment sites. And an ice cream producer that no longer has a market for its products still has a fleet of refrigerated vehicles that could be very valuable for moving medical supplies.

6. At the World Trade Center the ICS system was strained At Katrina the ICS system collapsed In a Pandemic the current ICS system would not work

Since a pandemic would not be a single point disaster and since there would be few if any mutual aid resources, we need a dramatically different incident command system model so that federal, state, and local government authorities would be able to work hand in hand with citizen groups within resilience networks.

7. Standardization of assumptions If the public health officials are to be credible they have to be consistent – how can two different so-called experts have dramatically different opinions? You may understand that but the public does not and their response is to doubt all of you. Science is supposed to provide truth but if the scientists cannot agree then the public will perceive that you don’t know what the truth is and will dismiss your expertise.

8. Consensus on what individual citizens need to do to be prepared

9. Maximum push on informing the public on what they need to do

10. Maximum push on flu vaccination and pneumonia vaccination this

                      year

11. Flu training for CERTS Resilient communities would have CERT (Community Emergency Response Teams) coverage in every neighborhood and every business area and every educational institution. Each of those CERTs will need to have greatly expanded medical training. If we have an avian flu pandemic there will be virtually no medical facilities with capacity to treat the vast majority of the victims and we will also have nowhere to send the non-flu trauma and other emergency cases. Our only hope is to build resilience in each neighborhood and family. CERTs will need to be trained to perform triage, provide extended and extensive primary medical care and to perform a mortuary function. This will be a very challenging effort as it will be pushing the envelope to get non-medical professionals prepared and willing to undertake these difficult triage, treatment and mortuary functions.

12. Develop home care plans. We need to build capacity at the family level to diagnose and treat many of the flu patients for whom there will be no available capacity in the totally overwhelmed hospital facilities. And we need to develop and to institute neighborhood and family measures that will impede the spread of the epidemic. Individual families will need to be trained to take care of most of their emergency needs without reliance on the normal fire, police and public works services. To perform these expanded roles we will need to have pre-positioned emergency supplies in every neighborhood and each family will need to create its own multi-week supply of emergency food, water and supplies.

The best practical guide for home treatment of the flu has been written by an Atlanta, Georgia physician, Grattan Woodson, who states in his preface

“It is certain that we will have another influenza pandemic, and probably soon. What is not known is whether the pandemic will be of the major variety resembling the 1918 flu, or a minor one more like the 1957 flu pandemic. My advice is to prepare for the worst and hope for the best.”

Woodson is also refreshingly honest:

“Are these the right treatments for this symptom in every case? Of course not! I am providing you with my best guess of how to manage the average very sick flu patient, but not every very sick flu patient. I recognize that for some like those with Adult Respiratory Distress Syndrome (ADRS) or congestive heart failure for instance, these suggestions will not be helpful and would be considered harmful under usual circumstances. You will not be able to tell when you are dealing with one of these rare patients. So, what should you do? For most patients, following the advice will do a lot of good and makes the most sense under these unique circumstances. All you can do is the best you can do. So do that with a satisfied mind. You can’t save every patient. Don’t let any tragic loss prevent you from keeping faith in your ability to help most patients with the techniques found here. You are their only hope.”

This is the kind of communication that the public desperately needs.

13. Leadership for pandemic planning in all non-governmental sectors

Today I am pleased to announce the formation of the Mid-Peninsula Citizens Preparedness Committee.

This Citizen’s Committee will involve all of the non governmental institutions in our community, to find ways to educate them about the challenges of a potential pandemic and, most important, to help them plan for a community wide response in the event a such a pandemic occurs.

If successful, this effort will provide both a basis for all risk disaster planning for the involved communities and a model for other communities to undertake both pandemic and all risk disaster planning. This was unintentionally omitted in my presentation

14. Dramatically more horizontal planning

15. Develop ethical policy on responsibility for caring for quarantined people

16. Create a close partnership with elected officials before the crisis. Most political leaders are uninformed and uninvolved – convenient for now but will be fatal when the crisis arrives.

17. Use simulations and exercises with full participation of elected leaders and non-governmental sectors to build trust an understanding

18. Use each annual flu season for practice and evaluation Practice doesn’t make Perfect”; “Perfect Practice makes Perfect”.

Mobilize the collective health conscience

Put the Public back into Public Health by informing, leading and inspiring ALL citizens

Build Resilient Communities from the ground up

Resource:

http://www.fluwikie.com/pmwiki.php?n=About.About

Melanie – at 13:02

Thanks, Peter. Sorry I couldn’t join you for the East Bay/Peninsula Summit this week.

DemFromCTat 13:19

Thank you, Peter!

NauticalManat 13:44

Excellent Peter, but I am not optimistic that what needs to be done will be, given the lack of funds, the lack of transparency, and the absence of common sense in D.C. and other places. I will say the awareness level is much higher than say a few months back.

Certainly agree with you about Dr. Woodson’s guide, have given it to many, recommended it to all. To me it is the single best document, simple and direct, all that most folks will need. (Well, that and spending some time on Fluwikie of course!)

Very well thought out. Hope the powers that be will read this and more importantly, take some action. While I see some glimmers of hope, it is an awful dark empty place we are trying to illuminate!

BroncoBillat 20:18

Bump

14 June 2006

Christian Rivers – at 21:46

Excellent post. Can we conduct a virtual pandemic exercise? We could begin with the 18 points listed above or maybe there is an exercise designed for drilling on the web. We could even act out some of the interventions and report back. I will start with items 7 and 3. [] Item 7 argues for the public health community to develop a consistent message based on truth. <> The truth is there is Uncertainty about the truth. Public pressure to generate a clear answer may tempt officials to present a premature answer. Ivan Walks MD of Washington DC tells of the story when he went to the main post office (?brentwood) to tell the workers there was no risk to postal workers from anthrax. In the next few days he had to order over 100 people including himself on Cipro prophylaxis due to the exposure in the facility at that press conference. The truth is there is uncertainty but we are working on a finite set of hypotheses. Let’s ty this message of “truth is there is uncertainty” with friends, people we meet and see how it works.

[] Special needs populations <> I work in a forensic mental health facility. We are essentially a closed society that is dependent on the outside world for workers and supplies. If I do not have a minimum set of workers, I cannot allow the few remaining workers to walk around inside the secure area with over 200 violent men. No one wants my faciity to open the doors and release the men to the streets. I cannot lock them in and leave, so I must ensure that I keep at least 60% of my usual workforce on all shifts. The danger for spread of pandemic flu comes from our contact with the outside world. Do I stop admissions? Then the jails back up? Employees pose a risk by bringing in infection from the community. So we are considering setting up a temporary housing on near by grounds so that employees could work in 30 day shifts with a 2–4 day quarantive prior to going inside. New admissions would go to a quarantine admissions building for a few days so we could try to rule out infection. If they develop illness they would go to our “hot” building with other infected patients. We would disinfect the receiving facility before resuming admissions.

Similar issues apply to prisons (over 1 million people in prison in America). Jails are even more complex due to rapid turnover (another million people in jails).

{} I invite comments on these two narrow areas or ask others to address some of the remaining items in the post. CR

DemFromCTat 22:53

Prisons remain a very tough issue. I wish I had answers there.

Peter also, btw, had a good post here.

15 June 2006

Will – at 07:14

bump

anonymous – at 09:33

too long. I’m not reading such long posts without abstract or summary. No idea, what a “resilient” community is.

anon_22 – at 10:58

anon,

Some people might find it easier if they copy and paste into a different program such as Word, then you can separate that into sections.

Resilient = having the ability to recover readily, as from misfortune.

http://dictionary.reference.com/

anonymous – at 11:23

recover from a pandemic ? But I thought, that weren’t an “ability” rather than a matter of preparation.

16 June 2006

Christian Rivers – at 23:31

Preparation is one component that strengthens resiliency. Many other factors are important also some of which were noted above (optimism, spirituality, integrity, social connectedness, cognitive reframing, acceptance of reality). In fact, I frequently argue that the true value of planning and preparation is not the actual plan (since the course of events usually takes unexpected turns) but the skills and social networks developed in the planning process.

DemFromCTat 23:48

Indeed, it’s planning (not The Plan) that is beneficial. And communities don’t prep the way individuals do.

Birdie Kate – at 23:53

excellent article Peter, I borrowed it to inform a few people. Thank you very much!

17 June 2006

MaMaat 01:13

bump

Hurricane Alley RN – at 02:16

bump

Hurricane Alley RN – at 02:38

bump

20 June 2006

MaMa- Still open – at 00:51

04 September 2006

Closed - BB – at 00:38

Closed to maintain Forum speed.

DemFromCT11 December 2006, 16:11

peter Carpenter’s atest comments here:

http://www.newfluwiki2.com/showComment.do?commentId=8380

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