Building Community Resiliency: A Key Step in Preparedness

To identify one of our greatest challenges in pandemic preparedness, we don’t have to delve deeply into history. Let’s go back two years to Hurricane Katrina.

As the storm approached the Gulf Coast, millions of people prepared as well as they could or knew how. Many evacuated. Some hunkered down to shelter in place. Others did little to prepare and hoped to ride it out. But as we learned, those most greatly affected by this catastrophe were the ones least able to sustain it — those who were low-income, young, elderly and chronically ill among others.

This very recent tragedy laid bare one of our greatest challenges in preparing for the next health emergency, whether it’s a hurricane or flu pandemic. How do we — health, business, faith and community leaders — best help the most vulnerable and those living in underserved communities prepare? We work to build resilient communities.

In a disaster, a resilient community should be able to mitigate the risks to individuals, families and the community as a whole from preventable, serious health threats. Its goal should be to go from chaos to controlled disorder and then to recovery. But how do we start to build resilient communities?

1. We first begin with planning. We must engage the entire community in local emergency and pandemic planning, including food banks and soup kitchens and the clients they serve, religious congregations and schools. The goal should be to identify and proactively reach out to all community stakeholders. Some activities include developing individual and family plans, business continuity plans and school emergency plans and assessing the surge capacity of the health system.
2. We need to educate the community and build awareness within the community of the need and steps to prepare. We should build awareness of the plan, engage the community in drills and reach out to the local media. These activities may require developing materials in multiple languages and establishing culturally appropriate mechanisms for distribution.
3. We need to work to empower the individual or family to prepare. This may include helping individuals develop a family plan or learn first aid. Many living in underserved communities don’t have health insurance, don’t have a medical “home” or primary care physician and don’t have health records or a personal health history. Immunizations are often not up-to-date. Many are not health literate. We need to help them resolve these problems.
4. We need to strengthen the community’s capacity to respond by strengthening first responders such as
   EMS and police and fire departments, and the capacity of the public health system to provide disease identification and tracking services and to deliver potable water, food and basic sanitation among other services.
5. We also need to support communities’ capacity to recover. This may require addressing housing needs, conducting environmental assessments and mitigation, rebuilding the health infrastructure and ensuring the delivery of mental health services.

While catastrophic, Hurricane Katrina was a relatively localized event. A flu pandemic will likely be far more widespread and pose greater challenges to vulnerable populations and to the government’s response. By building resilient communities as a part of our preparedness approach, we can better minimize the impact pandemic flu will have on all of us.

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The Road to Preparedness Starts with Awareness

We have a problem. Pandemic flu is not on the radar for most people in this country. It’s not even in the solar system.

I am embarrassed to admit this in the face of all I’ve been learning this week, but until I was invited to participate in this blog, I had never given much thought to pandemic flu. I consider myself pretty knowledgeable about health issues, I’m a member of my local Community Emergency Response Team, I have all my earthquake supplies ready to go, I get a flu shot every year. But I was almost entirely unaware of the likelihood of a flu pandemic, let alone how I should protect my family. If someone like me, with a background in public health no less, is so unaware, we have a lot of work to do.

We can’t realistically expect to jump from a state of almost total ignorance to community readiness in a short period of time. We need to be in it for the long haul. A useful way of thinking about the behavior change process is with the Stages of Change theory, or Transtheoretical Model, that we often use quite effectively in social marketing. This model says that behavior change is not a one-step process, in which first someone is not doing a behavior and then they are. Behavior change is a continuum, in which people move from stage to stage, or they may stop at any point without actually making the change. Knowing what stage they are in helps us determine the correct approaches to use to help them move to the next point.

The first stage is called precontemplation. People at this point are not aware that there is a problem or that they may be at risk, and do not intend to make any changes in their behavior. On the issue of pandemic flu, most people would fall into this group. To move them to the next stage, we need to make them aware of the issue. Greg Dworkin’s excellent post lays out the basics that people need to know before they will be willing to even consider taking action.

The next stage is contemplation, where people now know about the problem and are considering whether they want to do something about it. For this group, show the benefits they will receive from taking action, and demonstrate that people like them, as well as others they look up to, have already made this change. So, we might emphasize the benefits of protecting their family and community, staying healthy and alive, the security of feeling prepared, avoiding the inevitable rush to purchase supplies — whatever works with the different groups we need to reach. We could also share testimonials from real people who have already prepared for a flu pandemic and use spokespeople that each audience sees as credible on this issue.

Once someone decides they want to take the target action, they move into the preparation stage. They start to think about what it will take to do it, whether they are able to do it, and they start to bump up against barriers that will keep them from moving forward. At this point, people need the barriers removed — make it easy for them to do what you are asking and take away all the reasons why they will tell themselves they can’t do it. Someone in the preparation stage might acquire a list of items they need to buy, intending to get them, but run into problems like not knowing where to go to purchase face masks or not having the storage space in their home for so much food and water. We could offer things like prepackaged supply kits that obviate the need to go from store to store looking for the items on the list, tips for how to build up an emergency food supply and store it unobtrusively, fill-in-the-blank preparedness plans that businesses can customize to their own situations, and other effort-reducing approaches.

Once they are prepared and barriers are removed, then people can take action. For a one-time behavior, the action step is the end of the process. But for an action that has to be done more than once over a period of time, they will move into the maintenance stage, which may not have an end-point. Once people build up their food and medication supplies, they will eventually need to replace them with fresh items, and as they move through various life stages their needs may change as well. They will require positive feedback and ongoing motivational messaging to avoid becoming burned out on the process.

Our challenge, then, is to help people move through all of these stages. The first priority, based on where the majority of the population lies, is in raising awareness of the issue — not in getting individuals to take action (yet). We need to use all methods available to shout the message from the mountaintops so that people are as knowledgeable about pandemic flu as they are about the lives of Paris Hilton and Britney Spears. We can work with the news media, professional organizations, schools, entertainment TV (like E.R. or 24), TV and radio talk shows, local emergency response organizations, physicians, boy scout troops, online social networks, blogs, and other means of disseminating information. HHS should consider using the Surgeon General as a prominent spokesperson to underscore the seriousness of this public health issue, as C. Everett Koop did with his brochure on AIDS that was sent to every American household in 1988.

The awareness communications should include a website or phone number, which will then offer the types of messaging and social reinforcement that will bring people to the next step. Different types of approaches can be devised for people in each behavior change stage, as well as for different audiences. Leaders in each sector will need to play an important role in getting the word about about the existence of the threat of pandemic flu to their constituents, and HHS can help to facilitate that. The volume of communications to create the necessary level of awareness will not be cheap.

So far, there have been many great ideas coming out of this blog as to how to get people to take action. But let’s not get ahead of ourselves. The focus right now needs to be on getting the words “pandemic flu” onto the tips of hundreds of millions of tongues.

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Leading to Better Preparedness

Being prepared is an ongoing activity - one that is never complete. As leaders and interested citizens, we each have an obligation to continue to preach the preparedness gospel. I, along with the American Nurses Association, am dedicated to providing leadership in promoting preparedness and response. Not only for pandemic influenza, but for all types of disasters that occur in our community and nation.

From my perspective, the challenges that we face as leaders is to keep the momentum! We all live very busy lives, our finances may be stretched, and our motivation to continue to prepare may be reflexive to the event of the day. Developing strategies that will help maintain consistent preparation ~strategies that promote preparation out of vigilence and not fear ~ should be the focus. For example, providing a planning list that includes small, “bite-size” actions that are attached to a timeline will help families to see how they can work toward a higher level of preparedness and then include “bite-size” actions that can assist in maintaining preparedness. I realize that there are many preparedness planning guides that already exist. Let us take those guides and break them down into small priority actions to be accomplished within a reasonable timeframe.

As professionals who will be called on to respond, registered nurses and other health care providers have to be prepared in a variety of ways. ANA has been strongly advocating that registered nurses develop both a personal and a professional preparedness plan. Information on creating such plans can be found at www.nursingworld.org….

Being prepared is not a one-time activity, but a life-long process. As leaders, we need to demonstrate a commitment to preparedness and response.

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Protecting Those Who Serve

Many people have wondered what they could possibly do during a pandemic to help. After all, most people are not trained to be medics, or cops, or utility workers. Is there a place for them, too? Can they really contribute, and are there ways to do so without endangering their own safety?

There will, of course, be a need for volunteers. And we should all be thinking about setting up, or maintaining a neighborhood watch. We need to check on our neighbors, particularly those who are elderly, infirmed, or who live alone. But there is something else we can all do, something that is relatively painless and safe.

We can adopt the families of essential workers.

In the normal course of events, we give little thought to those whose job it is to protect and serve our communities. They wear uniforms of fire departments, EMS outfits, police departments, utility companies, and hospitals from around the country. They go out every day and quietly do extraordinary things, rarely garnering attention unless something goes tragically wrong.

It’s not a glamorous job. The pay is often less than they could make in the private sector, the hours are long, and the tasks they perform are often difficult, and sometimes dangerous. It isn’t like on TV, though. Most of the time it’s just dirty, hard, mind numbing work.

Most of these men and women will need to work, even during a pandemic. Their communities expect it, and most of them will consider it their duty.

But most of these people have families. Spouses and kids, and parents. And they will have a terrible decision to make if a pandemic comes. How do they report for duty while leaving their families unprotected? For many, it is an agonizing conflict of interest.

It doesn’t matter if it’s a cop, a firefighter, an EMT, doctor, nurse, mortuary worker, utility worker, or anyone else who will be on the front lines. And no, they don’t all wear uniforms. Essential workers come from all sectors, and will include those citizens who volunteer to help during a pandemic.

We can help them. We owe them that.

While they are out working during a crisis, protecting us, they shouldn’t have to worry that no one is looking after their families. Those people who will stay home can be good neighbors and check on these families each day, make sure they have adequate supplies, and help them if they need it.

Single parents may need assistance with daycare. For lack of someone to watch their children, we could lose many badly needed nurses, or firefighters, or utility workers. During a crisis, these people should be able to depend on their neighbors.

Immediate neighbors can extend a `zone of protection’ to these families. Watch their homes, and knock on their door each day to check on them.

It doesn’t take a lot. Even a telephone call, a sympathetic ear when the stress of having a spouse or family member on duty gets to be a bit much, would be a service. Maybe a casserole handed over the fence, or a treat for their kids. There are a hundred ways to make life easier for them, and to relieve some of the burden off those who are out protecting us.

During a national crisis, we will be asking a lot of these people. It’s only right we try to give something back in return.

During a pandemic there is no kindness too small not to make a difference.

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Our Responsibility Is To Teach The Basics

I’m going to cheat a bit and use some of the wonderful material that’s been posted already, both by commenters and by blog posters. This is from a recent online interview of Nedra Weinreich:

Many of the people who are leaving comments are those who have been working on and thinking about this issue for a long time (professionals and private citizens), and their input is extremely valuable.

And in reading the input we can see a few important themes emerging from the conversation on the HHS blog.

• The information about pandemics does not seem to be disseminating as well as it needs to, at least up until now
• There is a role for government, using its authority, in disseminating information (and in legitimizing others to do so)
• Once legitimized, there is also a role and responsibility for community leaders and members to disseminate information, using whatever social and professional networks are available

Sister Patricia Talone wrote:

Education, information, and repetition will help the public to prepare for a pandemic. But, while facts are important, we need to change hearts. We need to remember that we are our brothers’ and sisters’ keepers, that we are responsible not just for ourselves and our families but for the common good. Until we move into a more communitarian mind-set we will not even be able to engage the notion of “public health.”

So, let’s do all of that. Since we are in the position to communicate, and it’s our responsibility to do so, what are the pandemic preparedness basics that people need to know? What are the possible outcomes that motivate us to work for the common good?

Much of what follows has been pointed out by our commenters. For many of us, the impetus for understanding the possibilities goes back to 1918. We know the Great Influenza killed upwards of 50 million people worldwide, and that pandemics have happened before (more here in The Need For Personal and Community Preparedness). We know that, while it’s unpredictable, some previous pandemics have occurred in multiple waves (Congressional Budget Office report), each with different effects on the population:

The pandemic would probably spread across geographic areas and vulnerable populations in waves. In any given geographic region, each wave could last for three to five months, and a second wave could appear anywhere from one to three months after the first disappears.

At any given time in the midst of a pandemic, a third or more of the workforce may be out (illness or caring for family members), and that statistic most assuredly includes health care workers, first responders, key parts of the Just In Time economy delivery system, and the utility infrastructure workforce.

We also know that children can spread illness throughout a community and when packed into schools, are easily infected and bring viruses home. It is for that reason that CDC suggests closing schools for up to three months in case of a severe (category 4 or 5 ) pandemic. That closure can’t take place at the last minute; flu can spread before one appears to be ill. So, to be effective, closure would have to be early and sustained in order to delay or reduce the impact of a pandemic on a community, and parents will insist upon it to protect their children. Taking into account the school closure, the Department of Homeland Security (April, 2007) states that

The population may be directed to remain in their homes under self-quarantine for up to 90 days per wave of the outbreak to support social distancing.” (page 7 of 37)

There’s quite a bit more in that DHS document, including

Since a community will continue to require public services, service organizations must take a pro-active stance and be prepared to recognize hazards associated with a potential outbreak and implement prevention and protection measures for their workforce as soon as a suspected outbreak occurs.

So, there’s a community factor, a workforce factor, a school factor and health care factor (adding in the over-burdening of the medical system with so many patients being ill). But we also know that vaccine will not be available for up to six months after a pandemic starts (production time, and not knowing which virus to use in advance), that there will be shortages of hospital beds, antivirals, and personnel (’staff’ and ’stuff’), requiring rationing at some level for at least some things.

Note that I have not mentioned H5N1 until now; if the pandemic were to occur with this particular virus, with its current 60% case fatality rate, and its propensity to affect young people, things would even be more grim (1918 was devastating with a CFR of 2.5%). The next influenza pandemic could be H5N1 or, the current H7N2 infection in Wales, or an H9 not yet on the horizon.

So, with that in mind, and with 90 days suggested by both DHS and CDC for severe pandemics, and with the severity, timing and viral type not predictable, what’s the community to do? As individuals, we have to take responsibility to start preparing now., As community leaders, we need to help HHS get that message out, in whatever ways we can. It is a shared responsibility, and not simply one for HHS to do alone (or for community leaders to do alone, for that matter).

And, as has been pointed out by commenters, that acceptance of responsibility has already happened. It is for all of the above reasons that the online community has discussed the need for stockpiling of food and water for up to three months (to match the 90 days cited by DHS, and the three months of school closure for severe pandemics suggested by CDC) and started the process of stockpiling food and water, and thinking through the implications of school closure, workplace disruption and voluntary canceling of social events, or in some cases, self-quarantine. It must be an individual, a family, a community responsibility to consider preparation, and to work out ways to help those vulnerable populations that cannot help themselves (Sister Talone’s point about the common good).

The Feds have a vital leadership role in all of this (well expressed by the commenters). And not everyone will prep, and not everyone that does so will prep for three months. But our responsibility, nonetheless, is to get the message out as best we can, with whatever tools are available to us, that there’s a recommendation for prepping and a reason to do so. We’d be shirking our responsibility if we did not at least try to teach the basics and having done so, communicate the need to prep.

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