Nancy VanDevanter DrPH* David Abramson PhD** Perri Leviss*** Joyce Moon Howard** Peggy Honore ****

1. The Changing Role of Public Health in Disaster ResponseWhat does it mean to be a public health first responder? Nancy VanDevanter DrPH* David Abramson PhD** Perri Leviss*** Joyce Moon Howard** Peggy Honore **** *New York University College of Nursing **Columbia University Mailman School of Public Health ***Consultant ****US Department of Health and Human Services

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

3. Acknowledgements • We would like to thank the leadership and staff of the Louisiana State Department of Health and Hospitals, the City of New Orleans Department of Health and the Mississippi State Department of Health for sharing their extraordinary experiences and insights. • The Robert Wood Johnson Foundation who funded the study.

4. How the study was conducted • A purposive sample of 50 key informants identified by leadership of the three participating health departments were invited to participate in the Katrina Oral History Project. • Individuals were identified on the basis of their disaster related responsibilities and included both organizational leaders and a smaller number of line staff.

5. How the study was conducted (cont) • The study was described to potential participants as an Oral History being conducted to better understand the role of public health in responding to disaster and a permanent record of these historical events that would be available in local universities for future study. • 44/50 key informants were interviewed.

6. How the study was conducted (cont) • In-depth qualitative interviews 1 ½- 2 hrs 9-13 months post disaster • Interviews audio taped and transcribed • Transcripts returned to interviewee for review and correction • Thematic analysis was conducted by the research team who developed a code book • Data was coded by 2 independent coders and entered into Atlas ti (kappa .85) for further analysis.

7. Oral History as Tool in Public Health Systems Research • Provide personal accounts and observations of historical events by participants • Allow researchers to document events and identify themes as they emerge naturally from the data • Provide opportunities to examine interfaces between organizational and environmental issues • Allow for historical data to be gathered for future research

8. Main Themes: 1 • Expectations for public health disaster preparedness have greatly increased since 9/11 with the increase in funding to provide leadership and workforce training.

9. “Public Health, is not used to being a response system, it’s used to being a Public Health System. Well, the incidents of 9/11 and Katrina and the threat of bio-terrorism and chemical terrorism and agro terrorism and all this has made, really, Public Health has had to shift gears and become a response agency. “

10. Main Themes: 2 • Public Health leadership has a responded to it’s new responsibilities in disaster response utilizing the following strategies: 1. Training public health staff in emergency response 2. Recruitment of emergency response personnel 3. Capacity building through strategic partnerships with community agencies

11. Challenges in implementing these strategies: PH employee training • Skills necessary to carry out PH functions differ significantly from emergency response skills. • Aging PH workforce may not be able to function as first responders due to family responsibilities and physical limitations. • Identification with traditional public health role may create barriers to adoption of new role.

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

13. “You know, our workforce is an aging workforce and I think the mindset of our older nurses was like-OK this is enough for me- and this was the final straw that broke the camel’s back. And that was…we’ll call it quits after this. And so we’ve had a lot of our older workforce to early retirement.”

14. Challenges in implementing these strategies: Hiring Emergency Responder Experts • Difficultly integrating into public health culture. • Lack of public health experience. • Risk of having parallel versus integrated workforce.

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

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

17. Challenges in implementing strategies: Building community capacity through partnership development • Public health workers were not historically trained in capacity building and community partnership development.

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

19. Findings from 9-11/Anthrax Oral History • “Historically there have been significant challenges to integrating the cultures of public health with that of the OEM. These result from the nature of the mission of each agency. Public health must always be focused on the larger population issues while emergency responders are concerned with the health and safety of the individual.”

20. Conclusions • There are inherent tensions to the integration of first responder and public health roles that should be acknowledged. • Traditional public health workers need clear guidelines and expectations for their emergency response roles that are consistent with their skills and training. • Emergency response staff need to recognize the public health environment and it’s primary mission. • Because the demands on public health in emergency response are likely to far exceed the resources available it is essential to build strategic community partnerships that can fill some of those gaps.