Health workers wear masks and protective gowns as they carry a man acting as a patient during an anti-avian flu drill at a hospital in Hong Kong. September 2006. Photo by Vincent Yu/Courtesy of The Associated Press.

Whether it involves education, law enforcement or public health, preparation for pandemic flu should be underway in every community. Speakers addressed tasks and topics that should be examined by reporters, who could use them to investigate how well their region’s planning is proceeding.

Betty Kirby, Assistant Professor, Department of Educational Administration and Community Leadership, Central Michigan University

Beyond teaching ‘Cough and Cover’: Getting schools ready for a pandemic.

Last May the U.S. Department of Education released its pandemic plan for K-12 schools. It was two pages in length and was meant to go along with the disaster plans that schools have. I was somewhat disappointed when I saw the RELATED WEB LINK
School District (K-12) Pandemic Influenza Planning Checklist
checklist with four areas for schools to take care of: planning and coordination, continuity of student learning and core operations, infection control policies, and communications planning. Schools were asked to check off whether they had completed these tasks already, or were in progress or, as I suspect in most cases, not started. What we should be thinking about and talking about is the interruption of school and what happens to children, parents and teachers. We should be talking to people who experienced Hurricane Katrina to find out what that was like for children who were not in school for a long period of time and who switched to different schools and whose families were reorganized. We should be talking, too, about maybe preparing our students with some conflict resolution curriculum, because it seems to me that they may very well be dealing with those types of issues in their home, and that might be more valuable than geometry.

In Oakland County, Michigan, one of my state’s more densely populated counties, a two-day symposium was held to examine the four areas of this checklist with team teaching done by health and educational leaders. They created a 90-page booklet called “Pandemic Action Kit for Schools.” I was very RELATED WEB LINK
Pandemic Action Kit for Schools (pdf)
impressed with this resource, and it can serve as a model program. But one has to remember this is a very wealthy county with the financial and human capital to pull this off. It is definitely the exception and not the rule when we are talking about what is attainable for the majority of health departments and schools. And in Michigan alone there are 552 school districts with more than 4,000 schools and almost two million students who will be affected.

When I talked with an elementary principal I know and asked what his school was doing, he told me not much, and he was very happy to tell me why. He said there are so many immediate needs that have to be attended to, and
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dealing with a possible pandemic is way off on the horizon. The state of Michigan, for example, mandated lockdown drills in our schools, so he was preparing for the first one, which has taken a lot of time. With all of the mandates of No Child Left Behind and other school initiatives, he told me there hasn’t been any breathing room for the schools to take on this pandemic planning. As he put it, if the federal government really thought that this was important, maybe they would say, let’s pause. Let’s take a break and let the schools get their house in order and take the time to establish plans and discuss with their staff what they need to have happen. But that’s not happening yet.

How many children use the federal school breakfast program? Where do these poor children live? They live everywhere. They live in our rural areas. They live in our urban areas. What percent of hungry Americans are children? Take a look: 36.4 percent are children. So the schools have an important place in terms of providing nutrition. And when we get down to the heart of the matter, when we’re talking about preparation for pandemic flu, it’s the children. We need to take a look at who is there for them 180 days plus of the year. Kids know that they can go to their teachers. They trust them, and if teachers aren’t prepared, they’re not going to be able to help. Schools should be serving on the frontline. They’re one of the best ways to get information out to the community. They can help us maintain public confidence.

For many students, school is the family. It provides safety, security and stability. For some students, home is a dangerous and a volatile place, and we’re worried about kids who are going to have to go home for that amount of time. Finally, I think it is insulting to educators that we have not put them in a more prominent role in preparing for this. Teachers have the potential to serve as the models for resiliency and the harboring of hope for our children. In the beginning they will be there to quell their fears, and in the end they will be there to pick up the pieces.

A man gets a shot during the mass vaccination clinic exercise in Fairbanks, Alaska. October 2006. Photo by Christine Lynch, Department of Health & Social Services/Courtesy of The Associated Press.

John Thompson, Deputy Executive Director, National Sheriffs’ Association

Enforcing quarantine, transporting the ill, grounding travelers: Training police to provide community disease control.

We have to think and get prepared locally. Let me give you a scenario. A community is hit with pandemic flu and loses 30 to 50 percent of its law enforcement officers. Don’t expect the next community to send anybody, because the pandemic doesn’t know towns and borders. Do you think the flu is going to stop at the river? That loss of officers is already going to cripple us, but guess what? We also have a 30 to 50 to maybe even 80 to 100 percent increase in demand. Why? Because a Channel 9 News reporter is down the street trying to cover a quarantine situation, and everybody jumps him and he calls the police. Or we need to quarantine 15 or 20 people. Or we need to transport people. The pandemic is going to cause more response for the police.

Now, what about our bad boys on the street, the gangs? Don’t you think they’re going to get empowered? What happens when you have a catastrophe? Look at Katrina, multiply it 100 times, and then take away half of the resources that we dumped into New Orleans, and that’s what you’re going to have. The gangs are going to come out. They’re going to feel powerful because there is no one to stop them. People do what they have to do to feed their families, and that’s the bottom line, and I don’t think there’s any limit to that. I really don’t. So we have to think of those things.

So the normal person, not the bad guy, in a time of crisis is going to go into survival mode, and that creates a problem. Think about it: What would cause you to go into survival mode? And if you went into survival mode, what would you do? Sit in your room and die, or would you go out and survive? Most of us would go out and survive. That’s what human nature is about. So you can see what the problems are going to be. I’ve been to several pandemic symposiums, and I’ve heard about what the police are going to do and what public safety officials are going to do. And it’s always about where we are going to stockpile this or where we are getting medicine and things like that. Well, the problem is not going to really be that — two or three weeks and we’re going to recover and be good to go. We’re not going to recover if the community is going out of control, because when you get well you’re not going to be able to go outside. We need to think of those things.

Let me tell you a bit about what the National Sheriffs’ Association has been doing. We have several training courses we’ve been doing for three years. One is jail evacuation. What are we going to do with 2,000 prisoners in a prison if pandemic flu breaks out? Well, if we can duct tape the jail up so it can’t get in, we’re all right. But if it gets in, what do you think that sheriff is going to do with 2,000 prisoners? The news media are going to have a field day because if the sheriff lets those prisoners out, he’s not getting reelected after they rape, rob and pillage. If the sheriff leaves them there to die, do you think he’s going to get reelected? Is he going to move 2,000 prisoners out of the jail in 30 minutes? Absolutely not, but when we teach this course we say to sheriffs that they must have a plan, even if your plan is for not being able to do anything. You’ve got to have some type of plan. You’ve got to think about it. Don’t wait until it happens and then start thinking about it, and that’s what we need to do now.

Journalists have the power to make people think about such things. Every time you write a story or put something on TV, that is very powerful. It does affect us, and we’re guided by it. So use it. Bridge those gaps — how many people here have a one-on-one relationship with your local law enforcement executive? When I was a chief of police for 15 years I was on TV more than any other police chief and even the sheriff. They said to me, “Why do you do it?,” and I told them because I trust the news media and I talk to them. We converse and work together. The other police chiefs all wanted the media in the town when the good stuff happened. So bridge those gaps. It’s not just law enforcement that has to — you have to put your hand out. If we all work together, we can overcome this.

A worker at a Washington State Department of Health laboratory in Seattle holds a box of DNA strands. They were sent to the lab by the Centers for Disease Control and Prevention. They are used to help highlight the presence of the H5N1 bird flu strain in the flu virus to find out if it is in general samples of common flu viruses that are subjected to ongoing testing at the lab. So far, no cases of the virus have been found in North America. February 2006. Photo by Ted S. Warren/Courtesy of The Associated Press.

Michael Loehr, Preparedness Section Manager, Public Health, Seattle & King County (Washington State)

Preparing for the next public health catastrophe: Convincing the public that community containment is a good thing.

Public health has incredible responsibilities. We are depended upon now by the cops and firefighters who didn’t know our names September 10, 2001. They wouldn’t allow us in their buildings. Now I promise you they don’t have a meeting or an exercise without us in the room. They are absolutely well aware of what our responsibilities are. Whether we can produce is another story. Our ability to succeed is highly dependent on our ability to gain and maintain the trust of the public, and nothing shows that more than a pandemic. How many solutions do we have to offer? And how do we keep that public trust and confidence during such an event? This is where the crux of our pandemic preparedness efforts ought to be.

Though we know that we need to incorporate public health into preparedness plans, we need to spin that around to say that we need to incorporate preparedness into public health practice, and I promise you at the local level in this country this is not the case. Grant funding for such programs has been in place since 2002, so for about four years now millions of dollars have come to states and have been passed down to local governments to help get us prepared for anthrax and bioterrorism, and then this evolved into all hazards and pandemic flu. If you talk to local health departments and ask them how important do they think preparedness is, they’ll start talking about money first. So let’s put the money aside. How important do you think preparedness is relative to what your responsibilities are? For most of them, it’s not going to be at the top. For some of them, it’s not even going to be on the list. They will talk about dealing with chronic diseases and maternal and child health. They go back to environmental health. They go back to core public health. That’s what they got in the business for. But preparedness is a critical issue. In my opinion, for local public health organizations, preparedness has to be incorporated as part of what we’re doing. It cannot be an add-on program, and I am not talking about the federal government totally funding everything. It has to be an ethic of change at the local level. [A Web site has been created to provide public access to information on pandemic flu preparedness for Seattle & King County, a planning process that has been underway for two years, with major initiatives still underway.]

I see three key issues or themes that we face in getting prepared:

  1. We have to get ready very, very quickly. Our responders who rely on us — the police, fire, public works, and elected leaders — expect us to be prepared. Our partners rely on us to be ready as the emerging threats keep coming at us.
  2. Public health needs to become prepared across a very broad spectrum. Most of the homeland security money that comes in, at least to our state, certainly to our county, goes to equipment for first responders. Firefighters and police buying this, buying that. I’m not saying it’s the wrong way to spend money, but that is absolutely not going to help health departments. Equipment doesn’t necessarily prepare us. We have to be ready to do things like implement disease surveillance programs in an expanded way, arrange for isolation and quarantine, dispense medicine — antibiotics or antivirals to a large number of people or give vaccines in a very short period of time. Risk communications and public education are two different things, both important. Massive patient care. We are part of the larger health care system from EMS, to clinicians, to hospitals, to the morgue, and everything in between, so how do we assist that when there is a huge surge in demand? Business continuity. Environmental health response. Lab services. Mass vitality response. You can’t be good at one or two. You have to be good at all of them. How do we attack that broad front? Ours is a department of 2,000 people. Most local health departments have probably fewer than 50 people. How do you even begin? So that’s a huge challenge.
  3. Effectiveness of public health preparedness is tied to the quality and extent of our partnerships on key planning issues. The most important thing is the planning and coordination. It’s the meetings and discussions and the understanding that this is how it’s really going to work. The key is the consistent partnerships that we maintain.

Pandemic Flu Preparedness in King County, WA
Let me quickly go through some of the specific preparedness issues we’ve been working on: social distancing; closing schools and daycare centers, and closing libraries, where people drop their kids off when there’s a snowstorm. Libraries have become the biggest daycare centers in town, but you’ve got to close libraries as well. The difficulty is that in doing this planning, no standards are available. I’m not blaming anybody, but no standards exist for knowing which measures to implement, when to implement them, and what the thresholds are. How do you coordinate it? It’s a huge challenge at the local level to figure out. How do we actually do something that’s never been done before? And the school lunch program — if we are closing schools Monday morning, the first question that needs to be asked and answered is how the children are being fed. While disasters are local, all preparedness is not necessarily local. At the local level, I don’t have control over the school lunch program. The federal government does. I can only hope the feds get that program worked out, because my whole plan goes down the toilet if they don’t.

Then there is health care sustainability. The way we see it in Seattle public health is part of the larger health care system. It’s already a fractured, competitive system day-to-day, a system that is overly stressed. During an emergency, things have to be done differently; we have to be able to operate as a single, unified system under central authority. This is totally revolutionary in the health care system, but it’s something that in Seattle we’re working towards, and it’s necessary. Centralized decisions need to be made about triaging and rationing care, more than it’s rationed on a daily basis. If people call 911, they are not necessarily going to get a paramedic. They might get a nurse’s line where you are taught how to care for a sick child at home because there are no beds available in the hospital.

Keeping business going is a critical issue for us. No pandemic flu plan can be functional unless our department has a business continuity plan in place so we can keep our most critical functions operating. A year ago, we had to look at the definition of business continuity, which isn’t something that public health departments in this country have likely had to do before.

Finally, public education — I’m almost asking for your advice on this. How do we inform and educate the public and at the same time maintain their confidence about closing schools for three months? If we close schools for seven days in our state, teachers no longer get paid. So it’s one thing compounds another, but we still need to do it. We still need to say we’ve got nothing good to offer you, but we need you to trust us and to work with us on this. How do we educate and inform the public that they are not going to get a paramedic? They’re just not coming. During a pandemic, when people go into grocery stores and because they have no money they take food from the store, that’s not a call that warrants the cops’ response. They’re going if someone has a gun. Those places are where the cops are going. I can assure you. So how do we again maintain the public’s confidence? And finally, how do we educate folks to rely on themselves for their health care? It’s just not done today.

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