Welcome, everyone. My name is Anita Balan. I'm with the American College of Preventive Medicine, where I'm the Director of Residency Engagement and Development. It gives me great pleasure in welcoming you to the second in a series of webinars that we are offering as part of the National Education Curriculum on Public Health Emergency Preparedness and Response for Preventive Medicine Residents. Today, we once again have the privilege of having Dr. Daniel Barnett with us, who will be speaking to you on the second topic, which he will introduce shortly. I'm going to let Dr. Barnett introduce himself. He has, of course, a very illustrious resume and incredible profile in public health emergency preparedness. Before that, I just want to cover briefly housekeeping. Please feel free to post questions in the Q&A or even in the chat, and we will be answering your questions towards the end. During the Q&A session, I will post a link to the survey to help us evaluate this webinar and to seek your feedback, so please complete the evaluation survey. We're very happy to announce that ACPM Pulse has launched. It is an online community forum where members of our college can continue discussing this critical topic and connect with one another. And then, of course, this meeting will be recorded, and ACPM will send you instructions to access the recording to share with all residents. With that, without further ado, Dr. Barnett, the floor is yours. Thank you so much, Anita, and welcome, everyone. It's a pleasure and an honor to deliver the second in a series of preparedness-related webinars. This is a very timely moment on many levels for the topic that we will be discussing today because, as I'm sure you're aware, and hopefully those of you who are in Florida, if you are in Florida, are safe, but we are dealing with what looks to be a major hurricane, Hurricane Helene in Florida, and we see more frequent and severe weather-related disasters all the time, undoubtedly due to climate change-related effects. And so we're going to talk about sort of the broad picture, but also be very applied in our discussion of health readiness for emergencies and disasters. I'll be providing conceptual perspectives, but also very practical operational ones. So next slide, please. And I have no disclosures for this presentation. So this is an abbreviated list of 21st century preparedness challenges. Unfortunately, this list keeps growing. But in terms of broad categories, as I mentioned a moment ago, we are seeing more frequent and severe weather-related disasters, and that doesn't even include geophysical, seismic-related events, earthquakes. Of course, when we think about pandemics, COVID-19 comes immediately to mind, but that unfortunately is almost certainly not going to be the last pandemic we will see in our lifetimes. There's concern, as you may have been seeing, regarding highly pathogenic avian influenza, and that, if it became easily person-to-person transmissible, could generate the next pandemic. Of course, we don't necessarily have a pandemic in the case, for example, of MPOCS, but it is a public health emergency of international concern as designated by World Health Organization. So we are seeing, just in that even second bullet, newly emerging and re-emerging infectious diseases. You may recall Zika from 2016. Zika actually was named after a town in Uganda. It got its name from 1947. Again, it's hard to point any one disease, for example, toward climate change, but I've communicated in depth with colleagues who are climate change experts who have conveyed that viruses like different temperatures, and we are likely to see that kind of pattern continuing. With regard to technological disasters, we can think of many, many examples, sadly. The Deepwater Horizon comes to mind as one of many. Very importantly, for all of you in your residency programs and future careers, we have to think about the mental health sequelae, both acute and longer-term, from disasters, everything from acute presentations of things ranging from anxiety responses to PTSD in the longer term. Terrorism, so intentional events. And as I mentioned earlier, last but not least, climate change. And this list is going to, unfortunately, grow even within the various categories, unfortunately, based on current trends. So this is a very timely, I think, topic for us to be discussing today. Next slide. So here are the learning objectives. I'm going to talk about something called the disaster life cycle. That's something that I think everyone needs to be familiar with. As I often, I do a training series I've been doing for the Johns Hopkins General Preventive Medicine Residency. Just by way of background, I'm a preventive medicine trained physician. I'm a professor at Johns Hopkins Bloomberg School of Public Health and Department of Environmental Health and Engineering. And I lead a preparedness training module for the general preventive medicine residents at Johns Hopkins. I've been doing that for, gosh, over 15 years now. And one of the things that we focus on is this concept of the disaster life cycle, which we will talk about. That's very important as a fundamental concept for framing these considerations. Next, we're going to talk about a list of what I think are key transformative events that have shaped where public health preparedness is since 2001. This is not going to be an exhaustive list, but I will include some of the highlights. So we'd like for you to be able to name at least three of them. Next, we'll be asking you to be able to describe the relevance of public health emergency preparedness system. There's actually a system, an adult, or a formal institute in the National Academy of Sciences, that depicts various elements and actors within response to a public health emergency or disaster. Next, we'll want for you to be able to describe the relevance of disaster preparedness exercises and evaluation, things like what we call tabletop exercises. I'll describe those later. And how they work for health-ready response. Last but not least, a very important area that I've been doing research on explicitly for since at least 2005 is the issue of willingness, not ability, but willingness of healthcare workers to come to work in high-dread environments. And this is a critical issue when we think about healthcare system surge capacity, because we have seen examples, and the research supports this, where while most people in the healthcare field will come to work in high-dread environments, there's a sizable proportion, depending on the scenario type, that research points to who will be unwilling to come to work because of a variety of factors relating to concerns about their own and their family's health and safety. So we'll talk about that as well. Next slide. So this is the disaster life cycle. I don't really like the term. I didn't come up with it. It sounds a bit like an oxymoron, disaster life cycle. But what I'd like to highlight here, at sort of 12 o'clock, you can see prevention and mitigation. And I don't know, Anita or Desi, if you might be able to, thank you so much for the cursor. Yep. So ideally, we want to prevent a disaster from occurring. Preparedness is what's in that red rectangle. Now preparedness, this is a bit of a confusing term, because we often use the word preparedness almost euphemistically to refer to this whole life cycle. But preparedness, in a formal sense, is a pre-event, mini-continuous quality improvement cycle of planning, training, exercising, and evaluating how we did in drills and exercises so we can optimize our readiness for a disaster. At 6 o'clock, you'll see response. And I say this not facetiously. When you see CNN covering, or Anderson Cooper specifically, or other TV anchors covering a disaster, as you will see in the next few days with Hurricane Helene, you are looking at the response phase of the disaster life cycle. That's what we mean by the acute phase of it. We're talking minutes to hours to days to even weeks. But at the 9 o'clock part of the dial, you'll see recovery. And unfortunately, and we see this time and again, six months, nine months, even sooner after a disaster like what we're encountering now in the Panhandle and other regional adjacent communities in Florida, six months, maybe even sooner than that, we will not be hearing the same or receiving the same kind of attention in media coverage. So this, though, overlaps with the recovery phase. And unfortunately, that is some of the heaviest lifting that public health and occupational health leaders have to do in the longer term aftermath of disasters. So for example, there are parts of New Orleans that are still in the recovery phase from Hurricane Katrina, which was in 2005. So not just physical infrastructure, but psychological damage and harm. So when we think about, for example, Zika, we don't hear much about Zika. But families in, for example, South America, whose children were born with devastating neurological deficits resulting from Zika, that is a lifetime psychological harm for families and their communities. So this is the sort of often neglected but critically important part of the disaster life cycle. Next slide, please. So there have been a number of events. And I'm not going to go into depth in the interest of time. But I do want to highlight that since the, even more so than the 9-11 attacks in 2001, the anthrax mailings that ensued. And you may recall there were anthrax mailings. And these are some, there's a photo of one of the letters. That resulted in a real paradigm shift of the role of public health in response to disasters and public health emergencies. So really, that was one of the sort of trigger points that led to an infusion of funding from the federal government to state public health departments that then went to local health departments. We're talking a billion dollars. And since the focus on anthrax from that time, we have evolved in public health into what we call the all hazards model, where the approaches that we use and things like incident command system, which we talked about last time in our last session, those are all hazards models. We can use incident command structure and the National Incident Management System, for example, to deal with anything ranging from a naturally occurring event to an intentional event. But we, for example, just anecdotally, my first job after completing my residency in general preventive medicine was at what was called Baltimore City Health Department Office of Terrorism Preparedness and Response. The new name for that is, as of several years ago, and aptly so, is the Baltimore City Health Department Office of Public Health Preparedness and Response to reflect that it's not just bioterrorism that's the focus here. And by the way, the slide on the right or the photo on the right is a photo of SARS in Toronto, which was a coronavirus, as you'll recall. And although that was not a pandemic, it was an event that had major impact. So next slide. So let me just briefly summarize kind of the evolution. So before September 2001, if you were to call a health department after hours, chances are you would get a, no one is available to answer, and please call us on the next business day. But subsequent to the anthrax attacks and other disasters that have occurred since, it's really, there's been a paradigm shift for public health agencies where it really has become a 24-7 model. Infectious disease crises do not observe business hours. Hurricanes do not observe business hours. And so we have to think in a way that more, quote unquote, traditional response agencies have for as long as one can think about. Fire and police and EMS have always been a 24-7 operation. Well, so too now is public health. And that has resulted in organizational cultural change in public health. And part of that has necessitated greater familiarity, training for public health agencies in things like the incident command system, which we talked about last time. And before September 2001, there really was relatively little collaboration and coordination between health departments and other key affiliated institutions like first response agencies and hospitals. That's all changed, thankfully. And we have a very different approach now in the United States, for instance, to the all hazards challenges of disaster readiness and response and recovery. Next slide. So this is, I won't even ask Anita to point to the cursors, use the cursor on this one. But I just want you to sort of take a sort of visual look left to right on this timeline. And I'm just going to highlight a few key things. The first is the anthrax mailings, which I mentioned, which followed 9-11. Subsequent to that, there was the creation of the Department of Homeland Security based on a growing recognition that we have to, following 9-11 and the anthrax mailings, that we had need a more, we actually need an explicit governmental agency to address a growing number of security threats. That led to an infusion of bioterrorism funding. Again, note bioterrorism, it wasn't all hazards at the time, from the Department of Health and Human Services. In 2003, during the Iraq war, there was a smallpox vaccination campaign that was launched in the US. The goal was to vaccinate 500,000 health workers. That goal fell far short because they found, basically from the anthrax vaccination, they found cardiac effects of the vaccine. That campaign was discontinued and actually, tragically, there were health workers who died of side effects related to that from the anthrax vaccination. SARS, I mentioned, in 2003, and then the creation in 2003 of the National Incident Management System, which we discussed last time. Hurricane Katrina was a major game changer, if you will, for public health agencies and other agencies. One of the things that was learned from Hurricane Katrina, among many, was that literally different state and local agencies and jurisdictions were literally not on the same radio frequency, which will absolutely decimate the ability of effective response. Then we're talking now about highly pathogenic avian influenza. This is not new. You'll see H5N1 pandemic influenza threat's been around since at least 2005. Thankfully, it has not yet shown the ability to become easily person-to-person transmissible. If it does, then we will have likely the next pandemic. Just fast forwarding, you'll recall the 2009 H1N1 pandemic, which was milder by orders of magnitude than the 1918 flu pandemic and compared to the COVID pandemic, but it was a significant event and really highlighted the importance of public health system readiness. In 2011, just very briefly, it's called the Great East Japan Earthquake. There was the nuclear disaster at Fukushima Daiichi facility. It began with an earthquake at the seafloor, which led to a tsunami, which led to an inundation of this very large nuclear reactor, which resulted in a meltdown. Hurricane Sandy was a domestic, another game changer, because it had devastating impacts in basically up and down the Northeast and Mid-Atlantic seaboard and many lessons learned in terms of enhancing collaboration and other aspects between public health and other agencies. Then you'll see Ebola. In 2014, there was an outbreak of Ebola, you may recall, in West Africa. There was a gentleman who was from Liberia, who flew to the United States to Dallas, was seen in an emergency department there, was discharged back to home, came back to the ER, and nursing staff were exposed. This just highlights the global ease of transmission of infectious disease. If you were to go off of this to the right, which is not visible here, you can add, and I intentionally did not go on and on, but COVID, obviously, we are now dealing with MPOCS, and we're looking at, as I mentioned, current concerns again with highly pathogenic avian influenza, and the list will undoubtedly continue. Everything we are talking about here is germane to these different types of scenarios within what we call the all-hazards framework. Again, we're not just thinking when we talk about public health preparedness about bioterrorism anymore. That's just one of many threats that we need to be positioned for in public health. Next slide. This is just summarized here. We'll continue to the next slide, just in the interest of time. Just I'll highlight a couple of important things about, very briefly, about, this is from the list that I provided, but just a couple of key points for each one. September 11th was a fundamental game changer in terms of the vulnerability of U.S. homeland security. It led directly to the creation of the Department of Homeland Security, also informed by the anthrax events, which really caught public health off guard, and public health really had not been poised for this kind of event in the United States. This is the kind of thing that really was a painful but critical impetus for health departments to change their approach to more agile readiness on a 24-7 basis. Next slide. The Office of Homeland Security, as I mentioned, it was the largest reorganization of the federal government in over 50 plus years. then there was an infusion of HHS bioterrorism preparedness funding, as I mentioned, over a billion dollars. And that was announced in 2002. And very importantly, this institutionalized, and I put this in italics, public health emergency readiness for the nation. So we think about the Cold War in the mid-20th century. Well, this is a whole different aspect of readiness, not just nuclear readiness, but public health readiness. And that's been a key modifier moving forward subsequently. Next slide. National Incident Management System, which we alluded to in our last session, was formulated and declared in February of 2003. And that is the framework that we still use to this day to organize responses to events like what you're seeing occurring in Florida with Hurricane Helene. Importantly, this is critical for public health and occupational health and any other aspect of response because the system, this is an all-hazard system, using that term again, it's applicable at all jurisdictional levels, whether we're talking about local, state, or federal, no matter what city, no matter what state. So we're all using the same sheet of music in terms of communication. And that's absolutely critical for effective response. Next slide. I mentioned the smallpox vaccination campaign. Next slide. SARS was a global crisis, but felt locally. So for people in Toronto, where there was a large concentration of SARS, that decimated the tourism industry, at least for a period of time. And it's really critical to think about because we don't have to have a pandemic, per se, for an event to have a significant impact on local or regional economies and the public health challenges attendant to responding to such events. Next slide. I mentioned Hurricane Katrina. Key word here, the last bullet is interoperability. So that's one of the tenets of the Incident Command System. You can see interoperability way at the very bottom. And interoperability literally means that my radio equipment is on the same or compatible frequency as yours. That may seem obvious, but we saw that that did not occur in, as I mentioned, in Hurricane Katrina. And so one of the things that we have been focusing on by we, I mean the public health community, the preparedness community, FEMA, and all of the other allied agencies, has been focusing on ensuring interoperability. So we can avoid those mistakes moving forward and those gaps moving forward. Next slide. So even legislatively, notice terms that start cropping up. In 2006, it was the Pandemic and All Hazards Preparedness Act. That's a little bit redundant because pandemic is part of all hazards, but that was the choice of name. But notice that pandemic is part of it, but all hazards is the key. So it wasn't the Bioterrorism Preparedness Act, it was the Pandemic and All Hazards. So we're starting to see, even at that time, an explicit terminological difference where we're seeing the word all hazards used or the phrase all hazards used in this context. Next slide. So this is a map from the 2009-2010 H1N1 pandemic. And I want to highlight a couple of things, and this is relevant to you in your current and future role as leaders in public health and occupational health. This is a typical slide that you'll see of a situational update from the World Health Organization. And the size of the dots are intended to be proportionate to the number of reported cases. Now, one of the things I'd like to highlight, take a look at Sub-Saharan Africa. If you'll just train your eye on Sub-Saharan Africa. Not a lot of dots. Does anyone want to hazard why there may not have been a lot of dots? Do you think it necessarily was because there weren't cases? Anyone want to, any thoughts about that? Does anyone want to type an answer into the chat or the Q&A? I can. Thank you. Thank you, Anita. Yep. Yes, go ahead, Jeremy. Please type your answer. Okay, I see. Yep, great. So cases not recorded. These are all correct answers. These are excellent. Lack of public health infrastructure in that part of the world. Surveillance gaps, right? So it's like a tree falling in the forest, in a sense, right? So that's very important. So this is just a little cautionary note to read these maps, you know, read these maps diligently, but with that little bit of, more than little bit of caveat, that even if you don't see a large dot, it doesn't mean that there are not cases. Okay, so this is important from a surveillance standpoint. They had prior immunity, that's entirely possible as well. So there could be a variety of reasons, but one of the things that we see in LMIC, low middle-income country context, is oftentimes gaps in baseline surveillance infrastructure. And this is one of the challenges that has to be acknowledged and addressed when we think about understanding the global status of a given event, whether it's MPOCS or another kind of event moving forward. Next slide. So Ebola, we talked about that. And interestingly, there were certain hospitals that had designated biocontainment facilities. University of Nebraska at Omaha was one of them. And actually, they were quite expert at it because they had done drills and exercises at that hospital on that scenario. So sometimes having done drills and exercises can make you quite expert at something. And that's just one of many examples. Next slide. We talked about Zika earlier. Next slide. COVID-19. So we could do a whole series on COVID-19. We are still learning lessons from COVID-19. Certainly the most significant global public health emergency in over a century since the 1918 flu pandemic. We are still dealing with effects, if you look at the fourth bullet, of chronic health considerations relating to what they call, what is called long-haul COVID. Also the third bullet, crisis risk communication challenges. Lack of trust was seen quite often. And we're learning about lessons in terms of gaps in risk communication to this day from COVID so that we can use those lessons and incorporate those into future risk communication efforts for future events. And we have to think now about a post-COVID world. So what does recovery look like for people who have lost family members, for people who themselves are experiencing long-term effects? Even though the pandemic has been officially declared over, we are still seeing cases of COVID, as you know. And we have to think about the psychological and physical long-term effects, even though the pandemic has officially been declared over by the World Health Organization and CDC. And there are many more lessons to be learned and that will undoubtedly surface. Next slide. So just to highlight, the next part I want to discuss, as I mentioned in the learning objectives, is willingness to respond. And this is not some abstract concept. This has great implications for disaster surge capacity. Surge means the ability of a hospital or healthcare system to ramp up resources in response to a surge in demand for those resources for acute need. And so here are actual headlines. This is from the New York Times. This was during the Ebola events of 2014. Delay in Dallas Ebola cleanup as workers balk at tasks. You can see there's a photo of a hazmat worker. This is not their first rodeo, as they say, with these kinds of events. But the gist of this article was that even hardened responders, like hazmat workers, were reluctant to go to this gentleman's home, the gentleman I mentioned, who came from Liberia and subsequently died of Ebola, to clean and remove his linens. So this is something that we have to think about. Also, Madrid, during the Ebola outbreak, there was a hospital in Madrid where staff quit over Ebola fears in large numbers. Next slide. This is from Liberia. There was an 11th hour strike that was narrowly averted among Ebola health workers because they wanted, understandably, hazard pay and were concerned that they were putting themselves at risk without appropriate compensation for doing so. And then on the next headline, not a peer-reviewed journal, I believe it's the New York Daily News, but nonetheless, there was a physician who was working with Doctors Without Borders who came back to the United States and came to Bellevue Hospital in New York City with Ebola. And then the article the next day mentioned that a large number of staffers called in sick after Ebola arrived. Now, there are a lot of possible reasons why one can call in sick, and I'm not trying to necessarily extrapolate, but Occam's razor often applies, and this is one of those examples. Next slide. We have seen this, unfortunately, during COVID-19. The Spanish military, sadly, found dead bodies and seniors who were abandoned in care homes. Now, I want to be very clear. Based on research and experience, most healthcare workers do come into work in harm's way. But again, as I'll describe, a sizable proportion, both experientially and based on the scenario-based research, do not or will not. And so that is a very big concern when we think of all hands-on-deck responses. Next slide. One of my excellent colleagues, Dr. Tom Kirsch with Uniformed Services University, he's an emergency physician. He wrote this article, note the date, March 24th, 2020. So coronavirus, COVID-19, was declared a pandemic on March 11th. So about a week later, you can see that he wrote this very prescient article where he said, what happens if healthcare workers stop showing up? And the sub-headline is, unless the country does dramatically more to provide them with the equipment they need to do their job safely, it risks disaster. And this occurred, sadly, more often than we would have liked to have seen. And part of it is, there's this sort of fiduciary role that healthcare systems need to have for their workers to give them primary access, or at least timely access, to vaccines and antivirals. So this is one of the points that Dr. Kirsch made in this article in The Atlantic. Next slide. So changing the culture of public health preparedness. I alluded to this earlier. And in the last 20, hard to believe, 23 years now, almost to the day, there has been a dramatically changing culture of public health preparedness. And in many ways, for the better. A set of expectations for public health agency workers, both newly onboarded ones and current employees, that emergency preparedness and response is part of their job description. And it's not a 9-to-5 job anymore. And so this is very important to think about as leaders. You all are leaders in public health and occupational health. And many of you will be leading health departments. And so it's important to think about how this applies to the changing culture of public health agencies. Next slide. So I alluded to some of these things. But I want to highlight five themes that are really critically relevant and timely when we think about public health preparedness education. So the first, I've already mentioned it in some depth, which is the all hazards model. Then we're going to talk about the public health system framework. There's a concept also that all disasters begin locally. So even events that we're seeing in real time, like Hurricane Helene, disasters should be led, according to the National Incident Management System and the Incident Command System, by local agencies, supplemented by state and federal resources. Now, the US has developed what's called, subsequent to Hurricane Katrina, something called the National Response Framework. Because one of the lessons, which basically says that the federal government is going to take much more of a forward-leaning response moving forward than it did during Hurricane Katrina. That was based on lessons learned, painful ones, where the government did not really intervene as soon or as assertively as it could have. And so you'll see, as you watch the news, you're going to see federal resources, they're already in place in the panhandle and surrounding states, in Florida and Georgia and areas surrounding it. Cyclical nature of readiness and response. We talked about the disaster life cycle. You can think of all of this as its own continuous quality improvement cycle. And it's a cycle that's going to continue to continue. And in fact, CQI principles are critically relevant to optimizing public health preparedness and response systems. And very importantly, you'll recall the three o'clock part of the dial for the preparedness part of the disaster life cycle. As I mentioned, that's its own mini quality improvement cycle in itself, of planning, training, exercising, and drills, and evaluating how we did on those exercises before an event. So we can identify areas of strengths and areas that need to be shored up before an event occurs. And last but not least, we've been talking about public health organizational culture. Public health agencies need to be agile in the sense of responding to unpredictable events at unpredictable times and not at nine to five business hours. Next slide. Oh, sorry. So the all hazards model is the current one that's used in the United States. And again, I've sort of alluded to some of these terms already. The National Incident Management System from 2003, that came from President George W. Bush, that was an example of the all hazards model. The National Response Framework that I mentioned a moment ago with that forward-leaning federal government agency response based on lessons learned from Hurricane Katrina, that is also all hazards. And that Pandemic and All Hazards Preparedness Act, that's another example of all hazards. It even has the phrase all hazards in it, as we described. And then, of course, the idea for all hazards, everything that we're talking about, whether it's incident command or other kinds of frameworks, it's standardized, and that's critical. So whether we're in Detroit or Denver, it doesn't matter. We're all using the same terminology. Think about Hurricane Helene right now. It's going to affect multiple states. Can you imagine if Florida was using a completely different set of response terminology than Georgia was? It would be an absolutely chaotic response. So intentionally, the Incident Command System and the National Incident Management System make sure that there is not jargon, that we don't use acronyms, and has standard terminology for personnel and other things that we talked about last time. So it's also scalable. So whether we're dealing with a smaller event or a larger event like we're dealing with currently, unfortunately, with Hurricane Helene. Next slide. So this is what I had alluded to earlier. This is called the Public Health Emergency Preparedness System. It arose from the Institute of Medicine and has really stood the test of time. I've also presented on related topics in Canada. And in Canada, they have a very similar model, or this model at least applies. And I've vetted that with some of the experts in emergency preparedness and public health in Canada. So my point here is that when we think about the United States, let's get back to domestic considerations. At the hub of this hub and spokes diagram, we have what's called the governmental public health infrastructure. By that, I mean public health agencies. And as I alluded to a few moments ago, all disasters begin locally. So it's really the local public health agency if we're dealing with an infectious disease event. Typically, these are the kinds of events that public health is best at handling, things that relate to infectious disease or other kinds of events that are similar to that. And you can see going from 12 o'clock health care delivery systems, that's hospitals, and then two o'clock on the dial, homeland security and public health and safety, five o'clock on the dial, the private sector. So that private sector, as you'll recall, played a critical role in vaccine development during COVID. Among many other examples, the media at six o'clock, the media can be a great ally to us in public health, but it can also have the opposite. And when I say to us, I mean in public health. So making sure that we have good relationship with media is critical to ensure effective communication. Academia, subject matter expertise, so that's about around seven o'clock or so. And then communities, we have community emergency response teams in the United States, and so community-based response. So these are all interlocking, intersecting, but at the hub of this is the governmental public health infrastructure. And unfortunately, the challenge has been for many years that subsequent to that large infusion of over a billion dollars in the aftermath of 9-11 and the anthrax mailings, governmental public health agencies have had to do more with fewer financial resources. And so that results in a rather fragile hub of this critical system. Next slide. So all disasters begin locally. Again, I'm alluding to Hurricane Helene because it's so timely. It's happening in real time. But when that makes landfall, we have to think about self-sustainable responses. So people who have not yet evacuated, the authorities, if you've been watching the updates today, they are telling folks it is too late to evacuate. You need, and the direct quote I heard today was, you need to hunker down, sheltering in place essentially. And so that requires a locally driven response because there will be people who will need to be rescued from their homes likely because of the storm surge. And we're going to see that. So I'd like for you to keep your eyes open for this because this is the kind of thing that is the sort of the real world sort of dynamics that we see based on what we're describing here. And we often will assume that the federal government or state or local resources will come, the cavalry will arrive right away. No, that's not the case. So that's why personal and family preparedness is so important. Having a preparedness kit and the like is absolutely critical. And we need to think about 72 hours self-sustainability at the local level post-onset of an event. And we need to think about 72 hours self-sustainability at the local level post-onset of an event. That's just a general rule of thumb. Next slide. So willingness to respond. I've talked about a lot of different things. One of the, a couple of things I just also want to highlight is things that are relevant and will be relevant to you as leaders. Continuity of operations. How do you keep your organization running in the face of an event like Hurricane Helene or other disaster? A common question, your employees may ask is where do I specifically, I, Jane Doe, fit into this response? So you've described generally what our agency is doing, but how do I, Jane Doe, myself fit into this bigger picture? And that relates to a broader concept that we're going to talk about now to conclude with it, which is willingness to respond. And I'm going to make sure we allow time for questions. Next slide. So one of the things that we, I just want to mention as a relevant note, we talked about preparedness exercises. I can't overemphasize the importance of doing these kinds of exercises. The most basic kind of exercise that we'll talk about in a moment is what's called a tabletop or discussion-based exercise, where you actually have a discussion of a scenario and how your agency or agencies with partners would respond collaboratively or it can be one agency involved in the exercise. And this needs to be ongoing. And there's also, the need for just-in-time training. So if you're at a health department, it's important to have just-in-time training about MPOCs, for example, or whatever the newest threat on the horizon is. And there's actually a federal program called the Homeland Security Exercise and Evaluation Program that specifies and provides guidance on how to conduct preparedness exercises in public health organizations. Next slide. So exercises are worth the effort. They allow for effective response. They are not just one-shot deals where you say, oh, we've exercised, we don't need to do it for another five years. Not the case at all. They need to be ongoing. The cadence of how often you do those exercises is based on your bandwidth as an agency. Obviously, for health departments that are in the midst of response, they're not doing exercises, right? So health departments in Florida that are responding to Hurricane Helene, this is a real-world event. So when we're talking about exercises, we're typically talking about what are called, the term is actually blue-sky days, days that we are not dealing with a disaster, but allow us to prepare for one. Next slide. So these are just a list of some common reasons why we do exercises, but very importantly, to improve individual-level performance. Importantly, exercises should not be ad hominem, oh, John Doe did this wrong. No, we don't, this is not a blame process. In fact, we call them no-fault exercises. And we anonymize if a given individual didn't do something to the optimal way. So very importantly, it needs to be constructive, but it does need to highlight areas for improvement as well as areas of strengths that surface from the exercise. Next slide. So these are the three different broad categories of exercises, as I mentioned a moment ago. Tabletop is a discussion-based functional exercise. It's like a clinic walkthrough. You don't have people wearing makeup, like what they call moulage, which is like fake ketchup to represent blood or the like. But it's sort of like a slow-paced clinic walkthrough. Full-scale is where you'll often see these kinds of exercises, where they involve large equipment, lots of people who are acting in roles to indicate different types of injury and the like. And Dr. Alexander, how does the political party in control affect the process? Well, really it shouldn't, because this is, and again, maybe that's aspirational. But the reality is that public health emergencies have happened on all different administrative parties' watches. And unfortunately, it can be one of the most politically damaging things if the government is viewed as having failed a response. And that was frankly one of the critiques during Hurricane Katrina. Great question, Dr. Alexander, thank you. So next slide. So this model, this Homeland Security Exercise Evaluation Program, this is the framework, but it's basically a continuous quality improvement cycle in itself. Next slide. Going to the response phase of the life cycle, we're gonna talk about willingness to respond now. So next slide. So based on work that colleagues and I have done dating back to 2005, we've found significant gaps in willingness to respond to different scenarios. An important take-home from this research is that my own individual willingness to respond to one type of event may not be equivalent to my own willingness to respond to a different type of event. Said another way, willingness to respond is a scenario-specific phenomenon, even within an individual. And based on our pilot study that we did in three health departments in Maryland, we found that only half of those workers indicated that they'd be likely to report to work during a flu pandemic. So note that this was done in 2005, so this was before H1N1 2009, obviously. To our surprise, we tried to hypothesize as to reasons going in why people would be unwilling to come to work. One important reason that we, and our main reason that we guessed, would be concern about their own and family's safety and well-being. Well, that was important, but it wasn't the most important factor. And I don't know, Anita, if you're able to put the cursor possibly on the 9.5, way at the last bullet there. So it turned out that the leading modifier of willingness to respond in this pilot study was how important that employee perceived their individual role to be in the overall agency response. So if they perceived their role to be important in responding to pandemic flu, they were 9.5 times more likely to be willing to come to work in that event than their counterparts who did not feel their roles were important. And that's critically relevant because one can think that their role's unimportant but be factually wrong. It's just never been explained to them through training how and why their role is important. We often see this, for example, and based on research for clerical and support staff. Will I just answer phones? No, you don't just answer phones. You're also on the front lines of risk communication at your agency. And if you have a fact sheet in front of you, you can help to sort of triage, if you will, questions from the general public that might be sources of concern. So, and if there's a question that you're not able to ask on the fact sheet, you can refer that to someone who has a clinical background. So these are the kinds of things that we need to think about very explicitly when we think about preparing public health and occupational health workforces for response. These are all hands-on-deck events, the kinds of events that we're seeing in Florida and countless other examples are all hands-on-deck events where everyone plays a role. But important part of that is everyone needs to know what their specific role is and how their daily skillset translates to that response role. So we don't want someone in fiscal vaccinating people, but we do want someone in fiscal tracking inventory, for example. So that's kind of the gist of one of the key aspects of our findings. Next slide. So we, when we published this article back in 2006, we published it in 2006, we got a lot of interesting queries from other health agencies who wanted us to survey their agency's willingness to respond. So this is kind of a, it's always exciting when you have a research question that generates interest from practitioners and indeed this did. And so we developed a survey instrument where we asked about willingness to respond using a threat and efficacy behavioral model called the extended parallel process model, looking at willingness to respond in public health agencies. And we also applied it to, we conducted the study among hospital workers, EMS personnel, even among MRC, Medical Reserve Corps volunteers, toward four representative scenarios that are listed here, weather disaster, pandemic, flu, dirty bomb, and inhalational anthrax. Next slide. I'm gonna just walk you very briefly through how this model works that underpinned our research. So let's say, and Anita, this is a bit of a tricky one, but if you can kindly try to put your cursor as I walk through, so perfect, the far left box. If I'm trying to get someone to make a preparedness kit before an emergency, I have to do two things, the model says. I need to, and to the right it says first appraisal. I need to convince that person that there's a legitimate threat out there worth making a preparedness kit for. So if I'm using Florida, for example, and if I'm saying you need to make a preparedness kit for a snowstorm, that's a non-starter, right, in Florida. It's not a non-starter in Duluth, Minnesota, though. So it's very jurisdictionally relevant. But if I'm trying to convince someone to make a preparedness kit in Florida, and I say this is for a hurricane, and we've had several hurricanes, they have been, you've impressed upon them their susceptibility to that event and the severity. If you cannot get them to believe in the susceptibility and severity, they will disregard the message and they'll reject it. Let's say, though, that I am able to convince the audience of the threat. My next job is, in parallel, I have to convince that audience of the efficacy piece. By that I mean there are two parts. Self-efficacy, which means confidence that I can put a kit together. In other words, self-efficacy is a psychological concept that loosely translates to confidence and agility in the face of uncertainty. And response efficacy, which has nothing to do with the disaster life cycle, but simply means that I feel like it'll make a difference in keeping me and my family safer if I make a kit. Otherwise, why should I invest time and money in making a kit? So let's say I convince someone of the threat, but I fail to convince them of the efficacy. Then you'll see below that they engage in what's called fear control, where we often see magical thinking. Oh, this hurricane will bypass my neighborhood, or this infectious disease will skirt my county, and it may seem irrational, but that's a coping mechanism. But it's a maladaptive one. And they will reject the message that they won't make a kit. But according to the model, if I can convince someone of the legitimacy of the threat and the efficacy of making a kit, then they are apt to accept the message and change their behavior accordingly, in this case, making a preparedness kit. So we use this model to underpin our examination of willingness to respond across these various relevant occupational cohorts that I mentioned. Next slide. So these are just a list of how we phrase these questions. In the interest of time, I won't go through verbatim, but let's go to the next slide, kindly. And if you had to pick one type of employee, and Anita, you moved the cursor perfectly, that is the most predictive of, the most likely to be willing to respond across all hazards, it's what we call the concerned and confident, high concern, high confidence. Meaning this person has a high sense that they are vulnerable to the threat to motivate them to take action, coupled with a sense of those two forms of efficacy that I mentioned. Now, all models are wrong and some are useful. That's an expression I learned when I was getting my MPH. And it's still true. And the reason that I mentioned that is that it turns out that this model, if you look at it in the way I presented it on the recent slide, it indicates or suggests that if I can't convince someone of the threat, it's game over, they won't, the efficacy piece doesn't matter. That's not the case. Based on our work on willingness to respond, my colleagues in my work, it turns out that if you can, as long as you can convince people of the efficacy component that they can, in this case, they know what their job is, they feel confident they can perform it effectively, and they feel that they matter in doing so, it doesn't matter as much if they think that the event will ever happen in their jurisdiction. Does that make sense? So efficacy outweighs threat when it comes to willingness to respond. And that's a good news message. What that means is we need to focus our trainings for emergency preparedness, not just on knowledge and skills, but also on building efficacy. Next slide. So we're gonna just quickly go very, very fast through these next few slides. But I just wanna highlight that this is rooted in research that we've conducted over the years in the U.S., starting in the U.S., looking at willingness to respond among health departments in nine different states, over 70 different health departments, and both urban and rural jurisdictions. Next slide. And this was a train-the-trainer curriculum. That's the third bullet underneath it. We call it the Public Health Infrastructure Training. We intentionally did not use the term willingness in the title, because we didn't wanna tip our hand as to what the training was about. That can contaminate the study. We had a control, this was a randomized control trial, where we had a training arm that got this novel curriculum and an intervention arm that did not. And we did baseline-synced surveys at baseline among the control versus intervention, and then one month, six months, and two years post. And then we did focus groups. So next slide. And this just shows you the number, almost 3,000 health department employees in nine states. This was a longitudinal study. This shows the different states and jurisdictions represented. Next slide. A couple things, and I'm not, don't even worry about the numbers as much. I want, the key points are as follows, okay? I wanna highlight that. From an organizational standpoint, willingness to respond is greater if your organization says we require you to come to work versus if we, versus if the organization says we ask but do not require you to come to work. So now, from a legal standpoint, you cannot drag someone out of bed to come to work. But as one of my colleagues, a retired public health officer in Maryland told me, he said, I can't make my employees come to work in a disaster, but I can revisit their employment status afterwards if they don't. Now, that may seem harsh, but that's part of organizational expectations that can be written into contracts and actually does have that kind of stick approach, if you will. Hate to use carrot versus stick, but does have that stick approach. Lower willingness if asked across different scenarios. And when you ask a given scenario whether people would be willing to come to work regardless of severity, that matters too. So asking someone if they'd be willing to come to work in a pandemic, it matters if it's a 2009 H1N1 pandemic versus a 1918 or COVID-like pandemic. So the more severe, the less willing. Next slide. So how do we further address willingness gaps? The take-home message is we need to, through this curriculum, which I'm not going to go into great depth here at all, but I do want to highlight that we need to explicitly build in efficacy-focused training. In a nutshell, explaining how one's day-to-day job translates or crosswalks into one's potential response role to give them a sense of confidence that their individual role translates well into disaster response. Also, response efficacy needs to be built into trainings for preparedness, meaning that we inculcate for our audiences how they individually matter, that it's an all-hands-on-deck and each person matters in coming to work. Next slide. And we did this as a facilitator-led mixed multimodal learning approach with blended learning with a facilitator-led discussion, independent learning activities, mapping multiple routes to work, for example, taking self-care-related training as part of psychological first aid, and then tabletop exercises. This was that intervention curriculum. Next slide, and we'll finish on time. The highlight here is that this curriculum, and there's a lot of numbers, but the point here is that this curriculum boosted willingness to respond regardless of severity by 14% for the scenario that had the lowest baseline rate of willingness to respond, the radiological dirty bomb. You may say, well, 14% isn't that much. If you have a health department with 10 people, 14% of 10 people is a big deal. And 14%, if you have a large health department of 1,300 employees, as many health departments do, is also a big deal when it's an all-hands-on-deck scenario. So this curriculum works particularly for high-dread scenarios like radiological dirty bomb and anthrax bioterrorism, less impactful for quote-unquote naturally occurring scenarios like weather-related and pandemic flu. Next slide. And we found through focus groups that people felt that they had a greater sense of the importance of their roles through this curriculum in the context of a public health emergency response. Next slide. And we'll just continue to the end. But these are some basic future research questions. One is efficacy toward disaster recovery. And we're doing current work, my colleagues and I, in LMIC context using mHealth to adapt the curriculum that I just described into an LMIC appropriate and contextually relevant mHealth learning module. And we have an NIH grant for that that we're very excited about. Next slide. Here are references and happy to answer questions. And thank you so much for your time and happy to entertain any questions. Thank you so much. Yes, we do understand it's 8.01, but we do wanna give an opportunity for the audience to ask questions. So please feel free to post questions. We wanna make sure that your questions are answered because this is going to be recorded so we can have these answers and questions on the recording. Dr. Barnett, do you mind staying for a few minutes in case there are questions in the audience? Okay, fantastic. We've got one question. Is there a way to assess what specific roles tend to be highest risk of unwillingness, aka maybe a group that consistently does not recognize their own value in an agency? Love that question. Terrific question. And yes, there is an answer to that that we found and others have found. It turns out that nurses have been found to be less willing to respond than physicians across different surveys and different studies in willingness to respond. This is a big problem because as you're all well aware, nurses comprise by far the largest cohort of health providers. And this is critically important when we think about training both current active nurses as well as in nursing education. And a lot more research needs to be done as to the sort of why nurses have this trend of lower willingness to respond compared to their physician counterparts. But it's a critically relevant question. And frankly, it is a threat to health security because we need a robust nursing response to the level of others. And Jeremy, in addition to nurses, there are still sectors of public health that lag behind in participation and willingness to respond. That's exactly right. So I don't wanna just highlight nurses, but that's one that just jumps off the page from research studies that have been done. But you're exactly right. We've even found gaps, as I mentioned, in willingness to respond among Medical Reserve Corps volunteers by scenario. So there's this assumption that if someone signs up to be a volunteer, they'll be willing to respond no matter what the scenario. Well, we found that willingness to respond among Medical Reserve Corps volunteers is far lower for a radiological event, which, by the way, is the lowest scenario rate for willingness to respond across different occupational cohorts from our research. And so willingness to volunteer is not monolithic. You may sign up for a volunteer, but not for that type of scenario necessarily. Great comment, Jeremy. Thank you. One more question. Does the National Incident Management System facilitate collaboration between federal, state, local agencies during disaster response efforts, or is it mainly federal? Another terrific question. All of the above. The whole idea of the National Incident Management System is to provide a standardized structure for agencies at all jurisdictional levels to be able to work synchronously and synergistically regardless of jurisdictional level, including local, state, and federal. And one more question from Dr. Alexander that came on my text here. Our health department's funding rely on how often they do training exercises. Since you mentioned training, we'll end with this final question. Well, so yes, there is an expectation that health departments conduct exercises and drills, and it is an expectation for federal funding. Frankly, it is not quite as, how can I say, explicitly, rigorously enforced as, let's say, oh, hospital-based exercises. So that's very important because we need to have that level of sort of rigor and reporting in health departments as we do in hospitals. Thank you, and I think Dr. Berger may have basically added one more comment on the chat if you wanna read out loud. Oh, yes, thank you, Dr. Berger. So point to structural need for more education on radiation crisis response. Absolutely. So the CDC has been very concerned about these findings from our work and others because there's this concept called radiophobia where radiation is very poorly understood. It's often considered a sometimes phenomenon. Well, we're actually always exposed all the time to ionizing radiation. And so one of the goals of training in radiation preparedness is sort of demystifying what radiation is and also giving guidance on how to optimally protect oneself through, we talk about time, distance, and shielding in terms of radiation safety and protection. Great question. Dr. Barnett. Dr. Barnett, thank you very much. And once again, I'm gonna share the slide where Dr. Barnett has shared contact information. And would it be okay if I reach out to you to get the link for the public health infrastructure training in case people want to learn more about the intensive training curriculum? Absolutely. We have an article on it that describes it in great depth and happy to share that. Wonderful. Thank you very much. Thank you very much, everybody. That's the end of today's presentation. It will be recorded and disseminated for those who want to, it's a lot of information to consume. So for those who want to rewatch it and for your colleagues who were not able to attend today, thank you everyone. Thank you.

public health emergency preparedness

disaster life cycle

climate change

weather-related disasters

pandemics

terrorism

National Incident Management System

healthcare workers

preparedness exercises

continuous quality improvement