In Case Of Emergency, Read Blog

I had the opportunity to attend Thursday’s U.S. H1N1 Flu Preparedness Summit held at the campus of the National Institutes of Health (NIH) in Bethesda, Maryland. The all-day event was organized by the Obama Administration to focus attention on preparation for and response to a possible more serious H1N1 outbreak in the Fall. Five hundred public health officers came from all over the nation to hear presentations from federal, state and local officials and discuss lessons learned from the Spring.

Administration officials announced that an H1N1 vaccine is expected to be ready in October and that more vulnerable populations, such as school age children, pregnant women and individuals with underlying illnesses will be the first in line for vaccination. There was also an announcement of increased federal funding for state and local preparedness initiatives and the launch of a one-stop government website, Flu.Gov. Particularly interesting for this blog was that much of the discussion focused on getting the public ready and informed — whether it be family preparation, school/workplace policies, mass vaccination and risk communications.

I thought it would be helpful to outline some of the key issues/questions regarding the public that were discussed during the Summit. In addition to attending the panels, I spoke to officials to find out what they want the public to do as well as their concerns, obstacles and challenges in getting Americans prepared by the Fall. (I videotaped a few interviews and include them below.) This is a long post; I hope it’s useful.

At the Summit, federal officials offered a clear message to the public to start preparing for a possibly more lethal H1N1 outbreak in the Fall. However, they are still working out the policy and logistical questions that citizens would face in the event of a serious outbreak. The gathering was an opportunity for local officials to ask questions, provide input, and relay on-the-ground concerns to the feds as they will ultimately be responsible for implementation in their communities. The Summit addressed many of the concerns raised by the experts that I spoke to and blogged about earlier this month, though the answers are still being worked on.

Cabinet secretaries Arne Duncan, Janet Napolitano and Kathleen Sebelius listening to their boss, President Obama, speak to the Summit via phone from Italy.

To get an overview of the Summit (in addition to this blog post), you can check these articles: New York Times‘  “Obama Warns Of Return Of Swine Flu In The Fall”, the Associated Press’ “Swine Flu shots at school: Bracing for a Fall return”, or for a state/local perspective the Rutland Herald’s “State Officials Attend H1N1 Summit”. You can go to Flu.Gov for the Summit press release and panel schedule. The Health and Human Services’ (HHS) social media Twitter feed, FluGov, live tweeted the Summit with a guest blogger, David Hale. Heidi Splete of Medical News Net also tweeted the proceedings. You can also check the #09fs Twitter tags to read about activity both at the conference and in the blogosphere. There was also a conference call during the day in which top officials answered some good questions from bloggers around the country, including Greg Dworkin from Flu Wiki and Daily Kos, Mike Coston of Avian Flu Diary, and Sharon Sanders of FluTrackers.com. A transcript can be found here. Videos of the sessions are available here.

The day began with cabinet secretaries Kathleen Sebelius, Janet Napolitano and Arne Duncan along with White House Homeland Security Advisor John Brennan speaking to a standing room crowd at NIH’s Natcher Conference Center. President Obama called in from Italy where he was attending another summit, the G-8. (Ironically, he was in the town of L’Aquila, the site of a recent natural disaster, last year’s earthquake). After the initial plenary, there were panels and smaller breakout sessions largely focusing on schools, work place issues, vaccine distribution and communications. The focus was on examining the lessons and experiences from the Spring — what worked and what didn’t — in a largely open, self-critical manner.

Federal officials outlined their initial plans and raised the questions that they are currently trying to figure out (e.g. what should school closing policy be?); it was both a briefing for state and local officials and a way to bring them all into the planning process. In addition, the day served as somewhat of a pep rally for health leaders across the nation who have had a challenging spring and may have an even tougher autumn and winter. It was also a way to get media and public attention that H1N1 was not going away as a problem, and that the government was still on the case.

I thought I would highlight a few of the overarching themes I heard throughout the day regarding public preparedness for H1N1:

* Preparing Not Scaring — In his remarks, President Obama said: “We want to make sure that we are not promoting panic, but are promoting vigilance and preparation.” And throughout the Summit, speakers looked for ways to underscore the seriousness of the potential situation (”We’re planning for the worst case scenario”, “It’s a deadly threat”, “Time is of the essence” were some of the phrases used), but in the same breath emphasize that to date the illness has largely displayed only mild virulence. The hope is that the public is able to hold  that balance in their minds going forward. One of the goals of the Summit was to get Americans’ attention that H1N1 was a threat (and underscore their responsibility to prepare) without frightening them. Towards the end of the day, Sebelius summed up the message: “It’s not about panicking people or striking fear but motivating Americans to prepare.” That approach is useful not only for pandemic preparedness but emergency preparedness in general.

* Giving The Public An Information Inoculation: “Be Prepared To Be Surprised” – Secretary Sebelius said that when it comes to this flu we should all “be prepared to be surprised.” It was a phrase repeated throughout the day. New Centers for Disease Control (CDC) Director Thomas Frieden noted in his remarks that influenza is among the most unpredictable of illnesses. As an example, many speakers mentioned that in most of their pandemic plans there was the expectation that the flu (most likely Avian) would come from another part of the world rather than just south of the border. And as a result, we would have more time to prepare. John Brennan called it a “very dynamic situation” with a lot still unknown. I think there is great value in putting that word out in advance to the citizenry in order to sensitize them to expect — and not be shocked — by change, and that we need to be prepared for whatever eventuality and be able to turn on a dime. It is almost as if this Summit was the first round of an information vaccination protocol which hopes to build up resistance and resilience in each of us by the Fall.

* Help Wanted: Leading & Listening – Officials repeatedly said that they did not have all the answers and would need to engage all aspects of society, including the public, to help them in preparing and responding to an H1N1 outbreak in the Fall. “We can’t do this alone,” Sebelius said. Brennan offered an honest but reassuring “we don’t have all the answers, but we’re committed to finding them.” Obama ended his remarks by saying: “If there are any issues we haven’t raised, please let us know.” I think that this kind of leading and listening — we’re doing all we can but we can use your help and input — is a winning communications strategy. As part of that approach, Sebelius urged state and local officials in the audience to convene ‘mini-summits’ at home; that sounds like a good forum to engage and involve the public.

The National Institutes of Health, site of the H1N1 Summit

* Top-Down & Bottom-Up — Most of the decisions in a pandemic are made by local and state authorities, but they need clear guidance on tricky issues that have far reaching effects (e.g. when to close schools) from the federal government. One of the goals of the Summit was to get everyone in public health on the same page. To me, this top-down and bottom-up approach echoes the optimal manner of dealing with other emergency preparedness challenges: most disasters are local responsibilities but there are things that only the federal government can do and say in a crisis. In the case of the Spring H1N1 outbreak, information was coming not only from feds but also from other governments and even an international body, the World Health Organization. In this era of unfamiliar, potentially serious threats as well as a new media environment, local officials cannot do it alone. It needs to be both the grass roots and tree tops working together.

* You Can’t Spell TEAM Without DOE, DHS, HHS, ASTHO, ETC. – One of the challenges I have found in the area of emergency preparedness is that it tends to blend different disciplines — emergency management, health, public safety, critical infrastructure — that have different languages, approaches and org charts but which must work together on challenging issues, sometimes in a crisis situation. Having the three top Cabinet officials jointly oversee this Summit underscored the need to deal with H1N1 across agencies and stove pipes at all levels both vertically and horizontally. Brennan called it a “team approach,” and you did feel that spirit in the Natcher building on Thursday.

* Not A Waste No Matter What Happens In The Fall – Secretary Napolitano made the important point that the preparation that government, business, schools and the public undertake for H1N1 will be useful even if the flu turns out to be not to be severe. Preparing for a pandemic will only increase the public’s (and in turn the nation’s) resilience going forward for other emergencies. Again, this is an idea — preparation is worth the time because it will come in handy sometime for something — that is the rationale for all citizen emergency preparedness. I would suggest that H1N1 citizen preparation be integrated into activities for the Department of Homeland Security’s National Preparedness Month this September. In fact, I would urge federal agencies involved in citizen preparedness to consider tying their communications to the public in this area more closely together. For example, many of the same preparation and response recommendations for a pandemic would be made for a bioterrorism attack (obviously, there are differences: washing your hands may be effective for the former but not the latter.)

* Using Viral Media To Take On A Virus (Thanks for that headline to Chris Thoman) – Social media played an important role in the government’s H1N1 public education efforts in the Spring and that will only increase in the Fall. In addition to the comprehensive Flu.Gov site, Secretary Sebelius announced a new H1N1 video PSA contest (YouTube announcement below) with a prize of $2500, hoping to tap the “creative ideas of average citizens and young Americans.”

HHS Secretary Kathleen Sebelius announces new 2009 Flu Preparedness PSA Contest.

Between sessions I spoke to Richard Besser who, as Acting Director of the CDC, earned widespread praise for his leadership during the Spring outbreak. I asked him what the public should be doing now to prepare for the Fall (n.b. the button on my Flip camera was sticking so the video continues a little bit beyond the end of the actual interview, and I haven’t yet learned how to edit — but I will soon):

Dr. Richard Besser advises the public what to do regarding the H1N1 Flu.

As Dr. Besser, who heads the CDC’s Coordinating Office for Terrorism Preparedness and Emergency Response, says on the video, officials are now reassessing school policy. It is one of what are called “community mitigation” steps. One of the nation’s leading public health policy analysts, Jeff Levi of the Trust for America’s Health, told me last month that the U.S. does not have in place the social and economic policies that can support the significant public health recommendations which might be necessary in a serious outbreak. During the Spring, there were numerous reports of citizens with flu symptoms who went to work because they would not be paid or feared losing their job. Similarly, the costs of closing schools — in child care needs or school lunches — turned out to be more significant than expected (in Chicago, for example, 80% of public school children are eligible for a federally subsidized meal at school).

I thought I would take a shot below at outlining the big policy and implementation questions that the public should know about:

Do School Closings Work? — “We’re reassessing” was a reoccurring comment when it comes to the decision on schools and H1N1. There was a consensus among most speakers that the school closing policies need to be clearer in the Fall than they were in the Spring. Typical was the comment of Belinda Pustka, superintendent of Texas’ Schertz-Cibolo-Universal City Independent School District, during one of the panels which was addressed to the feds: ”What I need from all of you is an idea of when it is best to close, when it is necessary to close and when it’s not.” New York City Assistant Health Commissioner Marci Layton said her department is currently surveying schools to determine the economic impact of the closings and see what kids did with their free time (going to the mall wasn’t going to help stop the flu). On another panel, a Chicago school official said the city only closed two schools but instead focused on “exclusion” (ie. keeping sick students home) rather than closing while a Texas educator  said he felt that their district shutdowns were effective in slowing the flu’s spread. Federal officials are now, in the words of Secretary Napolitano, “working the problem.”

One thing I think that needs to be part of the approach is that the public should be included in the discussion over the effectiveness of school closings and other community mitigation steps, such as preventing large gatherings and distributing masks. It is my sense that most Americans believe that closing schools and other mandates were effective in slowing the virus. If that is not true, then the mythology should be debunked so in the Fall there will not be public calls and pressure from political leaders for measures that are really useless and disruptive.

Another goal of the Summit was to bring in grass roots practioners to offer feedback from the spring. One speaker, Mary Pappas, the school nurse at St. Francis Prep in Queens, New York, diagnosed the Big Apple’s first H1N1 case in April. In her comments, she highlighted the value of student cellphones in quickly alerting their parents about the news from school (and recommended every school have a registry of the mobile numbers of all parents). And she drew laughs when she offered this ‘from the trenches’ tip on what she told students: “If it’s wet and not yours, don’t touch it.” (By the way, the often unsung school nurse received a lot kudos during the day.)

Will Workplace Plans Work? — While the H1N1 did not have as much impact on business as it did in schools this Spring, that might change this Fall. At the Summit press conference, I asked Napolitano about what the government was doing in regard to businesses and their employees, and what citizens should be doing and asking in their workplaces. Her answer is below:

Secretary Napolitano answers a question I asked at the Summit press conference about business/employee preparedness for H1N1.

While bigger companies often have contingency plans, will smaller companies be able to cope? You could never expect a seamless private sector net, but it seems as if there might be significant holes which could be very problematic during a major outbreak. In addition to reaching out to big companies and trade groups, I think the government will have to use a robust bully pulpit, putting societal pressure on the private sector that in the event of a significant crisis sick leave and telecommuting, where possible, is the norm.

Another potential vulnerability in the planning was raised during one of the sessions by Paul Jarris, executive director of the Association Of State & Territorial Health Officers (ASTHO): undocumented workers (a worry in other disaster responses as well) not wanting to volunteer to participate in a vaccination program and how that could impact the H1N1 public health effort.

Will A Mass Vaccine Distribution Work? – Officials say that they hope to have a vaccine in October (though it may take longer) and will embark on a voluntary vaccination distribution program. A big concern among some experts I spoke to is the scope. How will such a mass vaccine be distributed? Will the public have concerns about participating? Will there be ample supply? Will October be early enough? Federal officials acknowledged that the logistics of the vaccination program will be a Herculean challenge with schools, medical facilities and other retail locations possibly having to dispense both 100 million-plus doses of regular winter flu vaccine – and H1N1 shots. “We know a mass vaccination program of even modest scale will involve extraordinary effort on your part,” Sebelius told the Summit.

I spoke to Anne Schuchat, director of CDC´s National Center for Immunization and Respiratory Diseases, after a breakout session about what the citizens need to know about the vaccination program. (My camera stuck on this video as well so the end runs on a bit beyond the interview.)

Dr. Anne Schuchat talks about what citizens should know about the H1N1 vaccination.

Can Public Risk Communication Work As Well Again? — Though the federal government’s communications throughout the Spring outbreak was widely applauded, there were some issues being discussed at the Summit for the Fall. In her remarks, New York City’s Marci Leyton said that improvements were needed in getting messages out to the “non-afffected” (ie. the ‘worried well’ who jammed hospitals); reaching citizens in higher risk groups (e.g. pregnant women, asthma sufferers) who required treatment; as well as better explaining policy differences between local/state government actions and CDC  recommendations (whether that be on schools, N95 masks or public gatherings). It is a challenge: one local official said that the key for health officers in the field and the public is “communication, communication, communication” from federal officials, but that the communication needs to be “meaningful, quick, accurate”.

In the day’s last panel, Barbara Reynolds, a CDC communications adviser and Dr. Besser offered some very interesting communications advice for the state and local officials based on the experiences of the Spring. Among their recommendations: be first; be right: don’t be afraid to give out information in chunks (Reynolds said Twitter had made it more acceptable to parcel out information in stages since you only get 140 letters); be credible;  be empathetic; give people things to do; don’t give out mixed messages; don’t be paternalistic. Don’t treat people like children (”invite public into the process”) counter rumors and don’t turn down media requests. Besser, a pediatrician by training, said he spoke at press conferences as if he was talking to a parent in his office. He said you should acknowledge the public’s fear and uncertainty but then turn it into planning and action.

I had met Dr. Besser last year in Atlanta during a pandemic training session at NIH, and I had participated in a mock press conference as a reporter to test officials like him who might have to brief the media in the event of a pandemic. And in fact, one of the stakeholders that will be central to the communications challenge but did not get mentioned much during the Summit is the media (both mainstream and ‘new’). There is obviously no way to fully coordinate or manage the press’ coverage of H1N1. But the more knowledge and information the media has, the less likely it will stoke panic among the public. I imagine that officials will be briefing them soon on the same issues that were discussed at the Summit.

I asked Rear Admiral W. Craig Vanderwagen, who has been the HHS Assistant Secretary for Preparedness for the past three years, for his take on how citizens should be preparing for the Fall:

Dr. Craig Vanderwagen speaks about how the public and its institutions should be dealing with H1N1.

I also asked Paul Jarris, who oversees the state health officers association, what he recommended to the public in advance of the Fall. He said it should begin with some extra supplies:

Paul Jarris from ASTHO talks about making sure Americans are prepared for a possible H1N1 outbreak.

The value of the Summit may have been best summed up to me by California Public Health Officer Dr. Mark Horton (below) who said he had come across the nation with low expectations thinking that it would be just a bunch of public health officials talking to each other but he was struck by how much he learned.

Dr. Mark Horton, California’s Public Health Officer discusses the H1N1 Summit.

The challenge going forward, however, is not only to educate and persuade the public to prepare but it is to make sure that the institutions — ie. schools, businesses, public health and other government areas — are set up to make it easy for the public to do so. One way will be to have the kind of discussion with the American people that occurred at NIH on Thursday. This blog will continue to cover this unfolding story and the work being done on the federal, state and local level on behalf of the public. If you have comments or questions, I’d love to hear them.