Community Resilience: Beyond Wishful Thinking

Monica Schoch-Spana

This article is part of Crossroads in Biosecurity: Steps to Strengthen U.S. Preparedness, published by the Center for Biosecurity September 8, 2011 to mark the 10th anniversery of the 2001 anthrax attacks. Full document | Printable PDF

          
Community resilience, a concept frequently embedded in today’s U.S. government statements about disasters and public health emergencies, has upended previous notions of the public as hapless victims or hysteria driven mobs. The National Health Security Strategy (2009) and its Draft Biennial Implementation Plan (2010) single out an informed and empowered citizenry as fundamental to the nation’s ability to confront catastrophic health events.[1,2] Only a decade ago, however, the thinking was quite different, as I recall. Then, senior decision makers and emergency professionals contemplated worst-case bioterrorism scenarios in which the public was seen as a problem to manage, along with the pathogen and the perpetrator. During the anthrax letter attacks in 2001, the media zeroed in on so-called panic buying of antibiotics (a behavior displayed by very few people) and failed to remark on the order and patience exhibited when at-risk groups waited hours in line for their medication. Now, citizens are embraced as critical partners in managing public health emergencies; victims have become survivors.

Citizens’ Role in Public Health Emergency Preparedness

Trust in the ability of average people to cope with disastrous events and to play a key role in response and recovery is not misplaced, as the example of a severe pandemic influenza demonstrates. Thankfully, we escaped such a situation with the 2009 H1N1 influenza outbreaks. Citizen contributions—from personal preparedness at home to public deliberations in the town hall—can help mitigate both the health effects and the social discord possible with a large-scale public health emergency.[3]

The public’s role in health emergency management encompasses an individual’s (and household’s) ability to weather the crisis period. This includes acting on authorities’ guidance about community mitigation measures; being attuned to instructions on when and where to obtain vaccine and medications; and setting aside reserves of food, water, and medicines to weather shortages if they occur.

Volunteer networks, like the Medical Reserve Corps (MRC), enhance a locality’s preparedness and response capabilities. Neighborhood associations, faith communities, trade groups, and social service nonprofits can also rally constituents to convey event-related news, especially to hard-to-reach groups; fill key support positions at overburdened hospitals and health agencies; and stand up systems to aid the homebound sick and their families.

As part of pre-incident planning, policymakers can solicit the input of community residents on some of the tough choices posed by a pandemic flu. What guidelines, for instance, should hospitals follow if they have to turn patients away for lack of staffed beds? Actively involving residents in public health and safety policymaking can foster greater trust among officials and their constituents and generate new ideas that improve plans and enhance the social legitimacy of a final course of action.[4-6]

The Duty of Government to Leverage the Public’s Contributions

During the past 10 years, the U.S. government has increasingly asserted the need to integrate citizens into public health emergency preparedness (PHEP), and it has carried out initiatives on each of the fronts discussed above—from providing preparedness guidance at ready.gov and pandemic.gov, to expanding volunteer opportunities through Citizen Corps programs, to piloting public deliberations on the feasibility and social acceptance of pandemic flu containment measures (see Figure 1). Recognition of a citizen role in PHEP has also framed federal grants to state and local health departments for preparing their agencies and communities to respond to disasters with significant health impacts.

In March 2011, the Centers for Disease Control and Prevention (CDC) issued “Public Health Preparedness Capabilities: National Standards for State and Local Planning” to aid state and local health departments in forming strategic plans, setting priorities, and measuring progress.[7] At least 4 of the 15 capabilities bear on citizens and civil society contributions, with “community preparedness” presenting the most robust agenda. To strengthen this capability, state and local planners are advised to take key steps including: (1) convene coalitions that include business as well as community- and faith-based partners; (2) incorporate community input into emergency operations plans and into problem-solving sessions; (3) provide occasions for volunteers to participate in safety efforts year round and to help maintain health services during an incident; and (4) identify community leaders who can serve as trusted spokespersons to deliver public health messages.

The federal government is not alone, however, in singling out community engagement as critical to public health emergency preparedness. In 2008, the Institute of Medicine argued that citizens, communities, and businesses were part of the public health preparedness system and that the governmental public health infrastructure was the “final accountable entity” for integrating them.[8] More generally, current principles of practice call on public health professionals to work alongside community members in tackling top health concerns. Two of the CDC’s 10 “essential public health services” codify the importance of partnering with the public.[9] One is to “inform, educate, and empower people about health issues”; the other is to “mobilize community partnerships and action to identify and solve health problems.”

Local Health Departments’ Capacity for Community Engagement

Community engagement is enshrined in federal PHEP grant guidance, national consensus statements on preparedness, and current principles of public health practice. But does its popularity signify its common practice? Are health departments well equipped to achieve the national vision of broad-based PHEP coalitions and a ready and aware citizenry? With these questions in mind, the Center for Biosecurity has investigated the capacity of local health departments (LHDs) to engage the community in public health preparedness efforts. We first relied on national survey data on LHDs from 2005 and 2008 collected by the National Association of County and City Health Officials.[10] We then began to interview LHD leadership and staff about organizational elements that enable greater community engagement in PHEP.

Community Engagement Workforce

Our statistical analysis revealed that 3 LHD staff positions—emergency preparedness coordinator, public information specialist, and health educator—were strong predictors of whether an LHD involves the public in PHEP (controlling for other variables, including annual expenditure, size of population served, and whether the LHD is located in an urban, suburban, or rural setting). Like any other critical public health function, community engagement depends on proper staffing. LHDs with an emergency preparedness coordinator were 13% more likely to organize PHEP coalitions, 17.9% more likely to conduct PHEP public education, and 7.8% more likely to develop a local MRC unit. However, the data also showed that the presence of LHD personnel critical to community engagement in PHEP was highly variable across the country. Less than half of the LHDs surveyed had a public information specialist, and 1 of every 4 LHDs queried did not employ a health educator or preparedness coordinator.

Leadership and Political Backing

Although interviews are at an initial stage, some dominant themes have emerged during our conversations with practitioners. Skilled personnel, with fewer priorities competing for their time, are necessary if an LHD is going to engage the community in PHEP successfully. Dedicated people are needed to develop an engagement strategy, cultivate relationships with community- and faith-based groups, conduct broad public outreach and education, and mobilize volunteers. An influential, top LHD leader who explicitly endorses community engagement in PHEP as a strategic priority is seen as a prerequisite for the work to go forward.

Helping to trigger that endorsement is clear communication by the federal government that community engagement in PHEP is a genuine priority and a grant deliverable. The backing of local political leadership advances the goal of public involvement as well.

The Earnest Path to Greater Community Resilience

In thinking about the next 10 years in biosecurity, 3 key recommendations quickly come to mind in relation to community resilience.

Make It Happen

We need to stop talking about resilience in longing terms and start taking concrete steps known to enhance a community’s ability to anticipate and to mitigate the consequences of epidemics and disasters. These steps are well outlined in CDC’s new PHEP guidance to state and local health agencies on the community preparedness capability. No other public health preparedness capability—whether biosurveillance, medical countermeasure dispensing, or medical surge—is treated as if it were an organic process that will somehow happen on its own.

A little more than 10 years ago, a national assessment confirmed that U.S. public health laboratories were on the decline.[11] In response, investments in modern equipment were made, practice standards and protocols were developed, training sessions were offered, and more laboratorians were hired. As a result, the laboratory infrastructure was revitalized, and health agencies are now in a better position to detect, characterize, and communicate about confirmed threat agents. Resilience to disasters similarly depends on a robust community engagement infrastructure: sufficient staffing, practice standards, and training opportunities.

Admit the Costs

One of the appeals of community engagement models of disaster resilience is that business partners and community- and faith-based organizations can bring assets to the emergency planning table, thus extending scarce public sector resources. Like any other enterprise, however, there are upfront costs in garnering support from external partners. In the case of preparedness coalition building, the principal cost is stable support for skilled and dedicated personnel who can nurture trusting relationships over time, as suggested by our research. Nevertheless, at the 2011 Public Health Preparedness Summit in Atlanta, I heard a resilience panelist promote community engagement on the premise that it was inexpensive—virtually free.

During a period of economic austerity, it is sensible to package ideas for new government initiatives in terms of the “cheap factor.” But I would argue that this is disingenuous and ultimately undercuts the value of community engagement. The bottom line is that soliciting partnerships, volunteers, and citizen input requires resources once and forever. And doing so has the potential to multiply preparedness resources, improve the quality of emergency planning, better protect vulnerable populations, and save lives.

Commit the Personnel

Our research suggests that LHDs that retain a community engagement workforce and that give them a clear mandate are more likely to integrate citizens and community-based groups into the larger system for public health preparedness and response. Studies of community partnerships to advance population health, in general, indicate that dedicated staff and an institutional champion are among the key ingredients for successful collaborations.[12,13] The same was found when FEMA evaluated Project Impact, a program in the 1990s to build private-public linkages aimed at enhancing local disaster resistance.[14] Successful Project Impact communities had a full-time coordinator who could actively facilitate partnerships and champion program goals among diverse audiences. If, as the National Health Security Strategy sets forth, community resilience is one of the country’s top health security goals, then we need to put a greater priority on adequate staffing for community engagement work in public health departments.

Recommit to Strengthening the Public Health Infrastructure

During the past 10 years, it is has been gratifying to see a reversal in ideas about the role of average people in a public health emergency—from being a foil to the official response to serving as a critical ally. To seize the full potential of this vision, however, we must recommit to strengthening the public health infrastructure, this time with an emphasis on hiring, training, and assigning sufficient staff to engage the larger community in PHEP. Greater community resilience will not come through wistfully written federal doctrine, but through more and better inclusion of the public in local preparedness, response, and recovery systems.

Federal Policy Milestones Acknowledging Citizens and Community Groups
as Essential Partners in Public Health Emergency Preparednes

Public Health Security and Bioterrorism Preparedness and Response Act, 2002

Authorizes federal preparedness grants to state/local health departments that include priority on risk communication and health information dissemination.15

Citizen Corps launched, 2002

Broadens opportunities to volunteer in disasters, including Medical Reserve Corps units composed of volunteer health professionals and non–medically trained personnel.16,17

Ready.gov launched, 2003

Provides citizens with advice on threat awareness, personal preparedness, and protective actions for bioterrorism and other scenarios.18

Homeland Security Presidential Directive 10: Biodefense for the 21st Century, 2004

Asserts that “[t]imely communications with the general public…can significantly influence the success of response efforts, including health- and life-sustaining interventions.”19

Pandemic Flu Planning, 2005–06

Releases preparedness checklists for individuals, businesses, and faith-based and community organizations • Pilots public deliberations about best early use of limited vaccine and about community-wide controls.20

Pandemic and All-Hazards Preparedness Act, 2006

Names risk communication and public preparedness as “essential public health security capabilities”• Makes federal preparedness grants to state and local health agencies contingent on a mechanism “to obtain public comment and input” on preparedness and response plans.21

Homeland Security Presidential Directive 21: Public Health and Medical Preparedness, 2007

Identifies community resilience as 1 of the 4 “most critical components of public health and medical preparedness” • Promotes education initiatives to “enhance private citizen opportunities for contributions to local, regional, and national preparedness and response” • Asserts that resilient communities are made of empowered residents who are familiar with their local public health and medical systems and who are poised to provide neighbor-to-neighbor support.22

National Health Security Strategy (NHSS), 2009

Sets forth community resilience as 1 of 2 top national health security goals.1

NHSS Draft Biennial Implementation Plan, 2010

Singles out “informed, empowered individuals and communities” as essential to U.S. readiness and resilience; measures citizen empowerment in terms of: (1) community members, including at-risk groups, who are knowledgeable about health threats, what to do, and where to seek out help; (2) faith-based organizations, private business, and NGOs with community ties that are integrated into emergency planning; and (3) social networks that are adept at disseminating risk information and aiding community members in response and recovery.2

Public Health Preparedness Capabilities: National Standards for State & Local Planning, 2011

Provides capability definitions and functions for community preparedness, community recovery, emergency public information and warning, and volunteer mobilization.7

 

References

  1. U.S. Department of Health and Human Services. National Health Security Strategy. 2009. http://www.phe.gov/Preparedness/planning/ authority/nhss/strategy/Documents/nhss-final.pdf. Accessed August 9, 2010.

  2. U.S. Department of Health and Human Services. Biennial Implementation Plan for the National Health Security Strategy of the United States of America—Draft. July 2010. http://www.phe.gov/ Preparedness/planning/authority/nhss/comments/Documents/ nhssbip-draft-100719.pdf. Accessed August 9, 2010.

  3. Schoch-Spana M, Franco C, Nuzzo JB, Usenza C, on behalf of the Working Group on Community Engagement in Health Emergency Planning. Community engagement: leadership tool for catastrophic health events. Biosecur Bioterror 2007;5(1):8-25.

  4. Beierle TC. The quality of stakeholder-based decisions. Risk Anal 2002;22(4):739-749.

  5. Godschalk DR, Brody S, Burby R. Public participation in natural hazard mitigation policy formation: challenges for comprehensive planning. J Environ Planning Manage 2003;46(5):733-754.

  6. Lasker RD. Redefining Readiness: Terrorism Planning Through the Eyes of the Public. New York: New York Academy of Medicine; 2004.

  7. U.S. Centers for Disease Control and Prevention. Office of Public Health Preparedness and Response. Public Health Preparedness Capabilities: National Standards for State and Local Planning. March 2011. http:// www.cdc.gov/phpr/capabilities/. Accessed August 1, 2011.

  8. Altevogt BM, Pope AM, Hill, Shine KI. Research Priorities in Emergency Preparedness and Response for Public Health Systems: Letter Report. Washington, DC: National Academies Press; 2008.

  9. U.S. Centers for Disease Control and Prevention. 10 Essential Public Health Services. http://www.cdc.gov/od/ocphp/nphpsp/ EssentialPHServices.htm. Accessed August 11, 2010.

  10. Schoch-Spana M, Selck F, Sell TK, Morhard R. Health departments and the evolving role of the public in U.S. national health security. [Unpublished manuscript.]

  11. U.S. Centers for Disease Control and Prevention. Improving the Public Health Laboratory Infrastructure. http://www.bt.cdc.gov/lrn/ infrastructure.asp. Accessed August 1, 2011.

  12. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000;21:369-402.

  13. Orians C, Rose S, Hubbard B, et al. Strengthening the capacity of local health agencies through community-based assessment and planning. Public Health Rep 2009;124:875-882.

  14. Tierney KJ. Executive Summary: Disaster Resistant Communities Initiative: Evaluation of the Pilot Phase, Year 2. Submitted to the Federal Emergency Management Agency. University of Delaware Disaster Research Center. June 2000. http://www.udel.edu/DRC/archives/ Documents/Project%20Impact/projectreport42.pdf. Accessed August 1, 2011.

  15. Public Health Security and Bioterrorism Preparedness and Response Act of 2002. PL 107-188; 107th Congress. June 12, 2002. http:// frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=107_cong_ public_laws&docid=f:publ188.107. Accessed November 5, 2010.

  16. Middleton G. Medical Reserve Corps: engaging volunteers in public health preparedness and response. Biosecur Bioterror 2008;6(4):359- 360.

  17. Simpson DM. Community Emergency Response Training (CERTs): a recent history and review. Natural Hazards Rev 2001;2(2)54-63.

  18. Department of Homeland Security launches Citizen Preparedness Campaign [news release]. Washington, DC: Department of Homeland Security, Ready.gov website; February 19, 2003. http://www.ready.gov/ america/about/pressreleases/release_030218.html. Accessed August 6, 2010.

  19. Homeland Security Presidential Directive 10: Biodefense for the 21st Century. April 28, 2004. http://www.dhs.gov/xabout/laws/ gc_1217605824325.shtm#1. Accessed August 6, 2010.

  20. U.S. Department of Health and Human Services. H1N1 flu: a guide for community and faith-based organizations. http://www.pandemicflu.gov/ professional/community/cfboguidance.html. Accessed August 6, 2010.

  21. Pandemic and All-Hazards Preparedness Act. PL 109-417; 109th Congress, 2d sess. December 19, 2006. http://frwebgate. access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_ laws&docid=f:publ417.109.pdf. Accessed August 6, 2010.

  22. Homeland Security Presidential Directive 21: Public Health and Medical Preparedness. October 18, 2007. http://www.fas.org/irp/offdocs/nspd/ hspd-21.htm. Accessed October 13, 2010.