EIIP Virtual Forum Presentation — May 13, 2009

Averting the Tipping Point
Risk Communications for Swine Flu and Other Healthcare Emergencies

Suzanne L. Frew
Risk Communications Consultant
The Frew Group

Amy Sebring
EIIP Moderator

The following has been prepared from a transcription of the recording. The complete slide set (Adobe PDF) may be downloaded from http://www.emforum.org/vforum/flu/fluriskcomms.pdf for ease of printing.

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon everyone. Welcome to EMforum.org. Our topic today is "Averting the Tipping Point: Risk Communications for Swine Flu and Other Healthcare Emergencies" and we will be interested in hearing about your experience with and opinions about the recent events.

As usual, there is a related survey on our home page, "Overall, the flu communication in your community has been: Poor, Fair, Good, or Very Good." Please take time to participate and review the results thus far. Also, we will be using a Live Meeting polling tool in real time to ask related questions during the program today.

Now it is my pleasure to introduce today’s guest: Suzanne Frew is an international consultant, speaker, facilitator and instructor in emergency management throughout the United States, the Pacific Islands and Southeast Asia. She brings almost 20 years of public and private experience spearheading, designing and evaluating pre- and post-disaster risk and strategic communications, emergency management plans and partnership initiatives.

Through The Frew Group, her consulting practice based out of the San Francisco Bay Area, Suzanne works collaboratively with government agencies, business, community and faith-based organizations to develop solutions that meet the unique needs and circumstances of stakeholders at the national, regional and local community level.

Suzanne specializes in the communication and strategic/tactical planning needs of multi-cultural, high-risk populations, addressing cultural, socio-economic and faith-based concerns of "communities within the community" to develop sustainable approaches that engage priority audiences. Please see today’s Background Page for further biographical information, and links related to today’s topic.

Welcome Suzanne, and thank you very much for being with us today. I now turn the floor over to you to start us off please.


[Slide 1]

Suzanne Frew: Thank you, Amy. I appreciate it and welcome everybody, all of our participants. First off, let me just thanks so much, Amy and Avagene, for inviting me to join you all today for this very interesting topic.

[Slide 2]

I’d like to just go ahead and get started, focusing on sort of a premise of everything to do with communication which is, if there is a disaster risk to the community, folks need to know. They deserve to be informed. I want to use that as a baseline as we go forward into our discussion today.

[Slide 3]

Let’s chat about the context. What’s happening right now? What’s the big picture? There are a lot of new health risks that we’re starting to see emerge. There are a lot of risks overall. In the health care arena, also in dealing with all the concern regarding terrorism or natural disasters, but there are new challenges that we are now facing. In the context of the new challenges that are coming on board, we also have a lot of other things happening.

We have a lot of communities that are shifting, the demographics in the United States are shifting, older communities are growing, metropolitan areas are getting a lot of new people coming in, we’ve got very concentrated areas, and we’re very connected. The issues on globalization are really changing the way we take a look at how we do our business, how we really reach out in the public sector to safeguard the communities from whether it’s H1N1 or some other type of health care risk.

The interesting thing now as we look at this, there’s a lot more response integration. We’ve got public health working more closely with private sector, working more closely with emergency managers, with the academic community, so there are shifts going on as the agencies are beginning to come together a lot more than we were five or ten years ago. On top of that, we have a tremendous explosion of opportunity to reach out to the community and to communicate. We’ll talk a little bit about that.

[Slide 4]

For me, I’ve been involved with this for about 20 years, working in the whole disaster arena, starting with FEMA and then going out into the private sector, really focusing on this whole communication issue. In the public health arena, I’ve had a chance to look at these issues, when I’ve done training for, for examples the California State Department of Public Health, also working with local/city/county health jurisdictions on planning.

I’ve really felt the impact of what it’s like when you have an event and no one knows exactly what is going on. When I was over in Thailand a few years back teaching Risk Communications to emergency managers when we had the avian flu outbreak, and there were tremendous amounts of questions and we didn’t have a good sense of what was going on. There we had up close and personal, we had chicken dying around us, and we had a lot of people trying to figure out how we manage the media and to get that communication out.

[Slide 5]

Now let’s take a look at, just a very quick snapshot, of what is it that we’re talking about here. This flu pretty much emerged probably last fall (the focus of this is on the communications) but just sort of a background, we think it emerged last fall, a few months back, possibly in Mexico, I’m not the flu specialist, but we do know that on April 26 on a Sunday, the HHS Secretary declared a public health emergency in response to this outbreak.

Now these statistics that we put up her a couple of days ago when Amy and I were loading this up, but now we do know that we’ve got quite a few confirmed cases, over 3,300 confirmed cases in 45 different states, with Wisconsin really taking the lead, followed by Texas. We have some deaths in the United States and we’ve got people hospitalized.Internationally, the mortality is obviously much, much higher. It’s in 33 countries. We’ve got deaths in certain countries that we have not been experiencing here in the United States.

[Slide 6]

So what’s been shifting? We know it’s been fairly mild. The regular flu, we all know, kills tens of thousands of people every year. We do need to realize that the swine flu (and I will use those words although I know a lot of folks would prefer to use the H1N1, just for the sake of our conversation here, I will use "swine flu"), but it has killed. The situation has calmed down dramatically. It has pretty much normalized. There are still some sanitary filters in place.

What’s the concern now? Where are we looking at? What’s happening now? Well, it’s moving into the Southern hemisphere and the flu season is just beginning. We also know that the virus could be mixing with other flu viruses. We really don’t know what the output is going to be. We don’t know what these new strains are going to be. In the background, the World Health Organization, the Public Health officials, the Emergency Management officials, back in the back of their minds, they’re saying, "What’s going to happen? We don’t know. Come November, what’s it going to look like? And are we ready for that?"

Let’s now go in and let’s do a poll. So we really start talking about the communications. How did you feel the H1N1 was handled? We’d just like to hear back, because that’s a big part of what we’re doing today, getting that sense.

[Poll Question 1]

How did you feel the H1N1 Swine Flu communications were handled?
Results: Appropriately = 25; Inappropriately = 8

It looks like we’re getting some folks more in the favor that it was handled appropriately. It looks like most of us felt that it was for the most part that it was handled appropriately. Good.

[Slide 7]

Let’s take a look now at really what are some of our big challenges. We’re getting out there and the folks that are on the call, we’ve got people from different sectors. But the big challenge that we’re all facing, whether we’re coming from the private sector, the public sector, whether we’re working with non-governmental organizations, community based organizations, we’ve got to communicate the risk. We need to communicate that risk way across all the different communities we need to serve, with a lot of different viewpoints out there.

Amy talked about the community within the community. There are a lot of pockets of individuals who perhaps don’t speak English as a first language, who are not familiar with how the system works. Our big challenge is upon us to figure out how to get people to really understand what we’re talking about and to reduce the risk. If it becomes a major event, to respond, and ultimately, to recover.

This is for the H1N1. It’s also for any other public health emergency, or any other type of emergency, whether we had an incident where we had some kind of toxic release from a train derailment, where we had a plume that’s gone up, communication challenge pretty much remains the same.

[Slide 8]

Let’s think about what some of those key health risk concerns might be. As we look at this, we can kind of look at this as a kind of checklist of "wow, if I’m out there and trying to put a communications campaign out there, and needing to address community issues, what are some of those questions?" Well, what’s the hazard? What is it that we’re really talking about? A lot of people are trying to say, "can we get it, can we not get it"? How far is the exposure going to be? If it’s a health care problem, is it going to expand, or is it going to stay very localized? Those are the kinds of questions and concerns that communities have that we really need to be able to address in our communications.

What type of harm is it going to be? Is it going to be skin? Is it going to be something that’s going to be inhaled? Is it going to be something that’s going to burn us? Is it some kind of chemical release? Really understanding that, and who it is that’s going to be impacted? And what happens if it expands and goes in with some other type of hazard? Really sizing up the characteristics and who all is at risk. These are some of the key risk concerns when we start talking about communication as we start thinking about communications that it’s very important to address when we go out there.

[Slide 9]

What I’d really like to point out is four key pieces to kind of keep in the back of our mind which is especially when it comes to health care issues, is that going beyond the technical information level and science to really reach out to that emotional level. That’s really fundamental to having a good communication outreach. Oftentimes, we don’t know anything. If the data are out there, we don’t know if they’re complete. We don’t know what it is. This happens a lot. We’re in real time. It’s not Monday morning quarterbacking. We’re out there trying to get messages out.

We do know the Red Cross has done loads and loads of studies early on, Rocky Lopes and a lot of our friends have looked at things that have said, from the Red Cross and other organizations that said: Reassurance factors are very critical—if you scare them, it just increases the fear. It doesn’t do us well in the long run, especially if we have real timely issues.

[Slide 10]

What are some of those issues that we might want to address? Well, everyone’s going to say "wow, what’s the worst thing that could happen?" What’s the likelihood? What’s our safety limit? Do I need to get Johnny off the soccer field? Do I need to keep my kid home? Do I need to go into work? Should I cancel my airplane trip? Those are the kind of issues that start coming up.

How is the media handling this? That’s always the big question. How do I figure out what’s real and what’s not real? What do I do about it—always the bottom line. What do you want me to do about it? And knowing that they’ve got good solid information sources to go to, always an important issue that we should address.

[Slide 11]

Let’s think about, how do we really put together an outreach? How should we really go about that? Well, I can go back to the old-fashioned step approach. First off, they’ve got to have access to it. I used to say they need to hear you. Now it might be they need to see you by texting. We’ve got to get that information in front of the people who are at risk.

[Slide 12]

Then, they need to understand what we’re saying. It needs to be culturally appropriate. It needs to be very understandable and not very technical terms. It also has to be very believable. So whoever we’re putting out there on the front line needs to be able to believe. Then we’ve got to figure out what that means for them.

A lot of times, one of my colleagues, Dennis Malletti, who is a communications specialist, always talks about the milling factor—let’s talk it out, let’s figure out, what do you think? How do I handle this? There’s going to be some pieces in there. And then, really getting them to respond. Getting them out there to do something where they will take some action and not just listen.

[Slide 13]

One of the first things is figuring out, who do we really need to address? In a lot of environments, it might be the young, it might be the old, it might be people who live in very confined quarters. Before, I lived in the San Francisco Bay area, a place like Chinatown, where you have very high density. Those are key issues. Figuring out who that priority audience is is very important.

[Slide 14]

How do we set where our priorities are? In the old days, we used to definitely silo our approach. Now, let’s get everybody involved. Figure out who’s out there, who can be our partners, our champions, who can in essence carry our water and take that message. All the way through what we’re doing, figuring out, getting input, getting feedback. Are we right? Are we wrong? Are we missing? Always asking for feedback. Too often, we don’t ask for enough feedback.

Being consistent in what we’re saying—all the different players saying the same thing, and getting it out promptly, especially critical and public health issues. Getting that information out in a 24-hour, around the clock new cycle, we can get information out. We’ve got a lot of sources now. All the social medias—the Twitters, the means—the all kinds of new social media. We’ve also got the traditional media that people turn to. We’ve got official statements. We’ve got all kinds of ways that we can get out there now. Especially for a lot of hybrid communities, the importance of social networking. But through all of this, really figuring out how to retain our credibility and trust is absolutely critical in a public health environment.

[Slide 15]

One of the things that I wanted to throw in here was who our stakeholders are. Who is it that we really need to get out to? Especially in public health, if people don’t necessarily trust a public official, or they don’t really engage that much with a school official, figuring out who it is that people really trust and they will listen to. It could be state safety organizations. It could be the social networking through soccer clubs, or through civic clubs. Figuring out in our own communities who could be our best message carrier and figuring out who can get that information to us. That’s who is really critical to work with.

[Slide 16]

Let’s think about, in this environment, what’s been going on in the swine flu environment. What are some of risk communications that have been out there, whether it’s been a lot of passive work, for example, through the web. There’s been very active work, we’ve got people being able to call in. The social media, where they’re pushing messages out. So there’s been sort of two phases—the passive and the active.

What I listed up here are just some examples—the CDC, extremely proactive, getting that information out there, up front, all very regulated, pushing it out, to the state public health departments. I know that the Rand Corporation went and did survey work on this, and they found that states, for the most part, a great many of the states had come up and put out information right away on their websites, either through direct link to the CDC or primary site information.

So we’ve got the CDC pushing out a lot. The World Health Organization was providing some good interactive tools, pushing out information. Again, the state and county and local health departments were pushing out websites. One of the findings of the Rand study was that the state tended to have a bit more information than the locals, and it could be because of cutbacks in budgets and money, but that seemed to be on of their findings.

One of the things that was a concern was the fact that there wasn’t a lot of variety in languages being accessed, but the bottom line was that there was a lot of information out on the sites. There was a lot of private sector, for example in the Bay Area, BENS (Business Executives for National Security) were quite proactive with conference calls, with local departments of emergency management and public health, and then also doing interaction work, interactive media work. Then CARD (Collaborating Agencies Responding to Disaster) were active on some of the social medias, like Twitter. So there was a lot of proactiveness, and then on list serve—we all got a lot of list serves.

[Slide 17]

I think we’ve got some basic overviews of what those messages were. It was about what it was, what the swine flu was, how to prevent it, what to do about it, how to control it in your environment. What are some of those emergency actions, what impact was it going to have on the community and what’s the kind of follow-up? What do we need to do to follow-up?

[Slide 18]

I think right now, the big question is, did we avoid some kind of tipping point by this proactivity, or was it hyped up? Now’s the time for a lot of Monday morning quarterbacking, so to speak. We’ve seen a lot of comments coming out on the press, a lot of the pundits talking about things. Our big question is, what do we all think? We’re very interested in everybody on the call. How do we feel? We do have some questions and we’d like to take another poll. The first question is: Do you feel that the H1N1 information provided to the public was not enough, was it enough, or was it too much. So take a few moments and fill it out.

[Poll Question 2]

Do you feel the H1N1 information provided to the public was:
Results: Not Enough = 2; Enough = 24; Too Much = 5

It looks like we’ve got some folks saying it was enough. We’ve got enough response back. The bottom line from this poll is that it was enough. It was good information, it wasn’t being too much. There are some individuals who are saying not enough. Perhaps that might be in some of the smaller communities. There were some indications that in some of the states there wasn’t a lot of information at the local level, so perhaps this might refer to that.

Let’s go to the next poll. In our next poll, do we think that this experience will strengthen our ability to address public health challenges in the future?

[Poll Question 3]

Will this experience strengthen our abilities to address public health challenges in the future?
Results: Yes = 31; No = 1

Okay, good. That’s pretty much an overwhelming response.

I think that’s an important piece on here, because especially in a public health environment, the good news is, we haven’t had a lot of opportunities to exercise and rehearse. That’s the very good news. Now, we’ve had an opportunity to really push things out there, and it looks like all our participants feel like we will be able to use this experience to get out. That’s good, because there’s going to be a lot more focus on measuring our ability to prepare. State, federal and local governments are really investing heavily on figuring out how to measure what we’re doing on this preparedness. This poll is a good indication.

[Slide 19]

We’ll go back and just say sort of as a closing spot. Hofstede is a European theorist who really sums it up well. The point is we’ve got to work together on this. I think this is a very good example of how we came together, no matter what the risk level is, or the hazard, and what sector we’re coming from, doing this proactive planning process and getting out there, that’s what it’s all about. Hopefully, we won’t have to wait for a crisis situation, but we can move into this real proactive planning, and especially provide support to especially the local level participants.

[Slide 20]

At this point, I would like to say that if anyone has any questions for me, please feel free to shoot me an Email and I’d be happy to give you some information back. At this point, I’ve really enjoyed being with you, and let’s turn it over to Amy for the next session.

Amy Sebring: Thank you very much Suzanne. Now, to proceed to our Q&A.

[Audience Questions & Answers]

John Bowman: What do you mean when you say "the tipping point"?

Suzanne Frew: The Tipping Point is basically from Malcolm Gladwell, who is an author, a few years back put out some very good literature regarding what does it take to move information or to move a social movement through a community. He likened it to a match being struck and flaring up. When it takes over, it sweeps. That’s what I was referring to on this, which was averting that sweep of any kind of major concern regarding swine flu or our response to it.

Paul John: Suggestions on continuity of operation such as allowing working from home?

Suzanne Frew: The continuity of operations is, there are plenty of materials usually found, you can go on, you can Google—all of the states have been pushing to have continuity of operations. What that means, for folks who might not be familiar with the term, is how do we keep business going as usual? The concern is, if you’ve got a public health care emergency, where there might be contagious elements out there, how do you keep businesses going, how do you keep schools going, when one of the things is social distancing. In public health care, that is one of the key ways you can work around it, which is keep folks about. Don’t go in big public environments, work from home.

Working from home, of course, if an extremely important approach for doing some. They might call that alternate worksites. Finding new worksites, places you can work, where you can be separated from other individuals who might be contagious. The continuity of operations—there should be lots of materials online, and I would also encourage asking your local emergency managers about their continuity of operations planning that’s going on locally or at a state level.

Rocky Lopes: Why do you think the media became so hysterical about this matter and do you think they contributed to misunderstanding and (potential) misbehavior by the public (such as wearing dust masks while walking down the streets?)

Suzanne Frew: I have thoughts on that. Your opinion would be that the media was hysterical. I know your opinion is shared by quite a few out there. There have been emails that have been coming out regarding the way that the press has been handling it. I think there are a few things. I think on the very practical level, news sells, and this kind of thing sells. We’ve got 24 hours around the clock where we have to provide news. It’s a good way, we’ve got a lot of problems right now going on with our newspapers being able to stay in business, and good information that’s unclear. The data is not there exactly. That’s one of the reasons why perhaps we might see such a focus.

Do I think that this contributed to the misunderstanding? I also think because we didn’t know what we were dealing with and because the public health officials weren’t exactly sure what we were dealing with, it wasn’t the regular flu. It was coming from international quarters as well. Because of the transitioning, transnational travel of individuals, we saw that with SARS, we saw the consequences of that with SARS where we had a lot of quarantining going on. People tend to be, in many ways, very proactive on it.

CDC apparently has a motto that says, "Be first, be right, be credible". Getting it out there, and I think perhaps that there was some information on that, and that’s what the news was doing.

Brian McClory: While the communications from Government groups was appropriate, the media seemed to create a level of ambivalence in the general population by hyper-focusing on the issue at the onset. What lessons have been or should be learned about managing the media’s focus on items?

Suzanne Frew: I think one of the things (remember, I just said what the CDC motto was, "be first, be right, be credible) that everybody has looked at, even the Rand corporation put out a release that actually Rocky was kind enough to have sent me yesterday, which was early risk communications by state and local health departments during swine flu epidemic and assessment of performance, and one of the things they were looking at was, how fast did they get it out?

One of the key pieces here was, when you have some type of public health emergency, that first 24-hour period, that first period where people are trying to figure out what it is and take care, looking at what happens right on early on, so I think that there was the issue at the onset again, go back to my point earlier—we didn’t have all the data. I think that’s the key, and we’ve seen it in the past, with public health issues in the past.

Trust me, when I was in Thailand, when we were listening to the news reports and we were trying to figure out what was going on with the avian flu, and I was there with public affairs officers trying to figure out, how do we manage this? It was becoming an economic crisis. The fallout with that was, more proactivity earlier on.

The way we handled that—the media can be our best friend and our worst enemy. Having been a public affairs officers for the feds on this stuff, getting to know the media, getting to know our reporters, getting to know our outlets before this ever happens, is one of the key—you don’t need to be waiting until the last minute to be picking up the phone. We need to know those reporters’ names, we need to know the folks who are actually pushing that information out.

Hank Straub: Suggestions for overcoming suspicions by cultural/ethnic/special interest groups about measures the government is trying to implement during an emergency, e.g. reluctance to report to a POD for medications?

Suzanne Frew: This is definitely a big concern of mine. I call it the "communities within a community". The issue has been, consistently (we’ve been dealing with this for years now) which is, if you’ve got public health concerns, and you’ve got large population groups who do not, for example, trust the government officials and will stay away. How do we deal with that? How do we get that information out?

This has been an issue, and this is not just public health care, this goes across the board to everything regarding disaster. First off, you saw the slide I put out earlier. This is where we go to our stakeholders. This is the social networking. When I was working with community resiliency for FEMA (I’m going way back then) when I would go out into the communities, I would say to the leaders, "get somebody else who is from that organization, that demographics group, that cultural group, to carry that message for you". It’s much more powerful to have somebody who speaks the language, who is from the community, who has the trust and the credibility to get in there. That’s the kind of thing that we can break through. We know that we can break through by partnering up with these stakeholders.

Art Botterell: Suzanne, you touched on the problem of communicating uncertainty regarding risks. There's a tension between being quick and being precisely accurate. Could you say a bit more about that? How important is it to be precise, and how can we do better at communicating information that isn't precise?

Suzanne Frew: We always say, "Tell them what we know, appropriately. Tell them what we know and tell them what we’re going to get to them". That is so important when we don’t know—let’s just take something that’s not even healthcare. If we have an earthquake, or we have a dam that’s breaking, if we have information that we do know, one of the biggest things is getting out the information, as much as we know, and what we’re going to do about getting them the information to clarify.

I think Art, who has an extensive background on dealing with these issues, knows so well that when we don’t have that information, it does create a lot of uncertainty. What we can do is say, "This is what we know, and this is what we’re doing to find out". That’s going to be the best way to approach. And importantly, this is what you can do, as a priority audience or our community members, this is what you can do to keep abreast of what we find out. Tell them where to go, tell them what they need to look for, and what to do in the meantime. Giving them very specific actionable steps, culturally understanding how to do that, is the best thing we can do.

Jo Moss: What Joint Information System guidance do you have for local jurisdictions to ensure that all messages are coordinated, consistent, and consolidated? Who should be part of the system (more specific than "all stakeholders")?

Suzanne Frew: I’ll give an example here in the Bay Area. One of the things I participated in a couple of years ago was for a regional joint information effort, where we were pulling together across jurisdictions, because a flu bug doesn’t stop at the county border. It crosses over. If we’ve got contamination in a water system, it’s a huge concern for many of us. That water doesn’t stop at one residence, it keeps flowing through those tubes.

Figuring out how to work across jurisdictional boundaries, how to figure out going in an working with our state and our county and our local jurisdictions to pull these messages together and to have a cohesive message. The message needs to be cohesive; everybody needs to be on board.

What we did here in the Bay Area working with a regional coordination planning effort, that Art Botterell was very actively involved with as well, we brought the stakeholders together, the emergency managers, we brought public health together, we brought individuals from the airports, from all the different transportation agencies, from the community based organizations, those that really reach out to those who often live below the safety net, that have very low income or are from the medically fragile communities. Making sure that folks were there at the planning session and figuring out how we work together to get those messages out, who can help us get those messages out when they need to get out—so getting everybody to the table.

All states and local jurisdictions should have joint information processes, and certainly the feds do as well. CDC has some excellent materials that have been put out on how to deal with public health. I do lots of trainings in this for all kinds of clients. There are a lot of opportunities out there. I would say, many stakeholders across sectors, public/private, and getting them together way before an incident takes place, and doing follow up after an incident takes place.

Amy Sebring: Suzanne, I would like to put a question out to the group to stimulate a little more comments on experiences that may have had during this episode, and what I am interested in knowing is was there better coordination between public health and emergency management doing this? In the past we have seen them developing their efforts in some cases in parallel, but not terribly coordinated together. So, I would be interested in some feedback from the group that is here today. Did emergency management and the public health sector work well together?

Rocky Lopes: Is there a trick to teaching medical professionals how to speak plain English? They did better this time, but there still were some docs interviewed on TV who spoke using technical language that frightened more people than reassured them. (examples available on request.)

Suzanne Frew: As Rocky certainly knows, and that’s what I talked about earlier on, communication goes way beyond the technical information and the scientific data. There’s so much emotion packed into these messages that go out. The scare factor is huge. I really want to applaud, for example, San Francisco Department of Health, when they were getting out there to say, when we had conference calls here in the Bay Area, some of the individuals who were engaged, like I talked about earlier, BENS (Business Executives for National Security), a lot of those got together, they put information out, they made information accessible.

One of most important things, was the first thing that was said was, "comments that reduce the fear factor", and I really think that’s really important to see. Figuring out ways to support doctors and nurses, and anybody who speaks technical language, figuring out ways to keep it very simple, is critical.

The big challenge that I’ve seen in the past when I was teaching with public health, is that when you have an issue that is not fully understood, people sort of stick into the data and don’t go into what the data means. They’re oftentimes trying to explain what it is. We don’t know exactly what this mutation pattern is. We don’t know when it’s going to pop up again. People tend to stick back into the tech talk. Tech talk destroys public trust a lot of the time. Talk to me like I will understand. Usually critical, and elderly population, and children populations and non-English speaking populations.

John Bowman: In response to the moderator's question: I'm in Toronto. Our experience with SARS helped ensure close collaboration between public health and emergency management. Plans developed post-SARS were very effectively activated.

Jo Moss: In the Austin, Texas, area our health and emergency management partners worked well together. It took a little longer to get school districts involved in the process, which was important since school-based decisions had a big impact on the fear factor and the perception. Any suggestions?

Suzanne Frew: Let me respond to a couple of things. One is Toronto, our colleagues from the Toronto: I did interviews with some of the individuals who were in charge of that SARS outbreak up there when helping develop some alternate care site plans for local jurisdictions. Yes, they were very proactive after the SARS incident, and very honest. I think that’s extremely important. The individuals that I spoke with said, "Yes, looking back we would have perhaps done it differently". I think doing that post-mortem where you can go in and identify where we can make it better.

First, they came up with planning documents and tools, but then they also shared. That is also critical, too, not keeping the information so tight, but being able to share it out. The point is, this is about public safety. We need to share with our colleagues across jurisdictions, whether they’re national jurisdictions or state jurisdictions. That’s a very important piece.

In Texas, one of the areas that had a lot of outbreaks (I think they were second behind Wisconsin), the issues with the school districts, those were issues. That was one of the things that got people questioning. Do we shut down the schools? Do we keep them open? In my area, I have an eight-year-old in school in the local area, in a private school, and there was information that went out through her school, there were links given to all the parents to stay closely in touch with the county public health department.

That’s an important thing to do, to keep those links with the public health. Our school did that. We had a bad experience on a health outbreak, and we learned our lesson. Learning our lesson is a very important piece on this.

Art Botterell: I think this was a great "team building" opportunity between the health folks and the emergency managers. Real-world events are great for revealing the blind spots that can develop in formal planning... which is why this relatively benign event (as it turned out, at least so far) has been so beneficial. Now the challenge will be consolidating the lessons learned and converting them into behaviors next time.

Suzanne Frew: I could not agree more. That’s the big challenge where public health is involved. We don’t have a lot of opportunities to really rehearse outside of specific exercises, but we’re hoping everybody will be doing trainings and exercises, getting that information out, especially if you’re in a very huge mega-city environment, where you’ve got a people breathing the same air in transit, in public transportation, and in school districts, in all kinds of places like that.

The team-building aspect of this could not be emphasized more. We know that there are some jurisdictions that did a great job getting everybody together. I would say, in addition to the public health and the local emergency managers, this was a very good opportunity where the private sector got involved. If we start looking at those multiple sectors and figuring out ways to do multiple-disciplinary approach, we’re going to learn a lot more. Because we can’t cut it—the community includes everybody. We need to be inclusive.

I will say one other thing on this, too. In the team building, it’s very important to think about who are those who are affected that might not necessarily be in our own backyard, that have relationships with individuals within our communities. That goes back to the continuity of operations question earlier. Often, we look at it as, how does that long distance approach, looking at what’s happening, where our ships go, looking at where our airplanes fly to, looking at where our relationships are. Thinking about that, that’s the continuity of operations. Where our people travel to—there’s a large Samoan population in the Los Angeles area as well as others, there’s relationships between the two, there’s a lot of back and forth. We need to think about those linkages outside of our own jurisdictions.

Elizabeth Friauf: Are there models for city/county collaboration in a crisis?

Suzanne Frew: I think the Bay Area has been doing some very outstanding work through the Urban Area Security Initiative. If you go in and look at who has been doing regional planning, there have been quite a few areas around the country. I would suggest taking a look at what those models are out there, and also going to and talking to your folks at your state.

There has been a lot of emphasis in the recent years on what’s called "mitigation", which is the long-term effects reduction. There has been a big push to have everybody come together at the table. That is all about collaboration. The preparedness—work is being done through the feds, and also through the states. The public health department is really pushing since 2001, they’ve been really investing heavily on this public health planning. Now is the time to really take a look at preparedness.

Go on to the national site, go to CDC, go to your state site, and to DHS/FEMA site, take a look at what resources are out there.

Amy Sebring:
I’m going to throw one more question out to our audience, and then we’ll begin wrapping it up. One of the things I’ve been curious about also is a lot of the pan flu planning was based on alert levels from the World Health Organization, and I’m wondering how did those work out? Is that something that folks are going to be taking a post-event, lessons-learned, closer look at, those alert levels?

Suzanne Frew: I would like to put it out to our audience, I really would, because that’s a great questions. The pan flu piece has been hovering over everyone’s head. Some of our local counties where I am here in the Bay Area have been very proactive in trying to address what that looks like and how to get that out there. How that interfaces with what we’ve just experienced now is a good question.

I just want to say that I think you all brought this up to the Forum, brought this out so quickly, because I think that especially as we’re going to see over the next few weeks, we’re going to see a lot of feedback about how it was handled correctly, how it wasn’t handled correctly. It happens in every disaster. I think this was a little bit unique. We don’t know what’s going to happen, going out into the future.

Having looked at what we went through with SARS, what we went through with the avian flu, what we are still going through with this, I think the health care issues are going to continue to grow, whether it’s this virulent tuberculosis issue, which some communities are dealing with. I think because we’ve got more globalization going on, we’ve got people, and things are going to be coming in from other countries, we’re taking them out.

We don’t need to just walk away and not do some looking back and figuring out how we can make this better. We can look at it as an exercise. We can also look at it as a way to simulate some dialogue with our stakeholders in our local communities and to move it forward. Hopefully, by the time a next event does happen, whatever that event is, we’re going to have some closer collaboration with our stakeholders.

So thank you all, Amy, for making this a Forum event.

Art Botterell: The geographic-distribution-based WHO levels, in particular, were problematic because they were apples-and-oranges with the severity scales being used locally. We need to be careful generally about using these sorts of specialized "codewords" without explaining them. They may be convenient for us, but they're potentially very confusing for our audiences.

Hank Straub: Foreign governments implemented different detection/mitigation measures in response to the H1N1 outbreak. For instance, the Chinese did not hesitate to employ quarantines and forced isolation whereas the Japanese relied more on monitoring and surveillance of symptoms. What sources of information are available to companies with overseas operations in this regard?

Suzanne Frew: They’ve had a really difficult time. They’ve had to do quarantines before. When we had the SARS outbreak, there were some serious quarantines, and isolation. But look at the Japanese. The Japanese have had some difficult experiences on their subways, when there were toxic releases in their subways through terrorist action. The Japanese have had their own set of experiences, just like the Chinese have had their set of experience, and now the U.S. is having theirs.

One very good source of information that we can go to is the World Health Organization. We can also take a look at the International Association of Emergency Managers (IAEM) and we can post questions to them, because that is what they are there for—for resources. There are certainly resources out there in Asia, for example, the Asian Disaster Preparedness Center has been on the ground providing information there regarding the H1N1 and sending out information.

I would suggest take a look at the existing organizations, the professional organizations, and also find out, too, through the business community, especially ones that have multi-national corporations, what kind of continuity of operations planning has been put in place. You can pull that down then into your own local community or apply it. The coup, continuity of operations planning, is something that everybody is very aggressively being involved in right now.


Amy Sebring: Time to wrap for today. Thank you very much Suzanne for an excellent job, and we hope you enjoyed the experience.

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Thanks to everyone for participating today. We stand adjourned.