EIIP Virtual Forum Presentation — August 8, 2007

Community Engagement
Leadership Tool for Catastrophic Health Events

Monica Schoch-Spana, Ph.D.
Senior Associate, Center for Biosecurity
Assistant Professor, School of Medicine, Division of Infectious Diseases
University of Pittsburgh Medical Center (UPMC)

Amy Sebring
EIIP Moderator

The following version of the transcript has been edited for easier reading and comprehension. A raw, unedited transcript is available from our archives. See our home page at http://www.emforum.org

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon everyone. Thank you for joining us today. On behalf of Avagene and myself, welcome to the EIIP Virtual Forum! Our topic today is the "Community Engagement: Leadership Tool for Catastrophic Health Events."

This recently published report of the findings and recommendations of the Working Group on Community Engagement in Health Emergency Planning, organized by the Center for Biosecurity of the University of Pittsburgh Medical Center, provides mayors, governors, and health and safety officials with recommendations on why and how to involve community partners in disaster- and epidemic-related policymaking. The actual document may be accessed from a link on our Background Page or directly at:


Now it is my pleasure to introduce Dr. Monica Schoch-Spana, Chair of the Working Group and Senior Associate with the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC). She is also an Assistant Professor in the School of Medicine Division of Infectious Diseases. Over the last nine years, Dr. Schoch-Spana has briefed numerous federal, state, and local officials, as well as medical, public health, and public safety professionals on critical issues in biosecurity. She also serves on the faculty for the National Consortium for the Study of Terrorism and Responses to Terrorism (START), a university-based center of excellence supported by the U.S. Department of Homeland Security.

If you have not already done so, please review our Background Page for further biographical details, as well as links to materials related to today's topic.

Welcome Dr. Schoch-Spana, and thank you for taking the time to be with us today. I now turn the floor over to you to start us off please.


Monica Schoch-Spana: Many thanks to all of you for joining me today, and to Amy Sebring and Avagene Moore for inviting me to participate in the web forum. My comments will address three main items: the WG process (e.g., members, goals, evidence), the major WG findings, and their implications for practitioners and policy makers. First question:

What was the Working Group on Community Engagement?

The WG was an advisory group convened by the Biosecurity Center in 2006. The purpose of the group was to counsel government leaders and public health and safety professionals on the value and feasibility of active collaborations with citizens and civil society institutions in preparing for, responding to, and recovering from an extreme health event.

Members included decision makers at all levels of government; public health officials who have responded to high-profile events; heads of community-based partnerships for public health and/or disaster mitigation; and subject matter experts in civic engagement, community development, risk communication, public health preparedness, disaster management, health disparities, and infectious diseases.

Informing the WG's deliberations and final recommendations were members' experience and professional judgment as well as evidence obtained by the review of relevant literatures including social and behavioral research into hazards, disasters, and epidemics; the theory and practice of public participation; and medical and public health management of extreme events including pandemic influenza.

In April 2007, the WG released a set of consensus recommendations for governors, mayors, health and safety officers, and national decision makers with homeland security and health emergency-related responsibilities. These are published as "Community Engagement: Leadership Tool for Catastrophic Health Events" in the March 2007 issue of Biosecurity & Bioterrorism.

WG research and deliberations were funded by the U.S. Department of Homeland Security (DHS) through the National Center for the Study of Terrorism and Responses to Terrorism (START) and The Alfred P. Sloan Foundation. However, the WG report does not necessarily reflect views of DHS or the Sloan Foundation.

On to the second question:

What Were the Major Findings of the Working Group?

Finding 1. Members of the public are first responders and outbreak managers, too.

By this we meant the following: Disasters and epidemics are big shocking events that require the judgment, effort, and courage of many people, not just authorities. Research shows that family, friends, coworkers, neighbors, and total strangers often conduct search and rescue activities and provide medical aid before police, fire, and other officials arrive.

During epidemics, volunteers have helped run mass vaccination clinics, nurse home-bound patients, support the sick and their families with basics like grocery shopping and childcare, and participate in policy decisions about drug development and disease prevention.

Finding 2. Stockpiling in case of an emergency is both too much and too little to ask of Americans.

Social networks and public institutions that help people provide and receive help are critical to surviving a disaster, more so than basement stockpiles of canned goods. Because many Americans struggle to put food on the table everyday and because many have no homes in which to "shelter in place," realistic planning entails much more than a list of things people should buy to protect themselves.

Officials need to work with citizens and community-based organizations before disaster strikes to promote all the ways the public can contribute to preparedness, including taking part in policy decisions, building more robust volunteer networks, and obtaining support for tax or bond measures that help reduce vulnerability and improve health and safety agencies. American ideals about self-sufficiency can inadvertently stymie preparedness by undervaluing the benefits of mutual aid. This finding brings us to the next point.

Finding 3. "Citizen" preparedness must look outside the individual home to the civic infrastructure.

People live, work, play, worship, and vote together, and these networks form a local infrastructure that should be involved in disaster planning. This approach to disaster readiness improves upon today's mass education efforts directed at a largely anonymous and individuated "public."

The civic infrastructure represents many heads, hands, and hearts-real persons bonded to one another who hold knowledge, experience, skills, and goods that can help emergency response and recovery. For example, trade groups, neighborhood associations, faith communities, fraternal organizations, chambers of commerce, ethnic centers, voluntary associations, and social service agencies all have members and contacts who can help each other as individuals, or who could be called upon as a group to help others.

Finding 4. The civic infrastructure has much to offer before, during, and after an event.

Before a disaster happens, the civic infrastructure can raise awareness, energize trust in authorities, help decide fair and feasible contingency plans, set realistic expectations about community-wide resources, and delineate shared responsibilities to protect against mass tragedy. The pre-event inclusion of civil society groups in emergency planning is essential.

During the crisis, civic networks can relay self-protective advice, reach out to people who do not use mainstream media or who do not trust public officials, provide information about what is really happening on the ground, and give material and moral support to first responders and health professionals.

Things do not end at the response period either. Following an emergency, the civic infrastructure can help recovery by providing comfort and reassurance to citizens in ways that government cannot, and by recommending improvements to public policies that guard against extreme events and that shape future response and restoration.

Finding 5. Adept crisis managers engage community partners prior to an event, and not just hone their media skills.

Recently, officials have improved public education and crisis communication efforts for natural disasters, terrorist attacks, and health emergencies like pandemic flu. They have relied on press releases, pamphlets, websites, and other mass media, and consulting with target audiences through focus groups and advisory panels has helped make the messages more meaningful.

But in each of these instances, information flows in one direction-from officials to the public, or vice versa-and officials determine when information is released. Community engagement, on the other hand, is a two-way exchange of information that allows for joint learning and problem solving over time and that outlines the responsibilities of authorities, local opinion leaders, and citizens at-large about a matter of public concern.

Finding 6. Partnerships provide leaders the wisdom and courage to weigh tradeoffs and confront difficult scenarios.

The community engagement model keeps a dialogue going about complex issues, and it brings together diverse parties to create and implement solutions. This kind of collaboration has helped communities navigate through tough issues that combine social values with scientific and technical information, including "Brownfield" management, environmental health, and nature conservation.

Health emergencies pose ethical issues such as: who should receive the limited supplies of life-saving medical resources, and where is the balance between personal civil liberties and government controls to prevent the spread of disease.

Dilemmas such as these should be planned for in advance and with input from local opinion leaders and community members, so that when a crisis situation is evolving, authorities can exercise better judgments that represent citizens' best interest and reflect the community's wishes.

Finding 7. Certain ingredients are necessary for genuine community engagement.

Like other enduring public works --roadway maintenance, economic development, etc.-community engagement in health emergency policy requires top level support, proper budgeting, dedicated personnel, careful planning, and tracking of success. Disasters and epidemics are high impact, low probability events, and not at the forefront of most peoples' minds; so involving citizens in the policymaking process will more likely succeed if laid upon some prior structure.

Deliberate outreach-through trusted intermediaries-to groups who are typically absent from the policymaking table will be necessary to include the perspectives of the poor, the working class, the less educated, recent immigrants, and people of color. Institutionalized resources to interface with civic groups are a measure of good government.

Finding 8. The community needs strong health and safety institutions with which to partner.

Several recent disasters highlight survivors' creative coping and the generosity of others: people taking in strangers displaced by Katrina, the ad hoc fleet ferrying people away from lower Manhattan and the smoldering twin towers, physicians volunteering to work at understaffed Toronto hospitals during the SARS outbreak.

Private industry, civic groups, nonprofits, and individuals all play important roles during extreme events. Government need not and should not act alone, but sharing the burden of immense and unexpected tragedy requires strong and vital health and safety agencies.

Public institutions have the ability to act in ways that the well-intentioned and under-resourced cannot, as well as the obligation to spur the best use of communally held resources.

Thanks for your patience in reviewing the main findings. Now on to the last question:

How Can We Translate the WG Advice from the Abstract to the Real?

The WG concluded that in the context of a health emergency, strong partnerships between authorities and local civic networks can enhance officials' ability to govern in a crisis, improve application of communally held resources, and reduce social and economic costs.

The Biosecurity Center recommends the following steps to make this scenario a reality in the U.S.:

1. Federal authorities should make a sustained national investment in local health emergency preparedness systems that collaborate with civic groups and incorporate citizen input. Important first steps include:

HHS, when drafting guidance to state and local grantees of the Cooperative Agreement Programs for Public Health and Hospital Preparedness, should convey the value of civic partnerships (as distinct from mass education) to foster neighborhood readiness and to consult, in advance of an event, on community-wide decisions regarding scarce medical resources, altering standards of care, and emergency distribution of medicines.

Congress, when making future appropriations, should fund "risk communication and public preparedness" at a level commensurate with their status as "essential public health security capabilities" as identified in The Pandemic and All Hazards Preparedness Act (PAHPA, PL 109-417). Specifically, Congress should authorize funds that support state/local health agencies in hiring the fulltime staff necessary for community engagement in preparedness and that vitalize the Citizens Corps in more localities.

HHS and DHS-in their joint efforts to expand the Lessons Learned Information System (LLIS) as required by PAHPA-should facilitate the collection, analysis, and sharing of best practices related to civic engagement, volunteer mobilization, and other forms of public involvement in disaster and health emergency management.

2. Action is needed by leaders at all levels, not just the federal, so mayors, governors, and county executives should provide the political support and visibility necessary to institutionalize preparedness partnerships between civic groups and health and safety officials. Key actions at state and local levels include:

Provide financial and programmatic support for a fulltime qualified coordinator within the health department (or emergency management office) with experience in community engagement.

Assess their own administration's means to engage local opinion leaders and citizens at-large (e.g., advisory boards, neighborhood liaison offices, health education and outreach staff) and how these might be tapped for health emergency objectives.

Build community engagement into present pandemic flu preparedness efforts, with special attention to plans to contain the spread of contagious disease; care for large numbers of sick people when hospitals are overburdened; and, handle the dead with dignity in the face of mass fatalities.

3. Change must also come from the grassroots level as well. Heads of community-based groups should contact their political representatives, as well as local health officers and emergency managers, to offer advice on a community engagement structure.

At the same time, grassroots leaders should work with officials to obtain guidance on organizational continuity planning, learn about pre-event protocols for volunteer integration, and discuss a possible "memorandum of understanding" regarding how the group might mobilize its own network as part of a pre-event education campaign and/or crisis & recovery support system.

Thank you for your interest in the Working Group. The Center for Biosecurity would like to invite you to join us in advancing the community engagement agenda forward at all levels of government.

I would like to turn the keyboard over to Amy Sebring, the moderator, and I am happy to take your questions.

Amy Sebring: Thank you very much Monica. Now, to proceed to your questions or comments...

[Audience Questions & Answers]

Rocky Lopes: I work for the National Association of Counties, representing county interests. Is there a reason why you mentioned governors and mayors in most of the presentation and not counties until recommendation #2? I think it is important to refer to counties as well, and include county health departments by specific reference, many of which operate clinics and county hospitals.

Monica Schoch-Spana: Most definitely, county executives have a critical role to play. As we move this agenda forward, we are interested in working with intergovernmental groups relevant to the county level of government.

Ric Skinner: Monica, some of you're action steps track nicely with some of the 53 recommendations made in the AMA/APHA report "Improving Health System Preparedness for Terrorism and Mass Casualty Events." Are you familiar with that report and if so have you considered meeting with the 18 national health organizations in that Leadership Summit which formulated that report to compare notes and recommendations?

Monica Schoch-Spana: Yes, thanks for making that connection. I did review the report when it came out, and those are exactly the collaborating groups we need to move this ahead. I should mention, too, the American Journal of Public Health recently had an article regarding a standard definition for Public Health preparedness and it singled out "community engagement" as a pillar.

Avagene Moore: Monica, I especially like point #5 pointing out that we need a two-way information flow from officials to citizens and vice versa, not the usual public information campaign. I am also impressed that the report findings are relevant to all types of disasters and planning situations. Have the WG report and recommendations been shared with the broader EM community (federal, state and local)? If not, how can we help spread the word to all levels of involvement? I believe this is something sorely missing in this country.

Monica Schoch-Spana: We are preparing an executive friendly "leadership handbook" that distills the WG recommendations. This publication (print and digital) is similar to one we distributed nation-wide in 2004, and with the help of IAEM and NEMA. We'll be looking to these professional groups again for distributing this. In the meantime, I recommend that everyone pass along the quick and dirty briefing materials we have posted at our website, and which Ava and Amy have made available.

Rocky Lopes: Did the WG address the issue of residents providing info up the chain, and lack of consideration of the validity of that direction of information flow? Seems to me always that there is skepticism in info flow "up" rather than "down." I agree a two-way communication loop is important, and we've talked about it a lot, but it hasn't happened with any degree of success.

Monica Schoch-Spana: Good point. Yes, the Working Group recognized that members of on-the-ground communities could pass up information about what's happening around them, and raise the ‘situational awareness' index of decision-makers. Many outbreaks of disease come to the awareness of officials through residents' noting something unusual. Great stories of how it is farmers who play essential role in surveillance of animal-borne disease outbreaks.

Bill Lang: Was there information on how the private sector would be engaged since on any given day many people would be in the workplace? Is it all through existing government or local faith-based groups? We have teams in businesses that take on volunteer work in emergencies and even some life-safety training. How would we integrate?

Monica Schoch-Spana: Yes, the WG made the caveat in its report that businesses are vital to the community's social fabric and can mobilize their own resources for preparedness /response /recovery purposes. The WG, however, chose not to emphasize businesses in its report to the same extent as civic networks because Business Executives for National Security, the Business Roundtable’s Partnership for Disaster Response, and other national initiatives are successfully underway to mobilize private industry around extreme events. Civic-based networks, in comparison, do not yet have a similar mechanism to spotlight and enable their contributions in disasters and epidemics.

Regina Hollins: Will the leadership handbook be available for your "grassroots" groups as well?

Monica Schoch-Spana: Yes, although we have not settled on whether to produce a single leadership handbook or equip heads of community-based groups with a different set of tools; things that they need to know to better insert themselves into formal planning networks, for example.

Joan Valas: Political officials need a short version or you lose their interest.

I recently made recommendations to engage the community to our local OEM, Mayor and Council. The OEM replied that they had lists of addresses and numbers of the elderly and disabled with "life lines." This is typical and problematic when local emergency managers feel they already have things in place. Any suggestions?

Monica Schoch-Spana: Joan, you are right to point out the importance of top leaders embracing this approach. It really has to have their support. But we all know that this is more than having a list of addresses and phone numbers of vulnerable populations. It is about the organizing principles of emergency plans themselves, and whether or not the requirements of the entire, diverse population are embedded within them.

Bert Struik: Is there a collection of community engagement examples? Dr. Maryam Golnaraghi of the UN gave a presentation yesterday (Vancouver, BC) and highlighted Bangladesh as a good example of community engagement in dealing with cyclone events.

Monica Schoch-Spana: Good point. Community engagement is a "squishy" concept so it's good to back it up with concrete examples. Montgomery County (MD) health department is exploring the concept of "neighborhood support teams" with civic organizations and homeowners associations to foster mutual assistance among neighbors and to improve communications between county residents and officials during a health emergency like pandemic influenza.

Amy Sebring: There is a key recommendation for using professionals experienced in community engagement. How many of them are out there? Do we need more specific training developed?

Monica Schoch-Spana: Trained personnel are a critical ingredient. Many of the professionals with this expertise come out of the environmental health wars, for example. We need to pull in those people who have had experience in the interface between community groups and health & safety professions.

Rocky Lopes: I am a civic leader in Montgomery County, Maryland, representing some 50 homeowner and civic groups who reach some 10,000 residents. First I've heard what you have described. I'd like to know whom to contact in my county so we can become better connected.

Monica Schoch-Spana: Carol Jordan, head of communicable diseases was a member of WG. I can send you her contact info off-line, if you like.

Rocky Lopes: This is not meant to be critical, but is a pet peeve of mine. Throughout your entire presentation, you referred to "citizens... citizens... citizens." Does one's United States citizenship (or not) have anything to do with this? (I'm really not trying to be p.c. as much as being inclusive, which is the thrust of your presentation.) Might you consider rephrasing your presentation for the future, to talk about "public" and "residents" and not delineate based on "government-speak" of using the word "citizens" so more will be included and less disenfranchised?

Monica Schoch-Spana: Great point!!!! We struggled over the language of the recommendations quite a bit. We were more interested in raising awareness around "civic networks" than about the individual actions of citizens. Citizen, in the context of immigration reform discussions, is a loaded term. We mean people on the street - regardless of formal citizenship status.

Amy Sebring: Would you agree that community engagement should be implemented for all aspects of disaster planning, that is, not just limited to the public health arena? What kind of structure or framework is envisioned?

Monica Schoch-Spana: Yes. The report focused on mass health emergencies given the mission of the Biosecurity Center but the WG membership represented people with an "all hazards" perspective who were sensitive to the special challenges involving an outbreak of infectious disease. Project Impact was one organizational vehicle that embodied engagement principles.

Amy Sebring: Can you see this as some kind of formally implemented advisory body?

Monica Schoch-Spana: The proposal is not necessarily to create yet another advisory group, but work with the ones you have and bring them into a preparedness and planning agenda.

Avagene Moore: Monica, perhaps I missed it but is there a jurisdiction that you can refer to as a community engagement model? Are there any case studies or pilots ongoing that folks can study and learn from?

Monica Schoch-Spana: Seattle King County has elements of this. They have a Vulnerable Populations Action Coalition (VPAC) that follows this approach. There have also been some experiments at the national level involving public engagement techniques to help decide the policies for prioritizing the use of scarce influenza vaccine during a pandemic and for finding remedies to the social and economic effects of implementing community-wide disease containment measures in a pandemic flu. You can go to the Keystone group in Colorado to access the reports of these endeavors.

Amy Sebring: You mentioned a handbook. Do you have any other follow on activities planned for the future?

Monica Schoch-Spana: Yes. The Biosecurity Center would like to facilitate a national virtual coalition of interested individuals and institutions with expertise and influence in public health, emergency management, homeland security, etc. We would like to have a core who could help monitor policy developments relevant to community engagement in disaster and public health emergency policy-making, and create a strategy for intervening in productive ways. A coalition could present a united front around these issues, and also act as an information-sharing network, circulating best practices, lessons. There are many people working individually on this that need to be knit together.

Amy Sebring: Are you familiar with Roz Lasker who has also been doing work in a similar area, and if so, are you in touch?

Monica Schoch-Spana: Yes, Roz and I have been in touch in the past, and will be participating together in a Congressional briefing in September. Her group is set to release its own report regarding the experiments in this vein being carried out in four localities over the last couple of years.

Chip Hines: It seems to me that there may be a conflict between the roles of emergency managers in this arena and the traditional role of the press. How do you see this working out?

Monica Schoch-Spana: The WG was keen to point out to EM's that they have other communication options out there. Community-based groups are conduits through which information can be channeled to discrete groups within a community. This would be parallel to mass communications model that relies upon the press.


Amy Sebring: Let's wrap it up for today. Thank you very much Monica for an excellent job. We hope you enjoyed the experience. Please stand by just a moment while we make a couple of quick announcements. Again, the formatted transcript will be available later today. If you are not on our mailing list and would like to get notices of future sessions and availability of transcripts, just go to our home page to Subscribe.

We are pleased to welcome a new partner today, Black Coral, Inc.; URL: www.blackcoral.net; POC: Darrell O'Donnell, CTO. "Black Coral Inc. is a leading edge product company developing geospatial collaboration capabilities that enable better outcomes for personnel and tactical teams operating in emergency response and military environments." If your organization is interested in becoming an EIIP Partner, please see the link to Partnership for You from our home page.

Finally, it is my pleasure to invite you to a very special Forum session, next Wed., August 15th, when the EIIP will be celebrating it's TENTH ANNIVERSARY! Please watch your email for a birthday party invitation.

Thanks to everyone for participating today. We stand adjourned but before you go, please help me show our appreciation to Monica for a fine job.