HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Town Hall Meeting

CASSIE LAUVER: Not to take up more time, ditto what Peter said: Staff worked very hard with all of you. One thing we did find was that Title V or the programs that you represent in the states that we were communicating with so frequently were clearly at part of the command and part of the loop of knowledge of what was going on in the states. And so that was very impressive. We had a roundtable, and John alluded to that yesterday, and some very interesting things came out. And we wanted to see in a little broader group whether we could continue part of that conversation.

One is one thing that I think we heard loud and clear not only in the roundtable but in others, questions from you all saying: What is MCHB, what is HRSA's role in helping develop some system of preparedness for the states and for the programs and you all that are working with children and families. And I think that's something that we want to talk about, what is the association's role in working with you all and with us in terms of developing that.

I think some of you or many of you have just wanted to hear a little bit about the experiences that people have been going through in these states, both direct experience ‑‑ I know Florida had a lot of previous experience that they were able to share. It was very helpful to go through some of their experiences in the past, and I've heard from other states, for example, that haven't been actually even indirectly impacted that much by the hurricanes, but because of the lack of preparedness or perceived lack of preparedness are being asked to reevaluate their evacuation plans for their NICUs or for other vulnerable populations, and how did these experiences go? What did they learn, and how can we be prepared for the next time? Because I think we probably all agree that there will be a next time. We don't know what that is. Hopefully it's not Wilma coming up through the Gulf in the next day or so. But questions about pandemic flu: How are states ready for that?

I'd like to open this up for discussion. I've asked several of the people, some folks over here from Louisiana and Mississippi, Arkansas, Texas, I think some folks from Florida and Alabama are here. And do you all have questions that you would like to ask, or, if not, I could ask maybe Mary from Louisiana, if you just want to say you a few words, just a couple of minutes at the microphone, to summarize a little bit with Mississippi as well.

UNKNOWN SPEAKER: I think the important message to get out is just communication in Mississippi, or in Louisiana went totally down. I mean we had no communication, no ‑‑ our MCH offices were totally located in New Orleans. So when we left our offices on Friday, when the hurricane came Sunday night, Monday morning, we didn't even think to unplug our computers. I was actually going to be doing some more work on the road and at home. So I loaded up some statistics and things like that, because I was working on the FMR conference. But most everybody just walked out the door. So everything was left there. Everything you work with, all your manuals, your computer drive where you put all your contracts, everything like that.

Then after the storm, there was no cell phones worked. No emails worked. Nobody had electricity. The state of Mississippi was without electricity. It was an incredible thing. First, on Monday, when my husband and I evacuated up to Monroe, Northern Louisiana, I kept working on the conference, I thought it blew over and maybe we have a house, we live in Mississippi, maybe we don't. I'll just keep working.

On Monday, when the flood and all those things were happening in New Orleans, it's like oh my God. Because everybody though hurricane, you'll be out for a couple days, couple days off of work. Because we're programmatic people, we're not in the clinics.

We had some very important strengths in the state of Louisiana. One is we have a public health system, clinic system throughout the state, and so everyone who worked for the Office Of Public Health was trained in bioterrorism, in special need shelters. All of the perish health units went out and ran the special need shelters that had been set up. And so they really had a very active system. They were also all trained as many of you were in incident command center training.

So that was a strength. The other strength that we had for maternal and child health is that we have a very active fetal and infant mortality reduction initiative throughout the state, where we have all the communities in our state now have, or were just coming on board, FMR programs, as that's called. We had very active community groups who were already without communication already had their networks set up within the community. So individually they were all jumping on whatever issues were needed from within their communities.

But I think my main thing is before I turn it over to Anita is the communication. You have no idea, you know, what happens when you can't communicate with people. And then it turned out that a couple of us had bought with our own funds Blackberries a few months before when there was a special sale going on. So we were able to text message, because then it was like, oh my goodness, is everyone all right within our staff, the secretaries, and those who maybe didn't have, you know, the means that some of the rest of us did.

So we were then able to begin, it took like almost a whole week to just locate staff and where they were. But we were not in maternal and child health that aware of what was happening within the hospitals. We were not as integrally involved in that as say the State of Mississippi was because of their organizational structure.

But communication was huge. We were also very fortunate we had another strength because we have a help line for our 1‑800‑251‑BABY that was located in Dallas. When I checked in with them, then I found out that nobody had been in contact with them. They didn't know where staff was. They were getting some calls from here and there from those who had evacuated to Houston and so forth. So I was able to get them really moving along. They also became quite an advocate for us pulling in their board, sending out press releases. This was way over and above what their contract required them to do. They brought in extra people so it was good to have something outside the state, far away that could do some communication for you.

Also, when we had evacuated, I was able to work with the American college of physicians, and I got them to open up their website. And they, regardless of membership. So that ‑‑ and I was trying to text message that back to the nurses in our state for all the needs.

There were also some other issues with the Red Cross. And the one thing that came up was that now going forward, I mean this will happen at a much higher level than myself. But going forward, it becomes very important to involve the Red Cross at the beginning, at your planning stages and in any future plans going forward so that there's a little bit more clearer delineation of roles and so forth.

We were getting some messages from nurses that the Red Cross had things that weren't being shared with the special needs shelters and they had better beds than the special needs shelters, better cots and so forth. So there were some issues with that.

There were also some things coming through to me outside that, you know, we need insulin here. We need desperately need formula here. We need diapers here. And then I found out a week or so after that that when they had evacuated babies from Charity Hospital from the NICU, they evacuated up to Baton Rouge. And 220 babies, something like that, that were evacuated up there from the nursery in the NICU, and the March of Dimes jumped in. They're very active in our state, especially in Baton Rouge. So they jumped in and they were actually connecting the birth mothers to those babies and they were able to make that connection.

But I think, you know, as prepared as we thought we were in Louisiana for a lot of things, the magnitude just was very difficult. And the nurses who were over in the Lake Charles area in the special needs shelters, they still hadn't gone back to their perish health units, running the special needs shelters, they were exhausted. Absolutely exhausted. And I know there were some of the issues you know, problems because the public health nurses, you know, may not be as clinically trained. So many of the people in the shelter had great mental health issues. They had HIV. I mean they were all kinds of issues. And I know that all of us would be working towards reports from what we know and, of course, at the state level and for those who were more directly involved with special needs shelters, you know there would be other reports coming from the state of Louisiana.

Our child health medical director had just come on board in July, and she was there to replace Dr. Jeanne Takana, who some of you may know, who retired during the crisis. She was there for a couple of weeks. But Dr. LaGuarde, MCH child health director, she was put to work in credentialing all volunteer physicians who came into the state and also for going out and examining any of the shelters in the whole area of Baton Rouge, Lafayette. She was on the road for that.

The problem that we still have going forward in our state is that we still have staff who are dispersed everywhere. Most of our MCH staff lost their homes. You're talking about 30, 35 people, lost their homes in the New Orleans area. They have nowhere to go back to. There are no offices to go back to. They're in the process of negotiating for some office space back in New Orleans. But all the staff, you know, they're wondering what's going to happen.

I was able to set up a weekly teleconference, and we heard not to do it through the state of Louisiana, because of all the emergencies that were going on within the state. So our MCH lead epidemiologist had just left to take over as the lead at CDC, Dr. Juan Acuña. Dr. Acuña and I had been very involved together with the FMRs throughout the state. I said can you set up a teleconference for us give us 25 lines and let's try and get our staff in.

What we did was brought in right away that first week, brought in our staff and our partners for MCH. So at least we were all able to get on the same teleconference call, find out, you know, everybody was safe, where their families were, ten people living in one home and what their direct needs were, and what they could do, wherever they were. Whether they were in Tennessee or Texas and one was in Oklahoma, Norman, Oklahoma. They were really all over. Because as many of you may know, when we knew that the hurricane, maybe it's going to hit us pretty hard, you know, by Thursday there were no hotels or motels within about 700 miles of New Orleans. People were going to have to really travel far unless they happened to have friends or relatives.

So anyway I could go on a lot. I'll turn it over to Nita.

UNKNOWN SPEAKER: I'm Juanita Gray from the Mississippi Department of Health. I can ditto most of what Mary was saying as far as communication just being such a profound issue.

In addition, in Mississippi, we had extensive power outages, all the way the entire extent of our state from the top to the bottom. And that in itself created issues, and then we had transportation issues. We had no gasoline. We're an extremely technology driven society. We depend on ATM cards, credit cards, transportation, phone lines, computers and all of those things were taken away from us.

My personal experience in the first three days was in about the first 30 hours, I was trapped in my own home, because of timber being down. There was no way to get ‑‑ there were no roads out. I live in a very rural area in east central Mississippi. I had no way to call and ask for someone to come and cut this timber and open up the roads.

Then once that finally did happen, we got to town and there was no way to buy food or gasoline. If you could ‑‑ if those things were available, you had to pay cash for them. And of course cash depends on the access to an ATM. In my own community 100 miles from the coast we had people who had no food and water and no way to get it. There was an opportunity where trucks would come to our area that were giving out ice and water, but there was no way to notify people that those things were available.

If they had found that, received that notification, they couldn't drive to town and get them. So the loss of the technology is just a tremendous barrier that I don't even know how to overcome. We've worked so hard on getting away from a paper society, but then when a disaster like this hits us, we're totally blind‑sided. My husband was impressed that I knew how to cook eggs over an open fire.

You know, I've always had an electric stove, but I pull through. I did grow up in rural Mississippi.

A lot ‑‑ from the health department perspective, a lot of the things that Mary said were true for us, except for the fact that our public health nurses were not prepared.

We have paper pushing public health nurses. Myself included. If it hadn't been for the flu vaccine shortage last year it probably would have been about five years since I had given a vaccination. But I got a little shot, injection practice last year for the flu vaccine shortage. So when it came time for me to go and administer hepatitis A and that sort of thing in rural communities I was able to do that. I also got the experience of slipping on the floor in a warehouse with no electricity and the windows opened. You were at the mercy of the insects, which is a high risk in Mississippi with the West Nile virus.

So a lot of environmental issues there. Our ongoing problems is that a lot of ‑‑ almost 20% of our health department infrastructure was destroyed. We have wheat distribution centers. Mississippi is a center that they do their own wheat distribution, take bids and gather the supplies and distribute those out. A couple of our wheat distribution warehouses were broken into and looted for the food because that's where food was and people needed it.

So we have to replace that. We had to ‑‑ we had some facilities that were washed down to the pavement level. And we've got some mobile clinics and stuff like that going on. The problem is, like she said, we have staff that are homeless. Their families have been shipped off to other parts of the state to live with family and friends. But the staff that are on there fighting the ongoing battle are like sleeping on the floors of these mobile clinics.

So that's part of our ongoing challenge. Also, it's a huge impact on our revenue system for the state. It's a half a million dollars a day we're losing from the casino industry. So we had no choice but to go forward with the legislation to get those casinos back up and running and get them on land. We had to do that in order to regain some of our income.

Also, a lot of people from Louisiana, as well as the Mississippi Gulf coast, were displaced into the upper parts of Mississippi. So where we already had overcrowding in our school systems, we have even more now, bursting at the seams. And the same for a lot of our other resources what is north of the Mississippi is the delta traditionally known has one of the poorest areas in the nation with the least amount of resources available to it. Now we have a whole new society living there that have been displaced from the coast.

And that's my part of it. So I'll pass it on to the next person.

CASSIE LAUVER: Do people have comments or questions to either ask some of the folks here or to us or what? As you're thinking about it are you being asked in your states where are you in preparedness for whatever that you might be facing or comments that you would like to see us thinking about and the bureau and HRSA in terms of what role can we be playing.

JENNIFER CERNOCH: My name is Jennifer Cernoch, the executive director of Family Voices. And as Dr. Duke said I come from that big hearted state of Texas. And we took many of those evacuees. And I truly understand the devastation that occurred. But what we found in Texas at the shelters, and particularly at the ones I worked at in San Antonio, was that we had no way of identifying, particularly some of the children. These children were plucked off roof tops, and they were taken because of the life and death situation, and they were taken and they were dropped on the side of the road without letting the families know in many cases where their children were.

And I understand the gravity of the situation, you've got to get these children off these roof tops so they don't drown. But we had no mechanism to be able to then identify where these children were taken. And these children were put on buses and they were brought to San Antonio and they were brought to Houston and they were brought to other states. And the families didn't know how, where they were either. So I think what you just said is our communication system was so lacking in that particular situation.

The other thing is, working with families of children with special healthcare needs, we had a very difficult time identifying where these children went. We could identify it through the children's hospitals. I knew which kids were in San Antonio at the children's hospitals. We knew what children were at the Arkansas children's hospitals. But we didn't know where children were. They were in hotels. They were in some of the shelters and stuff. So, once again, that identification. And the third thing is to be able to have the resources to be able to provide to these families immediately regarding their child's special healthcare needs. We didn't see it in San Antonio at all. We had children without underwear. We had children without special formula. We had children without diapers. We had children without G tubes. And to be able to ‑‑ and the Red Cross did an excellent job of trying to bring these families in and to try to identify them and give them shelter. But some of the special needs were not there for the families. So that is I think a lesson learned maybe on our first responders to be able to, number one, identify these children and then, number two, figure out what their special needs are.

UNKNOWN SPEAKER: Over here, is that Lynn?

UNKNOWN SPEAKER: I have a little bit of reluctance about speaking because I feel very emotional about what happened in Louisiana and the other states but I'm going to do it anyway and worry a little bit about how well it will come out.

One of the things that we heard this morning that I think was really important was that country's measured by its capacity to serve children, the elderly and those who are needy. And that's who we sat in our living rooms and watch die in Louisiana.

And we can do better as a country. I'd like to start by just applauding everyone who worked so hard in spite of the really difficult situations. So this is no criticism of all the great work that was done. But I want to say that we have a federal government. And if disasters are dependent upon states having the wealth to deal with their own disaster and to operate in a disaster when we know in crisis that people aren't able to make decisions in the way they need to, then we are operating in silos in the same way we ask people not to.

Soy I take a step back and look at a macro perspective of what happened and say: There needs to be an integrated approach. I listen to Fuad say yesterday in Texas the pharmacy stepped up and they provided the needed medication. The churches stepped up and they provided the needed care. And when the next disaster hit, they withdrew because those same folks found out that the federal government might not reimburse them. There's a disconnect between the state and the federal government. And I think that's a really risky disconnect. We can plan this, you know, we spent millions in bio team money for the states. There needs to be an integrated support between the states, because ‑‑ and the federal government, because if a state crumb bells, and what you described is a real crumbling when you can't even communicate with one another and all basic needs aren't met, then somebody needs to be able to make the step. If the step is dependent upon somebody making a call, there needs to be a hierarchy of five people who can make the call. There needs to be a plan in place where the federal government steps in and they say we do need help. This looks like one of the mega disasters that we thought it was and that's a plan and not a disconnect.

CASSIE LAUVER: Thank you, Lynn.

UNKNOWN SPEAKER: Dick (inaudible) from Arkansas. Arkansas, I guess, can be thought of as the example of the ring state, the ring states, in that there was very little storm damage in our state. We were extremely lucky that way. We had a tornado that hit two communities but nobody was killed. And we were really spared.

But as the evacuation from New Orleans occurred, I happened to be on bioterrorism call on my rotation that weekend and was watching the television on Saturday morning and seeing all the Exodus of automobiles along the highways, and I was thinking Arkansas is going to be taking evacuees and started calling around to hotels and motel chains to find out what was happening. By Saturday morning all of the hotels and motels were full all across the southern end of the state. By Saturday afternoon Pine Bluff and Little Rock in the center of the state were full. And by Sunday morning all the way up to the northern part of the state, Jonesboro and the north western part of the state. That was the only real reflection that I think anyone had in an attempt to quantify the evacuees who came in their own automobiles and who could afford their own hotels. And so it was based on information that the Governor could gather more or less anecdotal, and just making rough guesses about how many people actually came into the state, and the highest number reached about 75,000.

In terms of organized response beyond the private sector, there were three emergency operating centers that were set up in the state of Arkansas. The first one for the ‑‑ within the Arkansas Department of Emergency Management. The second one within the Division of Health, which also incorporated people from our sister divisions in human services.

And then the third was perhaps somewhat unique. It was set up by the Governor. It was called Operating Care. That is the Katrina assistance and relief response effort.

The care program was a web page and a 24/7 telephone response, which was linked into the state's Department of Information Services computers. It was linked to FEMA and also was linked to some degree with the Red Cross. So it became the computer base for trying to get registered all the people that evacuated that came into Arkansas that wanted to get registered for a service. A Red Cross service or a FEMA service or that came to one of the shelters in the state. The other thing that added was the Governor is a former minister, Baptist minister. And he had lots of relationships with the churches. And so that was the situation in which the churches really responded to evacuees. Many churches opened their doors. Their families opened their doors and there's a whole series of church summer camps, church camps all over the state that were in fact opened as shelters. So there was that general influx of people who came on their own and then there was another influx of people who were referred from places like the Super Dome and the Astro Dome and the convention center, which was a very different subset of people who were bused from those locations up to fort Chaffee and were received in fort Chaffee. In one 24‑hour period we received 8600 evacuees in those buses and that was so large that although we attempted in at Fort Chaffee to set up a health ‑‑ kind of just a very quick health review, we were only able to process about a thousand of those 8600. The remainder were put on school buses, air conditioned, and then sent to these camps all around the state.

At the largest ‑‑ at the time, when the largest number of evacuees that were counted in shelters existed, that was about three or four days after that sudden influx. And that reached 15,000 evacuees that were registered in a shelter.

So those shelters were set up through a collaboration of the Arkansas Department of Emergency Management, ADAM, and the churches and the Division of Health. So we were able to try to keep track by sending three groups of people, sometimes coordinated, sometimes not coordinated, to those shelters.

The first group was the ADAM emergency response personnel who designed and took with them early on a one‑page form that they inquired of each shelter how many beds they had, how many beds were full, what was the nature of the patients, the people they were taking care of among the evacuees.

And then they followed with some individual questionnaires that they would make to the people and evacuees themselves. So that was the beginning of the database that was eventually gathered and incorporated into this Operation Care computer base for the Division of Information Services.

So that was the beginning, that was kind of how our data was gathered. Fully 40% of all of the shelters that were opened and 40% of the capacity to shelter people was supplied by our churches and church camps throughout the state. So it was a strong public/private collaboration in that respect.

By two weeks after Katrina had hit, had hit New Orleans, and including some Rita evacuees, which were much smaller in number, we probably only got 1400 from the Rita evacuee as an additional wave.

But that care database which was cumulative had incorporated almost 30,000 registrants.

The number of folks who were registered there were not only those who were evacuees and in shelters, but also those who had come into the state under their own power but registered for services either through the Red Cross or through FEMA. So it turned out to be a fairly I guess comprehensive listing, line listing of people who needed these kinds of services.

And then the other database that we put in place, we created a team of about 30 epidemiologists and medical student volunteers who went out to selected shelters and actually approached people manning the street within the shelters and talked to the evacuees, where are you from. And for each one we got names and addresses and we went through a fairly detailed health history that would be related to their current circumstances.

So when we looked at the epidemiologist database and we asked two questions that could be ‑‑ relate the data to MCH population, we asked women: Are you pregnant? If you are, when is your due date? And we asked age. If you look at the percentage of the evacuees that were interviewed that were children, 18 and below, that figure was 17.8% for the epidemiology interviewed group and it was 19% for the list in that almost 30,000 evacuee group. So we have a little bit, you no, ma'am, at kind of a gross level, a little bit of correlation between those two data sets, which makes that an interesting thing to look at.

If you look at the number of women who were pregnant, the shelters identified only about 18 women who were pregnant and a third of those were in their third trimester. (Inaudible) we must have missed some. But when we got those names from the shelters of those pregnant women, and then we called back to our local health units, whose nurses and administrators had gone out to all the shelters in the region. We found 15 of those 18 women. And every one of them had either been taken care of by a local physician or had been reported to the health department to get in prenatal care.

The actual number of patients that came into our local health units as a result of the evacuation, in our ability to count them has been very small. Beginning on the 1st of October, we asked all of our local health unit staff, and when they encountered the evacuee to write the code letters KH on the encounter forms and send those in to us. The data that we have on those encounter forms is very small and probably reflects much less than the kind of experience that we had in the state.

But we'll have to go back to that and study I think these data will probably be coming in somewhat delayed and we'll try to look at that in a more thorough way as time goes on.

So Arkansas had a real different experience. We had some strengths. The fact that we had three EOCs going meant that there was some communication break downs between those three but by and large that was not a problem.

CASSIE LAUVER: Thanks, Dick. I think that there was a lot of on‑the‑job training. And I think you did marvelous, all of you, for the challenges that you experienced. But clearly there's need to investigate further what is it that we all need to be doing. I would ask Jeff and Pete to think about what role AMCHP as the association representing you as well as the bureau and HRSA working in partnership with you think about. And I think that one thing that we may want to think about, and I'll just toss this over to Peter, is going forward and knowing that this is a critical issue, the next emergency may not be this, it may not bring the same set of issues that you have to face such as massive evacuations. It could be totally different. But clearly there's lessons to be learned about medical records, how you identify people, the training that the public health staff needs to have and that we can bring people together to help us think that through and see what our role should be.

PETER VAN DYCK: I think it's a good idea for us to learn from all these experiences. And I know ‑‑ I'm sure there's more people in the room who could talk about other experiences and they're all different, because each state had to respond differently given their specific needs.

But underlying that, there's still a floor or there's still a core of services or elements which should be in place for us to communicate among ourselves, I think. And perhaps trying to describe what those elements or that core is or that basic floor of services which we should know how to help us know how to respond would be important.

Probably the person that's in the best position to kind of coordinate that is John. I didn't mention originally, but John coordinated all these responses that came from Cassie and Maribeth and other folks in the bureau, and had kind of a unique position because he was in on the national discussions with the Secretary. Also went through and edited all the responses from the bureau. So he's in kind of a unique position to have had a sense of what was being requested or perhaps demanded would be a better word, and the time frame for that and how that was translated into a request and then massaged into something that looked like what was demanded.

So maybe we can think about or perhaps I'll throw it out for another minute or two worth of discussion, if putting together a group that included some affected people and some people from the ring or even the third or fourth tier states, if people would find that useful, it might be something that we could do.