Thursday, December 3, 2015

Ready to Adapt: Experts Discuss Philadelphia Epidemic Preparedness

by Jamie DeNizio and Hannah Shoenhard


In early November, public health experts from a variety of organizations gathered on Penn’s campus to discuss Philadelphia’s communication strategies and preparation efforts in the event of an epidemic outbreak. In light of recent crises, such as H1N1 and Ebola in the US, AAAS Emerging Leaders in Science and Society (ELISS) fellows and the Penn Science Policy Group (PSPG) hosted local experts at both a public panel discussion and a focus group meeting to understand the systems currently in place and develop ideas about what more can be done.
Are we prepared?: Communication with the public
Dr. Max King, moderator of the public forum, set the tone for both events with a Benjamin Franklin quote: “By failing to prepare, you are preparing to fail.” Measures taken before a crisis begins can make or break the success of a public health response. In particular, in the age of the sensationalized, 24-hour news cycle, the only way for public health professionals to get the correct message to the public is to establish themselves as trustworthy sources of information in the community ahead of time.
For reaching the general population, the advent of social media has been game-changing. As an example, James Garrow, Director of Digital Public Health for the Philadelphia Department of Public Health, described Philadelphia’s use of its Facebook page to rapidly disseminate information during the H1N1 flu outbreak. The city was able to provide detailed information while interacting with and answering questions directly from members of the public in real time, a considerable advantage over traditional TV or print news.

However, Garrow was quick to note that “mass media still draws a ton of eyeballs,” and that any public health outreach program would be remiss to neglect traditional media such as TV, radio, and newspapers. At this point, social media is a complement to, but not a replacement for, other forms of media engagement.
Furthermore, those typically at greater risk during an epidemic are often unable to interact with social media channels due to economic disadvantage, age, or a language barrier. In Philadelphia, 21.5% of the population speaks a language other than English at home. Meanwhile, 12.5% of the population is over the age of 65 (U.S. Census Bureau). The focus group meeting specifically discussed how to reach these underserved groups. Some suggestions included having “block captains” or registries. “Block captains” would be Philadelphia citizens from a particular block or neighborhood that would be responsible for communicating important information to residents in their designated section. In addition to these methods of monitoring individuals, there was general agreement that there is a need for translation-friendly, culturally-relevant public health messages.

For example, during the open forum, Giang T. Nguyen, leader of the Penn Asian Health Initiative and Senior Fellow of the Penn Center for Public Health Initiatives, emphasized the importance of building ties with “ethnic media”: small publications or radio channels that primarily cater to immigrant communities in their own languages. He noted that, in the past, lack of direct contact between government public health organizations and non-English-speaking communities has led to the spread of misinformation in these communities.

On the other hand, Philadelphia has also successfully engaged immigrant communities in the recent past. For example, Garrow pointed to Philadelphia’s outreach in the Liberian immigrant community during the Ebola outbreak as a success story. When the outbreak began, the health department had already built strong ties with the Liberian community, to the point where the community actively asked the health department to hold a town hall meeting, rather than the reverse. This anecdote demonstrates the importance of establishing trust and building ties before a crisis emerges.
With regards to both general and community-targeted communication, the experts agreed that lack of funding is a major barrier to solving current problems. At the expert meeting, it was suggested that communication-specific grants, rather than larger grants with a certain percentage allotted for communication, might be one way of ameliorating this problem.
Are we prepared?: Communication between health organizations

The need for established communications networks extends beyond those for communicating directly with individuals. It is crucial for the local health department and healthcare system to have a strong relationship. Here in Philadelphia, the health department has a longstanding relationship with Penn Medicine, as well as other universities and major employers. In case of an emergency, these institutions are prepared to distribute vaccines or other medicines. Furthermore, mechanisms for distribution of vaccines already in place are “road-tested” every year during flu season. As an example, Penn vaccinated 2,500 students and faculty for the flu in eight hours during a recent vaccination drive, allowing personnel to sharpen their skills and identify any areas that need improvement.

In addition to the strong connections between major Philadelphia institutions, there is also a need for smaller health centers and community centers to be kept in the loop. These small providers serve as trusted intermediaries between large public health organizations and the public. According to the experts, these relationships are already in place. For example, during the recent Ebola crisis, the CDC set up a hotline for practitioners to call if one of their patients returned from an Ebola-stricken country with worrying symptoms. “You can’t expect everyone in the entire health system to know all they need to know [about treating a potential Ebola case],” said Nguyen, “but you can at least ensure that every practice manager and medical director knows the phone number to call.”

Can we adapt?
Ultimately, no crisis situation is fully predictable. Therefore, what matters most for responders is not merely having the proper protocols, resources, and avenues of communication in place, but also the ability to adjust their reaction to a crisis situation as it evolves. As Penn behavioral economics and health policy expert Mitesh Patel pointed out at the end of the open forum, “It’s not are we ready?, it’s are we ready to adapt?
The topic of adaptability was also heavily discussed at the focus group meeting. A lack of a central communication source was identified as a potential barrier to adaptability. So was a slow response from agencies further up the chain of command, such as the CDC. However, experts also disagreed about the precise degree of control the CDC should have at a local level. For example, representatives from local government agencies, which are more directly accountable to the CDC, expressed a desire for the CDC to proactively implement strategies, instead of attempting to direct the local response once it has already begun. Many physicians and hospital representatives, on the other hand, were of the opinion that plans formulated by the people closest to the crisis may be superior due to their situational specificity and lack of red tape. Despite this point of contention, experts agreed that there is a need for some consensus and coordination between hospitals in a particular region on how to respond to a large-scale health event.

One gap in Philadelphia’s preparedness identified by the experts in the focus group is its ability to case manage novel diseases—a challenge, since often the transmission route of novel diseases is not known. Some experts in the meeting also expressed doubt that Philadelphia is prepared for a direct biological attack. However, numerous epidemic-response frameworks already in place could potentially be repurposed for novel or deliberately-spread pathogens. In these cases, even more so than in “typical” epidemic situations, the experts identified adaptability as a key factor for success.

At the end of the open forum, the panelists affirmed the belief that Philadelphia is as prepared as it can be for an infectious disease crisis.  Furthermore, it seemed they had also moved the opinions of the event’s attendees: before the forum, attendees rated Philadelphia’s readiness at an average of 3.1 on a 6-point scale (with 0 being “not at all ready” and 6 being “completely ready”), while afterwards, the same attendees rated Philadelphia’s readiness at an average of 3.9 on the same scale (p=0.07, paired t-test).

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