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Just When You Thought It Could Not Get More Complicated!

Conference OnPsychosocial Response to Pandemic Disasters, Infectious Disease, and

Bioterrorism

Institute for Disaster Mental HealthState University of New York at New Paltz

April 7, 2017

Brian W. Flynn, Ed.D.(RADM/Assistant Surgeon General, USPHS, Ret.)

Adjunct Professor of PsychiatryAssociate Director

Center for the Study of Traumatic Stress Department of Psychiatry

Disclaimer

Ideas, attitudes, and opinions expressed herein are my own and do

not necessarily reflect those of the USUHS, DoD, or other branches of the

US government

Overview of Today Presentation…

• Part I--Why should we care about these types of events? Why is preparedness and response so difficult?

• Part II--Comparing and contrasting these types of events and more typical disasters

• Part III--Special considerations

• Part IV--Keys to improving preparedness and response

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Part I

Why should we care about these types of events?

Why is preparedness and response so difficult?

Scope of Consequences

• Crosses geopolitical boundaries

• Crosses many/all demographic groups

• Impacts many life domains

• Personal life

• Community and social life

• Could span generations

Magnitude of Consequences

• Could adversely impact millions of people

• Destroy/compromise systems (health, government, educational, business, etc.)

• Destroy/compromise economies on an unprecedented scale

• Long-term social disruption (relocation, stigma, ostracizing, etc.)

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Disaster Scope…Typical Disaster

Katrina

Pandemic

Bringing The Elephant Into The Living Room:We Lack Models/Preparedness for National and TransnationalDisasters With Behavioral & Other Health Consequences(Such As Pan Flu)

AndWho Owns the Responsibility for

Preparedness, Response, and Recovery?

Different Than More Typical Disasters

• More limited history with these types of events in modern time

• Preparedness and response involved different systems and legal/civil authorities

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Complexity of Preparedness & Response

• Preparation of many systems

• Capability of many systems

• Integrated response of many systems

• Sustained and adaptive integrated systems over extended periods

All this is a context of loss, grief (and probably blame)

Why Should We Integrate?• The problems are too large and complex to manage

alone (e.g., IOM Crisis Standards of Care: A Toolkit for Indicators & Triggers)

Hospital

PediatricEmergency Med.

State PH

Behavioral Health

Public Safety

Fed. Disaster Policy

State EMS

EMS Certification

The Cost of Failure• Increased fear, pain, suffering and loss

• Potentially severe social and economic decline or collapse

• Continued/accelerated loss of confidence in government

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If We Fail…

• Fear & Anger basedbehavior/choices could kill more people, and do more socioeconomic damage, than the event itself.

Benefits of Success

• Reduced death, loss, suffering

• Reduced socioeconomic adverse impact

• Economic growth

• Stronger individuals and communities

• Restoration in confidence in leadership

• Promote pro-social/positively adaptive behavioral choices leading to enhancing the public’s health

Why Is Developing and Delivering Good Preparedness, Response and Recovery

so Difficult?

Seven Cracks in the Foundation

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Crack #1

Lack of understanding that the psychosocial factors are the most significant human impact

in disasters

Behavioral health footprint is far greater than the medical footprint

Psychosocial impact is the very purpose of terrorism

There is a psychosocial component in every part of disaster preparedness, response, and recovery

The cost of adverse psychosocial consequences are greater than any other health impacts

The behavioral choices people make to stay in place, evacuate, seek/not seek medical care, search forloved ones,etc. are veryreal life anddeathdecisions.

Crack #2

Lack of understanding of the broad scope of roles behavioral health can play (in addition to direct

intervention)

Consultation to leadership

Risk and crisis communication

Needs assessment

Program evaluation, etc.

(NIMH Consensus Workshop)

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Crack #3

Leadership—Absent, inconsistent, lacking big picture

Executive and legislative branches

Federal, state, local, GNO, academic

Ability to integrate/balance/advocate science, real world response complexity, political realities, and

compassion

Crack #4

Progress, innovation, and

integration is personality

dependent

When the personality leaves the progress, innovation, and integration suffer

Crack #5

Lack of adequate resources

Human resources

Funding

Time

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Mission/Program Challenges…

• Declining funds and increasing mission

• Sustainability challenges

Crack #6

• Culture

• We are a culture that seeks easy, cheap, immediate, one size fits all, doable by anyone, solutions to complex problems

• We do not seek, value,or learn from the lessonsof other countries

• We view ourselves asself-sufficient andunlike others

Crack # 7

Failure to include the public in planning. Resulting in…

Inaccurate assumption about human behavior

Reduced compliance, trust, confidence

Lacking understanding of factors influencing comfort with and confidence in planning (Redefining

Readiness, NY Academy of Medicine)

We must learn from MH consumers/ advocates: “With us not for us.”

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Why Is Developing and Delivering Good Preparedness, Response and

Recovery so Difficult?

Areas Lacking Consensus in

Pandemic Disasters, Infectious Disease, and Bioterrorism

Who Owns It? Legislatively/Financially

• Legislatively• Do we have adequate/appropriate legislation?• Local, state, federal, international?• Who does what under what authority?

• Financially (very long-term potential-even global economic collapse)• Who will pay?• Pay for what?• Pay for how long?

• What is the role of behavioral health?

Who Owns It? Strategically

• Strategically—

• Where will resources come from?

• Where will the personnel come from?• Will they come? For how long? What about families?

Where will reinforcements come from?

• How are these decisions

made? Who makes them?

• What is the role of

behavioral health?

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Who Owns It? Socially

• Culturally/Socially (“Terrorism strikes along the fault lines of society” - Robert Ursano)• Are we anticipating the potential of class, ethnic,

racial, national disparity?

• What about ostracizing the potentially exposed?

• Who is more valued? Who gets immunized? Who gets treatment?

• How are these decisions made? Who makes them?

• What is the role of behavioral health?

Who Owns It? Existentially

• Perhaps our greatest challenge

• Who are we individually and collectively?

• How will we define “success”?

• How will we define “failure”?

• What does it mean to have our support system becomes our “enemy”?

• Who is the “we” and who is the “they”

Who Owns It? Existentially

• Who will we be when it is over?

• How will we be judged?

• Are we even capable as a nation to have this discussion?

• Who leads this discussion?

• What does behavioral health have to contribute to this discussion?

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Part II

Comparing and contrasting these types of events and more typical disasters

Who Are We Talking About?

• Individual, family, community consequences, visitors/transients

• Primary victims and survivors

• Responders and workers

• Leadership (formal/informal)

Context of Consequences

• Home & family

• Workplace

• School

• Healthcare

• Social service

• Care locations (daycare, nursing homes, assisted living, etc.)

• Government

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What Are We Talking About?

• Event characteristics

• Demographic characteristics

• Impact characteristics

Adverse Psychosocial Consequences

MassViolence

TechnologicalDisasters

NaturalDisasters

> >

Norris et al, 2000

Event Characteristics

Pandemic InfectiousDisease

Bioterrorism

Warning Yes Some Little

Duration Yes/Variable Yes/Variable Yes/Variable

Novelty Some Some Some

Cause Maybe Maybe Yes

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Event Characteristics (Scope)

Pandemic InfectiousDisease

Bioterrorism

Individual Yes Yes Yes

Family Yes Yes Yes/Variable

Community Yes Yes/Variable Yes/Variable

State Yes Maybe Maybe

Regional Yes Maybe Maybe

National Yes Maybe Maybe

International/Global

Yes Maybe Maybe

Demographic Characteristics

Pandemic InfectiousDisease

Bioterrorism

Age Variable Variable Variable

Gender Variable Variable Location dependent

Education Little Little Little

SES Some Some Little

Cultural Perspective

Variable Variable Variable

Legal Status Some Some Some

Impact Characteristics

Pandemic InfectiousDisease

Bioterrorism

Death/Injury/illness

High High High

Community Fabric

Probable Variable Variable

Economic Loss

Probable Variable Variable

Dislocation/Separation

Probable Probable Variable

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Phases

www.samhsa.gov

Part III

Special considerations raised by these types of events

(and their psychosocial impacts)

Human Resources to Meet the Psychosocial Needs

• Where will they come from?

• Sustaining/adapting efforts across preparedness, response, and recovery phases

• Who will decide?

• Who will pay?

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Role Conflict / Complexity

• Understanding/managing personal and professional domains

• When the responder is also the victim

• When knowledge is also evidence

• Privacy

When There is No “Site”• Importance of a place to identify with the

event

• Importance of symbolism

• Location for

collective and

shared grief /

bereavement /

recovery

Impact of Disrupted Movement

• Compromised/mandated movement (e.g., closed borders, mass evacuation)

• Ancillary impacts impacting behavioral health:

• Supply chain disruption (e.g., medical, food, supplies, money)

• Disruption of social support systems

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Mass Fatalities• Managing large numbers of remains

• Large scale body identifications

• Contaminated remains

• Partial remains

• Cultural/religious

death rituals

Social Factors

• Social isolation

• Social justice (in all phases)

• Blame/accountability (we/they, social/cultural views)

Influenza Pandemic of 1918 (Spanish Flu)

• Infected approx. 500M people

• One explanation:• 1st reported case in Ft. Riley, Kansas (US troops destined for Europe in

WW I)

• Became wide spread in England, France, Spain, elsewhere in Europe

• European wartime press suppressed info because of morale

• Spain had a free press and released information angering

US and other governments

• Some say “Spanish Flu” name was political payback

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Part IV

Keys to Improving Preparedness and Response

Or

How Do We Mobilize and Sustain Interest in What Many See as

“Low Probability, High Impact events?”

Silver Bullet #1 For Reducing Trauma:

PROMOTING PREVENTION

East Africa Embassy Bombings:Same Time/Same Bomb

Nairobi:• Many deaths• Many injuries• Many psychological casualties

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East Africa Embassy Bombings:Same Time/Same Bomb

Dar Es Salaam:•Few deaths•Few injuries•Minimal psychological casualties

The Difference? Architecture!

Silver Bullet #2 For Reducing Trauma:

Leadership

Leadership Matters

• Preparation, response, and recovery can by successful or fail as a function of leadership

• Leadership can be studied

• Different leadership characteristics can be utilized for different tasks in different phases

• Leadership can be developed

• Brian’s bias– Successorship of leaders is a seriously overlooked priority/factor

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Leadership: Type & When

• Leadership

• Personal

• Organizational

• Stakeholder

• Leadership

• Prevention/mitigation

• Response

• Recovery

All Members Of An Organization

Leadership

Organization ContinuityPlanning

Human ContinuityPlanning

Families

OrganizationalCulture

Community

Stakeholders/Shareholders

Flynn & Lane, “Integrating Organizational and Behavioral Health Principles to Promote Resilience in Extreme Events” in International

Terrorism and Threats to Security: Managerial and Organizational Challenges. C. Cooper, R. Burke (eds.) Edward Elgar Publishing, 2008.

Leadership In Practice…• Meta-Leadership In Practice (Dimensions of

Preparation and Response)• The Person— Personal characteristics/attributes

• The Situation— Constantly adjusting picture of the event

• Lead the Silo— Support your staff so they will support you

• Lead Up— Know your boss’s priorities and deliver

• Lead Across— Exert leverage by building links

Source: Presentation December 19-20, 2007, At the IOM by Leonard J. Marcus, Ph.D.,Co-Director National Preparedness Leadership Initiative, A Joint Program of the Harvard School of Public

Health and the John F. Kennedy School of Government at Harvard University© 2007 Leonard J. Marcus

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Silver Bullet #3 For Reducing Trauma:

Inclusiveness & Integration

The Stove Pipes…Still Far Too Parallel

Integration: Enhance Understanding

Know History

and Context

Know professional/

organizational culture

Ride-along equivalents Spend time

together (in person)

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Integration: Preparing Together

Share planning efforts

Design & share training/education

efforts

Design/conductJoint exercises

Include health elements in BH

instruments

Include BH in health epi/

instruments

Integration: Respond Together

Integrate work force activities

where appropriate

Integrate deployment strategies

Integrate command/control

Integrate screening/monitoring

tools/strategies

Integrate force

protection efforts

Integration: Advocate Together (all event phases)

Jointly promote

integrated preparedness

Jointly promote

integrated response

Collaborate on healthy

deployment policies/practices

Jointly promote force

protection

Collaborate on post-event force monitoring

policies/practices

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Integration: Advocate Together (conditions effecting all health)

“If you want to reduce mental health problems after disasters, reduce poverty.”

-Craig Fugate, then FL Director of Emergency Managementat The Carter Center

Joint advocacy to

reduce injury/trauma

Joint advocacy for

environmental issues

Joint advocacy to

reduce violence

Joint advocacy for

education

Joint advocacy for social justice

Think About Organizations

• Public/private; multinational, mom & pop; franchises; service organizations; major community employers

• Establish partnerships• Think beyond EAPs and health care• Address organizational culture and how that

culture deals with extreme challenges and how people at all levels view the organizational culture (it may well make or break effective preparedness, response, and recovery)

Special Opportunities: Public/Academic Linkage

• Psychology

• Social Work

• Law

• Economics

• Theology/Pastoral Counseling

• Sociology

• Anthropology

• Homeland Security

• Communications

• Emergency Management

• Political science

• Business

• Journalism

• Public health

• Education

• Engineering

• Medicine

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System Preparedness And Integration…

“Without a great deal of forethought, prolonged training, and the development of systematic performances, drills, and tests of all participants, no community can prepare

itself to provide those additional health services that will be essential for civilians subject to disasters. When the

average community prepares itself for disasters, the effort of each citizen and every profession must be fitted into a coordinated system. Whoever guides each part of

the whole must have a clear concept of the working of all the other parts.”

Source: William Wilson (Col. MC, USA)U.S. Armed Forces Medical J., Vol 1, No.4

April 1950

Silver Bullet #4 For Reducing Trauma:

Communications

Communication is a behavioral health intervention

“Better than any medication we know, information treats anxiety in a crisis.”

Source: Saathoff, 2002

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Why Is Integrating Behavioral Science Expertise And Effective Risk/Crisis

Communication Essential?

The behavioral choices people make to stay in place, evacuate, seek/not seek medical care/decon, get immunized, socially distance, etc., arevery real life and death decisions.

FEAR AND DISTRESS

THREAT OR PERCEPTION OF THREAT

BEHAVIOR CHANGE

POSITIVE/

ADAPTIVE

NEGATIVE/

MALADAPTIVE

IMPORTANCE OF COMMUNICATION IN

RESPONSE TO THREAT

COMMUNICATIONS!

COMMUNICATIONS!

COMMUNICATIONS!

COMMUNICATIONS!

?

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Communication By Leaders

• Multiple purposes:

• Promote healthy pro-social behavior

• Risk/status/education/anticipatory guidance to population

• Inter-/Intra-organization support/direction/ integration

• Manage expectations

• Maintain political support

Communication Up And Down The Organizational Chart

Communication Across The Stovepipes

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Communication With Populations

Leadership

Bereaved

DisenfranchisedGroups Other

At-RiskGroups

Highly Exposed

GeneralPopulation

Silver Bullet #5 For Reducing Trauma:

Taking care of workers/responders

This Means:

• Promote a caring organizational culture

• Select/preparing people for what they are to do

• Match peoples’ skills/temperament/availability to the task

• Promote stress management as a job skill

• Establish healthy and supportive policies and SOPs

• Reject one-size-fits-all approaches

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Brian’s Final Reminders:

• All disasters are different but share important characteristics-Look for both similarities and differences

• Context matters

• Manage responsibility and advocacy

• All disasters are political events

• Take care of yourselves and your people

CSTS Website: http://www.cstsonline.org/

• Disaster fact sheets, current research citations, newsletters and conference reports, a “What’s New” section highlights recent disaster fact sheets, research initiatives, conference summaries, and announcements of key upcoming events.

• Social Media:

• Facebook: www.facebook.com/USU.CSTS

• Twitter: www.twitter.com/CSTS_USU

Contact Information:

Brian W. Flynn, Ed.D.

brian.flynn@usuhs.edu