Ready & Able - But Not Always Willing

by Raphael Barishansky & Audrey Mazurek

Public health agencies play a central role in responding to many different types of manmade and natural emergency situations – including, but not limited to, outbreaks of pandemic influenza, biological attacks, radiological incidents/events, and extreme weather emergencies. Unfortunately, the increased number of multi-casualty incidents in recent years (e.g., the 9/11 terrorist attacks, Hurricane Katrina in 2005, the 2009-2010 H1N1 pandemic, and even the 2011 earthquake and follow-on tsunami in Northern Japan) has changed the perspectives of many healthcare workers on how sudden disasters personally affect them and their families.

In addition, the willingness of health responders to report to duty during a public health emergency, particularly a widespread influenza pandemic, is no longer certain, and for that reason has become an important concern. Despite increased public awareness of the threat posed by multi-casualty incidents, biological attacks, and other public-health disasters, the emphasis on preparing the U.S. healthcare work force to cope with such disasters has been less than adequate. Recognizing the unwillingness of at least some public health personnel to report to work, and the various factors contributing to that mindset, has added a new complication for at least some public health agencies as they seek to move forward with effective response plans.

Public Health Responsiveness: The Operational Realities The most effective personnel who respond to public health emergencies are usually knowledgeable in more than one area of specialization. According to a 2010 report issued by the National Association of County and City Health Officials (NACCHO) on the topic of local health department capabilities, the departments surveyed by the association reported that, within the 12 months immediately prior to the survey, they had responded to a broad spectrum of emergencies ranging from infectious diseases (26 percent of the incidents) and natural disasters (23 percent) to foodborne outbreaks (21 percent), chemical spills or releases (9 percent), exposure to one or more potential biological agents (5 percent), and a long list of “others” (16 percent).

The responsibilities assigned to public health agencies in an emergency are not limited to the specific types of incidents listed above. Most agencies also are called upon to respond in various ways to such weather emergencies as hurricanes and major snowstorms. These duties cover a broad spectrum of capabilities – including but not limited to health system readiness, mass care responsibilities (e.g., the provision of shelters where, when, and as needed), public information and communications, the coordination of behavioral health services, epidemiological surveillance/investigations, food safety inspections and monitoring, and the responses to and investigations of various environmental hazards.

Working in close coordination with Columbia University, the Greater New York Hospital Association and Loyola College in Baltimore developed and carried out a 2005 New York survey with workers from 47 healthcare facilities – located in New York City and the surrounding metropolitan area – to determine the ability and willingness of individual employees to report to work during various catastrophic events. A relatively broad range of facility types and sizes was represented in the sample. In terms of individual willingness, the healthcare workers from all types of facilities said they were “least willing” to respond during a chemical event or incident (68 percent), a smallpox epidemic (61 percent), a radiological event (57 percent), and/or a SARS (sudden acute respiratory-distress syndrome) outbreak (48 percent). The reasons for such personal reluctance cited by those surveyed included transportation problems, fear and emotional concerns for their families (and for the responders themselves), and personal health fears. Surprisingly, none of these “fear factors” are particularly difficult to address.

At least one element of a public health emergency response is cultural in nature. Unlike more “traditional” first-responder organizations – e.g., police and fire departments, and emergency medical services (EMS) agencies – the capacity and willingness of health department workers to respond to crises on a 24/7 basis is not historically ingrained in the professional cultures and training of the individual work forces involved. Even in the post-9/11 environment, according to 2005 data from the non-profit RAND Corporation, the after-hours responses by health departments to urgent events has been inconsistent and sometimes slow, even when the responses involve such traditional public health issues as communicable diseases.

Understanding the Reasons Why To fully understand why such changes have occurred, it is important to first examine the reasons behind the unwillingness of public health workers to place themselves at risk of exposure to emerging infectious diseases. An earlier RAND article published in 2004 observed the emotional and behavioral consequences of such reluctance both during the 2003 SARS epidemic and in the early years (1980s) of the HIV/AIDS epidemic.

In the aftermath of the 9/11 terrorist attacks, and the anthrax attacks shortly thereafter, a growing body of research literature closely examined the personal willingness of a broad spectrum of healthcare professionals to respond to large-scale emergencies. Despite the evidence for fundamental distinctions between personal abilities and the willingness to respond, there remains a gap in the public health preparedness literature on the various approaches that explicitly address response willingness as a separate and specific training goal.

A study conducted in 2006-2007 and funded through a cooperative agreement with the U.S. Centers for Disease Control and Prevention measured the willingness of public health personnel in three states (Minnesota, Ohio, and West Virginia) to respond to a pandemic by: (a) measuring individual degrees of perceived threat (concern) and perceived efficacy (confidence); and (b) determining how those variables influenced their willingness to respond. The study found that personnel who had a perception of both high threat and high efficacy – i.e., a high threat to public health, but well trained, well-educated responders – also expressed the highest self-reported willingness to respond to a pandemic flu.

The same study reported that 16 percent of the workers surveyed were not willing to “respond to a pandemic flu emergency, regardless of its severity.” This conclusion is not surprising. The workload in public health agencies during a pandemic is immense, and an “all-hands-on-deck” approach is therefore required to meet the numerous challenges encountered, particularly when those challenges include significant changes from daily roles and responsibilities. Even so, the reported unwillingness to respond – by approximately one out of every six public health professionals – means that additional efforts are required to increase and sustain the overall percentage of local health department employees still willing to respond to dangerous emergencies of all types.

Several other studies of first responders – particularly in the public health and healthcare fields – reveal that a common concern about family safety is a major obstacle among those unwilling to report to work. Following are a few examples of significant findings derived from those studies:

  • A 1991 survey by members of the Israel Defense Forces Medical Corps – which examined the willingness of Israeli hospital personnel to report to work in response to an unconventional missile attack – drew several conclusions similar to those mentioned in the other surveys cited above. The majority of the Israeli respondents said that the need to care for their families was one of the principal reasons for their unwillingness to report to work.
  • The previously mentioned 2006-2007 study of healthcare workers in New York City revealed that family issues adversely affected both the willingness (concern for family) and the ability (childcare, eldercare, and pet care) of hospital workers to report for duty.
  • A 2010 study published in The Australian Journal of Emergency Management analyzed responses from 1,600 front-line staff of a regional health-service provider in Australia about their sometimes uncertain willingness to report to work during three types of public health emergencies: a major weather event; an influenza pandemic; and a bioterrorism incident. That study also reported “family preparedness” as one of the three most important variables associated with a greater willingness to report to work during all three scenarios.
  • A national study conducted by Columbia University in 2005 revealed that “concern for family” led the list of reasons why the EMS (emergency medical services) personnel surveyed might not be willing to respond in the wake of a major bioterrorist attack, a chemical incident, and/or a nuclear disaster.
  • A 2009 study, published by Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, focused on paramedics in Australia and concluded that recent chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE) training and a high degree of perceived personal resilience were the principal positive factors associated with the highest recorded level of CBRNE response readiness.

Organizational Responsibilities – Training & Personal Protection Organizations of all types – specifically including not only traditional response agencies (fire and police departments, and EMS units), but also other agencies (primarily public health) with newly developed emergency response roles – have a specific responsibility to ensure that employees respond quickly, where and when needed. Communicating the organizational goals expected in responses and providing the working tools needed by responders (and sometimes their families) to properly prepare are critical elements in ensuring a quick and effective response.

The importance of training as a variable in determining the willingness to respond is supported by another 2002 study that focused on preparedness training for public health nurses. That study, published in the Journal of Urban Health, found a 12-percent increase in the expressed intention of nurses to report for assignment after participating in the training. That was similar to the findings in the aforementioned national study by Columbia University in 2005, which determined that EMS providers who had received continuing medical education – specifically related to terrorism, though – were twice as likely to be willing to respond to potential terrorist-related incidents (e.g., smallpox outbreaks, chemical attacks, and/or radioactive dirty bombs) as those who had not received such training.

Another critical policy issue that is dynamically intertwined with the “willingness to respond” mindset is ensuring that responders are provided the personal protective equipment (PPE) they need to safely and effectively carry out their assigned duties. Many of the studies cited above confirmed that the willingness of responders to report is adversely affected not only by family concerns but also by fears for their own personal safety. Interestingly, those responders who are in fact issued, and are comfortable in using, proper PPE gear also seem to be less apprehensive, particularly in responses to biological or similar incidents – even when the potential exists to transmit a sudden illness from responders to family members.

A 2008 study, conducted by St. John Hospital and Medical Center in Detroit, Michigan, of hospital personnel during an avian influenza pandemic supports the same conclusion. The Detroit study asked a number of personnel if they would report to work during a pandemic situation; response categories were “yes,” “no,” and “maybe.” For the “maybe” responders, the most important factor (83 percent) was their individual and collective answers to one important question: “How confident am I that the hospital can protect me?” Somewhat surprisingly, 19 percent of the respondents said that financial incentives would not make a difference in their decisions, even if their normal pay were tripled. The study concluded, among other things, that the importance of providing adequate protection for the work force itself “may be very helpful in minimizing absenteeism.”

The aforementioned study of Israeli hospital workers supports the same point. In that study, 86 percent of respondents said that they would report for assignment if adequate safety measures were in place.

Encouraging Responses From Public Health Personnel The U.S. model of all-hazards emergency readiness has presented state and local health departments with several organizational challenges as well as some new learning curves. The all-hazards approach requires both the ability and the willingness to respond to a broad spectrum of disasters ranging from intentional CBRNE incidents to forces of nature such as hurricanes, earthquakes, and non-bioterrorism infectious-disease outbreaks.

Local health departments are considered the true backbone of public health responses to any and all infectious disease outbreaks. In addition to dealing with numerous issues and concerns over precisely how to prepare for and respond to emerging infectious diseases (e.g., H7N9 and MERS CoV), they must also be able to cope with influenza pandemics. In fact, many public health professionals ify such pandemics as one of the most significant and urgent threats facing the nation’s overall preparedness infrastructure.

As public health agencies and personnel have moved more definitively into new and more demanding emergency preparedness and response roles – at the same time that the emergencies have become both larger and more diverse (including, but not limited to pandemics, foodborne illness, anthrax attacks, etc.) – the question of willingness to respond comes into play. As mentioned previously, the primary reasons for some personnel to not respond during a public health emergency involve training, personal protection, and the safety of family members.

When developing disaster response plans and assessing ways to appropriately deal with various issues affecting the willingness of individuals to respond, U.S. public health authorities should consider a tentative plan of action that includes the following:

  • Determine the type and size of the staff required, and their individual and collective roles, beyond simply writing names on an Incident Command System (ICS) organizational chart. It encompasses a buy-in from leadership and all staff, appropriate notification to staff, and adequate as well as relevant training.
  • A