University at Albany Center for Public Health Preparedness
Addressing Health Care Needs in Disasters: The Houston Experience
Original Satellite Broadcast: 03/08/07
Moderator: Good morning and welcome to the University at Albany Center for Public Health Preparedness Grand Rounds Series. Im Peter Slocum and Ill be your moderator today. Before we start I want to please remind you to fill out your evaluations online. Your feedback is always helpful to the development of our programs, and continuing education credits are available. We will be taking your calls later in the program. We'll be extending this program by 15 minutes so that we will have plenty of time for your questions. The toll-free number is 800-452-0662. You may also send written questions any time during the broadcast to our fax number, which is 518-426-0696, or to the e-mail address on your screen. Today's program is Addressing Health Care Needs in Disasters: The Houston Experience. Our guest today is Dr. Mary Desvignes- Kendrick, Professor of Management Policy, Community Health and Deputy Director of Center for Biosecurity & Public Health Preparedness at the University of Texas School of Public Health in Houston. Welcome to the program.
Dr. Desvignes-Kendrick: Thank you. Pleasure being here.
Moderator: Delighted to have you here. We want to talk about the experience that you in Houston had, both as a citizen, as a former public health director there, and as someone who evaluated the response to the disaster that Katrina brought throughout much of the Southern part of our country. So let's start by describing your role in the shelters that were set up in Houston for Katrina evacuees.
Dr. Desvignes-Kendrick: Certainly. Let me just say that the Dean of the School of Public Health in Houston where I am, Dr. Guy parcel, had charged our Center for Biosecurity & Public Health Preparedness with leading the role, leading the response to Katrina for the school and working with the local health departments in our area and all of the response partners in responding and assisting as much as we can. In that capacity, our center director Dr. Scott Lillibridge then charged all of us, me as Deputy Director and our faculty and staff, to then pull together the response, and that included then working with our faculty, working with staff, working with students, working with volunteers to then coordinate this. It included developing first a rapid health assessment tool, and then basically carrying that out so that we could assist the local health departments in a surge capacity way to allow them to then hopefully make better decisions with the data that we could assist them in obtaining.
Moderator: So you really went from the academic environment to rolling up your sleeves and actually helping to conduct a response?
Dr. Desvignes-Kendrick: Absolutely. And our center has worked with the local health departments in the area for a good period of time, and so they had a surge capacity need, a need to really know as early as possible, as real-time as possible what the health needs of these evacuees were, and so we worked to provide that to them.
Moderator: Okay. Let's describe-- Ill let you describe some of the challenges that you all faced when you were dealing with this crisis.
Dr. Desvignes-Kendrick: Well, first of all we had issues related to the sheer volume of people that we knew would be coming to the shelters. We were expecting early on about 25 to 30,000 people within a very short period of time. So our local health departments, all of our preparedness partners, the city and the county, were all looking at how can we galvanize as quickly as possible both the shelter facility, and then also the people and the resources to address the needs as rapidly as possible?
Moderator: Well, when considering a disaster of this magnitude, what are some of the things that we need to keep in mind?
Dr. Desvignes- Kendrick: Well, first of all, we believe and we see over and over again that the disasters are local. We see the impact that's immediate, very direct. It affects those that are hit directly. However the response tends to be much more global. We are-- people are seeing and they're hearing all over the state, all over the country, all over the world what's happening there. So with Katrina, as an example, I have family that live in Texas, that live throughout the United States; I have family that live in England, Caribbean, New Zealand, all over, and they were seeing and hearing exactly what was happening in Houston. So they were looking at our capacity; they were looking at our compassion; they were looking at our competencies, and they were looking at how well we were communicating what they were doing and they were making judgments based on that. So while the direct impact I think is local, the response is so very global. People are seeing actively what's happening real-time, and they're making their decisions on whether they want to volunteer and come in or whether they want to send other kinds of resources. So in many ways that response is global.
Moderator: And it affects the governmental and political system, too, that people in congress who eventually are going to make big funding decisions are seeing and forming impressions right away as well.
Dr. Desvignes-Kendrick: Absolutely. And that's where I think a lot of the-- the first question you asked, how were we preparing for this? Certainly we were making some very rapid decisions, but a lot of our ability to-- as a city and a county, to make those rapid decisions and then move to action was in many ways based on our having done a lot of the preparedness work before we'd worked with each other, before we were aware of some of the technical issues that we needed to handle. We understood what we were-- what the situation was in New Orleans and in the Louisiana, Mississippi area so we'd done some of that work before.
Moderator: And we've all seen many programs on Katrina, but I wonder if you could sort of set us up by reminding us of some of the crucial events.
Dr. Desvignes-Kendrick: Absolutely. One of the things, just before I mention the crucial events. We all as local health departments and as academic centers think about is what happens to ourselves? What do we need to do to respond to a disaster? So many of us are very attuned to small emergencies, small meeting, maybe hundreds or thousands of individuals if you want to put a number to that. And so a lot of times we are used to preparing and responding in our community, or we have memoranda of understanding, agreements. We have different kinds of agreements with our surrounding communities to provide resources, people, so forth there. What we have not prepared for, and I think this applies to many of our partners throughout the country, is an experience of this magnitude. So one of the things I think people need to consider is another community's disaster. How prepared are you to address that? And in the Katrina situation, as an example, while I think we would have been prepared to accept smaller numbers and perhaps send our staff, our resources elsewhere, we were not prepared for about 30,000 people basically overnight. And the questions we would have for others is: Are you prepared? For a community of 2 million, perhaps it's not as difficult for us to absorb 200 to 250,000 people. But if you are a community of maybe 50 or 100,000 people, how ready are you prepared to absorb large numbers of folks? And then the last thing I wanted to point out is that we have found that if you plan together, if you train together, if you exercise together in a variety of situations, then you're much more ready to address that when the emergency hits you or a community close by.
Moderator: Right. And the emergency did hit.
Dr. Desvignes-Kendrick: And the emergency did hit, and it did hit in a very dramatic and abrupt way. And so the fact that we have done a lot of this preparedness together made it a lot easier for communication to move us to reasonably prompt action. The question about some of the crucial events that occurred in the area. One of the first things is looking at the time line. We know that August 28th and 29th, the hurricane hit the Louisiana and New Orleans area. And then on August-- by August 31st, we had a tremendous number of people who were getting ready to come to the Houston area. The levees separating New Orleans from the surrounding lakes did breach on the 29th and the 30th, and by the 31st, at least 80% of the city was under water. And part of the significant area here is that we're not talking-- although in this picture we can see knee or waist deep; but in some areas, it was as high as 20 feet of water. You saw in many of the pictures people standing on rooftops.
Moderator: Right.
Dr. Desvignes- Kendrick: There were more than a million people displaced and a tremendous loss of life. So these were the events that preceded folks coming, evacuees coming to Houston.
Moderator: Right. With that huge influx of refugees, can you tell us about Houston's involvement in absorbing that big population all of a sudden?
Dr. Desvignes-Kendrick: Absolutely. The mayor and county judge had made a very prompt decision to open up our facilities, the Reliant complex, which has large buildings, the Astrodome, the Astro center, to accept about 25,000 evacuees rather promptly. That was done on august 31st, and the Astrodome, one of those facilities were declared full as quickly as September 2nd. Two additional large facilities in the same complex were opened up to absorb another 10, 11,000 evacuees. And then on the 3rd, on the northern side of town, Georgia R. Brown convention center was then opened up to accept about 7,500 evacuees. So the mayor and county judge made a very prompt decision with Houston and Harris county willing to do its part and so these large facilities were opened up to shelter and to assist in taking care of evacuees.
Moderator: What was the atmosphere like? What was the feel? Was there-- actually on the ground in those shelters? Was there a sense of panic about people and their dislocation?
Dr. Desvignes-Kendrick: I don't think so. I think it was more a sense of this is a major challenge. How are we going to address this challenge? How are we going to work together? How are we going to make all of the things that we have talked about and that we have practiced for, how are we going to make this work? How will all of the pieces come together? We have prioritized areas “a,” “b” “c” and “d.” do we have all the parts in place and do we have all of the people in place? So thinking it was more an opportunity for us to look at how well can we do now that there was reality hitting us in the face? So I think it was the enormity that really gave a lot of us pause.
Moderator: And how many people did Houston end up absorbing and where did they all stay initially?
Dr. Desvignes-Kendrick: Initially we had about 200 to 250,000 people coming to the city of Houston, and of that number, about 27,000, over 27,000 was in one of the facilities in the shelters at peak. And then at the Georgia R. Brown convention center we had about 6,500 at peak census. So of the 200 to 250,000 people who came into our area, many went into the large shelters that I just mentioned. Many went into smaller shelters. These are shelters that were set up by the local health departments, also by community-based organizations, by churches, et cetera. So there were a good number of smaller shelters that were spread out through town, and that absorbed about another 20,000 evacuees. And then of course many of the evacuees coming into the Houston area went into hotel rooms. Many also went into private homes. A good number of folks in the community opened up their homes to families, particularly if they had any extra rooms, and housed them there until they could stabilize.
Moderator: What was the community's experience with a city that was so impacted, like Houston was? What can you tell us about Houston's experience?
Dr. Desvignes-Kendrick: Well, I think Houston learned a lot from this. Number one, we learned that it's very important to not only be ready to respond to your own direct emergency, but to be ready to respond to those who are coming into your community. We certainly had some short-term and some long-term kinds of issues to address, and we have actually I think done a much better job of being prepared for the future based on what happened here.
Moderator: The challenges with those families coming in, it must have been particularly challenging for children in figuring out how to handle their needs.
Dr. Desvignes-Kendrick: Absolutely. And we were-- we're very pleased that we have a facility and staff at Texas Children's Hospital, as an example, that came to the aid of us here in Houston and also accepted directly into their hospital by helicopter, et cetera, a good number of the children directly into the hospital. The Texas Children's Hospital set up a major clinic site in the Reliant complex and provided a tremendous number of services. They were seeing children who came without family members, that were put on the bus, separated from family members. They had no particular identifying information or any particular health information. As we were doing our rapid health assessments, we were seeing children of all ages, from just very shortly after birth to neonates, infants, young children, children, adolescents. I had, as an example, a little 13-year-old boy who had just started school and who was excited, he said, because this was one of the best times in his life ever. He had started school. He had started making friends. He was beginning to enjoy it. And as we were talking, he was now a young man who had no school, what he could see was the school was totally under water. His church was totally under water. The park where he played basketball was totally gone. All of his friends, he had no idea where they were. So here is a young man whose life had been totally changed. And he and his mother were there at the shelter, and they were trying to figure out their next steps. Which family members would they be staying with? Where might he be going to school? Might they be settling in Houston, looking to getting him into school there, getting a job and so forth. As we talked, I think what struck me the most was the fact that life as he had known it all of these years had been totally changed.
Moderator: Here he is in sort of the bloom of life opening up as a young teenager, and suddenly it's all ripped away from him.
Dr. Desvignes-Kendrick: All ripped away from him. And so we had children experiencing those kinds of situations, and then we had the elderly. As I was looking at one elderly woman, she was sitting in one of the bleacher benches and we can talk about her perhaps a little later. But here is a woman who had Alzheimers and was very ill. And so we had young, healthy individuals; we had youngsters who were also sick or had brought some chronic illnesses with them; and then we had adults who had major problems in their lives.
Moderator: How did you-- given all that, the variety, how did you go about getting a clearer sense of what your health care needs were?
Dr. Desvignes-Kendrick: The first thing we did-- and we did this having been asked by the dean of the school of public health and also by the local health departments to assist them. The first thing we did was worked to get a better handle on the health needs. So we worked to develop a tool and we started out with a paper tool, to look at collecting health assessment data as rapidly as we could. So we developed a tool that would allow us then to ask, interview the evacuees, and find out from them what their acute and chronic health care problems were. Our plan was then to obtain this information, analyze that, look at any particular trends; look at where the priority areas were, and to provide that information directly to the local health departments so they could get a better handle of the volume of health care problems, the particular areas that presented themselves, and then to prioritize how they would allocate their staff.
Moderator: Now, were the tools and methods that you used to develop these assessments something that you had in a box or that you had developed as you went along?
Dr. Desvignes-Kendrick: We had the experience in Houston with tropical storm Allison back in 2001. I was health director at that point. And we had used a tool that the centers for disease control and prevention had developed. We utilized that tool and modified it to our needs in Houston and we used that as the baseline tool for this particular event. Our faculty and staff then modified that somewhat to address the issues that we understood were coming to Houston.
Moderator: And you had as you said the initial assessment using paper tally forms and then had simplified that as you went along?
Dr. Desvignes-Kendrick: Yes. We used the paper tally form, and that was the quickest way that we could begin to go out to the shelter and to get that information as quickly as possible. And Ill show that form in a few minutes. It is very simple. It was all paper based, and at the end of the day, when we collected the information from the evacuees, we would then tally. We would all sit down at a large series of tables, tally that information, and then enter it into the computer and then by the end of the day, early the next morning, generally around 2 or 3 in the morning, we would then e-mail that to the local health departments. And also in some cases to the CDC.
Moderator: Sounds like old collection booth tallies when I used to be a newspaper reporter.
Dr. Desvignes-Kendrick: Absolutely. We felt that way.
Moderator: But then you moved to an electronic system?
Dr. Desvignes-Kendrick: Yes. We realized very rapidly that, with the sheer volume of people that we were interviewing, that this would not work in terms of our ultimate plan of getting information as quickly as possible to the local health departments and to the health care staff that were going to make decisions. So we moved in the next few days to a PDA Format of collecting that information. That would allow us then to analyze the information much more rapidly. We could look at different subgroups in our analysis, and then we could fairly easily download that and provide it to the local health departments. That helped us tremendously and almost halved the amount of time that it took for us to collect the information, to do the analysis and get it out. So it reduced the time from about 6 hours to about 3-and-a-half hours.
Moderator: Wow. And you have-- I know you have a little quick prcis for people to understand some of the pluses and minuses for each technique here.
Dr. Desvignes-Kendrick: Absolutely.
Moderator: The paper assessment form, inexpensive, quick to train people on, but other problems associated with it.
Dr. Desvignes-Kendrick: Right. We utilized the paper form. It was certainly very easy to use. All we needed were pads and a clipboard, and in this picture here you can see a young lady with the clipboard. Very easy to use. On the top part of the form on the right, you can see that there's-- you may not be able to see it but there are some identifiers up there that let us know what part of the shelter the interview took place. Where was the evacuee located? So that if there were any particular health problems that were spoken of at the time of the interviews, then our staff or our faculty or the local health department would know exactly where to go in the shelter to locate that evacuee.
Moderator: Right.
Dr. Desvignes-Kendrick: So it was a very easy form to use. It did not require a tremendous amount of training. It was certainly inexpensive. It had some pluses that went along in that arena. There were some negatives that went along with that also. Although tick marks would be fairly easy to read and be legible; we also found that, that had some problems, so that there were some bad handwriting issues. Some people, instead of doing four tick marks and then a cross, sometimes did 6 or 7 or 8. And so there were some problems with legibility there and interpretation. And it really did not allow us to make any sub analyses of data. It allowed us to get broad information, broad data only. At the end of the day, we all sat down with all of the forms and it took us quite a bit of time to tally it.
Moderator: Instead of being able to analyze and think about it, you were adding up all the tick marks.
Dr. Desvignes-Kendrick: Exactly.
Moderator: So the PDA Pluses and minuses, you've broken that out for us, too.
Dr. Desvignes-Kendrick: Right. We moved fairly rapidly to the PDA, and we found that to be a lot easier and a lot more effective and efficient. Number one, you had to-- if you go back to the picture we just had there a moment ago, we used one field to get information on one person. And you could not move to the next question until the previous question had been answered. So it allowed us to force the field. It allowed us to get some pretty quick tallies, and we felt that the information had been piloted and tested it prior to going out. We saw that it was reliable. However, in the minus column-- and that's what you were showing a moment ago-- because we had not done this before, we were unclear as to what the reliability actually will be. The screen is a PDA And it's fairly small, so sometimes people had a little problem if they had vision problems looking at it. And some of our younger staff and volunteers did not, but some of the older ones, if we didn't have our glasses, did have that. For some of our older non-technology people, the fear of technology was a problem and some preferred to use the paper tally, but we moved to the PDA and we did some more training in that area. The keyboard, wherever someone needed to enter information actually had to go into the keyboard, just as you would a computer, and actually type that in. So that slowed things down a little. And it was certainly expensive. We had 45 PDAs, and each one came at a cost of about $450 to $500 apiece. So that was very expensive. We did get a discount on that, and what we are doing is using that, the PDAs, on an ongoing basis as we train and we teach in the epidemiology, courses, et cetera. So it was something that helped us tremendously initially when we were trying to make sure that, that is being used on an ongoing basis.
Moderator: Right. Just one little follow-up question. Is there an online tool that could help people in our audience design their own forms or process or, as far as you know you've got that paper thing and then the PDA one.
Dr. Desvignes-Kendrick: We have the paper and the PDA, and we can certainly make that available to individuals. We have done our modification of that tool based on the problems that we anticipated from the natural disaster setting. But it's certainly available. We can provide that at the end of the broadcast.
Moderator: Okay. That's great. Now this rapid assessment program that you went into, did that give an overview of the situation of needs or did it simultaneously able to track individual evacuees' problems and health crises?
Dr. Desvignes-Kendrick: Because a major part of the information we collected told us exactly where that evacuee was located in any of the shelters that we-- where we were, that allowed us, it allowed our staff, it allowed the health department to go to that particular area if there was a problem that they needed to follow up on. Remember, though, that this was a dynamic setting. People were coming into the shelter on a daily basis. People were leaving the shelter on a daily basis as they found either other family members or as they found hotel rooms or they found homes within the community. So if someone was here on day three, they may not have been there on day four or day five.
Moderator: Right.
Dr. Desvignes-Kendrick: So as we were doing the interviews and doing the rapid health assessment, a key part of this was that if I, as the interviewer, Mary, interviewed you, Pete, and you said that you were having bloody diarrhea or you were having anxiety or depression or you had a really horrible skin rash or so forth and so on, then that information is part of our just in time training was noted but it was brought immediately to the attention of a faculty member and/or the local health department so that they could follow up very promptly with that.
Moderator: I see. But that's a real challenge.
Dr. Desvignes-Kendrick: It is a challenge, but we felt that it was important, if we were there to provide this information, that it be done on a timely basis.
Moderator: This is skipping back a little bit, but your professionals and also volunteers who helped out were trained on this PDA process?
Dr. Desvignes-Kendrick: Yes. Everyone went through a training process, and they had the opportunity to go through a series of interviews with each other and to just test this out. And so only when they felt comfortable in having done that well, were they sent out into the shelter. And all of us as faculty and staff were always in very close proximity, so if anything came up, they could come directly to me or to one of our other faculty members and say "Im having a problem" or this evacuee is having a problem.
Moderator: Right. So how many people did you all interview in these different shelters over the course of that emergency?
Dr. Desvignes- Kendrick: Over that period of time, we were-- in one of our large shelters, Georgia R. Brown convention center between September 5th and the 16th we conducted a total of about 5,500 interviews. On average that came to about 450 a night and it would range from a high number of interviews per night of 836, to a low number of 176. When you went to the Reliant complex, in that facility there were three large shelters. And so we had interviews occurring in all of those sites simultaneously. We conducted almost 30,000 interviews there, averaging about 1,700 a night, and as many as 3,200 a night down to a low of 487 as the numbers were dwindling over time. And so with that large number of interviews, we did determine and detect a GI Outbreak on the 5th of September where we had about 700 evacuees that were subsequently identified as having a Norovirus, and we believe that the rapid health assessments, along with the very timely and prompt response of our health care providers, allowed us to identify that very early on, put some interventions in place.
Moderator: Just to interrupt for a second. All those interviews, how many people did you actually have doing those interviews? This sounds like a major mobilization.
Dr. Desvignes-Kendrick: We had all together about 300 volunteers doing interviews. On any particular night, we had about 30 to 40 people doing interviews in the variety of shelters. So on one night, for instance, I would start out at the Georgia R. Brown convention center. We would have all of our volunteers there, we would do the interviews and we would finish there. Simultaneously at the Reliant complex, at the Astrodome, the Astro arena and Astro center, we had volunteers and our faculty and staff doing the interviews. We did those interviews at the time that the most people were settled in their cots. So we went from cot to cot to cot to cot and interviewed, or we went to the cafeteria area at a certain time in the evening where most people were going to be there, and we simultaneously did the interviews.
Moderator: Okay. Now how did the environment in the shelters affect the situation that you turned up in your health assessments
Dr. Desvignes-Kendrick: Well, we clearly saw that this was going to be a large number of people in an enclosed area. As you can see in this photograph, on the floor, a tremendous number of people in close proximity, some who have had respiratory problems, some of whom had GI Problems, some of whom have had skin rashes basically from standing and sitting in contaminated floodwaters for a period of time. As you look at this picture here, you can see that some evacuees moved into the tiered areas into the individual seats. And some of these individuals here moved up just basically to get away from the sheer volume of people on the floor, to get a little bit of space, to get a little bit of privacy. We realized very early on that the bright lights most of the day, most of the night was a problem. People just needed to have a time when the lights weren't quite as bright, where they weren't so close to each other all the time, where the noise was not quite as high. For the environment itself, we needed to pay attention to give people an opportunity to just have some quiet time, some lights-down time, and so at certain times of the day and night, that was modified to allow for that. At the same time, you can see the crowded conditions. We would not need to ourselves create more opportunities for the transmission of infectious diseases.
Moderator: Right, right. What did the findings reveal in terms of that virus that you've picked up?
Dr. Desvignes-Kendrick: Well, we found that-- certainly had a good number of episodes of vomiting and diarrhea. In this graph that you'll see here, from September 3rd through September 19th, you can see the lower side of the graph, that is the percentage of the evacuees with vomiting, and on the higher graph there, you will see these were the percentages of individuals with diarrhea. As you can see on September 5th was that first peak occurred. That was our first peak with diarrhea when the Norovirus was identified.
Moderator: It tapered but with a couple of other peaks along the way.
Dr. Desvignes-Kendrick: It tapered with a couple of peaks, but it allowed us to see and analyze where these outbreaks were occurring and if there was anything that needed to be done promptly that we could see that needed to be done in terms of interventions.
Moderator: Right. Of all the assessments that you did, what would you say was the key findings?
Dr. Desvignes- Kendrick: When we summarized all the data, what we found was that diarrhea and vomiting was one of the prominent findings-- also respiratory diseases, and you would expect this with a lot of people in close proximity. We saw a lot of runny noses, coughs and colds. We saw a good number of skin infections, again as anticipated, from people who had been standing or sitting in contaminated floodwaters. We saw some invasive soft tissue disease. And then of course people bring-- all of us bring with us all of our ongoing health care problems. For the people who needed to be immediately evacuated, did not have an opportunity to bring their medicines, diabetes, asthma, heart disease. Health diagnoses in the past. These are people who brought their chronic problems with them, did not have any medicines with them, and of course the traumatic experience exacerbated some of that.
Moderator: Absolutely. We touched on it just a little bit before, but who precisely attended to all these people's needs? I mean it's a fairly sizable undertaking.
Dr. Desvignes-Kendrick: Yes. In Houston and Harris County we had a tremendous number of organizations that came out. And Ill just list a small number here. For the Georgia R. Brown convention center, the UT Health Sciences Center was the primary health care provider there. So out of the adult and pediatric health care took place at the Georgia R. Brown convention center. Baylor College of Medicine, Texas Children's were stationed at the Reliant complex, the three large stations that we mentioned before. Harris county hospital district health care provider was also there. Mental Health, Mental Retardation Authority of Harris County were also there. We had some other providers, the Harris County Health Department, the Houston health department. Our center was there. And we also had centers for public health preparedness, some of our partners, that came in from Tulane, from Texas A&M, from Oklahoma. We had some of our partners from University of Texas Medical Branch of Galveston and the Texas Medical Rangers just to mention a few. In the surrounding University areas, we had a tremendous number of folks that came out, students and faculty, and volunteered their time, from Houston's community college, University of Houston. So we had a tremendous number of folks from Universities, from the city of Houston themselves that were local health care providers, and also employees just working for the city of Houston that came out. So we had a tremendous number of folks from inside the city, from outside of the city, and that's not even when we started including the religious community that came in.
Moderator: That's an extraordinary number of organizations pulled together. Had you ever done a drill, a practice with those folks?
Dr. Desvignes-Kendrick: We had done exercises with a good number of these partners, but we had not done exercises with all of these partners. We had worked for example with the Texas Medical Rangers. We had done some work with the health departments. We had done some work with the health care providers. But then we had volunteers coming in from all over, from our other centers for public health preparedness. We had folks coming from other states, from other parts of the country, and we had not done any kind of work and practice with them. So we had set up a system where just in time training was provided and then those individuals would fit into the areas that we needed them the most.
Moderator: Are you planning to do an expanded drill series in the future?
Dr. Desvignes-Kendrick: I think the city of Houston and Harris county health department are planning to do that, because they found that, although there were a good number of response partners, that they had practiced within a period of time, they found that there were some other-- some additional partners who came to the forefront that they had not anticipated would be able to do it to the degree that they came forth. So I think the plan is to include those in the future and to leave open opportunities for some additional folks.
Moderator: Okay. What were some of the typical conditions that you had to deal with among the individuals that you saw at the shelters?
Dr. Desvignes-Kendrick: We had the summary of the health care problems, we've already discussed. We had some data that came specifically from the pediatric population. This came from the Texas Children's Hospital Clinic that was at the Reliant complex. The thousands of children that they saw what the found were primarily foot lacerations, lower extremity sprains and strains and fractures. You could see how that could happen in floodwaters where people were wading through the waters or jumping from buildings. Also there were a good number of cases of asthma. Some of these children had not had anything to drink for a period of days or, if they did, it was contaminated. So we were seeing dehydration and some problems with beginning malnutrition. Lots of rashes, fevers and colds and then the chronic problems where people did not have their asthma medicines, did not have some of their other ongoing chronic condition medicines. And then of course there were a good number of individuals that were experiencing stress from this traumatic episode. And then there were abandoned children, where the health care providers were seeing these children but could not then speak with an adult that had any knowledge of them. So they were also involved in the social service perspective of trying to reconnect and find where those individuals were.
Moderator: Right. Which was-- that kid's major problem might be a cut foot but their major problem was no family connection.
Dr. Desvignes-Kendrick: Exactly.
Moderator: Were similar problems of individuals at all the centers; the Reliant complex list we just had up there, but the same kind of thing.
Dr. Desvignes-Kendrick: We saw the same kinds of problems in the Georgia R. Brown convention. There were also shelters spread throughout the city of Houston. We saw similar problems there. We had shelters in San Antonio, in Tyler, Texas, et cetera, and basically the same kinds of problems were seen there.
Moderator: Okay. So thinking about our audience facing a disaster like this, we hope not, but possibly in the future, what are some of the points of advice you'd have for people about what to expect?
Dr. Desvignes-Kendrick: I think we all looked as local health departments or centers for public health preparedness, we all look at an all hazards preparedness perspective where you should be ready to address any of the hazards. They can be environmental, chemical, biological, et cetera. And as we look at this all hazards preparedness, however, to be as prepared for the particular kind of disaster that's affecting you. So in this case, we knew that we were expecting evacuees from contaminated floodwater from New Orleans. We knew what some of the health care problems in New Orleans were. We knew that a large number of people would be coming into a facility. So we expected crowded conditions. We expected infectious diseases from a good number of folks that were living in a small area. We knew that they were coming from contaminated floodwaters, so we prepared for those immediate needs. We also anticipated that, with this large number of people, we would need to implement some sanitation and environmental measures so that we, ourselves, did not add to the problem.
Moderator: Right. So once they got there, their conditions weren't exacerbated or enhanced so to speak. So what could you do to limit the worsening of their conditions?
Dr. Desvignes-Kendrick: In anticipating this, what we did was-- basically you could not go anywhere in any of the shelters without seeing a lot of signs that were posted by the health department and others regarding hygiene. And so all of the signs about washing hands, using the hand sanitizers, they were all over. You could not probably move 10 feet in any of the shelters without seeing a large vat of the hand sanitizers. So we were very prepared in that arena with the signs and also the announcements about washing hands. We also provided constant cleaning of the shower and toilet areas. We mentioned the nausea and vomiting and the diarrhea before. Some people could just not make it to the toilet fast enough and again huge numbers of people. So just keeping the area clean became a major priority. Limiting the food and drink in the cot areas. As you saw in the picture earlier, there was a tendency of people then to bring a plate of hot or cold food, their juices and so forth and so on. And we did not want to create an even worsening problem, so we limited that, and basically people could only eat or drink in the cafeteria area. One of the things we found was that large barrels were set up with ice for a lot of the bottled drinks. For local health department fairly promptly came in and said fairly wisely, No this will not happen, and so the volunteers were standing at each of those barrels where those bottled drinks were with gloved hands. And as you came to get your cold drink, that was handed to you by a volunteer. So all of these efforts to really decrease any contamination and spread of disease. And then certainly the just in time training for all of the volunteers and staff, because we needed eyes and ears all over these large shelters, so that any time anyone saw a problem of health care or public health concern, all of the volunteers should have been aware of this is what you need to do, this is who you need to go to see and this is how you need to get this addressed. So anticipating the crowded conditions, the problems that might result, and then preparing for that, even if you just have to put up signs, makeshift signs to begin with and then get a little better.
Moderator: Right. What would you consider that some of your major challenges and major successes were in this situation, with an eye toward helping our audience understand where they might want to go?
Dr. Desvignes-Kendrick: Certainly. Part of the benefit of doing a rapid health assessment is focusing on the fact that it needs to be rapid. You need to be able to give the result to a local health department, health care providers quickly. If you're doing it two or three days later, it's difficult to have a meaningful intervention. So we focused very early on to the rapid part of rapid health assessment, and that's when we moved from the paper tick tally form to the PDA. So if you're a local health department, if you're doing this kind of surge capacity, it's very important to focus on getting accurate information but quickly. You need to be able to link the data to action. So, as we saw before in the peaks in the vomiting and diarrhea. If you see something, then you need to or the local health department needs to be able to take action based on that data. And so as we talked about, knowing where to locate an individual who has had bloody diarrhea or a little something else, the health department needed to be able to link the data that we provided to them to an intervention that would reduce any further problems in that area. So linking the data to action, containing infectious diseases, rapid analysis of the information which the PDA allowed us to do.
Moderator: Right.
Dr. Desvignes- Kendrick: And then linking that information to an intervention with a particular evacuee.
Moderator: Okay. All right. Let me take a break to remind our viewers that we're going to be taking your questions in just a few minutes. The toll-free number is 800-452-0662. And you may send written questions by fax to 518-426-0696. Before we go on, in honor of Public Health month, which is our week, which is coming up next month. We'll be celebrating national public health week in April. As a prelude, we have a piece here with Dr. Georges Benjamin, the president of the American Public Health Association. We'll just take a quick look at that before we come back to Houston.
Video: We're looking this year at public health week to focus on preparedness, and we're specifically focusing more on trying to engage communities in thinking about preparedness with an emphasis on vulnerable populations, because there are a lot of people that are talking about preparedness, but they're not talking about how do we get to the most vulnerable communities? And we saw that in Katrina. The people that did get out and had the means to take care of themselves were taken care of. But we left behind this huge population of people who we didn't take care of. You know, disasters are not just what nature does or what we do, you know, to each other, but it's also about what we don't do. And so public health week this year is going to focus on, very much, not on just the people who can help take care of themselves but also on the people who can't take care of themselves. I think that we have to think about how we take care of people who we evacuate from these sites. We need to have better plans for doing that. And we have to have triggers to know when to make those decisions, and we really have to have a command and control structure in place that-- with people that are willing to make the decisions quickly and efficiently. A lot of what happened in New Orleans was just failure of anyone being in charge, and for the people who were supposed to be in charge making rapid decisions. But things that were missing and that were not taken advantage of the most, at least in my opinion, is things that happened every single day. The things that we do every day are exactly the way we're going to behave in a disaster. It's about scale. And there may be some quirk about a particular event that makes it a little different, but, you know, the things that went wrong in New Orleans, the things that have gone on in every other disaster that we've had, are things that, at least in the vast number of these things, were predictable to some degree. We could have planned for them. We didn't test for them as part of our everyday activity. We always try to make public health week very local, so we ask the communities to customize public health week for their own needs. And so what we're hoping will happen is that, first of all, the public health community will use this as a time to connect with their local communities, connect with churches, connect with YMCAs, community groups; connect with their affiliates, connect with their local health departments and other health care provider groups so that they understand what would happen in a disaster, so they can help educate patients and communities about what to do.
Moderator: Sounds like you showed him this presentation.
Dr. Desvignes-Kendrick: It does.
Moderator: So let's talk about some of the lessons that you've learned from this experience, and I can't help but say how impressed I am that it was not just a matter of studying what was happening to the people but actually being in the trenches and trying to solve some of their health problems that this mobilization involves. Anyway, what was the lessons that you think other people need to understand out of this?
Dr. Desvignes-Kendrick: I try to be careful when I say lessons learned, because in my experience we tend to learn some of those things over and over and over again. So a big part of this is what I think went well; where were some of the challenges? What could we do differently? And then what can we actually integrate into all of our plans, into all of our policies and all of our training so that we can benefit from the mistakes of others and improve on things we know went well? What happened here I think is is that we went basically from the ordinary to extraordinary very rapidly. We were absorbing 200 to 250,000 new people. We were looking at 30,000-plus evacuees in our very large shelters. In settings like that, I think one of our first things we found and we learned was that you should expect misinformation and that you should plan to address that as quickly as possible. Rumors will start, and as a local health director or as someone making operational decisions, you need to be really sure that you're making those decisions based on accurate data and fact. So if there's any misinformation, track that down very quickly; get rid of that, and then address the facts and move quickly. So that requires a fair amount of ongoing information internally with your staff, and also with all of the external responders that are working with you. So plan for communication both internally and externally as often as you can, as often as is practical. We found two to four times a day to be very important. To plan for the immediate needs of individuals. When you come from a setting of flooding contaminated water, a lot of stress, that we need to address the shelter needs of individuals. We need to address sanitation, food, water, security and health care. So address the immediate needs of the evacuees and then plan simultaneously on how you're going to address the next tier of those needs. And so you have to plan for the psychological kinds of issues. We had mental health, mental retardation there at our shelters. We also had the clergy. We had counselors from other settings. We had to plan for the school needs of the children. We had a tremendous number of children. They needed to get back into some normalcy and some sort of pattern. And then we also needed to look at the medical homes. We were treating individuals in a makeshift setting, in a shelter setting, but these individuals would need follow-up care so medical home care, planning for that was very important.
Moderator: Of course they didn't have a chance to go to the local pediatrician and bring their medical records with them on their way to evacuate.
Dr. Desvignes-Kendrick: No, they did not.
Moderator: A recurring theme in a lot of our programming, frankly, seems to be the importance of networking and planning and collaborating with other folks in advance. Can you talk about that a little bit in your situation?
Dr. Desvignes-Kendrick: Absolutely. And all of the disasters in which Ive worked, and definitely here with Katrina, we found that communication and information are the key critical issues. Presuming that you've got the technical skills and the expertise there, then it's really how you communicate and the kind of information, the promptness of the information that you share. We find that the responder skills and experiences are extremely important. If you've trained together, if you've done those things together, then you can respond better. That does make a difference. Proceed in relationships are extremely important. Planning, training and responding together just plain makes you do a better job. You're much faster at doing it. You're much more efficient. You've worked on relationships where you can say this is not working; let's try something different without hurting a lot of feelings, and you're able to make those changes because everyone is on the same page of trying to find a win-win situation, trying to find that kind of an outcome, trying to be as flexible as possible because, at the end of the day, you realize that the bottom line is how good a job have you done and how can you do this better the next time? But as we talk about prior relationships being important in establishing that, I would be remiss if I did not also say that you should have a system in place so that if Im not there or you're not there and Im supposed to be leading this area, then we need to have that second and third person clearly very knowledgeable of what their responsibilities are, and also having those kinds of relationships with our responders. So relationships are important, but we also need to have a system in place that lets me know that if Pete is not there, then that agency that he represents will have Mary there then, who will be responsible for doing that. So the relationships are important but it's also important to know what that organization, that agency is there to do; what will they do? How will they do? How much will they do? And to be sure to improve on that each time.
Moderator: Okay. Do you have any other lessons that you want to share with people, lessons to relearn?
Dr. Desvignes-Kendrick: Yes. And again, we learned this over and over again. And I think Katrina is no exception here. What we find is that people, when there's a tremendous need, will continue to work long, long, long hours where they're really frazzled; they're burned out, and they're not very helpful to themselves or others. So we always recommend developing a staff change-out time. Rotate your staff after 8 or 10 hours, whatever your organization's decision is. Be sure to rotate staff out so that they're fresh. They don't get burned out, and they're actually able to be there to help ten days, 12 days, 15, 18 days down the line and have not martyred themselves and burned out or gotten sick on the first day. So rotating staff is very important. Managing the influx of helpers. If you look at it, we had about 60,000, six-oh, thousand volunteers coming into the area to help.
Moderator: Oh, my word.
Dr. Desvignes-Kendrick: To manage the influx of helpers. People want to help. People come with skills. People want to do a meaningful job. And our religious community did a particularly fabulous job of saying, okay, this group, you will come in on day four and five. This group, you will come in on day 6 or 7 in this location and so forth. So there was that constant influx of individuals who came in a very planned manner. So people want to help have a plan in place to bring those individuals out, knowing the players, we've talked about that before and having solid relationships with those individuals. And then strengthening relationships. If you and I are working together and we see something's working even better, how can we maximize that so the next disaster that we're working together, we have connected and can do even a better job. Creating new partners. We found that, although we thought we had done a lot of the waterfront of folks who might come in, agency organization wise to help, we found that there were some additional organizations and people who wanted to help. And so being flexible, looking at developing new relationships, creating new partnerships, extremely important. And then as we set up shelters, we look at how we do what we do, but sometimes we forget that, at some point, you have to close the shelter and you have to have a very well planned exit strategy so that, starting it up is one thing, but planning ahead of time; at what number will you plan to close the shelter? Where will those individuals go? And how will you then provide follow-up communication and information?
Moderator: I see. So the downstream steps that you have to think about and have a plan in place.
Dr. Desvignes-Kendrick: Exactly. So as we were expecting about 30,000 evacuees early, the plan is, okay, we're going to be looking at those individuals finding housing, going elsewhere over a period of time. Over 30,000. When will we look at planning to shut the shelter down? What will it take to do that? What will be the role of the American Red Cross, other community-based organizations? At what number will we do that? And how can we ensure that that will indeed be the closure, that we may not need to reopen because something new and unanticipated has occurred.
Moderator: Okay. I know you-- other lessons learned here. I know you talked a lot about the importance of the religious community chipping in and actually help with the flow of volunteers into the situation, which I could see could be critical. But there are other community institutions that you were able to draw on.
Dr. Desvignes-Kendrick: Absolutely. The religious community, I can't say enough about. They were there in large volumes at all of the shelters, and they were absolutely terrific. The other is that we found that there were some additional helpers, the beauticians, the barbers that came in. If you could think of that. If you were sitting on a roof or sitting in contaminated water for several days, you've not had a shower and you've not changed your clothes. You're looking scraggly and just feeling, in addition to the other traumas of your life, you're just physically just not feeling well. The beauticians and the barbers were able to do some terrific work. People then began to feel a little better at least about themselves, and they were able to use that and move on. We have to remember the human element. We talked about data before, but each of the sets of data represents our lives. We had children there. We had the elderly community. We had a woman with Alzheimer's where, if she was basically not boxed in, then she had a tendency to get up and wander around and may get lost. So we had family members that were taking care of fairly sick family members. But we know that it's very stressful for the victims. We know that it's stressful for staff and volunteers. But paying attention to the human element, very important. We had people experiencing missed events, birthdays. What about the nine and ten and 12-year-olds that were having birthdays while they were in the shelter? There were people who had planned to get married and did have a marriage that took place in one of the shelters. They had planned to get married, and they decided to go ahead and do that anyway. That was quite a rejuvenating experience. We also had church services and other kinds of religious services going on at the shelters to try to get some more of the normalcy and getting people back on their feet. So as we go in as faculty or staff or volunteers, the human element we think, I think is very important, and that we need to remember that, at the end of the day, at the end of the shift, at the end of however long we decide to stay there, we get a chance to go home to our families; but a good number of people don't get that opportunity to do that.
Moderator: Right. Before we start to take questions here in a moment, in your single take-home message I gather would be remember the human element and address that as much as you're addressing the technical/medical needs?
Dr. Desvignes-Kendrick: Absolutely. And I think sometimes we need to remember that, if we were in that kind of situation, how would we want to be treated? I think we would want to be treated courteously, respectfully. At the same time we would want our health care needs addressed. We would want to have our shelter, our other issues taken care of. So I think we're looking at being in a community where people will take care of each other and do that in a very respectful way. I would say that one of the take-home messages is, if you're going to do a good job at what you do, you have to plan well; you've got to train for it; you've got to bring in all the appropriate people; you've got to exercise well together, and you've got to look at where your gaps are and make those appropriate changes so that, in a disaster, you can move as seamlessly as possible.
Moderator: Okay. That's great. Let's see what the folks in the audience have to say. We're ready to take calls now. The number is 800-452-0662. You may also send written questions, which some of you have already, to our fax number 518-426-0696. Or to that e-mail address on the screen. So let me go to a couple questions. One was "were pets in shelters? Did people leave pets behind?" that can be really traumatic to begin with but that could have been a real problem in the shelter, too.
Dr. Desvignes- Kendrick: Right. There were no pets in the shelter where people were themselves. However, we did have a myriad of organizations and others that were there at all of the shelters and did address the pet needs. There were the various cages that were brought. All of the different cat or dog food, et cetera. And that whole issue of animals was then addressed by the organizations that took care of that area. We did not want to have animals and humans in the shelter together. So what we try to do is then find a setting where that evacuee and their animals could be elsewhere. We found that people did not want to be separated.
Moderator: Right.
Dr. Desvignes-Kendrick: From their animals. And that was a very important part of their lives, and we identified that fairly early. Both the city health department and the county health department have veterinarians and animal care areas, and so they worked with the veterinarians. That was an area identified fairly early on, but they were not in the shelter itself.
Moderator: Okay. I understand we have a call on the line from Nebraska. Go ahead, please.
Caller: Yes, hi. Ive really enjoyed your broadcast. I have a question regarding clarification of the role of public health in mass care sheltering. I understand that, as public health practitioners, we are to assure that medical piece. But what exactly is the role of public health in terms of mass care? And then how will that change, if at all, in light of Red Cross's announcement at the national level that they will no longer be the lead agency for mass care?
Dr. Desvignes-Kendrick: I think what we will find is that communities will be looking at the kinds of decisions that they need to make to ensure that the entire package of services is provided. In the shelters in Houston, the public health department works specifically to, number one, assess what the health care needs were; number 2, to specifically look at the public health kinds of issues that needed to be addressed. The infectious diseases in particular, the rashes. We were also looking at the immunization status. One of the real positives in our area is that Houston and Harris county had developed an immunization registry over the last number of years, and so with all of the health care information that we did not have access to because people did not bring that information with them, we were able to link up with the Louisiana immunization registry. And so the public health department was then able, for any of the children that presented, to then access the Louisiana immunization registry, get the information on the children, and then give the updates on the immunizations directly at the site. And there's a fair amount of data on how many immunizations and what type were given and what we feel the benefits and the savings were there. The local public health department was also very involved in looking at the special needs of the vulnerable population. So as we looked at the special needs of children, as we looked at the special needs of the elderly, a good number of the connections to the area agency on aging were then made. A good number of those resources were brought forward. In the shelters, the local health departments that had worked with pharmacies and others then worked to bring them in so that there were large vans. These are trailers basically that came in, where the pharmacies came in and set up with the health care system to provide the kind of medicines that were done. Both the psychiatric medicines and then also the other chronic disease non- psychiatric medicines. There were trailers that came in where people were then looking at some of the other issues, including the eye exams, et cetera. The public health department looked at addressing some of the other infectious disease, HIV needs and the kind of medicines that needed to be followed up. So as we looked at the population of the evacuees, as I saw it, the public health department was involved in looking at, number one, what are the key problems that we're seeing? What does public health need to specifically do to control any outbreaks and to make sure that people receive the services that they needed? They also were the facilitators in bringing in all of the various partners to work on addressing the comprehensive needs of the individuals so that I as an evacuee hopefully would not have been seen as, okay, what is my skin problem today? What is my hair problem? My eye problem today? What is my HIV? Or my hepatitis? So I think the local public health department is responsible for making sure that the community of evacuees' public health needs are addressed and that they facilitate all of the linkages. In Houston we are blessed in having a tremendous health care system, and so we worked directly with the Harris county hospital district, Texas Children's, UT Medical school and MHMRA, and they came in directly to do that. So in an area like Houston, I believe that is what would be done in the future. We've worked with the Red Cross many times in the past. We have also found that we needed to supplement the health care needs in terms of providing those services with the providers that are available in our communities.
Moderator: It certainly sounds like you took on the lion's share of the role, the public health community did, both in the immediate assessment and the whole global community sense, but also making sure-- arranging for care for specific health needs. And that's quite a challenge. I have another question here from-- that came in by fax before. "How do you assure a degree of privacy for individuals while you're interviewing them and doing that rapid health assessment in that hugely crowded scene that you showed us before?"
Dr. Desvignes-Kendrick: Right. And that's a really excellent question. As we developed our tool, it was a self-reported tool, and we went only with the questions that we had on the list that people answered. We asked for no personal identifiers of any kind, other than their name and then we'd ask them their age range. But we did not ask any of the HIPA protected kind of information in our interviews. Whenever individuals wanted to speak more about their particular issues, then we either moved to an area where we could speak more privately; or we arranged for them to be seen by a health care provider in a setting in the clinic that allowed for more privacy. The questions that we asked again were: Are you experiencing any health problems in these areas? And then you would go down the list. If they wanted to speak more and it was of a personal nature, then we would move them aside and go into that in more depth.
Moderator: Okay. I think we have time for a couple of more questions, maybe one, maybe two. "Did you take special measures to protect the volunteers who were doing these interviews from infectious disease threats in the shelters?"
Dr. Desvignes-Kendrick: Absolutely. And that's a big part of the just in time training, so that individuals are aware of what they can bring in terms of presenting a problem themselves or what they can take away that would present a problem. And so anyone who felt that their exposure might create problems, then we tried to aim-- the just in time training addressed that. There were several instances where there was a concern that an evacuee or so or more had tuberculosis. And in that kind of a setting, we try to again isolate or quarantine. And that presented a whole new set of issues. But just in time training was pretty much the way we decided to go with that.
Moderator: We have one minute, one question to go. "How accurate is the self-reporting did you find?" very quickly.
Dr. Desvignes-Kendrick: Well, in looking at self-reported data, in general for certain kinds of chronic disease, if you had your influenza immunization, et cetera, it's been found, from what I have seen to be reasonably accurate in some areas, 80% plus. The questions that we asked were of the nature that we found the self-reported responses to be very accurate. If someone said they had bloody diarrhea; if someone said that they were experiencing “x,” “y” and “z” problems, we did not find that that was a problem.
Moderator: Okay. I want to make sure the audience can contact you, because Im sure they'll find other questions. I think we have a slide with your contact information at the Center for Biosecurity & Public Health Preparedness at the UT School of Public Health in Houston. Yes, there it is. And the e-mail address and everything. Okay. Well, thank you very much for joining us. It's been a real pleasure, and I think the folks have gotten a lot out of it.
Dr. Desvignes-Kendrick: Thank you very much. For anyone where I can provide any additional information, please feel free to e-mail me. Thank you.
Moderator: Thank you. And I want to thank you all in the audience for joining us today. We'd like to please ask you to fill out your evaluations online. Continuing educational credits are available, and your feedback is helping us in the development of future programs. If you submitted a question for today's broadcast and we were not able to answer it-- and I know we have some right here-- please contact Dr. Desvignes-Kendrick at the e-mail address that we've provided. This program, as well as other previous programs, will be available online via web streaming within the week. Please see our web site for archived collection of past broadcasts. We hope you'll join us on April 12th for a program entitled "From Teachers to Leaders in Crisis" with Dr. Roseann Samson, Assistant Superintendent, Charlotte County public schools in Florida. Im Peter Slocum. We'll see you next time at the University at Albany's Center of Public Health Grand Rounds Series.