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What is Protective Home Isolation?
The following transcript is from Public Health Preparedness Grand Rounds at the School of Public Health at the State University of New York at Albany. The speaker is Roz D. Lasker, M.D., and the title of her presentation is “Engaging the public in pandemic flu planning.” The date of the presentation, which remains available online as of this writing, is January 11, 2007. (1) A previous SEMP Biot Report on Dr. Lasker’s work is available. (2) Dr. Lasker is currently the director of the Division of Public Health and the Center for the Advancement of Collaborative Strategies in Health at The New York Academy of Medicine. (3) All bolding in text below is by the transcriber (MRO). The objectives of Dr. Lasker’s talk, as noted elsewhere (1) are:
Moderator (Peter Slocum): …Welcome to the program. Dr. Lasker: Thank you very much. It is nice to be back. Moderator: It’s delightful to have you back. The demands of public health…have been expanding enormously in recent years, especially with pandemic flu planning, which is at the top of lots of people’s agenda. What do you see as the major challenges related to pandemic planning? Dr. Lasker: Well, there are clearly a lot of challenges, but for me two stand out. One, that has been clear for the last two years, is that unless we are very, very lucky, for the first six to eight months of an influenza pandemic, we’re not going to have any vaccine to deal with the epidemic. Moderator: It will take that long to make a vaccine? Dr. Lasker: It will take that long to develop an effective vaccine. So public health is going to be lacking its most effective strategy for dealing with a pandemic and controlling the disease. The second challenge may not be so obvious. Whereas public health is responsible for protecting the public, that’s the mission, that’s what’s important, the plans for responding to a pandemic flu have been developed largely without involving the public. And when we don’t have the voice of the public, do we really know what matters to people? Do we know the problems they would face? Do we even know the roles that they can play in controlling the epidemic? I think that these two challenges are interrelated. Our work has shown that if you work with the public in new ways, engage them in thinking about pandemic flu in new ways, you can identify and develop protection strategies that don’t involve vaccines and that are beyond the authority and resources for public health to carry out on its own, but not beyond the resources of entire communities to do. Moderator: What kind of non-vaccine strategies are you talking about putting in our toolbox here? Dr. Lasker: Well, the one I would like to talk about today is a form of social distancing that we call protective home isolation. This form of social distancing came up in the Redefining Readiness study [4] that I spoke about on this broadcast two years ago. In that study, we found that in a deadly contagious disease outbreak, two thirds of Americans want to avoid coming in contact with people they don’t know, primarily by isolating themselves with other family members at home. Now, this inclination towards protective home isolation I want to emphasize is not based on fear or panic. In fact, it is a very rational approach. And think about two types of deadly disease outbreaks, one a smallpox outbreak, which we had actually looked at in the Readiness study, and in a smallpox outbreak, isolating yourself at home is the ONLY sure protection strategy for 50 million Americans who are at risk of getting severely ill or even dying if they get the smallpox vaccine or come in contact with someone who was recently vaccinated. If we think about pandemic flu, protective home isolation is a way for people to avoid getting exposed and coming down with the disease before a vaccine is developed. Moderator: Do we have any data about the protectiveness of home isolation in the pandemic flu scenario? Dr. Lasker: We do, and it is actually quite striking. The federal government has recognized that we are unlikely to have a vaccine for the first six to eight months. So they have been funding some very sophisticated mathematical modeling for pandemic flu. The EpiSimS [Epidemiology System] modeling group at the Los Alamos National Laboratory [Los Alamos, New Mexico] [5] has shown that protective home isolation can have a big impact in reducing the proportion of people who are infected with the flu. If 30% of the population stays home, for example, the proportion of people infected is cut by half. If 40% of people stay home, you can cut the proportion of people infected by two-thirds. Now, interestingly, they have shown that if people can stay home for months and not leave the house, you can also reduce the duration of the epidemic itself. You can reduce the length of that epidemic one third if 30% of the population can actually stay home. So it is very impressive findings and it is actually the modeling they did was based on the assumption that people would not start to stay at home until 70 days of the first confirmed case of influenza in their community. If people actually started to stay home earlier, the impact would be much greater. Moderator: That would happen during the gap until the vaccine was available. Dr. Lasker: Exactly. So it would be even a bigger impact than this modeling shows. Moderator: If the modeling is so striking and it’s what people want to do—their rational instinct—why aren’t we planning for that [protective home isolation] more actively? Dr. Lasker: Good question! I think that there are two reasons that come to mind for me. One reason has to do with the fact that protective home isolation is very different from the way that we usually think about isolation in deadly contagious disease outbreaks. The form we are most used to is quarantine. In quarantine, people are isolated forcibly, are required to be isolated, and the people we are isolating are either sick or have been exposed to the disease. We are isolating them to prevent them from transmitting the disease to others. With protective home isolation, it’s a voluntary form of isolation. It’s something that people want to do for themselves when they are healthy, when they haven’t been exposed to the disease and they want to do it to prevent themselves from getting sick. Moderator: Are there other reasons we are not going after this [protective home isolation] as the right way to attack the problem. Dr. Lasker: I think the other big reason is that it [protective home isolation] is not something that is easy to pull off. In fact, it seems pretty daunting. If you want large numbers of the population to be able to stay home for months and you want to do this in ways that don’t destroy the economy, I think even thinking about that has made most people dismiss it as an option. The other reason related to that is that public health cannot do this on its own, so the idea of thinking about a strategy where there would have to be a lot of players involved to pull it off is also very difficult. Moderator: That’s right, as we get into some of the economic issues, businesses and the workplace, it’s clearly way beyond the authority of the public health people in our audience today and around the country. Dr. Lasker: Right, and it [protective home isolation] really has been dismissed, if you look at the literature, even though we are funding modeling about this, there is no planning going on that I am aware except what I am going to talk about today. Moderator: And you believe that public health can begin to achieve this approach by beginning to work with other organizations and people. Dr. Lasker: Yes, the work that I will be discussing from our Redefining Readiness demonstrations suggests that this [protective home isolation] is a very worthwhile strategy to pursue and it is likely that it can be pulled off in ways that actually sustain the economy, which is key. Moderator: You’ve done this demonstration site study in different locations around the country—maybe you should describe that for us. Dr. Lasker: Right, the first thing to clarify is that although the Redefining Readiness study was a research study, what we are doing now in the demonstrations and working with communities is actually creating with them a new way to engage community members in thinking about emergency preparedness and participating in identifying problems and figuring out how to address them. We are working with four sites around the country. They are both urban and rural. They include the city of Carlsbad and South Eddy County, New Mexico; Humboldt Park neighborhood in Chicago, Illinois; the Benjamin Van Clark, Dixon Park, Live Oak and Eastside Concerned Citizens neighborhoods in Savannah, Georgia; and in rural southeast Oklahoma, McCurtain and Pushmataha Counties. The populations in these communities are very diverse. They include Native American, African American, Caucasian and Hispanic populations, as well as others. Moderator: How has the public been involved at those sites in this project? Dr. Lasker: In very new ways and in different ways in different phases of the project. As I mentioned, the engagement process has been developed by teams of community residents in these sites working together and by a support team that has been organized by the center. The engagement process has three phases. In the first phase, which was completed over the summer [2006], people, community residents had been involved in small group discussions about preparedness problems. In the second phase, which is just beginning now [January 2007], the findings from the small group discussions are being shared with much broader community. Phase 3, which is going to be started this spring [2007], community teams are organized to take action on the findings. Moderator: OK. Maybe we should talk a little bit about how those discussion groups were run, since we’re going to be talking about the protective home isolation idea and thinking that came out of them. Dr. Lasker: Right. The discussions had two objectives. One was to provide a process that would enable people to tap into their own commonsense knowledge and to share that with each other and the community. The other objective was to actually to build resilience. One thing that strikes me as someone in public health and involved in emergency preparedness is that I and others have lots of opportunities to think about these types of epidemics or other emergencies, and there are TOPOFF exercises and tabletop exercises, and all sorts of things—and that helps to build resilience because you are thinking about it in advance, it is not a shock when it happens, you plan. But the public has no opportunity to do this. So we wanted to provide an opportunity for the public to think about it in advance. If you think about these two objectives—being able to tap into your own commonsense knowledge and build resilience, the sites had to develop a process that was very, very different from traditional kinds of focus groups, public deliberations, or townhall meetings. Moderator: How were they different, exactly? Dr. Lasker: Well, people got together for two hours, ten people at a time, and they got together to discuss two very specific and realistic scenarios. One was a scenario with a deadly contagious disease outbreak where they thought about protecting themselves by isolating themselves with other family members or household members for months. The other was a scenario where they need to take shelter in whatever building they happen to be in at the time, but just stay for a period of hours to a couple of days. People were presented with a scenario and then the ten people in the discussion thought about and identified the problems they would face trying to protect themselves in the situation. Then, based on the problems the group had identified, they talked about actions that they and the community could take to address those problems.
Moderator: I know as an example, if I could divert for one second, you were talking about the blackout [electric power outage] experience in New York City [2003] and one woman in your building had to walk all the way to Brooklyn. It took hours and hours and it may have been better for her to remain in that building where she was during the blackout time. [6] Dr. Lasker: Right, and you know, the Academy where I work and most other work places haven’t really thought about what if something happened where people might have to take shelter in the building, which you really need to do to make it safe and possible for that to happen. Again, if we think about these things in advance, we can prepare and make it possible. Moderator: That is why engaging the small group is so important--to get people to think about that and chew on ideas. Dr. Lasker: Right. Each of these discussion groups only had ten people in it, but actually a very large and representative group of folks were involved overall. These discussions were continued until almost 2,000 people had been involved in more than 200 discussions in these four communities. A lot of attention was paid to involving people who represented everybody in the population. When we compared the people who had participated with census data, they very closely matched the census data according to age, although we only involved people 18 and over; gender; race; ethnicity, education, including least educated; income, including people with minimal income; folks by household size; and even people who didn’t have telephone service. We had a very close match where all sorts of people in the community could come in and speak for themselves about what they and their family members would face. Moderator: How did you get such a representative sample of the community? Dr. Lasker: With a lot of intention! You are absolutely right. There were several strategies that the sites used. For one, it was critical to make participation as comfortable and easy for folks from all sorts of different groups. So to do that, the discussions were held at the most convenient times and places for people. They were held at community centers, churches, even in people’s homes who hosted it for other people who they knew in the neighborhood. A lot of supports were provided—transportation, child care, refreshments at the discussions. We held discussions in Spanish as well as English for people who were Spanish speakers in communities. The facilitators were selected for the most part to be very much like the participants of that particular group. They received a lot of training to make sure that they valued what people had to say and again the facilitators themselves were community residents. Another feature of the discussions was that a lot of attention was paid to create that made it possible for people to express what really mattered to them. In a lot of surveys or focus groups, people are asked very directed questions and they’ll respond to them, but here, it was quite an unconstrained discussion. All that happened was that people were put in realistic situations and then whatever problems they identified, that was the focus of their discussion. NO value judgments were made about what people said. The last aspect that I think is very important is that we made a lot of effort to make sure that the participants and the community as a whole had a complete and accurate record of what everyone said. You know, very often, we’ll have a discussion, but when we look at the notes, or minutes after a meeting, a lot of the essence of what people were saying is missing or things are reduced to sound bites or things have been reinterpreted sometimes or eliminated. The facilitators received a lot of training to help people to articulate what mattered to them as specifically as possible. The recorders wrote that in the own words of the participants on flip charts. Everyone received a complete record at the end and when an analysis was done, nothing was edited, reinterpreted or eliminated. So we were really true to what mattered to people. Moderator: That sounds great. It’s an awfully time consuming and resource intensive process though. Dr. Lasker: It is, but it is also thrilling. When people got the records of their discussion right afterwards, there were their words, written. As we’re now moving into community conversations, they are their ideas and I can’t even describe what that does for people. Moderator: The resources were part of a grant. I assume that would be a big amount of money. Dr. Lasker: Well, it actually wasn’t that much money, the funding for this demonstration project, which comes from W.K. Kellogg Foundation, and the money that has been involved has not been that great. It is resource intensive in terms of time and effort for individuals to put into this. Interestingly, again, the community residents who are leading the teams are very committed to the project and moving forward. Moderator: Getting those leaders, those community figures, is pretty important. Dr. Lasker: Yes. Moderator: One question: when people get their reports back of their conversations, is that reported anonymously or are their names in the report? Dr. Lasker: Thanks for asking that. During the discussions, everyone is on a first name basis only and when ideas are written on the flip chart and from that time on, no idea is ever associated with anyone’s name. Moderator: Oh, I see. Dr. Lasker: So, all of the ideas are there but not the name of the person who expressed it. Moderator: Let’s get to the protected home isolation question. What did the discussion groups reveal about that issue? Dr. Lasker: Well, clearly, there are a lot of challenges in pulling this off. If you look at the problems that people identified, basically, four conditions need to be met for this to happen:
Moderator: The first step here is knowing what to do before an outbreak, preparing in advance, right? Dr. Lasker: Right, and also getting information to people that occurs in the right way. Before an outbreak, right now, for example [pandemic influenza had not yet advanced when this talk was given in 2007], you can get information about this in many different ways. You can go out, you can speak to your doctor, you can go to community groups, you can think about this and folks in communities want to do that now. It’s very important. But once an outbreak occurs, if the objective is to get people to isolate themselves at home, then people need to get information in their homes without going outside and they need to get information from people they trust and that they can understand. And that is a big problem for people who don’t have telephones, don’t have a radio or a TV (like many people who participated in our group discussions). It is difficult for people who speak languages other than English and who don’t trust the government--and there are many people out there who fall into that category. Moderator: What did the discussions reveal about people’s thinking about maintaining an isolated household over a period of time? Dr. Lasker: Well, there are two points here. First, you need a place to isolate yourself. Folks in our discussions who were homeless or who lived in institutionalized settings actually don’t have that option, so those are groups of people we need to think about. But for everybody else, the folks who do have a home, the big issue here is you need to be able to carry out the activities of daily life and bring in the supplies that you need without exposing yourself to people who could make you sick. A few things to note here: we’ve been telling people to keep three days of food and water at home. That is going to last you for three days! And unless you are a self sufficient rancher or farmer, and we had a few of those in our discussions, it’s really not going to be possible to stock up for six months to take care of yourself. So you need to have—you can’t go outside to get it, because then you expose yourself to other people—so you need to have folks bring stuff to you. But the big problem is how do you know that the person bringing stuff to you doesn’t make you sick? You can be infected with influenza and be able to transmit it to others without looking sick at all. So that is a big trick. And people also cared about people bringing supplies to you need to be protected so they won’t get sick and put themselves at risk. And that’s the big challenge of maintaining an isolated household. Moderator: In medical terminology, it’s breaking isolation, and it’s not a matter of calling your favorite restaurant and having them deliver. Dr. Lasker: Even in New York City, when I do that many evenings, I wouldn’t be able to do that in this situation. I think it’s a issue that we need to find ways to be protected and safe who can bring supplies to people who are isolating themselves at home. Moderator: Another category which came up in the discussions—the emotional impact of isolating yourself and/or your family there for a long period of time, what kind of stresses would you face? Dr. Lasker: A lot. And there are different ones for different people. We need to think about them to make this possible for folks. Many people have a great need for social interactions, more than just the people in their household. Many people have mental health problems and are on medications and staying at home can exacerbate that. Folks who have family members who depend on them who live elsewhere can have a big problem. Living in close quarters can strain existing relationships between partners and their children and it can promote anger and violence. People can get bored. People need to go outside to get sunlight and to exercise. I think for folks, even thinking about public health and other health care workers, the idea of staying home and not being able to your job is a very big emotional stress as well. Those are what we identified. Moderator: Some of them we have spoken about here involve sacrifices involved in staying at home for months. How did people feel about those? Dr. Lasker: There are three big sacrifices or tradeoffs. One has to do with people who are not in your household but depend on you. If you have an elderly parent living elsewhere who depends on you, who is going to take care of him or her? If you have a pet that needs to go outside who is in your household, how are you going to take the pet outside. The second tradeoff involves education. You can’t go to school if you’re isolating yourself at home but parents are very concerned that their children will fall behind in their education and students in college do as well. So, the idea that you have to sacrifice your education for a period of six months is a very daunting one. Moderator: That one was a very passionate one among participants… Dr. Lasker: Very passionate. And the last is what I think of as being the catch-22 of this entire situation. For many people, if you can’t leave the house, if you can’t show up for work, you’re going to lose your job. When you lose your job, you lose your income. When you lose your income, you can no longer afford to pay for the supplies and assistance you need. You won’t be able to pay for your mortgage or your rent. You make actually lose your house. You can’t pay for your utilities, which will be turned off. So, basically, you can no longer protect yourself at home. So, this is the BIG catch-22 of protected home isolation. We need to find ways of doing this without people losing their jobs. Moderator: And in our society, you also lose your health insurance when you lose your job. Should you get sick, you are in trouble. So the problems people face trying to isolate themselves seem overwhelming, not too mild a word, I mean too strong a word. How can they possibly be addressed? Dr. Lasker: Well, as you say, they are so overwhelming, the whole idea has been dismissed. And I think that is premature. It’s true that there is no way that most people can do this on their own, again, unless they are a self-sufficient rancher or farmer. There is certainly no way that public health agencies can within their own authority and resources make this possible. But the ideas that people had about things that they and other people in other organizations in the community could do really showed that it is probably possible for communities to pull this off if diverse people and organizations work together and it is possible to do this in ways that would actually help sustain the economy. Moderator: How do we get to that solution. Dr. Lasker: There are five keys to the solution that are concepts that came out of these discussions that lead us to what it takes to make this possible. The first key is that everybody does not have to stay home. If everybody had to stay home this would absolutely be impossible to pull off. People who can be protected safely with pharmacologic agents can help others protect themselves by staying home. Think about it in two kinds of situations. In the smallpox kind of scenario [first situation], the only people who would need to protect themselves by staying home are the 50 million people who could get sick from the vaccine or if they came into contact with someone who was recently vaccinated. So a subset of the people who get the vaccine and it that situation [smallpox], we have plenty of vaccine, so that isn’t a problem, a subset of the people who can be safely vaccinated can be providing the supplies to folks who are staying home. In an influenza pandemic [second situation], it plays out a little differently. What is critical to make this work is that you have effective antiviral agents that can actually protect people from getting sick. In that kind of situation, even if there is a limited supply, a subset of people who get those antiviral agents can be providing the supplies and the assistance that make it possible for the others in the population to stay home. What is interesting is with this is that we learned through the discussion that although we never posed the problem directly about prioritization of limited supply of drugs and vaccines, that in fact the group solved the problem. When they were thinking about protection, they basically found a way for everyone to be protected one way or another. If we make sure that a subset of people who are getting antiviral agents or a limited supply of vaccine are making it possible for other people to stay at home, we actually have a very equitable system. Moderator: The people in the discussion came to that sense themselves. Dr. Lasker: Yes. Moderator: The second key? Dr. Lasker: The second key is that people who are isolating themselves at home can still play a very valuable role in society. There is a lot people can do at home. Some can continue to do their jobs from home. I certainly can do a lot of what I do from home. I have the communications systems. Other people could continue to work in their jobs if it is modified a little bit. For example, if you are a health care practitioner you can provide counseling over the phone or email. If you are schoolteacher, instead of going to classes, you can do education online or, again, by telephone. Some people can actually take on new job responsibilities that they didn’t have before by responding to the epidemic itself. For example, they can take hotline calls, they can organize the delivery of supply and assistance that other people would carry out. They could check in to see how people were doing. They could do cheer up calls to help people deal with emotional stress. There is actually a lot that people can do from home. One of the important aspects of this key is that by making it possible for people to work from home, you are not only helping them to deal with the boredom and emotional stress and everything else, you help to protect their income and the economic viability of their household. You also help to protect business continuity, which is a very key challenge in pandemic flu, no matter how it plays out. Moderator: You mention home communications. Is this essential for people who are going to be isolated at home. Dr. Lasker: Oh, absolutely! It is really the advances in technology over the last fifty years that make protective home isolation possible in a country like the United States. To make this work, as many households as possible in the country need a working telephone, a radio or a TV, and Internet access, and they need it for multiple reasons. They need it to be able to receive information in their homes, to communicate with people outside, to request assistance, to continue their work, to continue their education, to have access to entertainment to deal with the emotional stress, and to carry out certain household activities like banking. Moderator: Many of those things technologically possible, feasible for many, but those resources have not been extended to every home in the country. Dr. Lasker: Right, but that is something that is really key. Moderator: In past emergencies, we’ve all seen how people come together in ways that the media calls “remarkable.” But you say that in your experience, people are very inclined to come together as a community to work on an emergency. Dr. Lasker: Right. And I think that it is fascinating that in every one of the sites, repeatedly in the discussions, people talked about what groups of trusted neighbors could do for each other. But also that a lot of preparations need to be made in advance for this to be possible. And they are calling these groups and we are also calling these groups local networks of people and organizations, for lack of a better term. [This is key #4.] These local networks can help not only the residents in the neighborhood, but they can be a big boon to folks in public health and other forms of emergency management. The participants in the discussions talked about some of the roles these networks could play, e.g., serving as a trusted point of contact between people and others who need to find out about the emergency and what is going on. These networks can know and keep track of people in the neighborhood and who would need to protectively isolate themselves at home, who have dependents that live elsewhere. They can establish local phone calling or Internet calling centers where people can get information in a language that they understand. They can identify and train residents to provide assistance and supplies to isolated households. They can also work to organize the delivery of supplies and assistance and connect their network with many other larger organizations—locally, state-level and even nationally—to provide assistance. So they are really a link between a public health agency and the residents of different neighborhoods. Moderator: Are these networks loosely organized, not chartered? Dr. Lasker: Right. Loosely organized but with enough organization to be able to take action. What is interesting is the participants in these discussions saw these networks as being able to help a whole array of situations, not just pandemic flu. Many are being established informally. For example, if I’m coming home and there is no one to pick up my child from school, then the network knows this and I can put in a call and someone can go and pick up the child. These are very important kinds of connections. It is a form of building community. Moderator: I should let you talk about Key #5. Dr. Lasker: Key #5 is recognizing that people who are isolating themselves during a deadly contagious disease outbreak like pandemic are not only protecting themselves, they are contributing to the public good. That is because they are limiting the social interactions that sustain an epidemic and that of course is why the modeling [see above] shows the big impact of reducing the proportion of people who are infected and even the duration of the epidemic. And because they are protecting others, as well as themselves, people in isolated households deserve all of the protections that society owes to people under forced quarantine. And those protections include supplies, services, care to meet their basic medical need, job protection, and cash assistance to compensate for loss of earnings. Very important protections that are granted to people under forced quarantine, but right now do not exist for people in voluntary home isolation. Moderator: And that is a shift in thinking, but as you point out those assistances are already there for people under quarantine and these people are accomplishing the same thing in a voluntary way by protecting themselves at home. So they should have the same “benefits,” so to speak. Dr. Lasker: Right. Moderator: To make protective home isolation work, what would different people in organizations have to do? Dr. Lasker: The discussions, after people identified problems, they identified a broader way of actions that they and others in the community can take. And the findings of the discussions will be available in February [2007] and I’ll give people contact information to get that. These findings are going to be the starting points for the “community conversations” that we are going to be getting involved with. I don’t have time to go into all of the actions. But it might be valuable to go over some of the particular roles that public health would be contributing. Moderator: There is a slide with a list of the public health roles. Dr. Lasker: Right. Let me give you the list and then I can give more information about each. What is interesting is most of the effort is done by other people and organizations in the community. But there are six things that public health has the expertise and the authority to do and are really critical to make this work. One is the stockpiling and prioritization of antiviral drugs and vaccines. The second has to do with oversight systems. The third deals with the public health workforce itself. The fourth is relationships with local networks. The fifth is provision of medical support for isolated households. The last is extension of quarantine protection. Moderator: OK. In detail, they stockpile the antivirals? Dr. Lasker: There are actually two aspects to this. One is for public health to begin to start promoting adequate supplies of antiviral drugs when we are talking about pandemic flu. From what I understand, the supplies that we have right now are not adequate for doing what we are talking about. The second is to change the way we are thinking about the prioritization of antivirals or of vaccines when they are initially available and in limited in supply. Right now, from what I understand, we are making antivirals, or thinking of making antivirals, available antivirals to people who are very ill as a treatment mechanism and to health care workers as a form of protection. There are three other groups of people that we need to prioritize to receive protective antivirals, however. Obviously one group are the people that can take these medications safely who would be providing face-to-face assistance to isolated households, as I mentioned before. These people need to be identified and prioritized because there is no other way for the folks in isolated households to get the supplies they need. Moderator: They’re the contact. Dr. Lasker: Right, so they need to be protected and safe. The second is obviously people who are providing other essential services in the community. The last thing that you would want would be the utilities to go down. And the third group is people who must go outside to work (there is no way they can continue to work at home) in order to maintain the economic viability of their household. Public health can go a long way towards making that possible. Moderator: In concert with other organizations, utility companies, for example. Dr. Lasker: I think it involves identifying these groups of people as essential community workers that would receive prioritization. Moderator: You say that development of oversight is another role that public health can play. Dr. Lasker: Right. That may not be the best term here. But what I mean is developing two kinds of systems that people talk about in their discussions. One of them is to document that people providing face-to-face assistance to isolated households are protected and safe, in other words, they are really taking antiviral medications that will protect them from getting sick and prevent them from transmitting influenza to other people. In the case of a smallpox situation, it would be to assure that these are people who had been vaccinated and that their vaccination site has been completely healed or is securely covered, so they can’t make anybody sick. The second kind of system that would need to be developed would be one that verified the need for certain groups of people to protect themselves by staying home in different kinds of outbreaks. This would be to make sure that your employer doesn’t think you are goofing off, or, as we have heard from some people, your parole officer, doesn’t think you are goofing off. In a smallpox situation, it would be that you really had one of the conditions that put you at risk for receiving the vaccine and in the case of pandemic flu, that you have not been prioritized to get antiviral agents and there is really no other way to protect yourself. So these two systems are very important and people in communities look to public health for that kind of support. Moderator: They believe that public health has the wisdom and experience to make those judgments. Dr. Lasker: I think it is important that public health obviously look to communities for help in doing this, but people really look to public health for this. Moderator: What about the public health work force itself? How do we deal with their needs and issues. Dr. Lasker: One thing for public health to be thinking about—I’m sure people have been doing it already—is that people who work in health departments are human beings, too, and face the same kinds of problems as everyone else. So one thing to be thinking about in advance is ways to that public health professionals and others in the community can support public health activities from their homes during an influenza pandemic, so that if not every person in the public health workforce is not prioritized to receive antiviral protection, what can they be doing from home. And to begin thinking about other people in the community who can also contribute to the achieving the goals of public health in this kind of outbreak, thinking how they can support the work of public health. The next step is to make sure that these people have the technology and training to actually do this stuff from home. It may mean making sure that people have the capacity to receive 800-number calls at their homes, hotline calls directly in their homes, or many other things. So it is beginning to think about the home communications technology. Moderator: Another fascinating public health role is networking with local networks. Dr. Lasker: The natural inclination is to think that if anything is happening locally we just have to go out and do it. Here it’s thinking about an intermediary body that is a local network and the local network would be the folks who are dealing one-on-one with the residents of the community, people in isolated households. Health departments can then start thinking about how they relate to these local networks. When I think about this, I think that networks can be an enormous boon to health departments not only during an epidemic but in other situations, too. It’s a way to communicate with diverse population groups that are going to be hearing things from people that they trust from people whose language they understand and so that can be very helpful. It is a way to make sure that people in isolated households really do have the supplies and assistance that they need. Public health departments can hook up the networks to other organizations. If your begin to think about the other core functions of public health, it is a wonderful opportunity to work with residents to understand and address complex public health problems down the line. Establishing these relationships and connections is really key. As the networks get established at our demonstration sites, we hope the health departments there will get very active and involved. Moderator: This is something you see as happening in advance, the development of networks and linking of those networks to local health agencies. In order to be effective, this organization needs to happen in advance. Dr. Lasker: You know, someone once said, “Relationships are primary; everything else is secondary.” When we are in crisis situations, we work much better when we have already developed trusting relationships with other folks. We can build on that. For that reason alone it is important and where all of the connections and links need to be needs to be thought out in advance as well. Moderator: What about the role of public health agencies in providing medical assistance to households in protective isolation? Dr. Lasker: Here I’m talking about mostly about medical assistance in an influenza pandemic that has nothing to do with the flu itself. What is so striking in the work we have done is the extent of chronic disease in this country; how many people, including children, who are on medication, multiple medications, need continuing medical treatment and of course there is the emotional overlay associated with home isolation. Public health can play an important role in organizing in advance physical and mental health assistance by phone, online, and when needed, in person to isolated households. People also talked about programming to help people deal with some of the emotional challenges of isolation, which could be made available on television. I think that people look to public health for that kind of assistance. The fear is that everything will be focused only on people who have influenza and yet the burden of disease that exists otherwise is enormous. Moderator: The number of people with heart disease, cancer patients, in New York State, you would get over 100,000 births in a case like this. Dr. Lasker: Absolutely. Moderator: The final role you mentioned earlier was to extend the quarantine benefits, so to speak, to conceive of these people being in the same category as forced quarantine people in terms of receiving the same rights and benefits they should get from society. Dr. Lasker: Public health can play a lead role here. There are a lot of examples, which vary by state. In New Mexico, for example, people under quarantine have legal job protection. During the SARS epidemic in many countries, cash awards were given to compensate people for lost earnings. There are protections in the model state emergency health powers act that we can look to as well. I emphasize that the quarantine protections are not the only ways to protect people’s jobs, incomes, services, and possessions. We have some wonderful legal consultants working with the demonstration project. Ann Hunter is one. We are really looking at the authority of the federal emergency declaration, what can be done with that, extending unemployment benefits to people who actually have a job but cannot go to work, using a jury system model to make sure people actually get compensation for doing something that is in the public interest, expanding the use of employment benefits like disability and sick leave. There are a lot of mechanisms to explore to do this. Public health is moving away from forced quarantine for a variety of reasons, one of which is the cost involved and the protections people get under quarantine and we’re here talking about expanding it! These are very important things to consider. We’re moving to do some economic analysis of this as well. Moderator: What is the next step for public health in addressing this kind of scenario? Dr. Lasker: Public health professionals have been involved in this work. Drew Harris from the Center for Emergency Preparedness has been on our support team and he had been very helpful. Public health professionals have been involved in some of the small group discussions at the various sites, which is why we know about the tradeoffs they face when they have to stay at home when they have job responsibilities. All of the sites are now preparing to brief local and state health departments about the work and invite them to participate in the community conversations and the action teams. I really encourage any folks in public health departments with jurisdiction over the demonstration sites to get actively involved in this. I don’t think you have anything to lose. When I think of any other options during the period when we don’t have a vaccine, there really aren’t very many out there. The fact that there may be a protective strategy that can be pulled off, to explore that with folks in the demonstration sites would be very helpful. People in public health need to know that no one places the onus for carrying this out on public health alone. Public health does not need to come in to do more than it is possible for it to do. The other reason to get involved is it is an opportunity to get to know other organizations and people in your community and develop relationships that will help you not only during epidemics but also in carrying out core functions. For people in public health who are not in these demonstration areas, I encourage you to review the findings and start a national discussion about non-vaccine strategies for helping people, especially protective home isolation. Some of the most difficult aspects of public health doing this is it being open to the idea itself and also being involved in a community process being run by other folks in the community. Moderator: Is there a way for viewers to reach you and find out more about this project? Dr. Lasker: There is a website: www.redefiningreadiness.com. A lot more will be available next month. See also: www.cacsh.org and www.pandemicflu.gov/vaccine/index/html#vprioritization. Moderator: We’re ready to take questions from the audience. [These are not transcribed here.] Notes:
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