Sept/Oct 2005 - Volume 4, Issue 5

City of Naperville Does the
FEMA “Integrated Emergency Management Course”

This dialogue occurred on September 14, 2005 at City Hall, Naperville, Illinois, and has been edited for publication. The following people participated (in alphabetical order): City Manager Peter Burchard; Northern Illinois University MPA Program intern Karen Deitch; Police Captain Kevin Kirk; Executive Assistant Regina Mullen; Emergency Preparedness Manager Pete Smith; Fire Chief John Wu; and SEMP Director Margaret O’Leary.

Margaret O’Leary: Please describe your experience at FEMA’s “Integrated Emergency Management Course” in Emmitsburg, Maryland, June 19-24, 2005.

Peter Burchard: John [Wu] got us started. It was his knowledge that put it together.

John Wu: I participated in on-campus programs at Emmitsburg for a number of years. A portion of the campus is dedicated to the Emergency Management Institute and another portion of the campus is devoted to the National Fire Academy. My prior experience had been with the Fire Academy but I knew of programs on the emergency management side through experiences I had many years ago while with the City of Boulder, Colorado. I thought this program would be really beneficial for the community here and that the more we could get people outside of our specific government employees to attend, the better off we’d be in terms of emergency preparedness.

We first asked whether our directors and city manager were interested and whether we had the commitment to make it work. There was a significant interest after September 11, 2001. It is so competitive to be selected for the program. It’s in the form of a grant. It is a fully-paid set of classes. The Institute only does a few of these each year. We put in our application in 2002 and finally got the grant and were able to go in 2005.

Peter Burchard: The reality is that we, as an organization [City of Naperville], have limited resources to get together for training and then do an actual exercise. We’ve done training and exercises internally. But we had never taken that to the level that FEMA was proposing, that FEMA would pay for. That made it unusual and special in our mind’s eye. We saw it as an opportunity and appreciated the emphasis on integrated training—it was exciting. The FEMA staff would expose us to people who would lecture us on best practices throughout the nation and then take us through an exercise that included not only Naperville employees but people we would work with in a response who were with another agency—county level, state level, Metra police, health officials from the county, the schools, two emergency physicians and a safety officer from a hospital. FEMA preworked the course with us by spending two days here in Naperville. Their setup was sophisticated in what they proposed and what they executed. That motivated us and when we brought the idea to the [Naperville] City Council, it immediately embraced the idea of integrated training and three of the councilmen participated in the exercise in Maryland. I became excited about the possibilities.

Margaret O’Leary: Who were your instructors?

Pete Smith: The instructors were all FEMA employees who were top notch in their fields. Some of them came to emergency management from careers in law enforcement and the fire service. They brought in some instructors from around the country as well. There was a core group of instructors to expose our group to the ideas and experiences that the instructors could provide. For example, we had an ex-military person--a general who was second in command at Blackhawk Down in Mogadishu; a fire chief who was the initial incident commander at the collapse of the highway in the Northridge Earthquake, California; and a Salvation Army executive who operated in numerous large incidents and had a depth of experience.

Kevin Kirk: My personal favorite was the retired colonel from the Baltimore police department.

Peter Burchard: Yes, he was a dynamic speaker, down to earth, and dead serious about what you need to do to prepare your community and then how to make sure that you do a true integrated response once an emergency occurs. He was riveting.

Kevin Kirk: The other fellow who was a doctor, a psychiatrist…

Peter Burchard: …That was Phil McDonald.

Pete Smith: Getting back to your original question of why we went there…One of the benefits of going there vs. having them come out here is that we had the opportunity to get this whole diverse group of city employees and outside community partners totally immersed in the go-round. If we stayed here, we would have had the cell phones, blackberries, palm pilots, and the rest of it interrupting us. There was no way that everyone could possibly step away from their day-to-day routine. By going there and becoming completely immersed, we had a learning atmosphere that bolstered what they were trying to present to us. It also promoted interactions with people from the city and outside of the city with whom we normally don’t have a close working relationship.

Margaret O’Leary: Can you give me examples of people from outside the city with whom you normally don’t have a close working relationship?

Pete Smith: Sure. I don’t often bump up against emergency room physicians. I don’t have a close relationship with the county coroner or the county-board vice chairman. Even within the city, there are some departments I deal with all the time, but I don’t always deal with public works. The course syllabus will show you what the FEMA staff do: they take an instructor from each of the disciplines and tailor the course around the disciplines. Rather than having each of us get up and do a show and tell, which we can do here and it’s the same old thing, not to say that we’re not expert enough to do that, the FEMA instructors got up and led the experience. It’s a better experience to have these instructors do it and cover something on fire, something on police, and something on public works. They basically covered all the disciplines but everybody was exposed to it en masse. All the presentations were interesting even if you came from a particular discipline. The way it was presented was interesting.

Peter Burchard: It was a critical part that our public works employees had to listen to the police side of it and vice versa. We were all exposed to the same training as opposed to the police doing their thing and fire doing their thing. That’s what made it special--that it was integrated training and then integrated exercise. Everyone is in the same ship together. It’s one thing to know your piece, but as you well know, the way that disasters unfold, knowing your piece IS critical but if you don’t know what’s occurring at the integrated NIMS [National Incident Management System] level, you don’t understand what is going on as a whole. If you’re in the policy group and don’t know what’s going on as a whole, you will in fact be deficient in your role and the way that you can help.

John Wu: We were able to get the mayor and two council members to come. That was one of the benefits that will pay long-term dividends. By their very nature, these events are not daily events; therefore they can lose traction very quickly. In recent months of course we’ve had disasters all over the country and you can point to those, highlight those, as examples of why we prepare. However, over the longer term, you hope that disasters are not monthly or even semi-annual events. At the same time, because they are not routine events, you wind up not thinking that they are something that could happen in your own community. The issue of preparedness requires funding, requires a devotion of resources, a commitment in terms of strategy. Look at your business plan in terms of continuity of recovery. All those things were brought to some focus for the council members who can then influence their development members and discuss in a very intelligent way their specific experience, what they heard and saw through the eyes of the instructors, but also through the exercise, that this was an important topic and was important to keep on the front burner of our thinking. We must go forward with budgeting and thinking about public safety as a component of city services. I thought that having the mayor and city council members involved was an incredible benefit.

Pete Smith: The FEMA staff did a fine job of tying in all of the classroom instruction with the exercises. The exercises were broken into three parts, a cascading situation: a short one on the second day we were there, a longer one on the third day we were there, and the longest one (all day) on the final. The FEMA staff actually came out here in February 2005 to pick up our policies, review things with people, observe how we do things, and understand how we’re set up. They went around the community to take photographs, review graphs and procedures, and visit our emergency operations center. They designed the exercises around our community. The exercises were not imaginary exercises taking place in City A and just going through the motions.

Peter Burchard: It was not a boiler-plate exercise. They tailored it. Let me talk about what the challenges have been both politically and internally and matching to the national scene. Historically, and I have perhaps have a narrower perspective than police or fire might bring to the table, but from the management standpoint, the traditional issue in the United States and the way things were taught nationally, emergencies, be it the type that occurred in New Orleans, or something here locally like a tornado, the response is police and fire. They have been well trained in being able to respond. Obviously the hospitals had a role as well. Over the last several years the federal government, FEMA, and we have certainly recognized that this focus has been TOO narrow. We had to truly get to the point of involving every aspect of local government service, including public works, health, utilities, connections with the hospitals, for example. We had to improve our ability to respond in a good way through bringing EVERYONE to the table. That was what we were able to gain in Emmitsburg, and that’s where the national emphasis is going. You’ve got to make sure that all hands are on deck. You can’t leave departments behind because they are traditionally not in the emergency response business. You see it in emergencies across the board—the public utilities, public works, and code enforcement employees are critical to the police and fire being able to do their work. This was one of the important things we learned at Emmitsburg.

Then take it to another step with the elected officials. It’s so amazing how the culture in the organizations that I have been exposed to across the nation [believe] that emergency management is police and fire business. But when you open up the plan, it’s the elected officials who are supposed to command and decide certain steps and take actions with certain documents and declarations and yet, for the 20-25 years I’ve been involved with this, elected officials were NOT invited to the table for the planning, the programming and the understanding of what it took to get the job done. So when a major emergency occurs, such as in New Orleans, for example, we hear people assailing the role of local elected officials as well as some of the appointed officials. Emmitsburg has taught us the importance of bringing it all together, so that when an emergency occurs, elected officials and appointed officials can act flawlessly or as close to flawlessly as possible.

Regina Mullen: It was a great experience and got more intense each day. At the beginning, the exercise was rough, but as we progressed we were able to identify our weak areas. After each exercise we would sit down with our groups to identify how we could do better. We integrated those lessons learned from each exercise into the next exercise, including taking notes and putting them on a board and having someone stand next to a dry-erase board to record everything that was going on in the room. There were so many things that were thrown at us. It helped us to be able to follow what was going on by having something to view.

John Wu: The instructors conducted a critique of the entire week at the end. One of the things that kept coming up for each of the instructors who also facilitated the various groups as we went through the exercise, is that by the end of the week, we were actually ahead of the instructors. We could predict what they were going to throw at us. They said that we were one of the best groups that had ever come through here. All the participants from city, county, and other groups began to gel together, to think ahead, to plan, to critique themselves ahead of time so that they could do a little bit better each time. In the end we had very, very good comments from those instructors.

Peter Burchard: One of the issues that came up about human behavior also came up in our book: “The First 72 Hours: A Community Approach to Disaster Preparedness.” I try to relate a lot of what occurs during an emergency to human behavior. And I want to draw on one point that was made when we were in Emmitsburg as well as what you can hear about and see in New Orleans. I’m going to start with the Pentagon during 9/11—the FBI agent in charge at the Pentagon has been saying in training programs all over the country that the fact that they had exercised, trained with each other, and knew each other, made all the difference in the world. They had exercised for catastrophes at the Pentagon in the months and years before 9/11, according to a program that Chief Dial [Police Chief David Dial, City of Naperville] and I attended. He was making a point about the relationships and the exercises—that piece—the knowing and the doing ahead of time made all the difference in having a successful response at the Pentagon.

One of the things that the FEMA team said is that it is rare, in fact they said extremely rare, for them to experience a training program like we went through where the police and fire actually get along with one another, where a municipality actually has a relationship with a hospital, that the county officials know the municipal officials. They repeated and said time and again that “You guys are starting on a different level—the fact that you know and respect one another. You create room for one another, no one tries to get in there and be headstrong with another person over anything. One of the people from Metra [commuter rail agency that serves Chicago and all of northeastern Illinois] who participated with us and made the comment during a wrap up that he is used to organizations where there is so much internal strife over management issues and morale that when they go about talking about how to respond in an emergency, all those personal human behavior issues are getting in the way. That is an issue that you can see occurring in New Orleans where there is a significant level of organizational conflict and competition and lack of respect for one another before a tragedy occurs. People bring all that baggage into an emergency and it’s hard for them to respond well when they have organizational conflicts, differences of opinions, and personality conflicts with other agencies. A very important observation that the FEMA folks made, I think, was that you’ve got to have relationships that are good, for the public good, and that you need to work things out ahead of time so that you’re not bringing in all this personal baggage to an emergency.

Margaret O’Leary: It goes back to leadership at the municipal, county, state and federal levels, and the environment that leaders are creating so that people can get along and give one another space so that in an emergency, leaders can make tough decisions, say for evacuation, and people will respond appropriately. If leaders don’t shape this kind of environment on a continuous basis, they have basically failed the public citizenry. A fire chief or police chief cannot make an evacuation decision—more and more we’re seeing the mayor has to get out there and make those tough decisions, sometimes at risk of looking like a fool if he or she overcalls it but resulting in tragedy if he or she undercalls it, which is what happened in New Orleans. The mayor in Seattle during the World Trade Organization riots and the Millennium bomber incident had the same kind of tough decisions to make. The importance of elected leadership to me is becoming more and more important. I hear what you are saying.

Peter Burchard: The police and the fire are going to do a superb job at the scene of anything that occurs. But as soon as we have to crank that out, Pete [Smith] has to coordinate something that is integrated where people are cooperating with one another and they’re agreeing up front in a planning way on the deployment of resources—it can easily break down. And while the police and the fire piece may be well served—the question is whether the total outcome is what it ought to be if that coordination doesn’t occur.

Pete Smith: For example down in New Orleans, they have police and fire at risk because of all the debris in the streets and all of their tires are going flat. Police and firemen are out there changing tires. There needs to be support of them in terms of getting a couple hundred spare tires and maybe we will need personnel to go out and support the equipment we have. I don’t think they thought about that down there. The whole mess you’ve got down in New Orleans, there’s a whole lot of debating and we’ll be talking about this for a year, but some of the early lessons learned is that #1, this is an unprecedented disaster, the course that the disaster took, that an entire city filled up like a fishbowl with no way in and no way out, to get it organized initially. That being said, some of the obvious lessons learned: there appears to be plans that were in place but not executed; command and control was not set up and exercised; local government people were trying to put band-aids on things you couldn’t put band-aids on. You can point all the fingers you want and I don’t care if it was an “incident of national significance,” the bottom line is that the local elected official is in charge of that incident. That person is in charge from the time it happens until everyone packs up their tents and goes away. That has to be done in conjunction with state elected officials, has to be worked through those roles. I’m sure that when all is said and done, there’s going to be plenty of blame to go around. The fact that command and control was not in effect, that resources were called for from Illinois and other states; when they got down there they didn’t have a job for them.

John Wu: [Naperville Fire Department] Assistant Chief Rich Mikel and three others from my department went to New Orleans. They’re supposed to come back this Saturday but now we’re hearing that they are asking for a possible second deployment.

Margaret O’Leary: It’s a great learning experience for them. There’s nothing like being on the scene. The experience and knowledge gained can always feed into your own preparedness.

John Wu: You’re exactly right. Not only from the operations side, but Chief Mikel has been able to sit on some of the fire planning meetings. They have a base camp of 400 fire fighters deployed within a larger base camp that is being protected by the military cavalry. They plan the next day’s duties and they actually issue an incident action plan as prescribed in these documents. They’re actually doing this stuff real time, rather than in an exercise. They’re doing it live. In his particular base camp, there are firefighters from Maryland, New York, New Orleans, and Illinois. Illinois has sent 600 firefighters total down there and most are still there.

Pete Smith: The experience they’re gaining down there is invaluable and helpful. While they’re certainly down there to help and that’s the purpose, it’s always preferential to get your disaster experience handling somebody else’s disaster rather than your own.

John Wu: Just one more point about this leadership idea. One of the things that Naperville did was create a key position under the direction of the fire chief. As much as it was able to get done, the emergency management agency was a small division of a large fire department organization that may have paid occasional attention to it, but not to the extent that it now has. Pete Smith as emergency preparedness manager is a person who reports directly to the city manager’s office and who has the ability, actually the responsibility, to bring together all the departments within the city system but also connect with all the agencies outside the city through the city manager’s office. That in itself is symbolic but also in practice is a very significant difference in the way we look at emergency management.

Pete Smith: You don’t hear the word “first responder” anymore. It has disappeared from the lexicon. First responder has always meant police, fire, EMS. Now you just hear the word “responder.” That’s further evidence that the training required through NIMS [National Incident Management System] requires that ANYBODY who is in your emergency response plan needs to receive some level of this training because anybody could now be a first responder. It’s no longer a police issue or a fire issue – it’s a community issue—the entire city, county, or state or whoever happens to be handling it on the front end—it is all of the departments and all of the resources working as a team.

Margaret O’Leary: Do you see any difference in the terms “emergency,” “disaster,” and “catastrophe”?

Pete Smith: There’s a technical-legal difference between an emergency and a disaster. But I think on a day-to-day basis they’re all pretty much thrown together, interchangeable.

Kevin Kirk: I think there is a difference at an emotional level. The difference between 9/11 and the hurricane is that one is manmade killing thousands of people and the other is not manmade. I think it is more emotional when it’s manmade. There’s a lot of interest in Louisiana. A lot of that is driven by the perceived lack of coordinated response which has been spread out over time. But during 9/11 the response was immediate, coast to coast. There is a prevention piece in here, too: what could we have done to prevent 9/11—we couldn’t have done anything to prevent the hurricane.

John Wu: Emergencies are anything you can handle with local resources. Anything beyond that is a specific declaration that the community makes and a declaration that the governor makes beyond that.

Pete Smith: An emergency is declared, whether by the president or by the local officials, it is a legal declaration that allows that jurisdiction to plug in their emergency plan, allows their plan to go forward, and gives powers to the certain person in charge usually having something to do with expending funds, calling up reserves, and putting certain things into practice or effect. That’s what the President did prior to Katrina’s landfall. He declared a national emergency, which allowed resources to be expended. That’s what would happen on a local basis if we were dealing with an emergency situation and needed to ramp up. A disaster, on the other hand, means, in a legal sense, that you have exceeded your ability to handle an incident on your own. That puts somebody up the line’s emergency plan into effect. In our case, it would be the county and ultimately the state. The governor would declare a disaster and look for federal help. So it’s really a technical-legal thing. But as far as everyday use goes, people refer to disasters, emergencies, and catastrophes all as the same thing in common usage. But there are real reasons for those terms and they mean definite things.

Margaret O’Leary: What’s the next step for Naperville after Emmitsburg?

Pete Smith: When we came back we required everyone to write down lessons learned—things they had observed. I’d like to preface it with our own observations and those of the FEMA staff, we did really well. Our policies and procedures came together well. We didn’t identify any drastic things we needed to do.

John Wu: Our mayor delegates planning and response down to the department heads, including Pete. What we’re going to do following our FEMA Emmitsburg experience, Pete is primarily responsible for gathering and deciphering this information—things we can be doing differently today vs. before we went. Even before he did that, the department heads were responsible for putting together our own internal operations and going through a process of evaluating that. The example I have is that the fire department went through a SWOT [strengths, weaknesses, opportunities, threats] analysis and came out with some top actions we could take in our officer training. One of the topics was the relationship between the emergency management component and daily operations component. How does that fit together? Many of my officers have not sat in an emergency operations center exercise. They know what happens out there on the line but don’t know how that connects with the EOC environment—where people are doing the planning and logistics and thinking ahead a couple of days and where a policy group is sitting in a separate room discussing the implications of having, for example, businesses out of service for a period of a few days to a few months, or the implications of people not having phone service or electrical service. There is not a connection between the services provided on the ground and logistics. We want to try to create that connection and help fire service officers understand where they fit within the whole structure. That’s one aspect of it. Another one is creating a bigger core within the house that can speak to the media. One of the exercises shows that we have some minor gaps in who can talk to the media, who can’t, and how we control it but at the same time allow communication to flow outward so people aren’t in the dark while they are addressing their own specific needs out in the community. Those are the two things we’re going to address.

FEMA Integrated Emergency Management Course:
The Suburban Community Hospital Perspective

The following interview took place on September 22, 2005, and has been edited for publication. Jack Hickey is administrative director of safety and corporate risk at Edward Hospital and Health Services Corp. in Naperville, Illinois.

Please describe your experience at the FEMA Integrated Emergency Management Course at Emmitsburg, Maryland, June 19-24 2005, from the hospital perspective.

It went real well. It was a pure academic laboratory-type setting that prevented distraction from what was going on at home or work. You could focus on the material and the environment and work with a lot of your peers.

I was especially happy because I took two of our ER [emergency room] docs with me, one who is currently the EMS [emergency medical services] director, Dean Porter, MD, and another, Scott Padalik, MD, who is going to become the new EMS director for Edward Hospital. They are obviously our liaison to the EMS community. We had the entire leadership of the EMS section of the Naperville Fire Department as well. The physicians really enjoyed being there and being able to talk with police department and fire department personnel. Fire department personnel became very comfortable with approaching the docs when they needed information.

There were altogether around 75 of us. About 60 persons were from City of Naperville management and the rest were community partners and DuPage County representatives, including the county emergency manager, the vice chairman of DuPage County board, someone from the coroner’s office, two people from the health department, and someone from the sheriff’s department.

The first day (Monday) was devoted to classroom presentations. The second day was classroom presentation in the morning and an exercise in the afternoon. We picked up the exercise the next day (Wednesday). On Thursday, we exercised the whole day. Across the exercises the course leaders tried four different bioterrorism scenarios with patients presenting with certain sets of symptoms. The ER docs and public health officials, who were sitting right behind us, would together figure out the threat. Then we would tell the course leaders the bioterrorism threat looks like it’s going to be this and we are going to do this and this and this. The course leaders would take that bioterrorism scenario out of play because we had gotten it right! We were very much in tune with what people from the health department were thinking. We did very well. Everyone did very well. The leadership did very well with their piece of it.

Was this your first time attending a FEMA course at Emmitsburg?

I’ve been there five times now. The four previous times I was there as a student for educational programs. This is the first time I was part of the Integrated Emergency Management Course. This particular program is best done on a community basis. FEMA also does this course with individuals with different disciplines and different skill levels who send in their applications from around the country. The problem with that approach is that the convened persons are a pretend community and there’s no reality to it. We had the City of Naperville and DuPage County, which are Edward Hospital’s two main community ties, so we knew exactly what we had and what we could do. We participate in DuPage and Naperville exercises and they participate in ours, so we knew one another well. We work hard to stay integrated in what we’re doing.

The Emmitsburg experience was almost as good as the TOPOFF experience. The nice thing about the federal full-scale TOPOFF exercise was that it went on for a period of time. In hospitals we do exercises and in two hours the exercise is over. We all do well; nobody fails miserably, and we move on because we’ve completed our requirement for six months. I believe that’s one of the lessons that will be coming out of the New Orleans hospital crisis following Hurricane Katrina on August 29, 2005. The disaster exercises we do don’t test our organizations nearly enough. The problem is going to be how hospitals find the money, the time, and the commitment to participate in grander, more full-scale practical exercises. That’s going to be real tough. I don’t know how that’s going to happen. The government can afford to literally stop and do TOPOFF-type exercises. Hospitals can’t stop taking care of patients in order to go through an exercise. And you can’t have the patients involved in the exercise. So if you’re going to practice an evacuation, you’re going to pretend, which is a lot different from a real evacuation. The comparison is so far apart. If you’ve never gone through an evacuation, you have no idea what it’s really like. It’s very difficult to organize and stay on track.

Describe the instructors.

They were good. They came from a broad spectrum. None of them had a health care or hospital or even a public health background. There was one presenter with an EMS background. We didn’t gain a lot beyond a current understanding of the thinking at the federal level, for example, the current concept of operations, and how the federal level envisions working with the various segments of a community from the law enforcement, fire, public utilities, and management perspectives. That’s an opportunity for us, especially my two docs, to see how the rest of that world is playing on out there, while they are seeing patients in the emergency department.

Was the National Incident Management System covered?

I didn’t think there was enough conversation about the roles of law enforcement, fire, utilities, and health under NIMS—what the impact of NIMS is going to be. But so much of that is still in development that I can understand why they couldn’t delve into what they were thinking. The City of Naperville is NIMS compliant. Pete Smith [City of Naperville emergency preparedness manager) taught the NIMS course to all the staff in the City of Naperville.

The Robert Wood Johnson Foundation and Katrina Catastrophe:
An Interview with Senior Vice President Dr. John Lumpkin

This dialogue between John Lumpkin, MD, MPH, and Margaret O’Leary occurred by telephone on October 4, 2005, and has been edited for publication. For more information on The Robert Wood Johnson Foundation, please visit its website at http://www.rwjf.org/index.jsp, and SEMP Biots http://www.semp.us/biots/biot_262.html and http://www.semp.us/biots/biot_263.html.
The Robert Wood Johnson Foundation, headquartered in Princeton, New Jersey, became a national philanthropic organization in 1972 as a result of Robert Wood Johnson’s bequest of virtually his entire estate in the form of Johnson & Johnson stock. Robert Wood Johnson led the Johnson & Johnson Company, manufacturer of health care products and services, from 1932 until his death in 1968. Johnson anticipated strong ties between the Foundation and Johnson & Johnson, which did not materialize because of new federal tax laws instituted via the Tax Reform Act of 1969. Johnson & Johnson produces for the masses Band-Aids, Tylenol, Motrin, and hundreds of other products. A world without the products provided by this company for the past century is difficult to imagine.
John Lumpkin, MD, MPH, according to his bio, has “participated directly in the health and health care system, first practicing emergency medicine and teaching medical students and residents at the University of Chicago and Northwestern University. After earning his MPH in 1985, he began caring for the more than 12 million people of Illinois as director of a state public health agency with more than 1,300 employees in seven regional offices, three laboratories and locations in Springfield and Chicago. He led improvements to programs dealing with women's and men's health, information and technology, emergency and bioterrorism preparedness, infectious disease prevention and control, immunization, local health department coverage and the state's laboratory services.”
Please describe your role at The Robert Wood Johnson Foundation.

I am senior vice president and the director of the Health Care Group. I’ve been here since April of 2003. It’s a very nice and exciting place to work. Our mission, which is to improve health and health care for all Americans, is a nice extension of what I was doing at IDPH [Illinois Department of Public Health]. It allows me in many ways to get involved with health policy at the national level.

What does your current position entail?

I’m in charge of a group of health care programs, which are working toward covering the uninsured, improving quality and outpatient health care delivery, reducing disparities in health-care delivery, and reengineering the nurse environment. I’m also in charge our programs relating to health and health care human capital, so some of our signature programs, e.g., clinical scholars and fellowships. In addition, most recently, I headed up our Katrina response team, which is doing grant making to help relief and recovery for the major hurricane that hit the Gulf.

Robert Wood Johnson Foundation has long been known for its health care mission. If you’re head of health care, then what is the chief executive officer head of?

We split the RWJF programs between health and health care. On the health side, the programs that aren’t under me include public health infrastructure, tobacco, substance abuse, and vulnerable populations such as the aging population, and childhood obesity.

Can you explain RWJF’s typology of “health” and “health care”? Is “health care” part of “health” or is “health” part of “health care” or are both of them subsumed under something else?

I would probably ascribe to “health” as the broader term. As a foundation in our early years, our major focus was on health care. In the early 1990s, we began to have more of a balance. We use the terms health and health care to remind ourselves, as well as the outside world, that we are concerned not only with health care but with the broader concept of health.

Was former RWJF President and CEO Dr. Stephen A. Schroeder (1990-2002) responsible for that transition?

He played a key role in that change.

Then, even though you have an extensive public health background, you were brought on board to oversee the health-care program side of RWJF?

Right. But again, I participate on the public health team, which is an internal team that looks at the public health infrastructure programs. It’s not as structured here as having said there are health and health care sides would imply. We all work very collaboratively. Teamwork is a key component of what we do.

In the past, RWJF was deeply involved in emergency medical services systems development. SEMP has published several essays on this history. In light of the Hurricane Katrina event last month, does your organization distinguish between emergencies, disasters, and catastrophes, or does it conflate the three?

First of all, you need to put all of this in context. As a foundation, we’ve adopted what we call our “impact framework.” Prior to the arrival of our current president, Risa Lavizzo-Mourey, we had 32 programmatic areas. For a foundation our size, it’s hard to have an impact when you’re trying to influence 32 different areas. So we developed four investment portfolios. We’re different than a capital company that is investing trying to get a profit return on investment. We’re looking for social change as a return on our investment. Within that metaphor we have four portfolios. The first portfolio is our “pioneer” portfolio. This is an area that we use to basically try to encourage the development of innovation that make some time to develop, may be more risky than what we usually do in our usual grant making but, if successful, has the potential to be transformative. For example, we are funding the development and currently we are in the testing phase of “icons” that can be used by people of low English proficiency to navigate the health care system, like international road signs that tell you how to get around a hospital or clinic.

So these icons would be part of hospital signage or used on the Internet?

They could be used anywhere. When you think about it, there’s a universal sign for “stop” and that plays a role not only in driving around in streets but is also used in different ways on computer screens. We don’t know what all the implications are for people who don’t speak English as their first language or are fully literate to navigate a hospital. How do you find the laboratory if you can’t read or you can’t read English? How do find any of the major destinations that people have to find in a hospital? A universal sign, once learned, would enable a person to navigate any health care system. Now it may applicable to use these same icons in electronic or personal health records. So that’s an example of something that I’ve been looking at in our pioneer portfolio.

Are you then pioneering a new language, a visual language?

It’s not quite as extensive as a language might be. There may be a set of 30 or 40 icons. In our pioneer portfolio, we’re exploring the development of the use of health courts as a solution to the malpractice crisis.

What are your other three portfolios?

The second portfolio is “vulnerable populations,” which includes aging, mental health, and the homeless, and faith-based programs that touch people’s lives at a very basic level. The third portfolio is “human capital,” which involves various scholars and investigators and other programs that start out as early as college level programs to assist minority and disadvantaged individuals to go into the health professions. Some programs are very advanced, for example, researchers, particularly investigators in social science, political science, and economics who do research in the field of health in the broad sense. The fourth target is our “target” portfolio, which is split into health and health care. Within the target portfolio are the eight programs that I talked about earlier. To reiterate, on the health side is tobacco, substance abuse, childhood obesity, and public health infrastructure. On the health care side is covering the uninsured, quality and outpatient care disparities in health care delivery, and reengineering the nursing environment.

Do emergencies, disasters, and catastrophes fit into any of these four portfolios?

To answer your question, except for the public health team that is looking at public health preparedness in the context of the public health infrastructure, we don’t see as our objective to really respond to emergencies, disasters, or catastrophes. However, we are organizational citizens of this country and this world. Within that context, last year there was the tsunami and we looked at that sort of event and identified that there was a whole host of organizations giving money upfront. Our concern was that a year later, which is where we are now, most of that funding was going to dry up. So we allocated funds to do some help and recovery with a strong focus on the public health systems, but we delayed the allocation of these funds until a year later when we thought that they would be most needed. The funds will start going out in the next couple of months.

Katrina is such a major disaster or catastrophe, which I believe is the most appropriate word, that even though we are again not in the relief business, we did feel that as a foundation we had to do something. So far we’ve allocated roughly 5 million dollars.

How has RWJF allocated its 5 million dollars in the Katrina catastrophe?

We’ve allocated some funds to the CDC [Centers for Disease Control and Prevention] Foundation, which is a philanthropy that, through an act of Congress, is affiliated with CDC [see http://www.cdcfoundation.org/]. The part of the work of CDC Foundation that we funded in Katrina was based on lessons learned during 9/11. CDC teams that were dispatched to the response site needed equipment that they couldn’t purchase with their government credit cards. So this fund was established within CDC to aid the CDC teams when they were onsite, in this instance with Katrina, to provide some services and get some materials that they couldn’t get through the regular procurement channels.

What couldn’t the CDC teams get during 9/11 and Katrina through regular procurement channels on government credit cards?

I’ll give you an example. During 9/11, at Ground Zero cell phones weren’t working. CDC responders didn’t have land lines and needed satellite phones. They could not get those using their federal credit card.

Because of scarcity of satellite phones?

They had difficulty procuring satellite phones because of procurement red tape. By the time they cut through it, it really was too late.

I would have used my own credit card to get a satellite phone if I needed one in that situation.

That’s what people did and then there was the question of whether they would get reimbursed. Another question is why are we putting our first responders and our front-line responders through that?

And in Katrina?

What we ended up doing in relationship to Katrina is that the CDC Foundation expanded that support system to state and local health departments. The state health department in Alabama, for example, was engaged in getting medications to displaced individuals. A few days after Katrina landfall, there were other organizations that moved in to do this.

Such as Walgreen’s and other the retail pharmacies?

Yes, but that was a few days later. So initially the CDC Foundation request went from the Alabama Health Department to the CDC emergency operations center [EOC]. They vetted that request for setting up a system for purchasing and distributing medications for people who were displaced, and then forwarded the request to the CDC Foundation. They already had the system to distribute the medications via state employees, but they needed the medications to do that. To buy the medications, the state employees needed cash. Again, the situation was such that there was no mechanism for those state employees to purchase the medications that they were giving to people. So the CDC Foundation funded this. The neat part about this is that the CDC Foundation gives the money contingently to the state or local health department. The contingency is that if the service or good is then covered by FEMA [Federal Emergency Management Agency], when the state or local health department gets reimbursed by FEMA, they will pay the money back to CDC Foundation. The paid-back money goes into a fund that is then available for the next disaster.

Does the CDC Foundation have the ability to track all this money going back and forth and enforce that monies be returned if FEMA chips in dollars?

The CDC Foundation does that. They have their own separate board and their own separate governance structure. We’re perfectly fine with the CDC Foundation giving some of the money that we contributed to them to local or state health departments to cover an emergent need that is subsequently found to be covered by FEMA. If our money ends up going back to the CDC Foundation, we are still contributing to this longer-range fund, which is good.

We also funded the Red Cross, the Salvation Army, and national organizations with ties into that area that do assessment, and provided some impact grants to community health centers and mental health centers to provide some short-term assistance to reestablish those centers. In some instances, we have grantees on the ground who were directly impacted and we have provided them some assistance to get them back up and running.

Have you been to the Gulf area since Katrina?

No, not yet. We’re also looking at a longer-term commitment to the area. One of the areas we’re particularly concerned with is how do you build a community so that it promotes exercise, health, and healthy communities? How do you build a hospital so that it actually promotes health? For example, consider a simple thing like natural lighting. Patients who are in ICUs [intensive care units] who are exposed to natural lighting have shorter stays compared to those who aren’t. That sort of evidence-based research has been collected by us in different programs and we’re going to find ways that we can provide assistance to those who are rebuilding the Gulf area, making sure that they have access to the evidence-based approach to rebuilding the community and rebuilding health care facilities.

“America’s Forgotten Pandemic: The Influenza of 1918”
Book Review

Hardly a day goes by without another story on the imminence of a pandemic roaring through and decimating America’s and the world’s populations. Thus, it may come as a surprise to some people that one of humanity’s worst pandemics—the 1918-1919 world influenza pandemic—was called “America’s Forgotten Pandemic” by the most-gifted historian Alfred W. Crosby whose book of the same name is the subject of this book review.

Crosby first published “America’s Forgotten Pandemic” in 1976 during the swine flu scare and debacle (see SEMP Biot #177: The Flawed 1976 National “Swine Flu” Influenza Immunization Program” at: http://www.semp.us/biots/biot_177.html), republished it with a different publisher in 1989, and issued the 2nd edition in 2003. Crosby artfully reconstructs the difficult history of the pandemic, and this alone stands as a monumental contribution. But Crosby’s framework for the story--society’s indifference to the disaster—was what caught my attention. He delves into this phenomenon in the book’s final chapter aptly titled, “An Inquiry into the Peculiarities of the Human Memory” (pp. 311-325).

Crosby described the situation this way: “Studying the record of the American people in 1918 and 1919 is like standing on a high hill and watching a fleet of many vessels sailing across a current of terrible power to which the sailors pay little attention. They grip their tillers firmly, peer at their compasses, and hold faithfully to courses, which, from their vantage, seem to be straight, but we can see that the secret current is sweeping them far downstream. The immense flow swamps many of the ships and their sailors drown, but the others take little notice. The others are intent on maintaining their own unwavering courses.”

“The important and almost incomprehensible fact about Spanish influenza [he explains the history of that term earlier in the book] is that it killed millions upon millions of people in a year or less. Nothing else--no infection, now war, no famine—has ever killed so many in as short a period. And yet it has never inspired awe, not in 1918 or since, not among the citizens of any particular land and not among the citizens of the United States. This inaptitude for wonder and fear cannot be attributed to a lack of information. The destruction wrought by Spanish influenza is memorialized in reams of published statistics in every technologically advanced nation that was not in a state of chaos in 1918.” (p. 311)

Why did Americans pay so little attention to the pandemic of 1918 and why have they so thoroughly forgotten it since?” Crosby queried. He offers two reasons. First, lethal epidemics were not as unexpected in the early 1900s as they are today. Terrific epidemics of typhoid, yellow fever, diphtheria, cholera, and smallpox were well within living memory. Second, the Great War (World War I) caused a relative indifference to the pandemic. Many people may have perceived the pandemic as merely a subdivision of the war. In fact, many doughboys-in-training in military camps strewn across the US died from the flu before they shipped out to Europe; some even died on the way to Europe or just after reaching her shores.

Crosby is correct about this second assessment—that it was tragic and noble to die in battle but hardly worth mentioning if death occurred in training camps or en route to battle. For example, “The Jayhawker 1919 Yearbook” from the University of Kansas (Lawrence, Kansas) was dedicated “[T]o the memory of the Men of the University of Kansas who so willingly served their government in its great crisis, even to the supreme sacrifice of life itself, we do solemnly dedicate The 1919 Jayhawker.” The Foreword says: “The 1919 Jayhawker is fittingly named ‘The Peace Book,’ and in all honor to the men who aided in the successful termination of the war, we have dedicated this book to them. A military atmosphere may predominate in this effort, but peace will soften it and enable us to look upon it all as a glorious history. Within, the pictures of military and college life prove an odd mixture, but this very mixture will give the Peace Book the essence of a history of our University, its efforts in the War and the rapid change from war to peace and reconstruction. We give you the 1919 Jayhawker, proud in its military aspects and joyous in its return to peace and normal times.”

Whole pages of the 26 University of Kansas collegiates who were killed in battle occupy the first section of the book, titled “Tribute.” Yet no photos or even a list of names of the collegiates who died from flu during the same time period is available in the yearbook. There is a short piece on page 246 of the yearbook titled, “The Influenza Epidemic at KUSATC” (Kansas University Students’ Army Training Corps) that again describes the situation but does not honor the soldiers who died from the flu. This piece is reproduced in its entirety below:

“The Influenza Epidemic at KUSATC”

“The influenza epidemic, which affected the entire program of the school year at the University of Kansas so disastrously, struck here shortly after school opened in the fall [September-October 1918]. It came, as epidemics do, unexpectedly and quickly. One by one the men of the Students’ Army Training Corps were attacked and before many days had passed the situation grew serious.

“At the very outset school was closed, the sick men were confined to one barracks exclusively and a quarantine was thrown around the camp. However, by the close of the second week so many men were stricken that four barracks were being used for them; numbers one, three and four for those very sick, and number six for the convalescents.

“The hospital organization, the fighting machine used to combat an epidemic, was found to be inadequate for taking care of the growing number of patients. The staff at first was very small. It was, however, assisted by many volunteer orderlies from the various companies on the hill. Hospital supplies for the staff and men were insufficient and the situation grew more alarming as time went on. Men connected with medical work here were called out of the ranks and detailed to assist in the hospital work. Collections were taken from among the SATC men to buy fruit, postage stamps and other wants.

“By the close of the third week new cases were reporting at the rate of nearly thirty a day. However, as the hospital unit had now had sufficient time to organize, no concern was expressed as to its being able to take care of the men comfortably and with results. Help had come from the outside by this time. Ladies of the town had made donations of hospital supplies, and later volunteered their services as nurses, as did also the girls of the many university organizations. More lieutenants from the army medical service as well as the doctors of the town had given their services and the situations showed signs of being checked.

“By the close of the fourth week most of the men were either convalescing or had had the “flu.” Of nearly 2,000 men in the Collegiate Division, SATC, only eight hundred escaped the influenza completely.

“The influx of many Section B men, Vocational Division, who were sent here by the government, contributed largely to the seriousness of the situation during the first few weeks. These men immediately began to contract the disease. Most of them did not report to the hospital until late. As a consequence, many serious cases developed, the majority of the deaths resulting among those men.

“At the height of the epidemic some thirty cases a day were reporting, and the percentage of deaths in proportion to the number of patients was considerably less than at other camps. Although the plans of the Students’ Army Training Corps and the University of Kansas were upset by the coming of the influenza epidemic, the government and the university may consider themselves fortunate not to have lost more men.”

According to one historical account, by the time the University reopened on November 8, [1918] nearly 1,000 faculty, students, and staff had been afflicted with the disease and 24 KU people had died from it. (1)

One of Alfred Crosby’s greatest disappointments was that so few of America’s literati chose to write about the great flu pandemic, including F. Scott Fitzgerald, Ernest Hemingway, among others, even though most of them were directly affected the pandemic. For example, “Spanish influenza frustrated F. Scott Fitzgerald’s ambition to get into the war and see something worth writing about. In October 191, his division was ordered to France, but fear of an outbreak of flu on the high seas delayed its embarkation,” Crosby wrote (pp. 315-316). “When the division finally boarded ship, the war ended and she never cleared port. Fitzgerald, to his sorrow, had missed World War I. His confidant and adviser, Father Sigourney Webster Fey, the original of Father Darcy in “This Side of Paradise,” died of pneumonia in January of 1919. Yet the pandemic plays no role of significance in “This Side of Paradise” or elsewhere in his fiction. Fitzgerald, who felt himself the chronicler of his age, left out something that killed a half million of his fellow citizens in a half year,” mused Crosby.

One American writer, Katherine Anne Porter, however, did write a story on her character’s near-death experience with the flu in 1918, which killed her lover. The story, which is still well known today, is called “Pale Horse, Pale Rider.” To Katherine Anne Porter, Crosby dedicated “America’s Forgotten Pandemic.”

Source:
1. “1918 The Grim Reaper Closes Campus.” The Week in KU History. Available at:
http://www.kuhistory.com/proto/story.asp?id=26. Accessed October 9, 2005.