1. Public Health Departments and Disaster Management Activities: An Oral History of the New York City Department of Health and Mental Hygiene (NYC DOHMH) and the Events of 9.11.01 Nancy VanDevanter, Dr PH* and Perri Leviss, MPM** *Columbia University, Mailman School of Public Health **Consultant

2. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 2 The Lasting Effect of 9.11.01 on Public Health “Public Health has been challenged to change its normal, historical way of doing business, to become more responsive to the kind of first responder orientation which often means making decisions…very rapidly with limited data available…. Something that the field historically hasn’t done.” Public Health needs to come to the table as a stakeholder in order to gain more attention, more support and, ultimately, more respect.

3. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 3 Acknowledgements We would like to thank the leadership and staff of the NYC DOHMH who generously shared their experiences and assessment of the role and function of the department in the World Trade Center (WTC)and Anthrax disasters of 2001. We would like to thank the leadership and staff of the NYC DOHMH who generously shared their experiences and assessment of the role and function of the department in the World Trade Center (WTC)and Anthrax disasters of 2001. David Rosner PhD, Professor of History, Mailman School of Public Health who collaborated on the study. David Rosner PhD, Professor of History, Mailman School of Public Health who collaborated on the study. Robert Wood Johnson Foundation, Columbia University Office of Oral History, New York Historical Society who funded the study. Robert Wood Johnson Foundation, Columbia University Office of Oral History, New York Historical Society who funded the study.

4. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 4 Chronology of Events 9.11.01 WTC attacked 9.11.01 WTC attacked 9.12.01 DOH headquarters closed; staff relocated 9.12.01 DOH headquarters closed; staff relocated 9.12-9.22.01 DOH at WTC site; 24 hr operations 9.12-9.22.01 DOH at WTC site; 24 hr operations 9.20-9.24.01 Staff returned to DOHMH headquarters 9.20-9.24.01 Staff returned to DOHMH headquarters 10.4.01 Anthrax reported in Miami 10.4.01 Anthrax reported in Miami 10.8.01 Anthrax suspected at NBC 10.8.01 Anthrax suspected at NBC 10.12.01 Anthrax confirmed at NBC 10.12.01 Anthrax confirmed at NBC 10.12-11.30.01 Multiple anthrax investigations 10.12-11.30.01 Multiple anthrax investigations

5. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 5 Methodology of Oral History Research In-depth qualitative interviews (1 ½- 2 hrs in length), 3-6 months post disaster In-depth qualitative interviews (1 ½- 2 hrs in length), 3-6 months post disaster Interviews transcribed Interviews transcribed Transcripts returned to interviewee for permission to deposit Transcripts returned to interviewee for permission to deposit Transcribed interviews entered into Atlas ti Transcribed interviews entered into Atlas ti Thematic analysis and coding of data by 2 independent coders (kappa.85) Thematic analysis and coding of data by 2 independent coders (kappa.85)

6. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 6 Oral History as Tool in Public Health Systems Research Provide personal accounts and observations of historical events by participants Provide personal accounts and observations of historical events by participants Allow researchers to document events and identify themes as they emerge from the data Allow researchers to document events and identify themes as they emerge from the data Provide opportunities to examine interfaces between organizational and structural issues Provide opportunities to examine interfaces between organizational and structural issues Allow for historical data to be gathered for future research Allow for historical data to be gathered for future research

7. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 7 Factors that Facilitated and Impeded the NYC DOHMH’s Response to 9.11.01 Unanticipated Functions and Demands Unanticipated Functions and Demands – Leadership role in disaster – Environmental health activities including air quality and worker safety – Public relations – First aid/first responder – Public health laboratory

8. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 8 Factors that Facilitated and Impeded the NYC DOHMH’s Response to 9.11.01 cont. Risk Factors Risk Factors – Physical proximity to the disaster site “The one plan we didn’t have was an evacuation plan.” – Antiquated physical plant/equipment – Overburdened staff – Lack of medical records information exchange – No system for procurement, inventorying, and distribution of supplies/equipment – No systems for monitoring worksite safety from a public health perspective (food, sanitation)

9. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 9 Factors that Facilitated and Impeded the NYC DOHMH’s Response to 9.11.01 Unique Capacities Unique Capacities – Pre-9.11.01disaster experience (Y2K, West Nile, table-top exercise training) – Strength of infrastructure: clinics, surveillance systems, relationship with CDC – Leadership of Mayor Rudolph Guiliani – Commitment of DOHMH workforce – Attention to mental health issues

10. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 10 Changes in NYC DOHMH After 9.11.01 Stronger and new relationships among staff Stronger and new relationships among staff “The other thing…that has been really phenomenal with World Trade Center and then also with Anthrax, that, you know, the people in this agency have been through a war together, I mean, at least people, you know, within these emergency response groups, it has forced us to assort, you very closely work for very long hours, under stressful conditions, with different people than we would ordinarily be dealing with. It’s forged some indescribable bonds …” New collaborations w/other city agencies New collaborations w/other city agencies

11. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 11 Changes in NYC DOHMH After 9.11.01 cont. Improved relations with community Improved relations with community Removed barriers between government and press Removed barriers between government and press Culture shift – being more prepared Culture shift – being more prepared – Protocols for staff with specific jobs in emergency management (EM) and staff training in EM procedures – Balance between being prepared and running the everyday responsibilities of core programs

12. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 12 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina 1.Press – Media Training Telling the public ‘what they know’ and ‘ what they do not know’ Telling the public ‘what they know’ and ‘ what they do not know’ Ensuring a consistent voice from multiple government organizations Ensuring a consistent voice from multiple government organizations Importance of public officials’ credibility Importance of public officials’ credibility

13. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 13 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. “Whether it’s in terms of just getting messages out on TV, having people get out and represent the health departments’ perspective on the crisis. We had a lot of people who spoke at one time or another or gave time to be interviewed. As a priority, it’s something that frequently we don’t feel comfortable – we’re not media people. We sort of work in our one arena and not deal with that but at least these times its just greatly important and its something that there has to be some focus and training on just how to do it.”

14. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 14 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 2.Role of Community Routine communications between public health departments and community Routine communications between public health departments and community “I think I was so struck by the need to find out what a community needs and wants, and to make sure the work that you’re doing is based on that—not what the government thinks people need, but what people say they need.” “So I just feel like sort of I’ve been impressed by the need to have your public health interventions very much connected to the reality of what communities need. So I think that’s sort of the biggest thing.”

15. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 15 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 3.Coordinating with Government Agencies Coordination between local, state and federal public health organizations Coordination between local, state and federal public health organizations Collaborative working relationship with public health and law enforcement Collaborative working relationship with public health and law enforcement Coordination and communications among local government agencies Coordination and communications among local government agencies Government relations Government relations “You don’t want to exchange business cards at the time of the emergency.”

16. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 16 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. “…the level of communications among agencies is really far less than what it needs to be to respond to these kinds of events. And I think its just another reflection of how that infrastructure, that communication structure has not really been developed or well developed. I think it also raises questions about thinking about public health in terms of the multiple agencies and disciplines and expertise that are needed.”

17. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 17 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 4.Building communication systems and collaborations with physicians Health alert network – web-based secure system Health alert network – web-based secure system Educating physicians and healthcare workers in emergency managementEducating physicians and healthcare workers in emergency management 5.Planning for the impact on routine public health activities (e.g., death and birth certificates)

18. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 18 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 6.Investing in information technology security and disaster recovery NYC DOHMH built second data center NYC DOHMH built second data center “When you think about it, registry data, you know, some of the living, breathing documents, bodies of information that we rely on to do our work, are so vulnerable”

19. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 19 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 7.Creating state of the art public health laboratories Data management – systems to track specimens Data management – systems to track specimens “…those systems need to be in place routinely and not to rely on being able to ramp up during a crisis.” 8.Developing health and safety plans/occupational health and safety Personal protective equipment Personal protective equipment Air monitoring Air monitoring

20. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 20 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 9.Assuming the role of emergency responder Emergency response plansEmergency response plans Staff cross-trainingStaff cross-training Inventory/distribution systems for medications and equipmentInventory/distribution systems for medications and equipment Use of volunteersUse of volunteers

21. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 21 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. “In my fourteen years with the Department of Health, I’ve seen a real shift that’s been accelerated in the last couple of years now. It really started with the emergency of West Nile (virus) in 1999. But traditionally, we were never, in the culture, a twenty-four-by-seven agency, and we are rapidly becoming a twenty-four-by-seven agency. We do not necessarily have to be a twenty-four-by-seven staff, but the thinking is around emergency response, and twenty-four-by- seven (response).”

22. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 22 Lessons from NYC DOHMH’s Experience in 9.11.01: Applicability to Hurricane Katrina cont. 10.Using spatial analysis ER chief complaints to identify upticks in certain symptoms citywide ER chief complaints to identify upticks in certain symptoms citywide

23. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 23 Importance of Public Health Systems Research in 9.11.01 and Hurricane Katrina 9-11 studies: Population Impact 9-11 studies: Population Impact – FEMA funded study of 9-11 residents at the time, employee-occupants, school children, rescue worker – NYC DOHMH study of domestic assaults following 9.11.01 – Traumatic brain injury study – Worker-injury surveillance system

24. February 8, 2006 2006 National Health Policy Conference Adjunct Meeting – Public Health Systems ResearchPage 24 Disaster Related Public Health Systems Research Questions Types of questions that researchers need to ask (e.g., contextual issues) Types of questions that researchers need to ask (e.g., contextual issues) – What basic public health systems need to be in place for EM? – What role does a public health department play in EM? – What organizations need to participate in EM and what functions do each serve? – How does the placement of the public health within the larger government structure affect its ability to respond to emergencies? Distribution channels for research Distribution channels for research Funding sources for research Funding sources for research