News From NACCHO
On a beautiful spring morning, your city's busiest weekday commute is suddenly interrupted by a tragic event. Sarin gas has been released on an overcrowded commuter train in the center of your community's major transportation hub. Information from the scene confirms at least 12 dead, and scores of others are flooding hospitals across your community. Emergency departments become overwhelmed with the surge of those injured or claiming they were exposed to the noxious gas. Their families overload your city's communication system by attempting to locate their missing loved ones.
Now picture this … a rapidly emerging pandemic influenza is sweeping our country. Your local public health system is crippled by the thousands of people presenting to the emergency department, ambulatory clinics, and the offices of their community practitioners. While many of these people will be sick with influenza, thousands of others will be suffering with the fear of being ill or of their family members contracting this deadly virus.
Although both scenarios make for entertaining television dramas, they unfortunately were very real events. The sarin gas attack occurred in 1995 on a mid-March day in Tokyo. While the release of this deadly gas killed a dozen people, it seemed insignificant in light of the number of people who presented for emergency treatment. More than 5 500 people presented to 280 Tokyo medical facilities. Even more striking was that, upon examination, more than 4 000 of those did not show any evidence of harm or even exposure to the gas. Although it has been decades since our last pandemic influenza, the death tolls from the pandemics of 1918 and 1957 leave their indelible mark.
The reality of another devastating terrorist attack or pandemic influenza outbreak looms large over the heads of our public health system. Fatality modeling suggests hundreds of thousands, if not millions, could perish from the influenza virus alone, creating a social and economic backlash that will likely be felt for years after. Emergency management and healthcare leaders see pandemic and bioterrorism preparedness planning as critical to preserving the nation's public health system in the face of such events. Millions of dollars are being spent on stockpiling medication, creating sophisticated detection systems, and training personnel to respond to the medical needs of those impacted. But are we prepared to address the psychological aftermath of these disasters? What resources do we have in place to emotionally support those who fear they have contracted a deadly virus or believe they were exposed to a biological agent? How will we divert the thousands of individuals for whom anxiety alone has prompted their healthcare visits that threaten to cripple our public health system?
Addressing the mental health concerns of disaster survivors and victims of public health emergencies has often been underappreciated. Lost are the numerous experiences that suggest that the psychological footprint of such events will grossly overshadow that of the medical footprint. Countless domestic and international disasters suggest that mental health to physical health casualties following such events are 4:1 at the conservative end and 500:1 such as they were during the Sarin gas attack described above. Such evidence suggests that responding to the mental health impact of disaster is a critical public health issue.
Traditionally, our country's public mental health system has been significantly underfunded, leaving limited resources to deal with only persons with chronic and persistent mental illness. Only in the last 6 years, since the devastating effects of September 11, 2001, has our nation's emergency preparedness included the need to address the psychological consequences of disaster and other public health emergencies, but the resources to address these issues and bring communities to a state of “psychological readiness” are few and far between. Decreased funding streams, coupled with insurmountable grant deliverables, have relegated mental health preparedness to the “low-priority” list. Public health and mental health community leaders have a tremendous dilemma ahead of them if they at all entertain the realities of the situations described above. The likelihood of their public health systems crashing down around them as they are surged with the mental health needs of those affected by disaster and other public health emergencies grows more pressing by the day. So what options do they have?
Community Partnerships for Public Mental Health Preparedness
This “call to action” requires a partnership between a community's public health and mental health leaders. No one individual or agency can address this issue and responsibility alone. Public and mental health directors might look to the resources of their community for assistance and take critical steps, such as the following, toward preparedness.
- Build a mental health disaster plan: Do not reinvent the wheel. Use existing resources in building your community's mental health disaster plan. One such resource is the Mental Health All-Hazards Planning Guidance document developed by the National Association of State Mental Health Program Directors. It is available for download at www.nasmhpd.org.
- Develop and implement a community-based psychological resilience program: Although the evidence on the efficacy of community-based psychological resilience programs is lacking, support for initiating such programs continues to grow. Resources to prepare communities for the mental health impact of disasters and public health emergencies include such measures as providing mental health information in family disaster preparedness tools and implementing psychological first aid training for adults and children. Such efforts can be instrumental in preparing individuals for the psychological consequences of disaster and giving them the skills to take care of themselves and their family members in a crisis. For more information on psychological first aid, go to www.nctsn.org. The San Mateo County (California) Public Health Department has also developed a variety of informational handouts for health department staff, their families, and the public related to coping with stress following a community crisis. These handouts are available in National Association of County & City Health Officials's toolbox at www.naccho.org/pubs/toolbox/tool.cfm?id=336.
- Train a Disaster Mental Health team: Preparing the right people to provide the right type of intervention at the right time is critical in disaster mental health response. Over the past few years, many communities have formed Medical Reserve Corps (MRC) teams. These volunteer-based programs are typically composed of healthcare personnel, including mental health professionals. Their primary goal is to be integrated in their community's disaster response infrastructure and respond to public health needs during times of disaster and other emergencies. The National Association of County & City Health Officials, in collaboration with the US Office of the Surgeon General's MRC program, has been working to raise the visibility of these programs and enhance these units' capacity to engage in public health preparedness at the local level. For more information on the MRC program go to www.naccho.org or www.medicalreservecorps.org.
- If your community does not have an MRC, then the first step would be to develop a specific disaster mental health team. Such a team should be able to provide a variety of supportive and clinical care to victims and others impacted by public health emergencies. Reaching out to hotline volunteers, rape crisis and domestic abuse counselors, group home and residential care staff, hospice workers, and clergy can fill the gap created by limited availability of professional mental health resources. Ensure that the team members are adequately trained to the level of their abilities, skill, and education. A course in psychological first aid can establish a baseline, minimum standard for your team. Meanwhile, additional training on the National Incident Management System, the Incident Command System, and the challenges of providing mental health intervention in the context of a disaster is also helpful. More extensive training in providing clinical psychiatric assessment and intervention will be warranted for those who have the academic background and need to have such skills and knowledge. For information on psychological first aid and other disaster mental health training, contact the American Red Cross at www.redcross.org.
- Protect your resources: Human resources are your most vital asset in disaster preparedness and response. Ensuring their protection and safety should be a top priority. Emotional and physical casualties are inherent in disaster work, requiring your personnel to be well equipped to address such risks. One way to mitigate such outcomes is to prepare your personnel for the roles they will assume in responding to public health emergencies. Provide them with information and resources that can help them take care of themselves and their family members. Resources such as those available on the Ready.gov Web site (www.ready.gov) and the Plan to be Safe Campaign from the Montgomery County Advanced Practice Center (www.montgomerycountymd.gov) provide helpful tips on family disaster planning. In addition, encourage your personnel to adhere to physical and psychological self-care techniques in an effort to preserve themselves for their disaster assignment. Education in infection control and psychological first aid will be helpful in achieving this goal.
- Practice and evaluate your plan: Most communities plan and prepare for disasters but consider the risk of such events low. Over time, the skills and knowledge of their responders deteriorate. Psychological interest in and commitment to volunteering may also wane. To maintain physical and mental states of readiness, communities must practice and drill their response activities. Doing so not only preserves and enhances one's skill base but also keeps one psychologically prepared for the real event. Take the time after the drills or event to evaluate how the plan worked and where it needs to be revised. How did your response personnel find their disaster experience? Feelings of disillusionment in the system or their individual efforts, coupled with the psychological battering they may have experienced helping disaster victims, may turn them away from volunteering during future events. Take the time to follow-up and assess the well-being of your response personnel. Providing opportunities for them to enhance their knowledge and skills and reshape their personal expectations could be critical to strengthening their commitment to disaster work and having the necessary resources at hand when your community needs them.
Public health and public mental health are not discrete concepts. They are intertwined, one being critically important to the other. Our public health and mental health authorities must work together to weave the impenetrable fabric of preparedness that will allow our communities to survive in the midst of inevitable public health emergencies.