Say what? Who? Me? Right here in the trenches? Collaborate on what?--Seeking common ground in regional all-hazards preparedness training.

Introduction

Recent challenges with respect to environmental health issues have led to the development of new tools and techniques for use by first responders, including simple and rapid detection of bacterial spores in powder (Min, Lee, & Deininger, 2006). In the future, if the world's trepidation is justified regarding the potential for an avian-flu pandemic, then, as Nelson Fabian put it, "undoubtedly, many environmental health professionals are going to be in the middle of these containment decisions and activities, as it will take every resource of local health departments to deal with the burdens that a flu pandemic could cause" (2006, page 51). Thus, in addition to benefiting from new techniques for solving today's problems, environmental health specialists may also benefit from interdisciplinary training shaped with other first responders, especially when the training focuses on the need for multidisciplinary collaboration among teams of professionals responding to crisis situations.

While sharing challenges, successes, and lessons learned from the development of a regional all-hazards preparedness training program, this article encourages readers to reflect on certain phrases from its title, namely: "Say what? Who? Me? Right here in the trenches? Collaborate on what?" Thoughts like these, if they occur either explicitly or implicitly during a community crisis response, may indicate a mindset fraught with roadblocks to collaborative partnerships.

This article also discusses ways of seeking common ground to help counterbalance some of the turf building that could jeopardize successful interagency collaboration.

Genuine Collaboration Versus Silo Mentality

The events surrounding September 11, 2001, as well as Hurricane Katrina in 2005 and other catastrophes, called forth heroic responses that demonstrate the need for genuine collaboration within communities and among environmental health professionals, public health agencies, multidisciplinary first responders, and other organizations. A collaborative interagency and multidisciplinary community response can enhance postevent outcomes, aid in the implementation of a well-coordinated and targeted response plan, and reduce wasteful duplication while supporting redundancy of backup, recovery, control, and mitigation efforts.

At the other extreme, "silo building," figuratively speaking, may be so deeply ingrained in the institutional memories of organizations that people unwittingly erect barriers to development of interdisciplinary initiatives needed for appropriate community response to catastrophes. Vertical conceptual silos--almost akin to tunnel vision--involve the isolated implementation of individual agency response plans and may denote a comfort zone within which the agency operates during times of crisis. Because each agency is so busy with its own agenda and often cannot see beyond its own limited parameters, there may be no room for meaningful interagency collaboration and a coordinated community response. Despite this observation, major kudos are due to all the great responders and their families out there, who bravely, and at great personal cost, respond to protect communities on a daily basis as well as during the specific emergency situations listed above.

No Man (or Woman) Is an Island

As McKenzie and co-authors put it, "If a community can organize its resources effectively into a unified force, it will be better equipped to address and resolve a community health problem." (McKenzie, Pinger, & Kotecki, 2002, page 8). Furthermore, said community "is likely to produce benefits in the form of increased effectiveness and productivity by reducing duplication of efforts and avoiding the imposition of solutions that are not congruent with the local culture and needs" (Institute of Medicine, 2003; McKenzie, Pinger, & Kotecki, 2005, page 10).

Just as it may take a village to raise a child, so local-regional collaboration is crucial to effective community response efforts. The role of national-global collaboration was also demonstrated during the 2004 tsunami relief efforts, and this kind of collaboration is now operating to forestall an avian-flu pandemic. Even estimates of 5 percent mortality in an avian-influenza pandemic, which represent a hopeful scenario, would translate into 325 million deaths worldwide and 15 million deaths in the United States (Fabian, 2006). In each locale, local and regional collaboration will be framed differently, and partnerships will be predicated on prevailing factors that affect the health of a community, including physical factors (the environment, geography, community size, and industrial development) and social factors (availability of community response agencies and their proximity to likely areas of need, beliefs, traditions and prejudices, the economy, socioeconomic status, politics, religion, social norms, and community hierarchical structures).

In northeastern Pennsylvania, a sample of physical factors to be considered include icy winters and the Appalachian mountain range and its low-lying valleys, which are prone to episodic flooding. Community size issues include the contrast between large urban areas and a preponderance of small, isolated rural communities with limited access to health facilities. Some counties have experienced a notable in-migration that has resulted in unprecedented population growth. Service agencies, faith-based organizations, and other community agencies may serve as partners in bringing preparedness and response plans home to members of the community. Also helpful are mass media reminders about the importance of building a disaster kit and having family disaster recovery plans (Bitto, 2005, 2006; National Disaster Education Coalition, 2004).

Sharing Lessons Learned: Experiences, Challenges, and Successes

The goal was to develop a regional all-hazards preparedness training program for the public health workforce and its participating collaborators, and to assist with navigating through the multiplicity of preparedness trainings offered on the Internet and elsewhere. The development of an all-hazards preparedness training program has been facilitated by intense regional collaboration with state and federal entities, involving local and regional health departments, universities, emergency management and emergency service agencies, and other first responders. Periodic meetings were held to review training needs and develop suggestions for meeting unmet needs. These steps were followed by edits of various drafts of the proposed training curriculum. Decisions on courses to be included in the training curriculum were based on identified local needs, internal recommendations from members of the collaborative, and external expert recommendations.

Challenges include working within bureaucratic systems that must follow established steps to protect the public but that, consequently may not necessarily entail quick response capabilities. Another dilemma involves carving out time slots for preparedness training within the busy schedules of professionals. This dilemma may necessitate tradeoffs when organizers are determining which staff should attend what training sessions and are juggling personnel replacements for important daily public health job functions. Attendance and learning by targeted trainees may be maximized by careful decisions about where to locate regional training sessions; the need for centrally located but appropriately equipped training facilities and resources must also be taken into account. Another challenge involves selection of the appropriate level of training for each regional workforce group. Should training be provided on an ad-hoc basis and be geared toward participants with the minimum educational qualifications? Or should it be aimed at participants with a master's-level education, as in the approach favored by certain states?

This section provides a synopsis of additional lessons learned during development of the regional collaborative training program:

* The regional workforce, including both the leadership and line staff, were eager to learn and improve their preparedness-planning knowledge and skills.

* Face-to-face trainings are preferable to distance education. Trainings are now being offered in several formats, with didactic sessions, practical laboratory sessions with table-top exercises, and sessions in seminar/conference format. Evaluations are providing useful feedback, as occurred after the conference Lessons Learned from the 1918 Flu Pandemic and Influenza Pandemic Planning: Pennsylvania's Approach to Preparedness (Huff and Davis, 2005; Piposzar, 2005). That conference was held on September 27, 2005, at East Stroudsburg University; keynote speakers came from the Pennsylvania Department of Health and the University of Pittsburgh, an academic Center for Public Health Preparedness.

* Proceedings have been marked by

-- openness in sharing training needs, resources, and information;

-- willingness to help educate members of the regional collaborative; and

-- commitment and dedication that have helped sustain this multidisciplinary regional effort.

* It has been critical to keep an open mind, spiced with humility and a willingness to learn from all.

* Working together in this regional collaborative is helping to break down interagency barriers.

* The project underscores a critical need for ongoing multidisciplinary regional collaboration on preparedness training. Organizers can continue to involve local, state, and federal governments, engaging environmental health and other professionals at the local and regional levels of public health. Other collaborators include medical service providers and clinical experts, universities and other colleges, emergency management and emergency service agencies, other first responders, concerned members of the community, and other relevant agencies and institutions.

* Many local, state, and federal agencies are more than willing to help foster and facilitate regional collaboration for preparedness training.

In addition to lessons learned directly from development of the training program for the author's region, information was obtained from several invaluable sources. The information was incorporated into planning, implementation, and formative evaluation of the program. With reference to training needs assessment, for example, the program looked at results from a survey conducted in 2001 by the Council of State and Territorial Epidemiologists (CSTE). CSTE conducted the survey before federal distribution of $1 billion in terrorism preparedness funds, whose purpose was to improve public health infrastructure (Centers for Disease Control and Prevention [CDC], 2003). The survey revealed that although epidemiology is the foundation of all public health functions and essential for the detection, control, and prevention of major health problems, epidemiology infrastructure in state and local health departments nationwide was far below optimal capacity. In 2001, about 42 percent of epidemiologists working in public health had no formal epidemiological training. Thus, increased resources were necessary to build the epidemiological capacity needed to address the major causes of morbidity and mortality. After the influx of funding in 2002, a 2004 follow-up survey indicated that a 26.9 percent increase in the total number of epidemiologists that occurred from 2001 to 2004 (CDC, 2005a) was still countered by the need for an additional 192 epidemiologists (45.3 percent increase) if terrorism and preparedness programs were to have full capacity (CDC, 2005b). Furthermore, epidemiological capacity decreased in six out of eight program areas, including environmental health. Forty-eight percent of the epidemiologists still had no academic degree in epidemiology, and 28.5 percent still lacked any formal training or academic coursework in epidemiology. (The survey defined epidemiologists in state and territorial health departments by job functions performed, irrespective of job titles.) Additional trained epidemiologists are needed to strengthen the public health infrastructure.

Several resources were utilized for understanding and developing key concepts in the training curriculum, including the National Response Plan (U.S. Department of Homeland Security, 2004) and the National Incident Management System/Incident Command System (NIMS/ICS) (Federal Emergency Management Agency, 2002; National Association of County and City Health Officials [NACCHO], 2004a, 2004b, 2004c; Pennsylvania Emergency Management Agency, 2005). Foundational elements were derived from the National Preparedness Goals (CDC, 2005c) and required workforce competencies from a range of sources (Center for Health Policy and Columbia University School of Nursing, 2001, 2002; Center for Health Policy, Columbia University School of Nursing, & Association of Teachers of Preventive Medicine, 2004; CDC Environmental Public Health Readiness Branch, 2004; Council on Linkages Between Academia and Public Health Practice, 2001). Additional information was obtained from other resources and a preparedness compendium (National Environmental Health Association [NEHA], 2006a, 2006b, 2006c).

[FIGURE 1 OMITTED]

Recommendations

The endeavor reported here led to the development of a training curriculum, and its success portends well for future collaboration. This section of the paper lists suggested trainees and selected courses from the new training curriculum. Figure 1 shows a conceptual model for training in interdisciplinary public health and other training. It emphasizes all-hazards preparedness and CDC's public health preparedness goals for local/regional and state level training. The conceptual model encourages the use of lessons learned from September 11, 2001; hurricanes Katrina, Rita, and Wilma in 2005; the Pennsylvania 2006 anthrax outbreak associated with uncured animal hide, the 2003 hepatitis outbreak associated with green onions; the 2006 nationwide spinach-related Escherichia coli outbreak; and other catastrophes and epidemics or disease outbreaks. The sidebar at right recommends multidisciplinary trainees who might benefit from completing all or a relevant subset of the proposed training programs within an interdisciplinary training framework.

[FIGURE 2 OMITTED]

Finally, Figure 2 indicates training courses that agencies might want to consider for their personnel, including the mandatory series on NIMS/ICS, all-hazards preparedness training, epidemiology, emergency risk communication, geographic information systems (GIS) & global positioning systems (GPS), a review of lessons to be learned from the past (1918 flu pandemic and others), public health and other leadership training, and additional trainings to be determined as the need may arise in each region.

Other training courses not shown under the miscellaneous category in Figure 2 may include the Surveillance Toolkit Program for public health professionals, which encompasses rapid statistical computing tools for emergency situations; regional interstate preparedness training; financial safety during disasters; review of basic life support for public health professionals; preparedness for bioterrorism, zoonotic diseases, and vector-borne diseases/emerging and re-emerging diseases; nutrition and physical exercise during disasters and emergency situations; environmental health (food and water security); worker safety; sexually transmitted diseases as a possible weapon of bioterrorism; more on chemical, radiological, and biological exposures; and train-the-trainer sessions combined with training or retraining of new employees. Agencies could kick off with an inaugural session or opening ceremony to introduce program participants to CDC's Public Health Preparedness Goals, the history and general principles of public health emergency preparedness, and coordination of training activities within jurisdictions and among participating multidisciplinary first responders. At the closing ceremony or wrap-up session, participants could discuss next steps and lessons learned from the training program. This training curriculum emphasizes the use of currently existing courses when available, to avoid reinventing the wheel.

Acknowledgements: The development of the preparedness training curriculum--meant as a contribution to a defining moment for public health in the 21st century--was made possible through the support, advice, encouragement, technical expertise, help, and assistance of many individuals from several agencies, including the project steering committees, CDC, the Pennsylvania Department of Health, the Pennsylvania Emergency Management Agency, the Pennsylvania Preparedness Leadership Institute, NEHA, the National Association of Local Boards of Health, the Library of Medicine-Middle Atlantic Region, the New York Academy of Medicine, the University of Pittsburgh Center for Public Health Preparedness, Drexel University, the Rollins School of Public Health at Emory University, the Johns Hopkins Center for Public Health Preparedness, and East Stroudsburg University The author particularly acknowledges the support she received from the office of the Dean of Health Sciences and Human Performance. Finally, the author dedicates this work to the blessed memory of Chief Harry Robidoux, who served as chair of the eight-county Northeast Pennsylvania Counter-Terrorism Task Force, director of emergency services in Monroe County, and member of the Tunkhannock Township Volunteer Fire Company. Chief Robidoux passed away recently, during flood-relief efforts in which he worked nearly round the clock. His tireless efforts to help those in need will make it impossible to replace him (Mark and Rodriguez, 2006).

Corresponding Author: Adenike Bitto, Epidemiologist and Professor of Health, East Stroudsburg University, 200 Prospect Street, East Stroudsburg, PA 18301. E-mail: [e-mail].

REFERENCES

Bitto, A. (2005, November 30). Avian-bird flu, the possibility of pandemic flu, and what grandma said is still true--Protect yourself from the flu! Paper presented at the West End Rotary Club Weekly Meeting, Sciota, PA.

Bitto, A. (2006, February 16). I know that being scared solves nothing, but is there anything people can do to help reduce risk of injury or loss when natural and human-caused disasters occur? [reprinted]. Pocono Record: The Weekly Professor. Retrieved February 24, 2006, from http://www.poconorecord.com/apps/pbcs.dll/article?AID=/20060216/NEWS01/602160303/1003/news16.

Center for Health Policy & Columbia University School of Nursing. (2001). Emergency preparedness: Core competencies for all public health workers [Pamphlet]. Retrieved October 6, 2006, from http://www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/compbroch.pdf.

Center for Health Policy & Columbia University School of Nursing. (2002). Bioterrorism & emergency readiness: Competences for all public health workers [Pamphlet]. Retrieved October 6, 2006, from http://www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/btcomps.pdf.

Center for Health Policy, Columbia University School of Nursing, & Association of Teachers of Preventive Medicine. (2004). Competency-to-curriculum toolkit: Developing curricula for public health workers. Retrieved October 6, 2006, from http://www.cumc.columbia.edu/dept/nursing/institutes-centers/chphsr/toolkit.pdf.

Centers for Disease Control and Prevention. (2003). Assessment of the epidemiologic capacity in state and territorial health departments--United States, 2001. Morbidity and Mortality Weekly Report, 52(43), 1049-1051.

Centers for Disease Control and Prevention. (2005a). Assessment of epidemiologic capacity in state and territorial health departments--United States, 2004. Morbidity and Mortality Weekly Report, 54(18), 457-459.

Centers for Disease Control and Prevention, (2005b). Brief report: Terrorism and emergency preparedness in state and territorial health departments--United States, 2004. Morbidity and Mortality Weekly Report, 54(18);459-460.

Centers for Disease Control and Prevention. (2005c). Interim national preparedness goal: Homeland security presidential directive 8: National preparedness. Retrieved November 8, 2005, from http://www.ojp.usdoj.gov/odp/docs/InterimNationalPreparednessGoal_03-31-05_1.pdf.

Centers for Disease Control and Prevention, Environmental Public Health Readiness Branch. (2004). Public health emergency response guide for state, local, and tribal public health directors. Retrieved October 6, 2006, from http://www.bt.cdc.gov/planning/responseguide.asp.

Council on Linkages Between Academia and Public Health Practice. (2001). Core competencies for public health professionals. Retrieved June 16, 2005, from http://www.trainingfinder.org/competencies/list.htm.

Fabian, N. (2006). H5N1: A special report--What is the threat and why should the environmental health profession be concerned? Journal of Environmental Health, 68(6), 51, 46-63.

Federal Emergency Management Agency. (2002). National incident management system. Retrieved October 6, 2006, from http://www.fema.gov/emergency/nims/.

Huff, M.K., & Davis, M.S. (2005, September 27). Influenza pandemic planning: Pennsylvania's approach to preparedness. Paper presented at the Lessons Learned from the 1918 Flu Pandemic and Influenza Pandemic Planning: Pennsylvania's Approach to Preparedness Conference, East Stroudsburg, PA.

Institute of Medicine. (2003). The future of the public's health. Washington, DC: The National Academies Press.

Mark, E., & Rodriguez, C. (2006, July 6). Mourned Monroe disaster director impossible to replace. Pocono Record. Retrieved July 6, 2006 from http://www.poconorecord.com/apps/pbcs.dll/article?AID=/20060706/NEWS/607060329&Template=printart.

Mckenzie, J.F., Pinger R.R., & Kotecki J.E. (2002). An introduction to community health (4th ed.). Sudbury, MA: Jones and Bartlett Publishers.

McKenzie J.F, Pinger RR, & Kotecki. J.E. (2005). An introduction to community health (5th ed.). Sudbury, MA: Jones and Bartlett Publishers.

Min, J., Lee, J., & Deininger, R.A. (2006). Simple and rapid method for detection of bacterial spores in powder useful for first responders. Journal of Environmental Health, 68(8), 34-37.

National Association of County and City Health Officials. (2004a). Advanced practice center 2004 highlights: Training for public health preparedness [CD-ROM software]. Washington, DC: Author.

National Association of County and City Health Officials. (2004b). Making sense of the national incident management systems for public health [CD-ROM software]. Washington, DC: Author.

National Association of County and City Health Officials. (2004c). The public health agency role in the incident command system: (ICS) CD-ROM training course and student booklet [CD-ROM software]. Washington, DC: Author.

National Disaster Education Coalition. (2004). Talking about disaster: Guide for standard messages. Retrieved October 6, 2005, from http://www.disastercenter.com/guide/guide.htm.

National Environmental Health Association. (2006a). Avian and pandemic flu awareness and preparedness. Retrieved April 5, 2006, from http://www.neha.org/avianandpandemicflu/index.html.

National Environmental Health Association. (2006b). Hurricane Katrina resources. Retrieved March 24, 2006, from http://www.neha.org/katrina_links.html.

National Environmental Health Association. (2006c). 70th Annual Educational Conference (AEC) & Exhibition, June 25-28, 2006, San Antonio, Texas. Journal of Environmental Health, 68(8), 9-24.

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Piposzar, J.D. (2005, September 27). Lessons learned from the 1918 flu pandemic. Paper presented at the Lessons Learned from the 1918 Flu Pandemic and Influenza Pandemic Planning: Pennsylvania's Approach to Preparedness Conference, East Stroudsburg, PA.

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Adenike Bitto, M.D., M.P.H., Dr.P.H., C.H.E.S., F.R.I.P.H.

RELATED ARTICLE: Suggested Trainees

Eligible trainees and other recommended participants for all-hazards preparedness training sessions are as follows:

1. environmental health professionals/environmental health scientists;

2. epidemiologists and communicable-disease investigators/"epi" staff;

3. public health administrators, including both the leadership and middle management;

4. members of local boards of health and local medical reserve corps teams;

5. laboratory scientists and laboratory support staff;

6. clerical staff and receptionists, drivers, couriers;

7. computer/data entry staff, public health engineers, and legal/financial personnel;

8. community health educators and media specialists;

9. nurses, physicians, and mental health and other public health clinical/hospital personnel;

10. emergency management agencies and first responders, including regional-task-force personnel, other interdisciplinary preparedness personnel, and public-safety and law enforcement personnel;

11. emergency medical services personnel and coroners/medical examiners; and

12. additional enrollees, possibly comprising selected community volunteers whom public health departments can mobilize during disasters and emergency situations, including religious leaders or representatives of faith-based organizations, service organizations, elementary and high school teachers/staff/administrators, regional colleges and businesses, other segments of the private sector, and members of the general public (who could start their training by preparing a family disaster recovery plan, building a disaster kit, and getting disaster survival training) (Bitto, 2005; National Disaster Education Coalition, 2004).