Quick Response Report #111
PUBLIC HEALTH EMERGENCY RESPONSE: EVALUATION OF IMPLEMENTATION OF A NEW EMERGENCY
MANAGEMENT SYSTEM FOR PUBLIC HEALTH IN THE STATE OF GEORGIA
Lora S. Werner, ICF Incorporated
Matt Naud, ICF Incorporated
Anita Kellogg, CEM, ICF Incorporated
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This material is based upon work supported by the National Science
Foundation under Grant No. CMS-9632458.
Any opinions, findings, and conclusions or recommendations expressed in
this material are those of the author(s) and do not necessarily reflect
the views of the National Science Foundation.
PUBLIC HEALTH EMERGENCY RESPONSE: EVALUATION OF IMPLEMENTATION OF A NEW EMERGENCY
MANAGEMENT SYSTEM FOR PUBLIC HEALTH IN THE STATE OF GEORGIA
Through a grant from the U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention (CDC), ICF Incorporated
assisted with the development of an emergency management system comprised
of emergency preparedness, response, recovery, and mitigation procedures
for the Georgia Division of Public Health (DPH) during 1996 and 1997.
Research revealed that the lack of pre-existing inter- and
intra-organizational involvement in emergency planning placed significant
burdens on public health professionals during large-scale disasters. ICF
developed an emergency management system for DPH, the public health
districts, and the county boards of health that is applicable and
adaptable for the range of medical and public health issues that arise
during a disaster. This report presents a qualitative evaluation of the
effectiveness of preparedness efforts in the state public health system
during two subsequent disasters in 1998. Overall, the state and district
staff reported that the planning process and regular plan maintenance
implemented under the new public health system greatly improved their
ability to respond effectively, especially in relation to staff
management, communications, reduced stress, and improved deployment times,
as well as other areas. However, some shortcomings with the new system
were also noted. Overall, the system worked well, but will continue to
require support and guidance from the DPH Emergency Coordinator for the
procedures to run smoothly. The general sentiment after the analysis was
that because of their prior flood experience, the public health staff knew
they could handle anything; because of their planning, they knew they
could do it efficiently.
How did implementation of a new emergency management system for response
of public health and medical emergencies in the state of Georgia in 1997
affect the Division of Public Health's (DPH's) response to closely timed
flooding and tornado disasters in 1998?
ICF Incorporated completed the an 18-month project to
assist the Georgia DPH in developing an emergency management system
emergency preparedness, response, recovery, and mitigation procedures in
1997. This project was funded through a grant from the U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention
(CDC), to Troup County, Georgia. The purpose of the grant was to sponsor
several mitigation initiatives in the aftermath of severe flooding and
devastation in southwestern Georgia as a result of Tropical Storm Alberto
Our research during the original grant (1996-1997) revealed that Georgia
public health professionals found themselves overwhelmed and
under-prepared to deal with a disaster on the scale of the 1994 floods.
The lack of pre-existing inter- and intra-organizational involvement in
emergency planning limited the ability of Georgia's DPH to effectively
respond to several public challenges including:
- Providing public health nurses to staff ad hoc shelters as well as the health services
role at American Red Cross shelters;
- Inspecting shelters for environmental health problems including food service;
- Meeting needs for pharmaceuticals;
- Inspecting potable water and septic systems;
- Conducting disease surveillance;
- Providing emergency medical services;
- Providing mosquito control; and
- Tracking displaced clients in the Federal-State Women, Infants, and Children's services program.
There was no clear understanding within the division of the role DPH would
be required to play during disaster conditions. Most local health
agencies at the district and county levels were not active participants in
the planning process with local emergency management agencies.
To address this need, ICF developed an emergency management system for DPH
and the state's 19 public health districts and 159 county boards of health
that is applicable for the range of medical and public health issues that
arise during a disaster. The resulting system 1) establishes the
organization, basic policies, delegations of authority, responsibilities,
and actions required for effective mobilization, decision making, and
resource use by public health staff during an emergency, and 2)
establishes a system for recovery and mitigation after an incident. The
concept of employing a functionally based emergency crisis system during a
response (See Exhibit 1) was tested during the
division's response operations for the 1996 Summer Olympic Games in
Atlanta, including operation of a Health Command Center. This emergency
management system was fully introduced to public health staff in the state
through training and exercises in the spring of 1997. Training was
conducted at the state agency and at all 19 of the regional public health
districts; county public health staff participated at the district
trainings. Further implementation and evaluation of the new emergency
response system was conducted in two table-top exercises in 1997.
Interestingly, one of the exercises conducted in 1997 to initially test
the new emergency management system parallels the disaster situation that
occurred in the state in 1998: the simulation involved severe flooding in
the southeastern portion of the state, followed by damage from eight
tornadoes striking counties in the north-central portion of the state.
Natural disasters (flooding and tornadoes) occurred in two different
portions of the state but only days apart in time (March 1998). These
incidents required actions by state, district, and county public health
responders on two fronts. Throughout both of these disasters, the State
DPH Health Command Center was fully operational, and district- and
county-level public health staff were active to varying degrees in
implementing the new emergency management procedures in each of the two
affected public health districts. These incidents provided an opportunity
to test the procedures developed for the state division and district
offices in 1996 through 1997.
Severe storms and flooding struck Georgia starting on Saturday, March 7,
1998. Federal disaster aid was made available for flood victims in six
Georgia counties (Baker, Dougherty, Irwin, Miller, Montgomery, and
Seminole) under a major disaster declaration issued for the state by
President Clinton on March 11, 1998. Ware County was added to the
governor's list of counties declared to be in a state of emergency on
March 12, 1998. The affected public health district, District 8.2,
activated its own Health Command Center. The American Red Cross
established several shelters. Public health staff monitored mobile
feeding sites, assisted with requests for bleach and clean-up kits,
established and staffed a shelter for persons with special needs,
performed field assessments, and conducted media outreach. District
public health staff deployed a multidisciplinary public health assessment
team ("PHAST," pronounced "fast") and provided assistance in the field.
Recovery from these floods lasted for months, particularly inspections of
potable water and septic systems.
Severe tornadoes hit five northeast Georgia counties on Friday, March 20,
1998. A presidential disaster declaration was approved for Hall and White
counties to include public and individual assistance. The affected public
health district, District 2, did not activate its own Health Command
Center, but rather operated from the county emergency management agency's
(EMA) Emergency Operations Center (EOC). The American Red Cross opened
shelters and DPH staff provided prescription services at one shelter.
District public health staff deployed a multidisciplinary PHAST and
provided assistance in the field.
Our methodology was to qualitatively evaluate the effectiveness of
preparedness efforts in the state public health system. We recognize that
it is difficult to evaluate these types of efforts quantitatively,
while the cost of plans and plan maintenance is readily available,
quantitative data on corresponding benefits are not. In addition,
disasters tend to vary in scale, making cross comparisons difficult. The
1998 flooding was not as large as that which occurred in 1994. The
analytical timeframe is also a factor in any effectiveness determination:
preparedness efforts paid for now, with appropriate maintenance, should
continue to provide benefits for decades into the future. The benefits of
DPH's planning may also be transferable to other states, further
increasing benefits and reducing overall costs. An important qualifying
factor in our analysis is that it was difficult to distinguish between the
experience gained from previous floods and disasters and the planning and
training efforts conducted under the new emergency management system. We
attempted to have interviewees delineate the perceived benefits of their
prior experience versus the newly developed plans.
The ICF Team of investigators deployed to Georgia for two days of
interviews on April 9 and 10, 1998. We felt that this approximately
20-day delay (from the initial onset of the disaster) was appropriate to
allow participants a small amount of time for reflection, yet was not too
distant from the response phase to forget important details. We
interviewed state public health staff in Georgia's DPH during our field
investigation, including the Division Deputy Director and Emergency
Coordinator. We also interviewed the two affected public health districts
(District 8.2, that was affected by flooding, and District 2, that was
affected by tornadoes), including the District Health Directors, Emergency
Coordinators, and staff who supported the response in each district. We
focused our interviews to highlight lessons learned from the
implementation of the new emergency management system for public health
response in the state. We also collected and analyzed situation reports,
and analyzed and observed ongoing recovery operations.
After these interviews with DPH staff, we conducted follow-up telephone
calls to further assess the level of inter- and intra-organizational
preparedness efforts that preceded the response and mitigation actions
following the events. In particular, we contacted county emergency
management officials, hospital representatives, and American Red Cross
officials by telephone. The goal was to discuss the response with staff
outside the DPH organization who interacted with the DPH organization or
who were customers for DPH services (e.g., the vice president of nursing
at Phoebe Hospital in Albany). Unfortunately, two rounds of telephone
calls - one round immediately following our on-site interviews and another
round several months later - to county EMA directors, the American Red
Cross, and Phoebe Hospital produced limited responses.
Plan maintenance, such as training, exercising, and ongoing communication
with state, district, and local counterparts, was crucial to obtaining the
full value of the new public health emergency management system and
preparedness efforts in Georgia. The DPH State Office and one of the
districts involved in the recent disasters, District 8.2, were very active
in working with and implementing their new plan and procedures prior to
the onset of flooding in 1998. DPH and District 8.2 both had top-down
management support for the new procedures, and were committed to
incorporating the new system into their operations. For example, District
8.2 conducted monthly preparedness meetings with staff, and made continued
progress in strengthening its relationships with the county EMA,
hospitals, and environmental health staff throughout the state.
However, District 2 management did not see the same value of the new
procedures, and thus did not work the new system into the district's daily
operations. Thus, when tornadoes struck this district, there was friction
between this district's ad hoc approach and DPH's ongoing implementation
of the new system. Exhibit 2 contrasts the
preparedness situations in the two affected districts in more detail.
Sharing situation reports "up and down" the public health system during
the disaster was found to be very important to providing all participants
with a sense of the scope of public health-related disaster efforts.
Sharing information was also helpful to reassure staff throughout the
state that the public health system was being effectively managed and
functioning well. District 8.2 distributed its situation reports to its
counties, the State Health Command Center, the local medical society, and
local hospitals. Both District 8.2 and 2 commented that they felt that
the state should have similarly shared its situation reports with them.
District 8.2 did not start receiving DPH situation reports until late in
the response, and District 2 complained that it did not know how the
information it submitted was ever used by the state.
An important finding is the difficulty in maintaining dedicated support
for a preparedness system. Even after (or perhaps because of!) successful
implementation of the new public health emergency management system in
Georgia, DPH is now considering eliminating the dedicated Emergency
Coordinator position at the state. Public health staff in District 8.2
and DPH in Atlanta strongly emphasized that this central position is
necessary and important to the continued success of the system.
Public health staff in DPH in Atlanta and in District 8.2 emphasized the
following benefits of preparedness and the new emergency management
- Enhanced control during the disaster.
Staff were managed more effectively and efficiently, and interactions
among the state, the district, and the county-level response were more
controlled. State staff believed the new system helped them to obtain the
information they needed more effectively. Both the state and District 8.2
emphasized that the centralized Health Command Center concept "to work the
disaster" was the key to this increased measure of control.
- Communications technology improved the response.
The state, in particular, relied heavily on Southern Company telephones
(a dual function cellular phone and radio system developed by Southern
and found that these radios were extremely effective in coordinating
activities. However, the benefit of this technology was more limited at
the district level; District 2 has only two of these radios, and District
8.2 only has one. Both districts expressed a desire for more of these
radios to further enhance communications during disaster response and
recovery, particularly when staff may be working in the field.
- Reduced stress and improved productivity.
Public health staff with experience in both the 1994 and the 1998 flooding
felt that their stress levels were considerably reduced in 1998. These
staff emphasized that they were more productive during the response and
recovery to the 1998 incidents.
- Improved media outreach.
A major benefit cited in District 8.2 was the capability to "get out ahead
of public information" through early and proactive press releases. Press
releases in 1994 tended to be reactive, whereas in 1998 public health
staff were prepared with proactive information. In 1998, the media turned
to the public health district for daily health information reports for the
- Faster public health assessment and deployment of staff.
In District 8.2, public health assessment teams were deployed to the field
more quickly in 1998 as compared to 1994. In 1998, teams were deployed
the afternoon of the onset of flooding and were able to complete their
assessment in the field in one day (note, however, that the extent of the
damage in 1998 was substantially less than in 1994).
- Better environmental health assessment procedures.
In general, environmental health deployment and assessment occurred more
smoothly in 1998 compared to 1994. In 1994, state environmental agency
staff "wanted to take over" the water contamination assessment. After the
1994 flooding, as part of the new public health disaster operating system,
DPH and its state environmental agency counterparts hammered out their
respective responsibilities. The result, in 1998, was a more informed and
coordinated approach with no arguments about public health's direction of
the environmental health assessment effort.
- Improved special needs procedures.
District 8.2 established a special needs shelter more rapidly during the
1998 response (e.g., two days in 1998 versus seven to nine days in 1994).
Furthermore, District 8.2 included questions on special needs and special
diets in the environmental health shelter assessment questionnaire in its
new disaster procedures. Thus, in 1998, public health staff members
analyzed special dietetic needs in the shelters and made arrangements
with a local hospital cafeteria to meet identified needs for special
- More efficient surveillance.
Staff members who started working for District 8.2 after the 1994 floods
observed that they were able to quickly and effectively assume the
responsibilities of their functional positions, as documented in the
procedures, during the 1998 response. An interview with the infectious
disease control nurse at the local hospital confirmed that finding with
respect to disease surveillance in 1998. Public health staff modified the
1994 disease surveillance survey instrument for use during the 1998
floods and thus were able to more efficiently review emergency room
records and tabulate the data from the onset of the disaster. In 1994,
surveillance data on 35,000 individual entries were delivered to the CDC.
However, these data were not returned to the health district in time to be
analyzed in a timely manner. In 1998, psychosocial and illness measures
were added to the survey, and data on 1,100 individual encounters targeted
from just the affected counties were recorded and directly analyzed at the
Public health staff at DPH in Atlanta and in Districts 2 and 8.2
emphasized the following shortcomings of the response effort:
- Shelter location and staffing problems continued.
American Red Cross rostered nurses did not staff emergency shelters but
left this responsibility to public health nurses. This occurred despite a
memorandum of agreement and new arrangements made since the 1994 flooding.
Furthermore, all three of the shelters opened by the American Red Cross in
District 2 were located at sites that were not pre-approved (i.e.,
pre-inspected by public health environmental staff).
- Administrative and technical demands were greater than anticipated.
The administrative support needed to implement the new procedures was more
burdensome than anticipated in District 8.2. Both districts stressed that
additional communications equipment is needed to optimize public health
response during a disaster. District 8.2 recommended that new staff
positions be added to the procedures, such as a "scrounger" to locate
resources from the community, and a technical person to manage hardware
and electronics issues (such as re-wiring phone and fax lines for the
command center and ensuring that computer and communication systems
function properly). District 8.2's experiences in 1998 emphasized that
each activated district EOC should, at a minimum, have at least one
dedicated outgoing fax machine, more phone lines, and operational
electronic mail. While District 2 did not feel that the reporting
procedures to DPH had value, District 8.2 felt that the procedures helped
minimize confusion by helping both the district and DPH to know what
information to expect and when.
- More progress is needed to integrate mental health into the assessment
District 8.2 noted that, because mental health services are in
the midst of being privatized in the state, it was difficult to convince
them of their role in the system. Mental health representatives were
included in planning and preparedness meetings prior to the disaster but
did not participate on the PHAST.
- Further implementation at the local level is still needed.
Both Districts 8.2 and 2 noted that they felt additional work is needed to
implement the emergency management system more fully with their respective
counties. The District 8.2 Director noted that this situation might be
improved by having the districts coordinate more closely with their
respective regional EMA coordinators. District 8.2 observed that
coordination at the county level, although not optimum in 1998, was
enhanced by the district's insistence that the county health department
head nurse deploy to the county EMA. Furthermore, in 1994, county EMA
staff did not even know who public health staff members were or what their
responsibilities might be. In 1998, county EMAs began to recognize public
health staff as a legitimate resource. However, there were still
implementation problems. For example, the new EMA chief at Dougherty
County in District 8.2 only wanted to deal with the county nurse manager
as opposed to the district EOC.
As mentioned previously, it is very difficult to separate the effects of
one's past experience from the effects of planning and preparing. We
found that the DPH State Office and District 8.2 staff clearly benefited
their previous disaster experience but virtually all of the interviewees
maintained that the planning process and regular plan maintenance also
added greatly to their ability to respond effectively. Regular meetings
acted to reinforce the importance of planning and the roles each staff
member would play (or could be asked to play) during disasters.
Key parts of the plan that were implemented include using a single point
of coordination for the Emergency Operations Center. In both the DPH
Office and District 8.2, the staff were prepared to begin working quickly
from a central room. Both districts used the PHAST created under the new
system to integrate key functions (e.g., nursing, environmental health,
disease surveillance) in one group. The PHAST was dispatched quickly to
assess public health needs immediately after the disasters and to
circulate through shelters to ensure that public health needs were being
met. Reporting and accounting procedures were set up quickly and
information was distributed to key stakeholders.
The plans continue to be changed as staff recognize ways to improve
procedures. For example, the administrative burden identified by District
8.2 will be corrected with some staff changes in addition to reporting
changes. The plans have stayed flexible: PHASTs were staffed only with
those staff required for the specific disaster circumstances and staff
were able to take on different roles as the impacts changed.
It is interesting to note that the district most heavily affected by
recent disasters is also the most supportive of the new planning process.
It appears that areas that have never been overwhelmed (District 2) are
content to assume that they can handle whatever is thrown their way.
District staff that were overwhelmed by the 1994 disaster recognized that
prior planning would have allowed them to work more effectively. During
their 1998 disaster, they believe that their planning efforts paid off
with a more proactive response and less stress on their staff. Because of
their prior flood experience, they knew they could handle anything;
because of the planning, they knew they could do it efficiently.
This statewide system will continue to need support and guidance from the
DPH Emergency Coordinator. Work remains to more fully integrate the local
county boards of health and county EMAs with the public health system.
Furthermore, not all districts in the state have fully embraced the new
disaster procedures, although significant progress in implementation has
been made. To maintain the preparedness and mitigation gains that have
been achieved, DPH will need to continuously emphasize exercising,
standardizing, and sharing of successful experiences and techniques
throughout the state. In particular, DPH will need to be creative and
persistent to solidify implementation of the system in districts with
real-world disaster experiences to motivate them.
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January 8, 1999