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Redefining Readiness Study
Research question and study design.While the public is the object of concern in emergency preparedness, strategies and plans have been developed without directly involving the public. Planners and policy makers spend a lot of time thinking about particular kinds of disasters and deciding what the public needs to know and do should such an event occur. Their focus then turns to educating and communicating with the public so that people in communities will do what planners believe they ought to do.
The Redefining Readiness study was designed to answer the question: Is the public's current role in emergency preparedness appropriate, or is their limited and passive involvement something that we should be concerned about?
Conducted in 2003-2004, the Redefining Readiness study gave the American people their first opportunity to describe how they would handle two kinds of emergencies: a smallpox outbreak and a dirty bomb explosion. Comprehensive and rigorous, the study involved in-depth conversations with government and private-sector planners, 14 group discussions with diverse community residents around the country, and a telephone survey of 2,545 randomly selected adults in the continental United States. To capture perspectives that would otherwise be under-represented, the survey was conducted in English and Spanish and oversampled African Americans and people in the cities that experienced the 9/11 attacks (New York City and Washington, D.C.).
Rather than asking people to think about emergencies in the abstract or to give their opinions about plans or policies, the study used scenarios that put people in specific and realistic situations at a place and time they would be likely to hear about the emergency and be told what to do. The smallpox scenario explored how people would react to instructions to go to a public site to be vaccinated if some residents in their community and people in other parts of the country became sick with smallpox after having been exposed to the virus in a terrorist attack at a major airport. The dirty bomb scenario explored how people would react to instructions to stay inside a building other than their own home if a dirty bomb exploded a mile from where they were and a cloud containing radioactive dust were moving in their direction.
Evidence that the public's perspectives matter. The study found that plans to respond to these emergencies won't work because people will not react the way planners want them to. In a smallpox outbreak, only 43% of the population said they would follow instructions to go to a public site to be vaccinated. In a dirty bomb explosion, only 59% of the population said they would stay inside the building they were in for as long as officials told them.
Contrary to conventional wisdom, the Redefining Readiness study found that the public's reluctance to follow instructions is not due to ignorance, recalcitrance, or panic. Quite the contrary, most people have solid, common-sense reasons for their behavior. Because current plans have been developed without the direct involvement of the public, they don't account for all of the risks people would face. As a result, the plans make it unnecessarily difficult for many people to decide on the best course of action to protect themselves and their family. Even worse, the plans inadvertently create serious and unnecessary risks for millions of people.
Instructions to go to a public vaccination site in a smallpox outbreak are very dangerous for 50 million Americans who are at risk of developing life-threatening complications if they either get the smallpox vaccine or come in contact with someone who has recently been vaccinated. At-risk groups include pregnant women, babies under the age of one, people who have ever had skin diseases like eczema, people taking medications like prednisone that suppress their immune system, people undergoing chemotherapy or radiation for cancer, and people with HIV/AIDS. The current strategy is for these people to find out about their risk at a public vaccination site. That means they will be told to leave the safety of their own home - a place the study found most Americans want to be in a deadly contagious disease outbreak - and go to a place that exposes them to many people who have just been vaccinated and, potentially, to people with smallpox.
A major problem with current dirty bomb response plans is that little has been done to create the conditions that make it possible for people to protect themselves by sheltering in place. Many people are likely to be away from home and separated from other family members - at work, in school, or shopping - when a dirty bomb explosion occurs. The Redefining Readiness study showed that millions of Americans will not follow instructions to stay inside the building they are in unless they are sure that they and their children and spouses are in places that have prepared in advance to take good care of them during the crisis. Unfortunately, very few places in the United States have prepared to function as safe havens should the need arise and even fewer places know the kinds of preparations that would actually make people feel safe.
Supporting evidence from Hurricane Katrina. In 2004, the report of the Redefining Readiness study predicted that large numbers of people would suffer and die unnecessarily if response strategies are not based on what people will actually face when a disaster strikes. Less than one year later, Hurricane Katrina proved that prediction to be correct.
Consider what happened in New Orleans. Everyone in the city was told to evacuate, but many could not do so on their own because they or other family members lacked transportation, didn't have enough money for gas and lodging, had impaired mobility, or had serious health problems. Quite a few of these people died. Those who sought shelter in the Super Dome experienced atrocious conditions, which compounded their psychological and physical suffering. Many of those who were eventually evacuated were separated from other members of their family and from their friends, which deprived them of the human supports that people need to deal with crisis situations.
If the problems that people face in an evacuation had been identified and addressed in advance, the outcome would have been very different. School buses (which ended up rusting under water) and military planes (which came in after the fact) could have been mobilized before the storm hit to evacuate disabled residents and those without cars. Debit cards could have been pre-issued to poor residents to use in the event of a disaster. Shelters could have been prepared that would actually keep people safe. Evacuation plans could have been developed to keep families and social networks together.
A fundamental flaw in emergency preparedness. Taken together, the Redefining Readiness study and our nation's experience with Hurricane Katrina uncover a fundamental flaw in emergency preparedness. Planners are developing instructions for people to follow without finding out whether it is actually possible for them to do so or whether the instructions are even the most protective action for certain groups of people to take.
Currently, this outcome is virtually inevitable because the approach we are using to prepare to respond to emergencies forces planners to be mind readers. Without hearing from the public directly, planners can't possibly be aware of the barriers and risks that make it difficult for certain groups of people to protect themselves in emergencies or what could be done to address those problems. When planners lack this information from the public, they end up developing instructions that are not feasible or safe for many people to follow - with dire consequences.
Impact on confidence and trust. The nature and consequences of the public's limited involvement in emergency preparedness may account, in part, for their discouraging perceptions about planning efforts. The Redefining Readiness study found that:
The study also found that 41% of the American people are seriously worried about what government officials say or do in emergency situations. The survey hasn't been repeated since Hurricane Katrina, but it is likely that trust and confidence levels are even lower after that experience.
On a positive note, the study showed that the American people are far from apathetic about preparedness planning, in spite of their negative perceptions about government officials and the planning process. One-half said they were extremely or very interested in learning more about emergency response plans, and one-third said they were extremely or very interested in personally helping government agencies or other community organizations develop such plans.
Fixing the flaw. What can be done to remedy the situation? Decades ago, James Baldwin warned us: "You cannot fix what you will not face." The first step, then, is to acknowledge that a serious flaw exists in our current approach to emergency preparedness, which needs to be fixed.
The next step involves a change in mindset. In addition to seeing the public as the object of their concern, planners need to view the public as a valuable and knowledgeable resource in preparing communities to respond to emergencies. The people who live and work in communities are the only ones who really know what they would face in these kinds of situations. Without their knowledge, planners are working at a distinct disadvantage.
The other changes have to do with process. The public needs opportunities to contribute their knowledge to community preparedness efforts and to combine their knowledge with that of experts. Creating such a process was the objective of the Redefining Readiness local demonstration projects.
|created 6/1/07||© 2007, Center for the Advancement of Collaborative Strategies in Health|