capt holly ann williams nurse epidemiologist/anthropologist cdc operations section chief usphs rapid...

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CAPT Holly Ann Williams Nurse Epidemiologist/Anthropolog ist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service Scientific and Training Symposium Vet Category Day New Orleans, LA 23 June 2011 Disaster Mental Health for Responders Center for Global Health International Emergency and Refugee Health Branch Man reunited with his dog after 2011 Japanese earthquake. Credit: Friend Burst, 2011

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Page 1: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

CAPT Holly Ann Williams

Nurse Epidemiologist/Anthropologist

CDCOperations Section Chief

USPHS Rapid Deployment Force 3

2011 U.S. Public Health Service Scientific and Training Symposium

Vet Category DayNew Orleans, LA

23 June 2011

Disaster Mental Health for Responders

Center for Global Health

International Emergency and Refugee Health Branch

Man reunited with his dog after 2011 Japanese earthquake.Credit: Friend Burst, 2011

Page 2: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Outline Visual portrayal of disasters: impact on

mental health Types of disasters:

Natural versus complex humanitarian emergency Settings Trajectory of disasters

Deployment environments: Organizational stress

• Veterinarian stress Individual stress Examples from PHS deployments

Mitigation strategies: Agency (OFRD) Team Individual

Page 3: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Reality of Disasters: Impact on our Senses

Page 4: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Japan Earthquake and Tsunami, 2011: Event and Consequences

Credits: National Geographic, March 2011

Page 5: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Credit: Global Animal, Japan, 2011

Credit: APF, Japan, 2011

Credit: AP, Japan, 2011

Human and animal suffering

Credit: Massoudi, CDC, Haiti, 2010

Page 6: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Credits: Massoudi, CDC, Haiti, 2010

Survivors!

Victims

Page 7: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Scenes of Destruction: Haiti Earthquake, 2010

Credits: Massoudi, CDC, Haiti, 2010

Page 8: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Scenes of Destruction: Hurricane Katrina, 2005

Credits: Bowers & Williams, CDC, New Orleans, LA, 2005

Page 9: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Complex Humanitarian Emergencies

Credit: Lopes-Cardoza, CDC, Mass Graves ,Kosovo, 1999

Credit: IERHB, CDC, Afghanistan, date unknown

Credit: Lopes-Cardoza, CDC, unknown location & date

Page 10: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Types of Disasters/Emergencies

Complex Humanitarian Disasters

War Civil Strife

Internally Displaced Persons

Refugees: cross

international border

Natural Disasters

EarthquakeFlood

Drought/Famine

HurricaneTornado

Page 11: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Settings and Timing of Disasters/Emergencies

Timing

Acute Protracted

Recovery/Rehabilitation

Each type of situation, setting and the point of time in which you respond will have a different impact on responder

mental health

Settings

Rural Urban

Developed versus Developing Country

Page 12: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Deployment Environments in General

Chaotic and often austere Lack of familiar context:

Food Environment, including climate Community

Little privacy – work and sleep in same area

Overload of responsibility Chronic sleep deprivation Travel difficulties and

delays Security/safety is not

assured Work piles up at home

agency, overwhelming upon return

Credit: Williams, RDF 3, LSU Field House, Hurricane Gustav, 2008

Page 13: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Organizational Stress Mission may be ambiguous or change mid-

stream Lack of efficient coordination:

Particularly in global responses Limited resources:

Insufficient number of staff Assigned personnel (i.e., Tier 3) may not

professionally match gaps in team Relief may be delayed secondary to

bureaucracy: Affected communities voice anger or feelings of

entitlement Conflict between individual values and

organizational goals Role confusion: mismatch of skills with

tasks

Page 14: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Veterinarian Roles in Disaster Response

Pre-disaster planning Surveillance and

control of diseases and vectors

Animal safety and control

Animal health care Zoonotic disease

surveillance and public health assessments

Search and rescue Assessment of disaster

impact on animal populations

Information dissemination

Credit: Peoplepets, Dog in Shelter, Japan, 2011

Page 15: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Organizational Stress: Veterinary Category

Deployment role may not match professional role: PHS vets may work in non-clinical settings and have

concerns about clinical care competencies Frustrations with having to work through chain of

command to make contact with local/state vet services

Frustration over challenges to providing adequate care for sheltered animals: Lack of necessary cache for vets in RDFs, unlike

National Veterinary Response Teams (NVRT) Lack of trained assistants to help provide basic care No control over animals that may arrive at shelters

(i.e., degree of aggression) Focus on companion and service animals: what

happens when faced with herd management in agricultural-focused communities?

Page 16: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Individual Stress During Deployment

Officers not prepared for stress of austere conditions over a 14-day or longer period

Lack of preparation for international deployments: Limited understanding of how international disasters

are managed Inexperience with global travel Unrealistic expectations

Visual impact of disaster on a daily basis, compounded with sheltered individuals needing to vent their feelings

No time to process impact of disaster during the deployment: Some agencies refuse to allow time off after

deployment

Page 17: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Common Stress Responses Cognitive:

Memory loss, insomnia, reduced attention span, nightmares

Physiological: Heart palpitations, dizziness, increased fatigue, tics, GI

upset

Behavioral/Emotional: Grief, guilt, sadness Increased startle reactions Crying easily Social withdrawal: feeling numb and lack of reaction Irritability, anger, increased conflicts with others

Page 18: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Examples of Stress-Inducing Deployment Situations

Lack of privacy: willingness to sleep on the ground in pup tents vs on cots in larger NDMS tents (Haiti)

Physical limitations not considered in austere conditions: Need for CPAP machines and assistive devices

Failure to pay attention to basic public health preventive measures: Did not use sunscreen or take prophylactic

medications Failure to drink enough fluids in situations of

extreme heat/humidity Multiple billeting changes:

Katrina: ~five moves in three weeks Haiti: four different tent locations in five weeks

Page 19: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Deployment Examples: II Limited dietary choices and food

availability: MREs x 3/day, no fresh fruit or dairy in Haiti Inability to meet specific dietary requirements:

• Kosher, vegan/vegetarian, gluten-free Failure of contracted food service to provide meals at

a time that was reasonable for those working night shift (Gustav)

Lack of contracted services to provide meals to sheltered patients requiring Preventive Medicine Branch staff to serve meals (Gustav)

Compounded stress of being co-deployed with Department of Defense: Lack of familiarity with rank, military customs and

etiquette Perception that during deployments and trainings,

officers asked to billet in circumstances not respectful of rank or perform functions for which enlisted would be expected to do

Page 20: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Deployment Examples: III Hurricane Gustav:

Perceived lack of collaboration among co-located teams (RDF & DMAT)

Marked anger over lack of clinical staff Team integrity fractured with team being split to three

locations Non-clinical officers: post-deployment nightmares

seeing patient that had died being placed in a closet during the hurricane

Post-traumatic stress re-activated by working in shelter situation:• Brought back memories of being in a refugee camp as a

child Only one Mental Health (MH) provider for entire team –

insufficient coverage for staff and patients Shared shower space with shelter residents:

• Perceived negative impact on ability to maintain professional relationship

Page 21: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Life as a Responder: SleepingHome Sweet Home Group Sleeping

Sleeping on Ship

Preparations for Sleeping on Ship Credits: Williams & CDC staff, 2005, 2008,

2010

Page 22: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Life as a Responder: Bathrooms and Shared Living

Haiti Respons

e

Credits: Williams, CDC, Haiti, 2010

Page 23: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Mitigation Strategies: Agency

Agency (OFRD): Improve travel clearance process

Work with PHS MH providers to develop training for officers in recognizing and mitigating signs of team and individual stress during deployment:• Screen officers pre-deployment for suitability,

especially for global deployments

Develop Standard Operating Procedures for managing stress that becomes disruptive to a team’s ability to function

Work with HHS to improve global preparation pre-deployment

Train ‘resiliency’ officers to work with MH providers

Page 24: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Mitigation Strategies: Team Team:

Develop team goals that stress the concepts of resiliency and team support

Ensure that all officers have access to team MH providers in safe and private area

Implement rotational schedules for time off and rest period

Develop an area for ‘rest & relaxation’ during duty hours that is not accessible to shelter residents

Promote feeling of safety with initiating ‘buddy’ system for accountability

Credit: Williams, CDC, “Club Fed”, Hurricane Gustav, LA, 2008

Page 25: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Mitigation Strategies: Individual

Individual: Know your individual stressors and plan ahead:

• Exercise if possible, include comfort snack foods, bring novels and headlamps for reading, keep packing organized, write in a journal, eat well

Maintain contact with family and friends

Alert team lead when you have reached your limit and need time alone

Try to find humor on a daily basis (individually and with team)

Meditate, use yoga or deep breathing exercises, attend spiritual services

Page 26: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

Credits: Williams, CDC, Hurricane Frances, FL, 2005

BBQ beats MRE’s any day!

Much needed and earned rest!

Credits: Williams, CDC, Hurricane Gustav, LA, 2008

Celebrating Louisiana style!

Credits: Williams, CDC, Hurricane Gustav, LA, 2008

Page 27: CAPT Holly Ann Williams Nurse Epidemiologist/Anthropologist CDC Operations Section Chief USPHS Rapid Deployment Force 3 2011 U.S. Public Health Service

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you to the various officers with whom I have had the honor and pleasure

to serve during a myriad of disaster responses.

Center for Global Health

International Emergency and Refugee Health Branch