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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
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
Reality of Disasters: Impact on our Senses
Japan Earthquake and Tsunami, 2011: Event and Consequences
Credits: National Geographic, March 2011
Credit: Global Animal, Japan, 2011
Credit: APF, Japan, 2011
Credit: AP, Japan, 2011
Human and animal suffering
Credit: Massoudi, CDC, Haiti, 2010
Credits: Massoudi, CDC, Haiti, 2010
Survivors!
Victims
Scenes of Destruction: Haiti Earthquake, 2010
Credits: Massoudi, CDC, Haiti, 2010
Scenes of Destruction: Hurricane Katrina, 2005
Credits: Bowers & Williams, CDC, New Orleans, LA, 2005
Complex Humanitarian Emergencies
Credit: Lopes-Cardoza, CDC, Mass Graves ,Kosovo, 1999
Credit: IERHB, CDC, Afghanistan, date unknown
Credit: Lopes-Cardoza, CDC, unknown location & date
Types of Disasters/Emergencies
Complex Humanitarian Disasters
War Civil Strife
Internally Displaced Persons
Refugees: cross
international border
Natural Disasters
EarthquakeFlood
Drought/Famine
HurricaneTornado
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
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
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
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
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?
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
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
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
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
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
Life as a Responder: SleepingHome Sweet Home Group Sleeping
Sleeping on Ship
Preparations for Sleeping on Ship Credits: Williams & CDC staff, 2005, 2008,
2010
Life as a Responder: Bathrooms and Shared Living
Haiti Respons
e
Credits: Williams, CDC, Haiti, 2010
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
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
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
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
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