I've had a very interesting time last week attending the OSDFS 2007 National Conference, organized by the Department of Education Office of Safe and Drug-Free Schools. The theme of the conference was "Reflecting on the Past and Looking Ahead", and conference topics included
- Preparedness and School Safety
- Health, Mental Health, and Student Well-Being
- Alcohol, Drug, and Violence Prevention
- Character and Civic Education
- Training
so pandemic planning formed only one strand of the full agenda of the conference, and I was only present in the relevant events.
First the big picture. Most of the attendees, as listed on their webpage were teachers, counselors, school administrators, etc. Since they are mostly representatives from their local areas, the observations here are not quite ground level, but quite a bit further down the chain for national strategies or policies to trickle down through! From the number of tables laid out for the luncheon events, I would say registered attendees probably numbered just over 1000. However, probably just under 80% of seats were filled for the luncheon plenary, which I would imagine was a keynote event. The closing session on Saturday, preceding the final round of workshops and the pandemic tabletop exercise, had only about 30% attendance. More on this later.
I did attend the luncheon plenary session on Thursday. The first speaker scheduled on the program was Frances Townsend, Assistant to the President for Homeland Security, who was going to speak on The role of Schools in Individual and Community Preparedness Efforts. In the event, she was unable to attend and the speech was given by Rajeev Venkayya MD, Special Assistant to the President and Senior Director for Biodefense at the Homeland Security Council. Dr Venkayya, as our forum regulars will recall, has won some brownie points on previous occasions as one of the people at the top leadership who really 'gets it'. ;-D
Given the last minute change of speaker, I must say he did a great job of utilizing the occasion to bring the pandemic message to the audience, especially the implications of a 1918-like pandemic, the current CFR for H5N1, the vital importance of community mitigation measures, as well as sincere acknowledgment that a lot more work needs to be done by the Feds and that implementation of the CMG will require a lot of effort on everyone's part. There were sharp intakes of breath and gasps around the room on '2 decades of child deaths in one season' and '60% CFR for H5N1 vs 1-2% for 1918'. He also elicited ripples of laughter when he commented on "you know how kids are with their secretions, right?" There were lots of furious note-taking and hearty rounds of applause.
That being the case, FW folks can hardly blame me for being mildly optimistic going into the next day's events, a morning plenary on pandemic preparedness followed by 'advanced pandemic planning' as one of several concurrent workshops. The plenary session (which had probably just over 50% attendance) was mainly focused on CMG, and featured 2 presentations, by Michael Doney from the Division of Global Migration & Quarantine, CDC, on the CMG itself, and by James Hodge, Center for Law and the Public's Health, Johns Hopkins University, on legal authority for school closures, followed by additional people from the USDA, Dept of Labor, and CDC as panelists for the Q&A.
I must say Michael Doney made a very coherent presentation on various aspects of the CMG, except for one slightly unsettling aspect. Now, I cannot say that I'm 100% certain, but apart from a passing reference to 'early' implementation of PH measures in St Louis vs Philadelphia, I don't recall any comments on when the trigger should be pulled, ie before 1% of the population is infected (from MIDAS modeling data), or, first confirmed cluster of community transmission at the state (or contiguous territories) level, as recommended in the CMG. Now given the time constraints, I wouldn't expect him or anyone to have been able to say everything that is included in the 108-page document, but to the extent that 1918 historical analyses show that the strongest correlation with outcome was with the timing of implementation of PH measures, I would have thought the emphasis on EARLY should be one key message for those who will need to implement the policy!
I don't know how much that affected subsequent outcomes, but in the workshop that followed, of which I only attended the second half, there was NO mention of early as opposed to reactive school closure, ie after 10% of kids are out sick, as I saw on one of the slides! At one point, one of the speakers made a reference to the goals of pandemic preparedness, the top one being "to limit death and disease". I was appalled to hear the next sentence that came out of this person was along the lines of "but we in education do not speak of death and illness, we talk about promoting health instead" and moved on to hand washing and other general hygiene measures.
Without going into further blow-by-blow accounts, let me share some observations that I took away from these and the final day's tabletop exercise, which was supposed to be "first come first serve" and "limited to 100" people, and which in the end attracted 26 including myself. Not exactly overwhelming interest.
For me, the big picture question was whether and to what extent we can depend on educators and administrators to implement CMG properly. I was more than a little troubled by the overall and deteriorating attendance rates in the conference. I'm sure many delegates left for legitimate reasons, but I have a suspicion when compared to other professional events that I have attended that the education profession probably contains a larger contingent of those who will go AWOL on government expense.
The second observation was on the question of what drives these people: based on the relative amount of time devoted to discussions, I would guess that - the top driver was funding
- how to obtain grants was a hot topic
- how to keep funding coming, specifically in the form of payrolls, was "the most important part" of continuity planning
- complaining about how the megabucks are going to PH and DHS, while probably legitimate, also took up an inordinate amount of time, in one instance 8 out of a 15 min presentation
- the second one was various versions of passing the buck
- The theme varied from something like "who's going to take the can" eg in the context of authority for school closure,
- to "why do we have to do this?", which was the first question at the tabletop exercise,
- on school meals, the emphasis appeared to be more on "where does it say we are the ones who have to feed the kids" than "how are we going to feed the kids"
- Despite official lip-service paid to how "schools have a vital role to play in community preparedness", echoing Venkayya's words, lamentations of how "schools can't do everything" were alas more prevalent than not, and coming out of the feds not attendees...
- the third driver is fulfilling requirements, which of course is also tied to funding. I do have some sympathies in this regard, as official guidance from the Dept of Ed on which if any of the requirements might be waived in a pandemic is not only absent, they were unable to even give a vague timeframe as to WHEN these guidances can be expected! As far as I can tell, the major concerns surround the following requiremens:
I did get a chance at the tabletop to bring up the concept of saving lives, that it's not just about "what we've been told to do". I quoted the reduction of mortality from 1918, and told them I haven't seen ANY intervention eg antivirals that comes even CLOSE to such efficacy, as I noted in this post yesterday, and that lowering the AR protects everyone, including those who have to go to work, which did appear to pacify some of the more reluctant people in the room. I think they also finally understood the concept of 'early'; I just wish there were more than 25 people (out of a national level conference) for me to convince, though.
Finally, as an illustration of the huge amount of work that still needs to be done, I have posted the files from the tabletop session, provided as a resource so educators can conduct their own exercises.
Take a look especially at the participants manual. Here are a number of errors that I picked up. I'm sure they will continue to correct and improve it, seeing that this has 'DRAFT' all over it, but it does illustrate as I said the extent of ignorance (or non-compliance) that we need to guard against.
Module 1 starts with year 2010, with limited cases of h5n1 in asia, etc, "in view of the situation, the WHO issued a phase 3 pandemic alert" - (at least there were a couple of people in the room who said, we're already in phase 3.)
Module 2 WHO phase 6, the virus gets to the US with sporadic cases, the manual says "given the highly infectious nature of the h5n1 virus and the escalating situation in asia, the pandemic severity index PSI is activated, prompting a move from alert to standby mode."
Module 3 - increased h2h in the US - with no reference to death rates anywhere, it says "because numerous human h5n1 cases have been confirmed throughout the US, the PSI level is raised to 5."
Module 4 (here's where it gets really fun, or weird) - first wave is over, cases on the decline, for now. "The PSI level has been raised to 6" while recovery starts.
Enough said! I believe the sum total of all these observations, from attendance rate to the lack of interest to the mistakes and distortions that happen to the federal guidance, is the perfect mirror of what happens to well-meaning hard-won policies when it comes to implementation. That the system is always going to be as strong as the weakest link, that a lot more work is needed to bring everyone along. But the most important lesson for me is that the ultimate effectiveness of any policy implemented in a 'trickle-down' fashion is totally dependent on the quality, intentions, and number of layers of players/institutions that the policy has to trickle through, such that the chance of the eventual outcome being equal to what was intended may be a rapidly dwindling number approaching zero, unless the top leadership actively, urgently, and directly empowers the ultimate end-users that the policy is supposed to protect, aka the general public.
With all respect to all the hard-working well-meaning creators of the CMG, including especially Dr Venkayya, my concern is that until the day every parent can stand up in public meetings and quote your document chapter and verse to hold officials accountable, we are a long way away from being able to save all those lives that the CMG in theory says we can save.
POSTSCRIPT: For CMG planning resource, go here for a short bullet-point version of the key points of the 108-page CMG document. |
