Association of Schools of Public Health

Identifying and Protecting Vulnerable Populations in Public Health Emergencies: Addressing

Gaps in Education and Training
Author(s): Martha S. Wingate, Emily C. Perry, Paul H. Campbell, Prabu David, Elizabeth M.
Weist
Source: Public Health Reports (1974-), Vol. 122, No. 3 (May - Jun., 2007), pp. 422-426
Published by: Association of Schools of Public Health
Stable URL: http://www.jstor.org/stable/20057147
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From the AgPH OF
ASSOCIATION
SCHOOLSOF
HEALTH
PUBLIC
Schools of Public Health

AND PROTECTING
IDENTIFYING a result, many of the vehicles never left the
parking
lot.5 The lack of public transportation out of the city
VULNERABLE POPULATIONS IN PUBLIC
created difficulties for the poor; Census data show that
HEALTHEMERGENCIES:ADDRESSING more than half of the poor households in New Orleans
GAPS IN EDUCATIONAND TRAINING (54%) did not have a car, truck, or van in 2000.l Those
who managed to leave New Orleans had to endure
Martha S. Wingate, DrPH many hardships, including lack of medications to treat
Emily C. Perry, MPH, CHES chronic disease. The situation did not improve after
Paul H. Campbell, ScD the storm, as five months after Katrina, many elderly
Prabu David, PhD and other residents on the Gulf Coast continued to
Elizabeth M. Weist, MA, MPH
suffer from aggravated health problems, emotional
strain, and stress.6
psychological

During an emergency, material and physical resources This recent

experience illustrates the need for
are stretched thin and, often, the needs of those who improvements in public health planning, response,
most need help, namely the vulnerable populations, and recovery. Among other initiatives, the Centers for
are left unmet. Vulnerable populations can be defined Disease Control and Prevention (CDC) established
broadly
to include those who are not able to access and academic Centers for Public Health Preparedness
use the standard resources offered in disaster
prepared (CPHP) in 2000 to assess and train the public health
ness and and class, and health-care workforce to better to threats
planning, response, recovery. Age, respond
race, poverty, language,
and a host of other social, to our nation's health, including the threat of bioter
cultural, economic, and psychological factors may be rorism, infectious disease outbreak, and other public
relevant
depending
on the nature of the emergency. health emergencies. In addition, CDC and Associa
In August 2005, Hurricane Katrina one tion of Schools of Public Health (ASPH) established
provided
illustration of the characteristics and vulner a nationwide network of CPHP to foster information
unique
abilities of specific populations in Louisiana, Missis sharing and reduce duplication among existing and
sippi, and Alabama. The storm most directly struck future
training
and educational resources. "Collabo

Mississippi, Louisiana, and Alabama, the poorest states ration groups"?workgroups of CPHP experts and
in the country.1 Almost 5,000 children were separated key practice partners staffed by ASPH?were created
from their families.2 Approximately 75% of all deaths in 2004 to address training issues in various top
in New Orleans, Louisiana, occurred among the
elderly,
ics of preparedness. Consequently, the ASPH/CDC
who represented only 15% of the city's total popula Preparedness Education for Vulnerable Populations
tion before the storm. Of nearly 240 shelters surveyed Collaboration Group focused in 2005-2006 on the
in the region, less than 30% had access to American challenges of meeting the needs of vulnerable popula
leaving those who were tions?also referred to as at-risk, or
Sign Language interpreters, high-risk, special,
deaf or hard of hearing with little or no access to vital special-needs populations?before, during,
and after a

information.3 public health emergency. These vulnerable populations

In addition, nearly all of the 280 nursing homes in have needs that are not fully addressed by traditional
Louisiana remained full despite the calls for evacu emergency preparedness plans and may require addi
ation and, as a consequence, 215 of their residents tional resources and special attention during and after
died.4 Hundreds of school buses were available in emergencies
or disasters.7

New Orleans as of the evacuation Unfor Initially, the

collaboration group conducted an
part plan.

tunately, however, the Louisiana

Department State extensive survey of available emergency preparedness
of Transportation and Development's plans had not training resources for public health that focused on spe
taken into account that hundreds of school bus drivers cific vulnerable populations. Upon completion of this
had already abandoned the city with their families. As survey, the resources were
organized
into a
grid,
which

Articles for From the Schools of Public Health activities at the schools. To submit an article, should
highlight practice-based faculty
send a short abstract (50-100 words) via e-mail to Allison Foster, ASPH Executive Director, at afoster@asph.org.
Deputy

422 O Public Health Reports / May-June 2007 / Volume 122

 From the Schools of Public Health O 423

was subsequently used to identify gaps. The purpose of Concrete proposals, including best practices or case
this article is to describe gaps in resources related to studies, could be useful. Specific plans for noninstitu
selected vulnerable populations to inform CPHP, public tionalized, home-bound older adult
populations
were

health agencies, and other organizations involved in not addressed in the resources. Inclusion of needs of

and course children

preparedness-related planning, training, (e.g., specific equipment requirements, surge
For both documents, see http://www capacity planning, family reunification plans, etc.) is
development.
. cfm. limited in many planning and policy resources. For
asph. org/ cphp/ CPHP_ResourceReport.
ethnic, racial and disadvan
minority, economically
evidence-based as to how
taged populations, practice
FINDINGS
to engage these communities in the planning process
Upon
review of gaps
across
populations,
some
general
is limited.
themes emerged, which may be categorized under six There is little evidence to suggest that available
areas: (1) policy and planning, (2) responder-targeted resources are sufficient to actively involve disadvantaged
courses, (3) training exercises and drills, (4) consumer groups in planning because of limited understanding of
oriented aids and resources for the special population, the culture of poverty and its impact on preparedness.
(5) collaborative efforts, and (6) measurement and In each of the vulnerable populations targeted by the
evaluation. Each area is described inmore detail in the collaborative group, there was a paucity of policy and
following sections. The Figure provides an overview of planning
resources.

the gaps noted in each population. While these rec

ommendations are not
comprehensive, they provide Responder-targeted courses/training
an initial framework for resource development and Although a number of courses available through the
curriculum design to train the public health workforce CPHP have modules that address the importance of
to meet the needs of vulnerable populations during vulnerable populations, few courses deal exclusively
an
emergency. with the needs of vulnerable populations. Preparedness
courses that focus
specifically on the needs of popula
Policy/planning gaps tions with disabilities were not available. Some courses
Despite the overarching recommendation found in were found that addressed the specific needs of rural
various policy documents to include special popula or
pediatric populations.
A
comprehensive
course on

tions in the planning process, few educational and cultural competency in the context of emergencies is
training resources provide tips or guidelines on how to available. However, the consideration of cultural com

include vulnerable populations at the planning stage. petence along

the continuum of
prevention, prepared

Figure. Training gaps in specific populations and areas to address these needs

General topics

Collaboration
Consumer with
Courses Training oriented government Measurement
Planning/ available for exercises information or other and
Population policy responders and drills aids organizations evaluation

Economically disadvantaged
populations X X

Ethnic and racial minority

X X X X X
populations

Mentally illpopulations X X X X X

Older adult X X X X X
populations
Pediatric X X X X X
populations
with disabilities X X X X X
Populations
Rural populations X X X X X

populations X X
Spanish-speaking

NOTE: X indicates a noted gap by general area.

topic

Public Health Reports / 2007 / Volume 122

May-June
424 O From the Schools of Public Health

ness, response, and recovery deserves more attention. detailed instructions. Also, Spanish-language resources
There is a clear need for more training related to are available on the Internet. Members of the group
cultural competence to better serve the needs of ethnic suggested that preparedness materials with illustra
and racial minorities. In summary,
more courses that tions and pictorial presentations that target Spanish
focus on
preparedness-related
information
specific
to
speaking populations would fill a gap. Such pictorial
vulnerable populations, such as people with disabilities, representations may be effective in reaching a diverse
economically disadvantaged, ethnic and racial minori population of Spanish-speaking people, with different
ties, pediatric,
and rural
populations,
are needed. levels of literacy and differences in Spanish language
across countries and of
regions origin.
Training exercises and drills
Members of the group highlighted the need for differ Collaboration
ent types of courses that are tailored to the learning Guidelines on how to foster collaboration among agen
objectives and the skill level of public health practitio cies and
organizations that serve vulnerable
popula
ners. The collaboration group highlighted the lack of tions are insufficient. For populations with disabilities,
intermediate and advanced courses needed to address communication gaps were identified among national
application and practice. Inclusion of the needs and agencies
and
organizations
and
nongovernmental
issues of special populations in drills and exercises are organizations, which serve people with disabilities on
of paramount importance in a comprehensive training a day-to-day basis. A similar gap was
recognized for the
curriculum. A vulnerable population component is a mentally ill populations, specifically with the National
part of some of the drills and exercises that are cur Alliance for the Mentally 111, Substance Abuse and
rently available through the CPHP network; however, Mental Health Services Administration, and the Ameri
there is an urgent need for more drills and exercises can Psychological Association. Committee members
that address the needs of vulnerable populations. recognized that community- and faith-based organiza
Also required are exercises that cover issues related to tions could play an instrumental role in the develop
vulnerable across the ment of and the of
populations planning, response, plans crafting pre-event messages.
and recovery spectrum. One lesson learned in 2005 from Hurricane Katrina
is that community groups, such as Rotary Club, faith
Consumer-oriented aids and resources for based and even local business owners
organizations,
vulnerable populations are valuable assets in
community responsiveness
and

The comprehensive matrix created by the collaboration recovery, particularly among rural
populations.
Col
consists of a vast number of consumer-oriented laboration and communication are critical of
group pieces
information aids and resources, which are primarily the emergency preparedness, response, and recovery
disseminated through the Internet. The majority of infrastructure and, consequently, play
a
pivotal
role in

these resources cannot be

easily
accessed
by
vulner
meeting the needs of the vulnerable populations.
able populations, which may not have access to the
Internet. For economically disadvantaged populations, Measurement and evaluation

there is a need for resources that are sensitive to the Standard metrics for the measurement and evaluation

working poor and those who are struggling to meet of successful training that addresses the needs of vulner
survival needs. As apparent during Hurricane able populations are not widely discussed in the current
daily
Katrina, understanding poverty is imperative. Resources resources.
Specifically,
there is no consensus measure

that are sensitive to the needs of daily survival within of organizational and individual cultural competence.
the context of
preparedness
are needed. In the absence of established measures, it is difficult to
For mentally ill populations, resources that prepare evaluate the effectiveness of the training. For mentally
consumers and
caregivers
to be able to obtain necessary ill populations, measures of post-disaster functioning
medications during and in the aftermath of a disaster of the individual and the system of care are limited. As
are essential. Also
required
are resources that account
trainings specifically related to vulnerable populations
for the low literacy among the mentally ill and some are increased and
improved,
evaluative measures for

of their caregivers. the individuals within the populations, the responders,

Checklists that focus on older adult populations and the system will have to be developed to provide a
are available on the Internet. However, a more assessment of the
significant comprehensive preparedness,

proportion of the older adult audience may not have response, and recovery of vulnerable
populations.
access to the Internet or may not be able to follow

Public Health Reports / May-June 2007 / Volume 122

 From the Schools of Public Health O 425

and organizations forces to produce this

CONCLUSIONS Many people joined
resource, including the Division of State and Local Readiness
for and to at the Centers for Disease Control and Prevention (CDC),
Improving preparedness response pub
lic health will
the informed take
and Coordinating Office for Terrorism Preparedness and Emergency
emergencies
Response staff, ASPH staff, and the following ASPH/CDC
combined effort of many people and organizations.
Preparedness Education for Vulnerable Populations Collaboration
Although government officials and agencies have an members members have
Group (while may multiple affiliations,
role to is not a their relevant Centers for Public Health
important play, preparedness solely gov Preparedness [CPHP]
ernment responsibility. Individual citizens and families affiliation is the one listed) :Dr. Paul Campbell, Harvard School

will continue to play a central role and organized efforts of Public Health, Harvard Center for Public Health Preparedness;
Dr. Dan The Johns Hopkins
Barnett, University Bloomberg
by both government and nongovernmental agencies School of Public
Health, The Johns Hopkins Center for Public
must be directed to encourage and facilitate informal Dr. Mark A. Brandenburg, of
Health Preparedness; University
community-based neighbor-helping-neighbor activities. Oklahoma of Public Health, Southwest Center for Public
College
Nonprofit organizations, including local faith-based Health Preparedness; Dr. Joe Coulter, University of Iowa College

and community-based will be critical of Public Health, Upper Midwest Center for Public Health
organizations,
Preparedness; Dr. Prabu David, Ohio State University School of
to successfully identifying, reaching, and protecting
Public
Health, Ohio Center for Public Health Preparedness; Dr.
our most vulnerable citizens. The U.S.
longstanding Zelde
Espinel, University of Miami, Center for Hispanic Disaster
network of service, and faith-based Center for Disaster
advocacy, organi Training, Epidemiology; Joshua Frances,
zations can be effectively utilized. The development Harvard University School of Public Health, Harvard Center for

of successful and informational Public Health Preparedness; Dr. Lynn Goldman, The Johns Hop
education, training,
kins University School of Public Health, The Johns
resources is critical to involving all of these organiza Bloomberg
Hopkins Center for Public Health Preparedness; Ana-Marie Jones,
tions and individuals. of California at Berkeley School of Public Health,
University
The work described previously by the 2005-2006 Center for Infectious Disease Dr. Michael
Berkeley Preparedness;
ASPH/CDC Preparedness Education for Vulnerable Meit, University of Pittsburgh Graduate School of Public Health,

Collaboration University of Pittsburgh Center for Public Health Preparedness;

Populations Group produced specific
Gilbert Nick, Harvard School of Public Health,
guidance for CPHP, as well as other organizations University
Harvard Center for Public Health Preparedness; Emily C. Perry,
involved in preparedness-related planning, training, of Medicine and Dentistry of New
University Jersey (UMDNJ)
and course development. First, public health prepared School of Public Health, New Jersey Center for Public Health
ness, and and activities Preparedness at UMDNJ; Dr. Robert Roush, University of Texas
response, recovery strategies
should include a strong focus on the needs of School of Public Health, Center for Biosecurity and Public Health
specific
Dr. Randy Rowel, State University and The
vulnerable populations. Second, care should be taken Preparedness; Morgan
Johns Hopkins University Bloomberg School of Public Health,
in defining vulnerable populations and their specific The Johns Hopkins Center for Public Health Preparedness; Dr.
needs. For an or disaster, of Miami, Center for Hispanic Disaster
example, during emergency Jim Shultz, University
the mental health or psychosocial needs of the gen Training, Center for Disaster Epidemiology; and, Dr. Martha
eral population be different from the needs Wingate, University of Alabama at Birmingham School of Public
may very
Health, South Central Center for Public Health
of mentally ill populations. Finally, evaluation efforts Preparedness.
In addition, the following external reviewers provided helpful
for emergency preparedness training in general and on final drafts of the resource
guidance group's grid: Dick Bohrer
measures relevant to vulnerable in and Robert Kidney from the National Association of Community
populations particu
lar should be to ensure evidence-based Health Centers; Jennifer Nieratko and at the Associa
strengthened colleagues
Inclusion of these resources related to vul tion of State and Territorial Health Officers; and Dr. George
guidance.
Mensah and colleagues at CDC's National Center for Chronic
nerable populations in additional training agendas is
Disease Prevention and Health Promotion.
an immediate need. It should be noted that the col Address correspondence to: Martha S. Wingate, DrPH,
laboration group is continuing itswork, and the needs of Alabama at Birmingham School of Public Health,
University
of additional vulnerable populations will be addressed RPHB 330, 1530 Third Ave. South, Birmingham, AL 35294-0022;
in fiscal year 2007. tel. 205-934-6783; fax 205-934-3347; e-mail <mwingate@ms.soph
.uab.edu>.

Martha S. Wingate is with the University of Alabama at Birming

ham School of Public Health, Birmingham, Alabama; Emily C.
Perry is formerly with the University of Medicine and Dentistry REFERENCES
of New Jersey School of Public Health, New Brunswick, New
1. Sherman A, Shapiro I. Essential facts about the victims of Hurri
Jersey; Paul H. Campbell is with the Harvard School of Public
cane Katrina, Global Center on
Budget and Policy Priorities. First
Health, Boston, Massachusetts; Prabu David is with the Ohio State on the CGPP website on 2005
published Sep 19 [cited 2006 Dec
University School of Communications, Columbus, Ohio; and 13]. Available from: URL: www.cbpp.org/9-19-05pov.htm
Elizabeth M. Weist is with the Association of Schools of Public 2. National Center for Missing & Exploited Children. Last of unac
Health DC companied children in Katrina shelters reunited with families [press
(ASPH), Washington,

Public Health Reports / May-June 2007 / Volume 122

426 O From the Schools of Public Health

release]; 2005 Oct 10 [cited 2006 Dec 19]. Available from: URL: 5. Spenser S. Pre-Katrina emergency plan for elderly faulted. Global
Action on Aging, New York. Based on article in the Washington
http://www.ncmec.org/missingkids/servlet/NewsEventServlet?
Post, 2006 Jan 31 [cited 2006 Oct 2]. Available from: URL: www
LanguageCountry=en_US&PageId=2150
3. National on Disability. on Special Needs .globalaging.org
Organization Report
Assessment for Katrina Evacuees (SNAKE) project [cited 2006 Dec 6. Leifer R. "It has disrupted my entire life." Global Action on Aging,
19]. Available from: URL: http://www.nod.org/Resources/PDFs/ New York. Based on article in the Hattiesburg American, 2006 Feb
2 [cited 2006 Oct 2]. Available from: URL: www.globalaging.org
katrina_snake_report.pdf
4. B. Six months after Katrina: who was left behind. Global 7. McGough M, Frank LL, Tipton S, Tinker TL, Vaughan E. Com
Quigley
Action on Aging, New York. Based on article in CommonDreams municating the risks of bioterrorism and other emergencies in a

.org, 2006 Feb 21 [cited 2006 Oct 2]. Available from: URL: www diverse society: a case study of special populations in North Dakota.
Biosecur Bioterror 2005;3:235-45.
.globalaging.org

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