In the times we live in, we are constantly facing all sorts of emergencies and preparedness is essential to keep families safe and promote health and wellbeing in challenging situations. In this episode, we explore how Tennessee has intentionally centered communities of color in response efforts and learn about Puerto Rico’s experience facing emergencies like Zika, Hurricane Maria, and the COVID-19 pandemic.
From Puerto Rico:
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Maura Leahy (AMCHP) (00:02):
Welcome to MCH Bridges, where we lift up innovative ideas and inspiring stories from people in the maternal and child health field. In today's episode, we're going to dive into Tennessee and Puerto Rico's emergency preparedness and response journey over these challenging past few years.
Nia Sutton (AMCHP) (00:19):
Hi, I'm your guest host for today, Nia Sutton, program manager for emergency preparedness and response on AMCHP's workforce development and capacity building team. In the times we live in, we are constantly facing all sorts of emergencies. Preparedness is essential to keep families safe and promote health and well-being in unexpected situations. Of course, COVID 19 has elevated the importance of this topic, and we have a lot to learn about what is going well and what we can do better in the future. We talked to our MCH friends in Tennessee about their COVID 19 journey.
Dr. Tobi Amosun (Tennessee MCH) (01:01):
Hi, my name, is Dr. Tobi Amosun. I am the assistant commissioner for the Tennessee Department of Health and the Title V director, as well as the Director of the Division of Family Health and Wellness.
Jacqueline Johnson (Tennessee MCH) (01:12):
Hi, I'm Jacqueline Johnson. I am the Title V Children and Youth with Special Health Care Needs Director for the state of Tennessee.
Nia Sutton (AMCHP) (01:19):
We asked our guests what their emergency preparedness and response efforts, or EPR, looked like before the COVID 19 pandemic. Jacqueline told us that their Division of Family Health and Wellness sits on a statewide emergency preparedness team and participated in annual updates of the continuity plan affectionately referred to as the co-op plan.
Jacqueline Johnson (Tennessee MCH) (01:44):
That plan was mainly to help programs to determine the essential functions necessary to in case of emergencies and identify the resources and recovery time that's required to complete, um, those functions. So for children, youth, with special healthcare needs, this included systems necessary for approval of medical treatment and services reimbursement for those services and the person's responsible for being there to make those services happen. So we, while we had always participated in the disaster response and efforts prior to March 2020, the program had not necessarily considered the guidelines and procedures in place for program participation and family participation and how that affected those individuals and families served. So we were prepared to bring our data systems up for within 12 to 48 hours, depending on the program. We could approve medical treatment and we could actually respond to natural disasters, you know, within a 12 to 24 hour timeframe.
Nia Sutton (AMCHP) (02:44):
So what was it like for the agency when faced with an unprecedented pandemic and public health emergency in early 2020?
Jacqueline Johnson (Tennessee MCH) (02:52):
March of 2020 was unique in that the state experienced tornadoes right before Tennessee's first COVID case was announced. I just wanna go on and say that there were many challenges initially in our response to the pandemic and not initially having equipment, testing supplies, and data infrastructure in place. It was just a little unsettling, I would say at the least. And there was also a big shift for the department for employees to work from home. We had not been agency that had brought work from home initiatives going on. In most places, equipment was not there for employees. Broadband was not there. And, um, wifi was somewhat nonexistent in our rural areas while our EP section was able to put plans in place relatively quickly in the state. And, but from an individual program perspective, we were really good with getting our systems back up if necessary and following other aspects of our coop plan, we realized relatively quick, that systems based response was not necessarily what our staff or our families that we served needed in order to be able to move forward in the pandemic.
Jacqueline Johnson (Tennessee MCH) (03:59):
Our care coordination initiative in some areas was not included in the coop plan. Tennessee had integrated three programs in 2018 to develop a care coordination model. That's unique to the state of Tennessee, the CYSHCN section was included. Um, however, those areas were created to assist families with assessing and navigating resources and services other than medical were not in the plan. This included the need for us to develop an individual, uh, continuity plan for the [indiscernible] services. At that time, it would, it was an in-person care coordination plan. Um, that was paper based application, charting documentation, food formula, pharmaceutical services. Everything we did was pretty much from a paper perspective and so not being able to be in the office, have access to that paper, created some significant challenges. And we had to create partners really quickly with our providers, with our formula, uh, food and formula providers with dropshipping food and formulas to homes, as well as local health departments, pharmacy providers, trying to work with them to provide 90 day supplies versus 30 day supplies. It became a real reality relatively quickly that we were not equipped actually to deal with some of the challenges that we faced in 2020.
Nia Sutton (AMCHP) (05:19):
Awesome. Thank you so much for sharing that. I heard that you touched on the experiences that you all had with overlapping emergencies and also how the pandemic kind of sped up or brought you all to more of a, a virtual workspace that you weren't initially prepared for. And I think that those are important things to consider when talking about emergency preparedness and response. And I know that you also touched on some of the challenges that you all faced as a result of where you were before. Um, you moved into responding to the pandemic, um, Dr. Amosun, is there anything that you would add about the challenges that you all had and any successes that you all had related to your EPR efforts since then?
Dr. Tobi Amosun (Tennessee MCH) (06:01):
Sure. So Jacquie had already referenced the tornadoes that came through the very beginning of March. And so I feel like that was really the beginning of the, it felt like the beginning of the end for us almost on the biblical proportion, but, um, Tennessee, it had some unique challenges. We had E F four tornadoes come through middle Tennessee in March, 2020. In addition to that, we had several other natural and manmade disasters happen over the course of 2020 and 2021. Obviously we went into lockdown just like the rest of the country did during 2020, but we also had a major Christmas day bombing that destroyed our newborn screening services laboratory. We also had, um, some significant flooding in the Western part of the state during 2021. And then tornadoes again, last year, those are some of the biggest challenges that we've faced. So in addition to all the challenges of COVID, we've really faced some just infrastructure challenges and you don't think about it, but all of those plans that you make in making sure you have a backup lab, making sure you have, um, backup generators, making sure you have go kits for your WIC program for your children, youth and special healthcare needs programs.
Dr. Tobi Amosun (Tennessee MCH) (07:06):
Those really came into play during, um, while we were dealing with all of those natural and manmade disasters. Other challenges are specific to Tennessee. And I think anywhere that has a lot of rural areas, Broadband access has been really difficult for us in Tennessee. There are certain spots in west Tennessee as, as well as east Tennessee that have difficult, um, access to internet. I think for a lot of people, the switch to this virtual environment, while it has created some unique challenges, some of the successes that we've had has been the increase in telehealth and telework, overall across our state. Um, it's been able to increase our, um, our access and representation. So very often if we're having committee meetings, whatever, whatever it might be, being able to get broad representation from all across the all across the state has been really great.
Jacqueline Johnson (Tennessee MCH) (07:54):
We developed an emergency preparedness tool kit with, with Tennessee faceing many, many, um, tornadoes a year and floods and all those things it's necessary that our families have those items that they need for FEMA and all the other processes they have to go through when they're affected. So one of the biggest things that we're proud of is our emergency decal and magnet, which is a decal that families can place on the windows or front doors as well, a magnet they can put on their car. They have an information card that actually provides emergency personnel with detailed information if there's a child with special healthcare needs, what common methods they may use, what other kinds of implements or material that may be necessary for that child in the emergency situation to lessen the burdens on our families.
Nia Sutton (AMCHP) (08:39):
All right, thank you so much for that response. And we've witnessed how COVID 19 disproportionately impacts communities of color. Black American, Latino, and indigenous people have experienced higher rates of infection, death, and other negative impacts due to systemic inequities. For example, housing inequity, reliance on public transportation being deemed an essential worker, just to name a few. How has your agency intentionally centered Black and other communities of color in your COVID 19 response efforts?
Dr. Tobi Amosun (Tennessee MCH) (09:13):
When you look at Tennessee's vaccine rollout, we were very, very intentional in terms of how we structured, not just access to care from a rural standpoint, but also people disproportionately for people of color. So when you look at where, how we calculated, where to send vaccines, we use the social vulnerability index from the CDC as a way for us to make sure that we were getting vaccines, the priority locations. And one of the other things that our office of health disparities elimination has been working really well on has been getting stories of people who've been personally affected by COVID 19 out there. They have PSAs that are really well done and really compelling. And it's sort having a person talk to a person cause we've found that those individual stories have been the most effective in terms of, in terms of changing people's opinion about COVID vaccination. The other thing that we've been doing and we've never really stopped doing is just continuing to reach out to community partners. We've hired a Hispanic engagement coordinator in the Tennessee department of health. We also have a health equity liaison physician who's been really instrumental in helping us get a lot of our priorities aligned. So that way that our messaging is consistent across the state.
Nia Sutton (AMCHP) (10:31):
What has Tennessee learned from the past two years of constant emergency response efforts?
Jacqueline Johnson (Tennessee MCH) (10:40):
Using individuals that, um, were from the same community to speak to those, uh, to people around the pandemic and what was happening and the need to get tested and the need for vaccinations, as you said, really helped with our being able to meet this, this crisis.
Nia Sutton (AMCHP) (10:57):
They told me their advice for others is to continue moving services to virtual environments, be open to adapting to change quickly, and working with new and nontraditional partners and look at everything with an equity lens. Sounds like a pretty great path forward for all of us. At AMCHP, we have the pleasure of getting to work with maternal and child health professionals in all 59 states and jurisdictions. So to say that every public health agency is unique is an understatement. After talking with our partners in Tennessee, I sat down with a colleague from Puerto Rico to see what emergency preparedness and response looks like for them.
Camille Delgado (Puerto Rico MCH) (11:43):
Hello. Uh, I'm, Camille Delgado, I'm an epidemiologist and the surveillance coordinator for the surveillance of emergency threats to mother and babies previously known as the Zika active pregnancy surveillance system. And we are one of the programs within the children with special medical needs division in the Puerto Rico Department of Health.
Nia Sutton (AMCHP) (12:03):
Camille mentioned the Zika epidemic. Remember that? The Zika virus spreads by the bite of an infected mosquito. In 2015 and 2016, the Zika virus was a major problem for MCH populations, especially pregnant people since we learned the virus can cause certain birth defects. Puerto Rico was especially hard hit by the epidemic
Camille Delgado (Puerto Rico MCH) (12:28):
Well Puerto Rico was the first US territory to report local transmission of the Zika virus. Warmer climates definitely may have facilitated the expansion of the geographic range of mosquito populations and potentially increased their capacity to transmits the Zika virus. Puerto Rico is an archipelago that is located in the Caribbean with the climate that it is perfect and suitable for mosquito species. Zika is spread mainly by the Aedes mosquitoes, which are endemic in Puerto Rico. As we know, Puerto Rico took it very seriously because the Zika was a public health emergency because it can be transmitted from mother to fetus during pregnancy. And it has been linked to increase in miscarriages death, newborns, birth defects, neurodevelopmental abnormalities, have become apparent during the first months and years of life. Then, as soon as the first case was reported, the Puerto Rico secretary of health passed administrative orders, declared a state of emergency in the island, and they required the report of any case to the Puerto Rico Department of Health.
Camille Delgado (Puerto Rico MCH) (13:37):
Another one mandated the report of pregnant women with laboratory evidence of Zika to the Puerto Rico Department of Health and the Zika active pregnancy surveillance system was established (ZAPs in short) in collaboration with the CDCC, the division, uh, and the epidemiology office of the Puerto Rico department of health. And through all of these administrative orders, partnerships and collaborations allowed ZAPs, a rapid ascertainment and identification of pregnant women with, with Zika infection. Another part was that ZAPs was also part of the Puerto Rico emergency operation center and that ensured that pregnant women and their children were a priority in the emergency response in many aspects within the division. The planning for the emergency started before a Zika case was identified in the island and that allowed the surveillance of pregnant women to start fairly quickly after the first case was identified. And another aspect of how the Zika epidemic changed emergency preparedness efforts for the MCH population in my opinion, is that our direct involvement allowed us to create these partnerships that we have maintained in all of the emergencies that followed the Zika epidemic.
Nia Sutton (AMCHP) (14:51):
After the Zika epidemic, Puerto Rico faced two other significant climate change related emergencies when it was hit with back-to-back hurricanes Irma and Maria in September, 2017. Could you share a little about Puerto Rico's department of health emergency preparedness efforts, especially as it was still dealing with the Zika epidemic. What were some of the challenges and the impacts of having to respond to intersecting and overlapping emergencies on pregnant people and technology-dependent, infants, children and youth?
Camille Delgado (Puerto Rico MCH) (15:27):
So Puerto Rico is particularly vulnerable to climate-related emergencies since it's an island and we see rising sea levels from climate change and stronger storms. Puerto Rico throughout history has experienced devastating hurricanes. But now we have seen an increase in intensity and occurrence due to climate change and rising global temperatures. The timing of Hurricane Maria was particularly damaging because Puerto Ricans were still recovering from the damage caused by Hurricane Ima. And we were still without power and water and just starting to rebuild when hurricane Maria hit. Just to give you some, some data, a hundred percent of residents were without electricity, 60% were without drinking water and 92% of the telecommunications towers were also down. The power outage in Puerto Rico after Hurricane Maria remains the largest power outage in the United States history.
Nia Sutton (AMCHP) (16:25):
Can you imagine? No electricity, no safe drinking water and no way to communicate with others. This extreme emergency definitely put the public health system to the test. I asked Camille to tell me about what the response in rebuilding looked like for their MCH program.
Camille Delgado (Puerto Rico MCH) (16:43):
I remember we started working just one week after Hurricane Maria hit. We were sharing spaces and, and getting back to work this new scenario, which to say was complicated is an understatement. We had no communication and, and no power. Our priority populations, I remember were infant children and youth with inborn hours of metabolism, infants born with mothers with Zika infection during pregnancy, the technology-dependent infants, children, and youth and the children and youth with autism spectrum disorder. The families that were being monitored by ZAPs, many were experiencing worry and anxiety thought there was gonna be a disruption in healthcare since 16 days after the hurricane, only 25 of the 78 hospitals were working. While they were experiencing these worries, they were also living out power and, and food and water. The most important things was to contact them, make sure that they were safe and, and if they needed something for us to help facilitate or be liaisons.
Camille Delgado (Puerto Rico MCH) (17:44):
We had service coordinators, family engagement support staff, and direct services teams that attempted to locate families in the field using their last known addresses. The other population that was in desperate need of help after the hurricanes was staying infants, children, and youth dependent of life-maintaining technology. Before the hurricanes, a centralized registry didn't exist. During and after the hurricanes, these children were going to the hospital, but not as patients, but as refugees. Access to generators and failure of the generators they had was one of the main challenges for these families. Many of the families made the decision to leave Puerto Rico, but that also brought new challenges. The process of identifying and getting the necessary equipment for these patients to travel, all the clearances needed. Then when they arrived at their destinations, ensuring that their, their medical plan covered outside of Puerto Rico, the health services they need was another challenge.
Camille Delgado (Puerto Rico MCH) (18:44):
Seeing all of this, the division created our registry. And right after the hurricane, the registry was able to identify and collect the needs of this population. And later served as a liaison between families, agencies, and foundations that were available to aid and ensure that these families received the services or equipment that they needed. The registry also helped in the process when families decided to move out of the island. The main challenge throughout the programs in the division was contacting the families because all of the telecommunications were down. The way that we worked to attend the overlapping emergencies was that all the different programs concentrated on their population of interest, of course, assisting and helping other programs if needed. But that way all the monitored populations within the division had a team just for them.
Nia Sutton (AMCHP) (19:36):
Thank you so much for that. Um, it sounds like a lot of learning happened in real time. You all were learning the, the things that needed to happen and making those adjustments, um, so that you could respond in real time. Um, and that's a very unique skill. Can you tell our listeners how Puerto Rico switched gears from Zika response and, hurricane response to COVID 19 response? What were some lessons learned or strategies from past emergencies that you all used to pivot to address COVID 19?
Camille Delgado (Puerto Rico MCH) (20:08):
We used the infrastructure that we had for Zika, all of our collaborative agreements and partners. We just updated them, like for example, with the Puerto Rico Vital Signs and the Puerto Rico Medicaid administration, we informed them and, and updated all our collaborative agreements with them and informed them that we were going to include COVID 19 pregnant cases to our surveillance and, and all of the data that they got from the COVID 19, we got, we have also. So that was a huge thing that, that we kept using. And in Puerto Rico, our data is currently being used to see if new or more influential infection, prevention, and vaccination strategies are needed to further protect pregnant women. My advice would be to document in detail, the problem or the emergency, its effects in the MCH population, and have ideas on how to manage it. And if you're thinking of preparedness, just making a plan for preparedness, you can take examples of places that are experiencing or have experienced the same impact of what you want to address and bring all that documentation to key stakeholders and personnel within your organization that can help make a change.
Camille Delgado (Puerto Rico MCH) (21:21):
Partnerships and collaborations are essential, and you will find that programs and organization outside the department of health do want to help and, and you'll find help with outside programs.
Nia Sutton (AMCHP) (21:36):
Great. Is there anything else that you want to share with us today?
Camille Delgado (Puerto Rico MCH) (21:38):
If, if you have the power connections to make sure that the MCH population is included and it's a priority when a real disaster or public health occurs, no one will forget about these vulnerable populations. There will be times that you and your program will not be able to maybe offer some services or help directly, but it's also important to identify and collect and document the needs that the population is seeing and serve as a liaison between these families and agencies or foundations that, that do have available those services and ensure that these families receive the services they need.
Nia Sutton (AMCHP) (22:15):
Puerto Rico's experience really drives home the importance of being prepared for emergencies, engaging with community partners and making sure that the unique needs of MCH populations are considered. Thank you so much to our guests from Tennessee and Puerto Rico for sharing their experiences with us and helping to prioritize MCH populations during public health emergencies.
Maura Leahy (AMCHP) (22:47):
Thank you all for joining us for this episode of MCH Bridges. We kindly ask that you take a few minutes to fill out a quick feedback survey and let us know what MCH related topics you're interested in and who you want to hear from on future episodes. A link to the podcast feedback survey, as well as a transcript of this episode can be found at www.mcbridges.org. Be sure to follow AMCHP on social media. We're on Twitter and Instagram at @DC_AMCHP. We hope this episode created some new connections for you stay well. And I hope our path crossed on the next MCH bridges. This project is supported by the Health Resources and Services Administration or HRSA of the US department of health and human services, or HHS as part of an award totaling $1,963,039 with 0% financed with non-governmental sources. This information or content and conclusions are those of the author, and should not be construed as the official position or policy of nor should any endorsements be inferred by HRSA, HHS or the US government
Speaker 6 (24:06):