Our first paneldiscussion, our first presenterwould be Mitch Stripling. Mitch Stripling currently servesas the deputy commissioner for busines preparednessand response at the New York City Departmentof Health and Mental Hygiene where he organizes measurements forplanning, training exercises, gamble analysis andevaluation among others. He has served insenior leadership personas across variou citywideemergencies including Hurricane Sandy, H1N1, the Ebola crisis and the internationalepidemic of Zika virus. In 2017 and’ 18 he controlled theHealth Department’s caring deployments to Puerto Ricoand the US Virgin Islands. His unit has developednationally-recognized threat response steers for2 1 high-risk situations that could be used to affect New York City; a data-driven riskassessment methodology, a list of health equity-basedrecommendations for RCS and an evidence-driven allhazards proposing database amongst other nationallyrecognized models. Prior to working in NewYork City, Mitch worked for the Florida Departmentof Health.There he cured program andimplement the response to six federally declareddisasters including the 2004 record-breaking hurricaneseason and Florida’s response in southern Mississippiafter Hurricane Katrina. Our second presenteron members of the panel, I’d like to introduce thehonorable Dr. Rafael Rodriguez Mercado who is currently thesecretary of the Department of Health of Puerto Ricoin which he has charge in the mission to design and implement the publichealth program as included in the government platform ofthe current administration. His agenda is based onthree strategic mainstays: a patient-centeredhealth system, fair and accessible healthservices, and emphasis on primary care and prevention. He dishes as administrator for renowned intervascularsurgery program and was chancellor of themedical disciplines campus at the Universityof Puerto Rico. Prior to his currentposition, he was a professor of neurosurgery at the schoolof medicine and the director of intervascular surgeryprogram at this institution.Dr. Mercado acquired a bachelorof discipline stage in chemistry and a doctor of medicine fromthe University of Puerto Rico. As a student he received theresearch and student honors as well as recognitionof the House of Representatives in 1988. He accomplished his specialty inneurosurgery after seven years of training at the University ofPuerto Rico institution of medicine. Then he attained a subspecialtyin intervascular neurosurgery from the State University ofNew York in Buffalo New York.In September of 2017 he wasappointed associate professor in surgery of uniformedservices, University of Health Discipline of the Armed Forcesof the United District. With this appointment, he attached the department of this prestigiousmilitary university. Until then “hes having” regarded theposition of dominate surgeon of the United Government ArmyReserve in Puerto Rico. He is currently attendingphysician as neurosurgeon at Walter Reed Medical Hospitaland Brook Army Medical Center. And he craved all of youto know that he’s married to Wanda Santiago Penmentaro — I hope I didn’t sayher last name wrong — who is a medical technologist. And he is the proud father of a young universitystudent Raphael. Our discussant for thismorning’s board is Captain Renee Funk. Captain Funk currentlyserves as associate superintendent for emergency control, officeof chairman, National Center for Environmental Health, and HSDR now at CDC. Dr. Funk received her doctorof veterinary medicine from Iowa State University, her master’s of public health in humid medication from TulaneUniversity, and a master’s of business administrationfrom Georgia State University.She is a diplomat ofthe American College of Veterinary PreventativeMedicine. Dr. Funk is a recognizedexpert in environmental and occupational healthand emergency management. Her portfolio includes emergencymanagement of chemical, radiological andnatural disasters. Dr. Funk recently servedas CDC’s happen director for the 2017 hurricane response. Please join me in welcomingCaptain Funk, Dr. Mercado and Mitch Stripling forthis first panel discussion.[ Applause] >> Okay. Good morning, everybody. >> Good morning. >> Somehow when yougive those bios, “youve never” actually thinkanybody’s going to read all of it, you know what I imply? All title, I’m going to standin between the two microphones.Is that how it makes? I just want to make sure Ihave all the buttons right. Okay. I’m going to tella personal tale today which is a very limited story. And I feel right now that I’min very distinguished company, so I want to makesure that it is heard in that sort of personal course. The reasonablenes I formulated everythingthat nature is that I work in New York City butI’m from South Georgia. And I have family that I knowof that were on the wrong side of the Civil Rights movementdeep into the 21 st century. And that’s why for me andfor us in New York City, when we do this work, wetalk about health equity and what health equity means.But when we do the work in NewYork now, we want to be clear that what we’re talkingabout is structural intolerance. Okay? Health equity is agreat set of intersections. There are a lot ofthings that are in there about functionalneeds and access. But the detail of the spearis the structures of dominance that we’ve createdin this society that have institutionalizedbias, right? And that’s led toa set of designs that clear emergencyresponse more difficult and in some ways dangerous.And that’s what I just wanted to framemy talk around this morning. When you have a disaster, the disaster isn’tcaused by the hazard. It’s caused by the peoplethe hazard affects, right? The last shows dida great job of formulating that. But those people are where theyare because the society has sort of procreated the institutionsthat leant them there, generally.And that’s why when you arecoming in as a representative of a government trying tohelp them, candidly trying to help them, and countless heroeshave worked in these responses, you are put back by that. That does your workharder, because you’re kind of fighting the system. Does that make sense? Okay. So it’s important tostart with the question, do our emergency responsesmake these prejudices that we’re talkingabout better or worse? We cannot assume that we’regoing to make them better. In a lot of ways we go in andsometimes they say the disaster after the disaster becausethe recovery efforts sometime makes issues thatweren’t there before.We have to be honest about that. And for us in New York City, this is a very personal story. This is no longer a story ofme trying to come in and criticize other tribes. When we did our Zika responseat the opening up of 2016, we like every good publichealth worker institution out there started messagingfor people to get measured. And so what you see here is thechart of our testing paces — and I don’t know if youcan see the quartiles.But as soon as we putout the messaging, the first thing we did waswe dispersed messaging around the city. Hey, metropoli, depart get researched. Who came experimented? Well, the people that got testedwere the lowest-priority kinfolks. They were the affluent folkson the upper west feature “whos” paranoid, who werenot going to be traveling to Zika-impactedcountries, right? And so we looked atthat and that motived us to take a hard-bitten, deep sigh. And there is indeed twocamps of kinfolks inside of our public healthincident command system, because we’re talking aboutemergency management today.And one camp was, “Well, you know what? That’s just the underlyinginequities of the healthcare plan, right? That’s just our sense is goingout into the healthcare system. What can we do about it? ” And then there was the voicethat said, “You know what? That is our problem.” And that’s the voicethat ultimately prevailed. And what you can see over thereis that we did five months of concentrated, resource-intensive work with our highest-priority areas, the areas that would light up on the socialvulnerability index.The areas of people who weretraveling to these countries but who also were lower privation, who had lower frequencies of care. And so when the summer stumbled, wewere able to flip our narrative and the highest areasof testing were in sizable place thehighest-priority quartiles. But that took deep andintentional labour and pushing of our commissionerfor five months, because the incident commandsystem that I am proud of, that I helped to build, propagandized against that, right? Because incident command isbuilt on the idea of achievement, deed, behave, execute, implement, implement. And if you executeunintentionally, you will acquire the issues worse. Are you with me? I want to see, becauseyou get sleepy. Parties get sleepy-eyed. Okay. So it’s importantwhen you’re working in happen require not towork from an equality make, because if you’redistributing resources evenly, everyone else who has less willcontinue to have less.But to figure out and usethese vulnerability tools to move towards anequity framework. And everybody getsthe box graphic. I don’t know why. I don’t know wherethis graphic came from, but for some reason thebox graphic is the thing that beats thisinto folks’ abilities. So if we are not intentional, emergency responses willreinforce underlying structural intolerance. I have insured it. I’ve been doing this since 2004. Every response that I’ve beenpart of that hasn’t stopped and thoughts and refocused hasreinforced structural racism. You’ve written apaper 4 years later and you felt reallybad about it, and now it’s timeto stop do it. So let me tell my personalstory about my experience in the US Virgin Islands. And members of the mission we didwas very limited, small-scale, one duty among numerous. And there were so manyheroes in that response.And Captain Funk and herteam were right there in the middle ofit being daring. And I want to make surethat that’s captured in the fib I’m going to tell. Because the thing to knowabout all of its national territory that I want to make sure wesay plainly in this space is that they operate inwhat’s pretty much a colonial fabric. If you look at them, they haveunfair CMS reimbursement rates, they have restraint authorityover all kinds of things. They are designed to be weakstructures governmentally. Not sanctioned theway a commonwealth is. And so when you gointo a neighbourhood like that, the characteristics of thestructures of influence that you use is important, right? It speaks to the mission. So the experience that I haveis the structures that we put in place as a commonwealth — well, first let me talk about — I got a little ahead of myself.Our duty, right, was to go down and help the localhealth department to craft a recovery plan. Me and a crew of five working professionals, we were working with the leaders of the health and medicalinfrastructure in the VI together with Natalie Grant andCaptain Funk and a assortment of federal authorities to buildand craft a recovery plan. That was our job. And we were approaching itfrom an empowerment frame. How do we empowerlocals to craft a contrive and to grab it and run with it? So when you go tothe Virgin Islands — and we were living inthe FEMA cruise ships. Everybody, if youdeployed, you maybe lived in the FEMA cruise ships. And tactically I totallyunderstand why you deploy a cruise ship into aharbor of a territory.Because where are yougoing to base, right? But at the same time, what do you form? You create a little fortress. You create a fortress, almost a militarized fortress with the Americanflag everywhere and garbs everywhere. And then inside of anabandoned Radio Shack in a shopping plaza you buildout a high-functioning, high-tech command centerthat is sequestered away from the life of the people. And then you builda bid formation that is only accountableto itself, a federal word structure that to my pointwasn’t fully integrated with the neighbourhood structuresof strength. What you are doing in someways is you are recreating an authority of colonizationin the infinite through emergency management. Does that make sense? You’re creating anew ability midst and although you’re maybepaying lip service to the idea that that dominance centeris supporting the locals, what you’re reallydoing is you’re saying, “There’s a new boss in town.” And this is not to speak tothe intent of any of the heroes who worked withinthat structure.This is not aboutpersonal purport. This is the way the structuresthat we are within kind of create us and force us to actin ways that are unpleasant and get in the wayof our goal. And for me the lesson was — and this is us standingwith Reuben Malloy who is our handshakein the VI — empowerment is nota great framework. It suggests of a savior framework. Who are we to empoweryou in your residences to do the job you need to do? Who are we to do that? I listen so many respondersin these situations — and we cast assets toPuerto Rico, we moved assets to the Virgin Islands andwe sent assets to Florida, we communicated assets to Texas.Only in Puerto Rican missions and VI duties did I hearthe locals announced incapable. All the time, over alcohols. And I’m trying to becandid in the office. “Why can’t these folksget it together? ” And the reason is because theyhave been structurally deprived of resources for 100 times. They were createdto be incompetent because of the structuralframeworks that they are trapped within. That’s what I think aboutcolonial frameworks. And so this is some artin the Virgin Islands that we were experiencing. The thing we have to learnis how to fit our resources which are so needed and ourexpertise which is so needed within the spirit of a placein a way that acknowledges that we are not theheroes in this situation. And so when I “re coming back” to NewYork City, we had to wrestle with these same things, becausewe have done the same thing. We did the same thing in Sandy. We did the same thing in H1N1. We did the same thing in Ebola.This is not a federalterritory difficulty. This is an emergencyresponse question. And I wanted to wrestle with it. I wanted to say, “Allright, guys, sitting there. Let’s fight the fight.” And so we went throughinternally. GARE process — the GovernmentAlliance for Racial Equity. I don’t know if you guysknow that group or not. They have a tool thatlets you sit down and look at your processesand interrogate them from an equity framework to seewhat you should do about it.And so we went through asix-month intensive process where we had focus groups withour occurrence require leads, incident command staff, our community craftsmen, inspections that went out. And it turned outwe were not as cool as we thought we were, right? That’s why I want to be soclear about my own fallibility and our process, right? And especially as a personfrom my background speaking about structural intolerance, I wantto be so intentional about this. But I want to giveyou practical stuff.What was the problem we obtained? Our community leadersfelt that we in New York City werenot be incorporated. Locals complained to thefeds all the time, “Well, you’re not including us, ” right? The community said, “You’re not including us. You’re telling us togo hand out booklets, but you’re not lettingus strategize about how to work in our communities.” So what we’ve done is we’veactually fetch the community leaders into our ICS framework. They’re in the incidentcommand system. There’s not a separate system. There’s not a separatebunch of confronts. They are right in there with us. Which is a dangerous anddifficult way to do business. People bring up spoilers, right? But if you’re going tomake a consolidated frame, it has to be that way. We heard that, “Hey, HealthDepartment, you were great at advocating forracial justice right up until the emergencyalarms go off.” That’s when you get scared.Because you go far a apartment withthe cops and the firefighters and the emergency managers andeverybody else and then you want to say, “Yes, sir, “and “No, sir, ” because the mayor ispounding on his desk and he’s saying, “Get the job done.” And if you’re going to dothis, you have to understand that advocating for racialequity means that it is part of your emergencyresponse function. When you are asked for anassessment of a disease or a catastrophe and whatthe state jolt is, you’d better talkabout racial equity or you’re not make your work. And so that is something thatwe have taken up this year. Our staff of color within ourHealth Department felt truly alienated from thedecision making process. They said, “Look, we arefrom these communities. We were from the West Africancommunities during Ebola.We were from Zika-impactedcountries. And you are not listeningto us.” And so we have put inplace objective criteria for our ICS leadership. We’re trying not to chooseour ICS chairmen based on gut, based on, “Oh, I think thatperson’s the best person.” But let’s have anobjective pathway for it. And we’re trying to changethe training of our leaders, to not train them in emergencyresponse, “Get it done, get it done, get it done, ” only. But to train them in humilityand cultural sensitivity and the artwork of listening. And we’ve written intoour accountability metrics and our assessment frames that our incidentcommanders will be accountable for advocating for racial equityboth inside of our designs and outside of our structures.And lastly, the finalthree things I approximate I want to give you. We’ve tried to figure outhow to build this idea of intentional equityinto our response systems. Because when we’ve done itbefore, where reference is altered tracks for Zika, when wesaid during Ebola that the police departmentcouldn’t be in charge of monitoring the West Africancase contacts even if they are their missing persons bureauwanted to have that job, it was because ourcommissioner stood up. And we needed to helpmake the system stand up. So we’re running right nowour preparedness projects through its own versionof an equity analysis. We are building a newvulnerability structure that’s based on the socialvulnerability index but included a number of otherracial equity estimates that we can use to doneighborhood vulnerabilities.And in particular we arechanging the principles and traditions ofour response system. We are building intothis system the idea that disaster managementis not a kindnes. That is now what we are doing. We are acting in solidaritywith our fellow residents who are having troubles. We are an agent of government. That means we areworking for them. We are starting froma place of humility , not heroism where the survivorsare the heroes in the situation. And we’re trying to makeemergency management more of a community organizingframework than a response structure. Because emergency managementis all about collaboration and coordination, right? That’s what it’s about.And so those are theframeworks we want to begin on. So “we ii” attaining sure equityis part of our schedules, that we’re decentralizingdecision-making and we are trying toprioritize locals knowing over our leaders knowing. That’s the hard one, right? Getting information out tothe locals before we tell our bosses. But that’s whereit’s needed, right? When you get information intothose handwritings, we’re there. And we’re trying neverto develop a goal — because what we want todo, we’re smart-alecky folks. We want to white committee it. “Tell me their own problems. I’m going to develop a mission.” We’re trying neverto develop a operation without informedcommunity participation. Because as soon as you develop amission and get feedback on it, when you ask forfeedback from the people that are most impactedby a disaster, they’re in the worstposition to give it, right? They’re in this territory of shock.And so you can’tdo it like that. They’re going to just say, “Thank you for being here. Whatever you wantto do is fine.” You “re going to have to” do themission growth with those impacted societies. Whew. I’m going totake a breath. That was a little bit of a rant. And I interpreted five minutes andI was actually grateful.I was like, “I havefive more minutes.” I’ve never felt that way before. Often I’m over time. So all of that is to say this. It’s all about the delta, right? In our responses we’re alwaystalking about the delta. What’s the differencewe’re making? What is the convert we’re making? And the lesson I want to give toyou as various kinds of an outside, okay, as person or persons speakingfrom structural intolerance, trying to own my rolein that privilege, trying to do good intentionally, is that equity isnot a moral force. I necessitate, it is. It’s a moral select; we need to do it. Equity is essential to thesuccess metrics of a response. Because in a response, you’re trying to recover from the emergency.You cannot do that effectivelywithout a clear understanding of the role that especiallyracial equity plays in the frameworks you’re doing. You’re just going to neglect. So you’ve got to doit or you’re going to get called before Congress, you’re going to get written up seriously in the papers becauseyou haven’t thought about it. And the other point is, when youtalk about building back better, you cannot do thatwithout equity.Right? Building back bettermeans building back equitably. It implies applying thedisaster as a programme opening to unpack the racialinjustices that are present in that situation andthat appointed the effects to the disaster. And then employing the influence and action the disasterrecovery brings to heal some of those inequities and employed themon a move towards resolution. Because a more equitablecommunity I guarantee you is a stronger and moreresilient disaster — sorry, is a stronger, more pliable parish when the next accident hits.Purely as a matter of practice, we must integratebetter equity frameworks into our emergencyresponse protocols. Thank you.[ Applause] >> Good morning, and on behalfof the governor of Puerto Rico, Ricardo Rosello, andmyself, thank you so much for what you didfor Puerto Rico. There are a lot of faces thatI remember from those epoches where Puerto Rico wasstruck by Hurricane Maria. And an excellent response. I am very proud of all of you. I am proud of beingan American citizen and an Us soldier extremely. So thank you so much, fromthe bottom of my centre.[ Applause] I become very emotional becauseit was very difficult times for me. Well, let’s see howI move this here. Right? Good. Before I start with what theCDC genuinely did for Puerto Rico and they are doing for PuertoRico, it’s better to start to address how we stayhealthy on the island.Because it’s totallydifferent from other moods, from other countries. You have to remember thatPuerto Rico has a population of 3.4 million. So really remember this is thesame population more or less of the state of Connecticut. But in terms of healthcare, we don’t have the same parity as Mississippi, which is thepoorest state in the nation with more socioeconomicproblems.That is an aspect that shapes ita little bit difficult to deal with the health systemin the island. Knowing that most of the people in Puerto Rico aremedically indigent. We have to recognize firstly whenwe deal with the health system, we have to understandthe importance of health and the impact on communitiesand people with vulnerabilities. Likewise the importance ofhaving a historic background about the developmentof the Department of Health throughout theyears and were we go, where we startedand where we go.Once we have that, we canestablish public policy in order to address the social problems and health problemsof the community. The health care system in PuertoRico is the responsibility of the government. So if something badhappens, they blame you. So over the years it has beena big challenge in Puerto Rico to give quality healthcare. Why? You well know that PuertoRico is under the control of an oversight boardby the Congress because of the financialbreakdown that happened many years ago. So that creates a challengein terms of accessibility and recruitment ofhealth professionals.Also, because all ofthe health professionals in Puerto Rico have the samepreparation and diploma and is just coming up academicinstitutions that are accredited with the same accreditationsfrom the United States, it’s easy for any healthprofessional in Puerto Rico to migrate to the United State. So that is causing a bigproblem in Puerto Rico because there is a big drainof health professionals in general in the island.So less health professionals, more challenges to offer servicesto the population. And also the increasingcost of the labor in delivering healthcareto parties. Well, the Puerto Ricaneconomic model after 1960, that was a big yearbecause that was when the private healthinsurance started on small island developing. Before that, all of the responsibility wasaddressed by the government. So it was like auniversal health service where the government hasthe total responsibility of the population. And in 1960 they startedprivate health insurance and that established a dualsystem that was administered by the government and asystem of health insurance that took care of offeringservices to the population. Some happenings about thePuerto Rican health system, from 1820 to 1949 thegovernment was responsible for the care of the population. 1916 to 1919, thecommissioner was part of the governmental cabinet. I want to mention that 1898 waswhen the United Government started to administer Puerto Rico.The healthcare was in thecharge of horde policemen, medical officers of the army, totake care of the health system. The constitution that establishedthe Health Department in Puerto Rico was from 1912. So it was one of the firstdepartments uttered in Puerto Rico by the American military physicians. And it was not until 1917 that there was the firstPuerto Rican appointed as secretary of health. So “youre seeing” the development of the Health Departmentthroughout the years. So now basically thehealth system involves this. The public sectorserves nearly 55% of the population. And the private sectorattends the other 45%. We have differenthealth reforms. The first reformwas the unionization of the health systemin the island, where they nominate sevenregions with regional hospices and primary, secondaryand tertiary caution. And for those thatdon’t know about it, there was a[ inaudible] that received a concede from the Rockefeller Foundation. And that’s how the healthsystem was built in Puerto Rico, have an organizationalstructure at the beginning. So numerous beings don’t know that the RockefellerFoundation was the one that introduced the money for it.And we have a second reformwhere the administration of the hospital wentinto private handwritings. And “its not” untilthe early’ 90′ s when they make the health reform where the governmenthired American insurance to give services to themedical indigent population. From 60 hospitals that thegovernment has, they sell it, and this is the only way haveseven hospitals. And this is listed like themost social justice difficulty in Puerto Rico becausepeople that — we have a dual systemwhere people that don’t have privatemedical insurance have to go to government hospitals. They don’t have any hand-picked. Now the patient can go toany physician, to any private or authority hospice toreceive their health services. So that is a synopsisof the health system. Okay. So what sees PuertoRico different in comparison with other domains? First, it’s in the Caribbean. This is a seismic regionso we are in a big threat of having earthquakes.That is something thatwe have to deal with. You know that weare also prone to Hurricanes and you listed it. We can have tsunamis. We can have any major naturaldisaster that you can imagine. We have 78 metropolis, diverse topography and a connection withthe Latin Americans. Because numerous peoplefrom The countries of latin america came to see you Puerto Rico first beforethey come to the State. So it’s like a bridgebetween The countries of latin america and the United Position. Okay, in terms of population, in 2017 there was3. 4 million people.We think that nowthere are like 3.3. A mint of people have migrated, especially during themonths of July and December. This is the demographic ofthe people in Puerto Rico. And as you learn, the levelof poverty is 44.9%. So we are worse thanMississippi. And in terms of healthcare, Mississippi receives $5.3 billion for their Medicaid program. Puerto Rico onlyreceives $1.8 billion from the federal government. So you can see thatMississippi has a population of 600,000 parties as compared with Puerto Ricothat has 3.3 million. So that is a big problem for us. And as I mentioned before, 61% of the population is covered by the government insurance. Health professionalsare leaving the island. The challenges thatwe have after Maria — just imagine that you went tosleep on the 19 th September 2017 and you wake up on the2 0th of September of 1945. That was really what happened. No communication , no power. From 68 hospices, weonly only knew 17 simply. And people from HHS andDOD made the lead to go to the distant locates of theisland to give us information about the condition ofthe hospitals and CDT’s, core of diagnosticsand treatment.Can you imagine that? No communication. Superhighways are provided for in dusts , none knows anythingabout what happened. We don’t know anything. We were completely blind. In periods of healthcare and public organisation, “were having” large-scale threats. We demonstrated a campaignof immunization of influenza that we started in July. We stopped it after Mariaand we don’t start it until October 9th of 2017. And it was because of thehelp of the CDSI foundation, the Red Relief and other NGO’sthat helped us do vaccines. Because all of the vaccinesin the island were damaged because there was no power. By that time we don’t haveany vaccines available. Okay? So can you imaginehow difficult it was? And with all of that, weestablished the campaign.For the first time in five yearswe prevent an epidemic outbreak of influenza in PuertoRico with all of the bad things that happened. So through that injure, you are familiar with, the limited responsecapabilities “that weve got”. Lesson learned is thatwhen you have that question, you have to go back to thebasics and rearrange everything. Because you have toestablish from good-for-nothing. There was nothingto give continuity. So we went back to the basicsand started from nothing. So if not for the help ofchurches, the Department of Defense, we reallywould not have come back to what we have right now. The assignment learned wasthat in the beginning, I think that for good orbad the military training that I had helpedme to coordinate with the federalagencies with a view to responding. And I think that whenyou are in an emergency, you have to work as a team. There is no FEMA, there isno HHS, there is no CDC, there is no PuertoRican Department.There is only one health team. One state team to bring peopleto normality and to save lives. That was our missionin the beginning. And one of the problemsthat parties miss is that we firstly gotErma and between Erma and Maria there was ahurricane announced Jose. So the help that was sentfrom the United Government to Puerto Rico had beendelayed because Jose was in the Atlantic Ocean. So all of the helparrived after Maria. So that was the delay interms of their response. We have to deal ourselves withthe resources that we have for early responseat the start. With the collaborationof the CDC and HHS, they braced thesenetwork mapping kinfolks that later they’re going to giveyou a give[ inaudible ]. It’s there. They worked with usfrom the beginning in the emergency of Maria. And she’s going to explainto you more about these too. Too, the responsefrom HHS helped us to move these Puerto Ricanhealthcare equipment, establish where wecan essentially. We determine all ofthe medical building, infirmaries, CDT’s[ inaudible ]. And we make a map thatincludes the type of facility, the patient capacity, generatemeans of communication, broadband, more facilities.So they throw us a evidence of whatwe have before the emergency and that we are able to direct patientsin case of an emergency. This map is updated on a monthlybasis so we have a good clue about what is the situation. Likewise, this program, we get areadiness check 48 hours prior to a disaster. We can elevate a lot of things. They have a rapidassignment tool and a comprehensivedisaster rating tool. Likewise the implementation ofCDC’s supplementary convalescence and mitigation projects thatare already taking place. The community assessmentis very important.It was performed by the CDC and by the Mental HealthDemographic Registry. That was a big problem becausethe registry was before a manual feeding of the data. There are always going to be digitalizedimmunization programs. All of these things. Okay, and now what theCDC does to help prepare. So I are of the view that thebest thing about all of this is the teamwork. They help us to — in orderto organize the federal power of the Department of Health, looking for gifts to help us in the recruiting of the bestprofessionals that can help us in the recovery ofthe Health Department. So there is a lot of initiativetaking place at the same time. And also coordination withother federal agencies. I’m going to show you now somefeatures of the typhoon. This was photo is from theInternational Space Station before and after Maria.So you can see that it wascompletely blacked out. Most of these lightsthat you see is by generators, all of them. The illustrate speaks for them. Maria is consideredthe worst disaster in the history ofthe United Country. So now that we are inthe face of convalescence, this is the bad thing abouteverything, is that the improvement and redesign, all of theprojects for recovery in Puerto Rico, they are goingto take between 5-15 years. That’s as bad as it was. This was the public healthsector directions during 2018. All of the problemsthat we are having.We were very lucky tocount too with the NGO’s. So now Commander ElizabethUrban Barnwell is going to tell you something abouthow the C-Dart Demo wreaks. Thank you so much.[ Applause] >> Hi, so I’m Elizabeth UrbanBarnwell, the acting chief of the EnvironmentalEpidemiology Branch in HSDR. And we rendered technicalassistance to Puerto Rico Department ofHealth for the development of the comprehensivedisaster assessment and readiness tools planned. And so I’m just going toshow one big case of this and it’s the readiness checkthat was developed as part of the preparedness activities under the HHS recoveryactivities. So it is a short survey thatcan be sent out via network link to healthcare facilitiesall across the island. It are also welcome to be completedusing our app.And it exactly contains afew simple questions, some specific generalfacility information. And then the geospatialcapabilities of the app, so you can see the spot of the equipment that’scompleting the information. And then basic questionson communications, capability, sea and in currentcapabilities. And so once the informationis completed and the facilitysends the survey in, then the database is immediatelypopulated and then the dashboard which shows the critical pieces of information isimmediately inhabited as well. And you can see herethe dashboard is space. And then as soonas it’s refreshed. So the healthcarefacilities have been — the one that I justentered is showing up. And then as each of thefacilities continues to enter their information, the dashboard continuouslypopulates, and you can see thedifferences between hospitals. So the TES, the 330′ s, andthen the dialysis centers all across the island.And I’ll continue uploading as my colleague is enteringdata rapidly in the back. And so one greatpiece of this instrument is that this informationcan be integrated across different agencies, and so you can get a very quicksnapshot of critical pieces of information, both forpreparedness and response. Which will allow the Departmentof Health to prioritize and to strategize deployment of their resources bothpre- and post-disaster. And then for any of thesepin descents on the delineate, you can just click on it and itbrings up a few critical bits of information aboutthat facility. Okay.[ Applause] >> Thanks, Elizabethand both the presenters. It was certainly my statu to getto deploy alongside of these two and the many staff in thePuerto Rico Department of Health and US Virgin Islands duringthe hurricane response in 2017. And I genuinely echoMitch’s commentary. So many times peoplewould ask me about, “Well, why are things so terrible? Why is it do so longfor the recover down there? ” And my response was always, “They’ve been chronicallyunderfunded for decades.” You know, they werehard-hit by these disasters, but that’s only a smallpiece of the whole picture of why it’s taking so long. And so I genuinely appreciatedyour observations. For Dr. Rodriguez, you are familiar with, as I went to PuertoRico many times — I’ve lost track of howmany times I’ve been there.I ponder maybe six or eight. I was really impressedby the staff in Puerto Rico Departmentof Health. They actually had a heart forthe vulnerable populations on small island developing and wereimmediately strategizing about how to reach the peoplein the mountains extremely. And we were able tocome alongside them and help support you in that. But genuinely you all were theleading force-out on procreating assured that those kinfolks were reachedand that they had access to healthcare and allof the important things.And I also think aboutthe community of Louisa. Immediately you all wantedto do a CSPER there and knew that that was a low-grade SESarea outside of San Juan and we were ableto come alongside and corroborate that as well. So I was just really impressedwith you and your staff’s focus on the vulnerable populationsof your communities, and like you said, contacting outto the community leaders as well to reform our responsethroughout the time. One small-scale thing I haveinstituted here is an issues of equity.You know, CDC often has thereputation of stealing the data and extending and publishing, you know. And so I institutedimmediately that the member states or neighbourhood co-author had tobe on every show, every publicationthat we publish coming out of the hurricane. And that’s just a small part ofsomething that each of us can do for equity, to make sure that we’re not leavingthe people behind that really providedthe information and genuinely are thesource of the information that we’re able to share.I’ll make the prerogativeof requesting a few questions to the presenters and thenI’ll open it up to you all. Mitch, you spoke a lot aboutthe response piece and equity. But I was wondering if youcould talk a little bit more about recuperation and equity. And maybe Dr. Rodriguezwould like to extremely. >> So there is only twoparts to this, because there are two parts ofthe story that I’m looking at, and one of them isthe Maria response and our big part in that.And the other iswithin New York City. And you are familiar with, one thing Iwill note about response and convalescence is thatthis question of EMAC support isvery difficult in a convalescence frame. You know, we started in, wewere there for three weeks. So many parties dropped in andout of these powers. Team after squad, youknow, here’s a new face, that face is gonein three weeks. And it’s hard to makea consistent sort of recovery pattern. I often thought it wouldbe great if there was a way to have local partnershipsthat lasted a long time.Like you know, I would haveloved to make a handshake with part of any of theimpacted areas that would last for six months so that you couldreally be partners in figuring out strategies for retrieval. The equity concern in retrieval that we know more locally isrecovery is really a process of letting see, right? At the end of the day, youwant to get out of town and leave communityleaders with something that is better thanit was before. But I don’t actually knowhow to do that right now. You know, one of myconfusions federally when I got to the Virgin Islands was therewere two separate incident bidding designs setup at the same time. One for response andone for recovery. They are now going to at the same pace and I never knewwhich one to talk to.Do I talk to theresponse structure? Who flows this or the above issues? And so I really think thatthis issue of figuring out at the beginningyour equity analysis, executing against thoseframeworks and preventing everybody on track to the same vision, that’s really theimportant thing. And I reflect the part direction wedo missions is against that. Because the missions are withinsubject matter expertise silos and they’re for alimited sum of time.So everybody only caresabout their assignment. And so you lose this questionof big picture vision. So if you could have a forwardplanning cell that was set aside for that, if you are able to includelocal mentors that have gone through cataclysms, youknow, who can prevent sort of a light star ahead of you, I think that would help a lot. Because we get distractedmission to mission. >> Did you want to add anything? >> Yes. Well, we havea lot of know. I think that the mostimportant thing is collaboration. And you have to have adirector of the objectives.You know, the thing is that sometimes they bringdifferent federal agencies and everybody’s askingyou for things, giving you grantsand all of that. And sometimes theycollide the efforts. Because it’s the same struggle. And when two positivecharges collide, they fight. So good-for-nothing happens.[ Laughter] So you know what I imply, right? And it’s happening anywhere. Even in the military forces, in the local government, federal government departments. So I think that everybodywants to help, but we need somedirector that unionizes and puts the peopletogether that they know all of the federal agenciesand are trying to help — like, “Okay, FEMA, whatare you going to do? HHS, what are you going to do? CDC, okay.” So you’re going todo this, this, this and then you canbe more effective. Too I foresee another lessonwe learned during the natural disaster was thehelp of the NGO’s. The NGO’s eliminate a lot ofred videotapeing from the federal and local governmentbecause they have money, they can act immediately.They can buy things. And it was very interestingthat it was the first time that they used a nationaldisaster NGO and it makes. The first vaccine that wereceived was from the NGO’s, so we don’t have towait for the government to bring us the firstbatch of vaccine. And a great deal of helpthat we received from different other localnonprofit organizations. I think that the thing is thatwe need to have a chair of preparedness andresponse in general. That they take the leadof all of the efforts of the different agenciesinvolved in natural disasters. That is my humble opinion. >> Thanks. And one more questionfor you, Dr. Rodriguez. You know, certainly we hope that a typhoon doesn’thit for a duet times. You have time to recover. >> I would resign.[ Laughter] >> But I’m just wondering, based on what all we’ve learned from this experience andthis recovery process, how do you think reaching thevulnerable populations will be different next time? >> I believe, as Imentioned before, we have a better interactionwith community leaders.We see their local communities. We talk with the communityleaders that they are aware truly who is the person and peoplethat really are in need. If they have somemental capacity, if they have othermedical problems, we identify the population. And we know right now what arethe ways that we have to act to that society ifsomething bad happens. We know where the people are. And I think that bydefault if we want to deal with natural disasters, wehave to know the community that we are going to impact. And the only way that we can doit is by doing the assessments. Community assessmentsare very essential for preparedness and response. Because they made us knowahead how we are going to react after a disaster.I think that that is themost important lesson earned from me. >> Great. Thanks. And with that, I’ll open it upto the audience for questions. Judy, you’re first. >> Thank you so much. It’s great to seeyou talk about this. I’m struck, Mitch, by your last-place explain when you said build back better. And I are of the view that when wewere working in the response to the typhoon, we wanted that. But we felt restricted by whatwe heard was FEMA’s policy which was to buildback the same.And when you start witha vulnerable situation, how do you suggestwe overcome that? Is there something CDC can thinkabout in its preparedness work to ensure that we’rebuilding back better instead of building back the sameas per FEMA’s requirements? >> That’s a big question. You know, buildingback the same is built into the Stafford Act, right? And so there have been alot of debates about it in disaster management. I think that the strongestargument is actually something like building back the sameis building back weaker. You know, wheneveryou say we’re going to build it back the same way, the contentions that I encountered start to change minds weresomething like, “We’ve rebuilt the USVirgin Islands electrical infrastructure 17 timesover the last 40 years.” You know, when is thatnot cost effective? There are these bottom line kind of utilitarian efficiencyarguments, overhead saving things. So that’s one way. I do think that — I guesslet me say two things.I please there was a policy course that naturally took thelessons learned from a disaster and articulated them intoa policy framework. So for example, theCMS reimbursement thing which Dr. Rodriguezwent back to the really, actually deep prejudices ofterritorial repayment. It’s something that I thinkwas alleviated temporarily in the Disaster Act. But there’s still –if I understand it — a Territorial Health Actthat has sitting next on the Congressional floor foryears now, years and times, that really hasn’t beenable to get transferred. So I think if there was away for CDC to use its articulate about public health risks andsay, “You know, we can tell you that tobacco kills people.We can tell you thatheart attacks kill people. You know what elsewe can tell you? Next disaster thesepeople are going to die because of the underlyinghealthcare systems, the bad electrical systems.” I think that sort of advocacyover meter, over a lengthy reporting period, is what if you startedit now would eventually pay off from a program position. And at the end of theday, you’ve also going to change the Stafford Act which is a whole differentpolitical football. >> And I would justadd onto that that we had a hard timecommunicating with FEMA and other federal agenciesto understand their mindset about building back is aboutbuildings and organizes. >> Right. >> And we are talking aboutpublic health planneds, and so these arethe staff people who are affected themselvesand are victims of the disaster who are also still trying toreach out to the populations that they dish throughtheir programs and trying to get those programsto back up. And that was a hard — forsome reason it was difficult for folks to understand.And I think it’s partly only because the system is orientedtowards, like you said, rebuilding infrastructureand buildings. But programs areharder to conceive of. >> Shawna? >> Yeah, thank you. This question maybeinitially is for Mitch, although Dr. Rodrigueztouched on it a little bit as he was wrapping up. But this is about when youmentioned incorporating community leaders into the ICSstructure which is excellent.And we’ve seen that start to happen a littlebit more and more. You mentioned developingobjective implements and mechanisms. You also mentioned thoseimpacted people are often at their most vulnerableand devastated when environmental emergencies touches. And there’s potentiallyso many community leaders in so many sectorsand so many tones. So where do you start, and what is your process? And Dr. Rodriguez mentioned thecommunity state analysis to identify thosestakeholders earlier. But actually in the structureand in your response schemes, is it multiple communications? Is it person or persons? I convey, what doesthat sort of look like and how do you establish whoyour community leaders are? >> I think that thebest partners that we have are the NGO’s. The NGO’s have been doingsuperb work in the communities. So we are using theNGO’s as liaisons between the PuertoRico Health Department and the community leaders.So we visit their countries together. We make efforts, we make alsohealth outreach to the region. Now we are going to sign anMOU with the Army Reserve in Puerto Rico and alsowith the Air force, that they will give outreach. They’re going to makeoutreach to those communities and we are going to be involvedwith them, so they’re going to fixing thingsthere, emptying streets. And at the same time we aregoing to give medical services. We are going to interviewthe communities. And we are going to make like asurveillance — so like a CSPR. But with the help of theCDC, Health Department and other NGO’s andfederal agencies.The most important thing isI think that the secretary of health in a territory like Puerto Ricocannot be a secretary of health while beingin their power. They have to be incontact with their people because it’s the only way that you know thenecessity, you are familiar with. I think that always thegovernment officials have to live and sufferwith the people. They cannot be in office andnot knowing what is going on. And I are of the view that in mypreparation from where I come from cured me a little bitmore in order to understand how to approach those problems. So I hope that bythe end of my tenure, we can have a good analysis ofthe communities in Puerto Rico and for the next emergency weknow how to react and respond in the area of Puerto Rico. At the moment, the most vulnerable area in Puerto Rico isthe mountain region.It was the one thatsuffered direct hit, gale up to 240 miles per hour. So you can imaginethe devastation. You find the pictures there. So I think that weidentified the vulnerable. We sharpens there with the NGO’s. The NGO’s, once again, the NGO’sare the nonprofit organizations, are partners of the Departmentof Health in that interval. So I think that thatis the way we have to address the situation. >> And let me justadd a couple — in terms of the mechanicsof how we make love, we have what we call EPEC which is the EmergencyPartner Engagement Council. And you are familiar with, there aresectors that were funded to reach the behavioralhealth sector, the social services sectoracross the 11 sectors. And then we had neighborhoods. We’re a town of vicinities. So what we do is we have amatrix approach where we say, “Who works in each sectors? Who are the NGO’s andthe partners we have in these sectors? And then who are the communityleaders in the neighborhood? ” And then for an impact, wekind of employed those together and “theyre saying”, what sectors areimpacted in which neighborhoods? And that begins thesort of formal partners.Now the ruse thoughis the real art. And we haven’t masteredthis yet. You have to be able to gointo your community and listen for the emergent captain. You know, who hasemerged in this disaster that is a valid spokesperson? And then you haveto not be afraid about letting theminside your tent. And that area isreally obliging beings — it’s awkward because thatmeans they’re going to come in from an advocacy perspectiveand they’re going to want to speak truth to ability to the system while it’strying to get it enterprise done. And that graduals youdown a couple of ticks.My experience is youhave to be really good at the listeningand the gather. If you start that relationshipearly, in a very short period of time, you’re going to havea very productive partnership. But you do have to havesenior leaders who are willing to sit there and justtake heat for half an hour and take it frankly and listen. And that’s hard to do. But if you have senior leadersthat will make that hot, then it’s much easier to buildthose partnerships during the disaster period. >> I think we have timefor just one more question. Thanks. >> It’s actuallymore of specific comments. Thanks for both introductions. I just wanted to say thatin listening to Mitch talk about the experiences inNew York, it brought to mind for me some of my ownexperiences now at CDC, both helping during the Zikaresponse as well as serving as an evaluator fora recent practise. Where I think that wemissed opportunities to take full advantage of thediversity that we have here at relevant agencies in the taskforce where I was serving as an evaluator thatI won’t name.Where I observed thatthat had some real impacts on how the kinfolks in theroom were reacting. And I think that ifwe had more diversity and could include more tones, it would have made adifference during that response. And I had real concerns thatif that was an actual event, what that they are able to mean forthose vulnerable populations that were being discussed inthe room while I was watching. So I certainly appreciatethose remarks. As well as the commentabout some of your staff of color feelingalienated and is of the view that their enunciates are not beingheard when they are in the room. And I think that’s something forCDC to think really hard about and see how we can make sure that we are both representingall of the populations that we serve as well asgiving some of the staff of color an opportunity toget some of these experiences. That I anticipate will help us aswe go forward as kinfolks retire and it is essential to bringnew kinfolks in. So I genuinely appreciatehearing that. >> Craig, did youwant to come back up? Oh, is there a questionfrom IPTV? No .>> Thank you. Very, very informativepresentations and very good Q and A session. Okay, our ten-minute break hasturned into a one-minute break. Just kidding. Let’s take a very shortfive-minute break. We’re just a fewminutes behind schedule, and we’ll come backand get started. Thank you .[ Applause ].
