Preparing Racially And Ethnically Diverse Communities For Public Health Emergencies

Preparing Racially And Ethnically Diverse Communities For Public Health Emergencies

Preparing Racially And Ethnically Diverse Communities For Public Health Emergencies

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The tragedy of Hurricane Katrina in New Orleans confirmed that effective im- plementation of public health preparedness programs and policies will require compliance from all racial and ethnic populations. This study reviews current resources and limitations and suggests future directions for integrating diverse communities into related strategies. It documents research and interventions, including promising models and practices that ad- dress preparedness for minorities. However, findings reveal a general lack of focus on diver- sity and suggest that future preparedness efforts need to fully integrate factors related to race, culture, and language into risk communication, public health training, measurement, coordination, and policy at all levels. [Health Affairs 26, no. 5 (2007): 1269-1279; 10.1377/hlthaff.26.5.1269]

THE WHITE HOUSE, CONGRESS, AND STATE and local governments havemade emergency preparedness one of their highest priorities.’ This long-term initiative will in essence require reorientation of the nation’s public health and health care infrastructure to reach, educate, and care for all citizens. The tragedy of Hurricane Katrina in August 2006 offers a graphic portrait of what happens when communities’ unique needs are not part of preparedness planning and execution. In New Orleans, poor racial and ethnic minorities suffered dispro- portionate magnitudes of destruction, injury, disease, and death.^ Areas most dam- aged by Katrina were largely populated by low-income African Americans, many living in substandard housing and lacking access to personal transportation for evacuation.^ In addition, many African Americans did not flee ahead of the storm primarily because of communication barriers, including limited or no evacuation orders, inconsistent orders, or orders they could not understand and follow.” In the

Dennis Andrulis (dpa28@drexeledu) is director and associate dean for research at the Center for Health Equality, School ofPuhlic Health, at Drexel University in Philadelphia. ‘Nadiajaheen Siddiqui is a health policy analyst there. Jenna Gantner is a research assistant.

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aftermath, cultural differences and lack of financial resources have largely hin- dered effective recovery for these communities.^ Latinos and Asian Americans faced similar barriers during Hurricane Katrina, compounded by issues of lan- guage, culture, and their status as undocumented or uninsured residents.*

Beyond Katrina, studies on racial/ethnic minorities and public health emergen- cies consistently illustrate that minority communities are more vulnerable than others across the range of events before and after a disaster/ Reasons are as varied and complex as they are important; they include socioeconomic differences, cul- ture and language barriers, lower perceived personal risk from emergencies, dis- trust of warning messengers, lack of preparation and protective action, and reli- ance on informal sources of information.^

Effective implementation of public health preparedness programs and policies will require compliance from all residents, including diverse populations. Pre- paredness strategies will need to recognize factors related to culture, language, literacy, and trust that are likely to play a major role in achieving their objectives. To date, however, few concerted efforts have assessed the extent to which public health preparedness research, programs, and policies address these factors as inte- gral components of preparedness.

The purpose of this study is to determine to what extent racial/ethnic minori- ties have been considered in pubhc health emergency preparedness and to identify leading research; promising efforts; and resources for training, education, and ini- tiative development. Emergency preparedness in our study refers to a commu- nity’s readiness to react constructively to natural as well as human-made threats, to minimize harm to public health.’

Study Data And Methods We identified and conducted a review of research. Web sites, and other re-

sources and reports published by government agencies, academic institutions, and private-sector organizations, including community-based programs. Our goals were to identify research and interventions that address public health emer- gency preparedness for racially/ethnically diverse communities and to explore to what extent current interventions and initiatives consider these communities’ distinct needs.

We identified peer-reviewed literature through a search of the PubMed data- base for 1977-2007 using the following key terms: race, ethnicity, vulnerable, at- risk, special needs, minority, immigrant, language, culture, public health, disaster, emergency, and preparedness. We also searched major government, private-sector organization, academic, and foundation Web sites for relevant reports and publi- cations. We included in our review only those publications and peer-reviewed studies that explicitly addressed racial/ethnic minorities in the context of emer- gencies, disasters, and public health preparedness.

We conducted a search of Web sites during January-May 2007 using our key

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terms to identify initiatives on preparedness and minority populations. Criteria for including Web sites were that they originate from the aforementioned pubhc and private sources and that they offer at least generic information on emergency preparedness; 301 Web sites met these inclusion criteria for further analysis. We then categorized each site by whether preparedness for racial/ethnic communities was the primary area of focus, acknowledged or briefly discussed, or not men- tioned and whether translated preparedness materials were available.

Study Findings Our review identified a large and rapidly growing number of reports and peer-

reviewed publications on emergency preparedness. However, we found a general paucity of information focusing specifically on racial/ethnic minorities. Of studies that did examine racial/ethnic differences in the context of emergencies, the ma- jority were pubhshed before the early 1990s; since then, and until Hurricane Ka- trina, few research studies addressed this priority. Studies and reports identifying specific and strategic interventions or best practices for addressing the needs of this vulnerable group in public health emergencies are also uncommon. However, related initiatives and actions are beginning to emerge.

Of the Web sites we identified that provide information on emergency pre- paredness, 149 (49.5 percent) make no mention of racial/ethnic minorities; 114 (37.9 percent) acknowledge the importance of preparedness as it concerns these populations; and 38 (12.6 percent) provide information, materials, or pubhcations that focus wholly or largely on preparing diverse communities. Erom these sources and our literature review, general themes and initiative areas emerged: emergency risk communication; training and education; resource guides for planners and re- sponders; measurement and evaluation; and policy and program initiatives.

• Emergency risk communication. Emergency risk communication is “the at- tempt by science or pubhc health professionals to provide information that allows an individual, stakeholders, or an entire community to make the best possible deci- sions about their well-being.”‘” Effective emergency risk communication requires the appropriate selection of messages, messengers, and methods of delivery to dis- seminate information to audiences from before an event to after it occurs.

Our review revealed that a growing number of government and private organi- zations are disseminating preparedness and response information to minority populations, particularly through translated resources. In fact, we found that of all Web sites included in our study, about one in three provide foreign-language ma- terials. Among these are federal agencies such as the Eederal Emergency Manage- ment Agency (EEMA) and the Centers for Disease Control and Prevention (CDC), national nonprofits such as the American Red Cross, and state and local emer- gency management agencies.

With general direction from national and state efforts, as well as local priori- ties, community-based organizations have also expanded their programs to reach

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minorities in disasters. These and other initiatives have focused on building part- nerships within the community to provide essential resources and information to prepare diverse residents, as well as tools and expertise to build the cultural and linguistic capacities of community volunteers and responders. For example, the Emergency Community Health Outreach (ECHO) network in Minnesota has es- tablished a unique partnership with a public television station to regularly broad- cast short programs presented by representatives from ethnic refugee and immi- grant groups in the state, in multiple languages and on topics including personal and government roles in disasters; family preparedness plans; pandemic flu; isola- tion and quarantine; severe weather; and crisis counseling.”

Although translated resources offer a promising approach to communicating with immigrant and minority populations with limited English proficiency, stud- ies caution that mere translation of English-language materials does not ensure that pubhc health messages will be clear and easily understood.’^ In particular, English words and concepts in American culture might not be directly translat- able to other languages.’^ We found in our review that the vast majority of major public health and safety organizations—federal agencies in particular—tend to provide literal translations of English-language materials, with variable consider- ation of accuracy and cultural acceptability. Eurthermore, our findings suggest that few current initiatives address the needs of English-speaking racial/ethnic groups requiring attention to culture, literacy, and trust. Although many studies suggest engaging faith-based organizations, developing community partnerships, and using other trusted venues to reach these populations, we found a paucity of such initiatives.”’ Einally, we found that most resources and materials targeting minorities are disseminated primarily through the Internet. Unfortunately, many racial/ethnic groups might not benefit from these resources because of limited ability to access the Internet and limited skills to navigate complex Web-based systems predominantly in English.’̂

• Training and education. Our review revealed an abundance of training and education programs, resources, and curriculum on pubhc health emergency pre- paredness, with many addressing broadly the importance of meeting the needs of vulnerable populations. Moreover, since Hurricane Katrina, a growing number of these modules incorporate specific topics related to race, ethnicity, and culture. In particular, the academic Centers for Public Health Preparedness (CPHP), estab- lished by the CDC, provides courses, workshops, seminars, and training on minority preparedness, targeting a broad range of audiences. Recently offered programs have addressed such topics as cultural competence, language-specific risk communica- tion, preparedness for Hispanic communities, and crisis communication for Native Americans.’̂ Although promising, many of these efforts have been short-term offer- ings at the basic or introductory level.”’

To address these shortcomings and add dimension and population-specific rel- evance to training programs, certain community-based organizations are offering

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culture-specific, practical programs. Eor example. Collaborating Agencies on Re- sponding to Disasters (CARD), a California-based organization, works with neighborhood and community organizations to build their capacity to respond to the needs of their racial/ethnic populations in emergencies by supporting the de- velopment and implementation of individually tailored emergency plans; provid- ing user-friendly and easily understood training on federal, state, and local response structures; and providing tabletop and practical exercises that incorpo- rate issues around culture and language.’̂ Similarly, in San Erancisco, the NICOS Chinese Health Coalition established a Chinatown Disaster Response Program to train community volunteers in leadership roles and to empower residents to pre- pare for independent survival.’̂ Specifically, each year the coalition coordinates a large-scale disaster drill in Chinatown to train volunteers on response and recov- ery in coordination with government and other agencies.

• Resource guides. Resource guides are intended to provide guiding principles, recommendations, and resources to assist development, planning, and dehvery of ef- fective emergency warning, response, and recovery activities.^” Although many are available on emergency planning broadly, few focus on minority populations. Excep- tions include two resources issued by federal health and human services agencies. The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a guide to help states and communities “plan, design and implement cul- turally competent disaster mental health services for survivors of emergencies.” ‘̂ Similarly, the CDC has developed a workbook providing guidance to state, local, and tribal planners to define, locate, and reach special populations, including racial/ ethnic minorities, in disasters.̂ ^

Some states, such as Texas, Michigan, and Idaho, have begun to provide pub- lished guidance and direction on effective emergency risk communication, includ- ing conducting community health assessments to elicit major racial/ethnic groups, major languages spoken, preferred messengers, and barriers to prepared- ness within communities.̂ ^ Although these federal and state sources offer direc- tions for planning and responding to racial/ethnic groups affected by mass emer- gency events, questions of coordination, responsibility, and accountability remain largely unanswered.

• iVIeasurement and evaiuation. Current literature reveals a general lack of discussion on standard metrics to measure and evaluate programs addressing needs of minorities in the context of disaster preparedness.̂ “* Our review of Web sites simi- larly reveals that metrics do exist to assess preparedness more broadly, but there is a lack of widely accepted evidence-based measures and performance indicators for as- sessing progress and level of preparedness of racial/ethnic communities. Eor exam- ple, the CDC has developed voluntary assessment inventories for local and state public health agencies to evaluate their capacity to respond to public health threats.̂ ^ Embedded within these inventories are broad questions to evaluate capac- ity to respond to minority populations with limited English proficiency and capac-

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ity to provide translated materials on preparedness and response. However, these measures and other similar metrics generally do not capture the capacity to address other major factors, such as culture, literacy, and trust.

Nonetheless, we found that in the immediate aftermath of Katrina, some state and local initiatives conducted rapid needs assessments of evacuees, by race/eth- nicity, to identify and meet the unique needs of diverse populations.-̂ ® Eor exam- ple, the Tri-County Health Department in Colorado conducted a needs assess- ment among a sample of evacuee households during their first week of arrival to metropolitan Denver.’̂ ” The assessment revealed that the ethnic makeup of evacu- ees (55 percent black) was very different from that of Colorado’s population (3.8 percent black). This important finding offered strong justification for the involve- ment of black church groups and community leaders in evacuee-service efforts to ensure cultural appropriateness. The Oklahoma State Department of Health con- ducted a similar needs assessment of evacuees to Oklahoma.̂ ^ Its findings sug- gested the need to provide active outreach to a predominantly minority evacuee population with substantial pre-existing mental conditions.

• Poiicy and program initiatives. Pohcies and widely accepted best practices on integrating and engaging minorities in preparedness plans have historically been lacking.^’ More recently, several agencies and organizations at the national, state, and local levels have started to support efforts, and in some cases taken the lead, in promoting related programs and initiatives.

Federal level. Eederal agencies are funding and stimulating initiatives for engag- ing racial/ethnic communities in preparedness activities.^” Eor example, the Office of Minority Health (OMH) of the U.S. Department of Health and Human Services (HHS) recently provided funding to train emergency managers and responders to provide culturally and linguistically appropriate services (CLAS) to Latino popu- lations in disasters.^’ Similarly, recent collaborations with the National Institutes of Health’s Centers of Excellence in Partnerships for Community Outreach, Research on Health Disparities, and Training (Project EXPORT) have emerged to build a cadre of academic health centers that can serve as screening, surveillance, commu- nication, and response resources for areas with large minority populations.̂ -̂

State and local activity. State and local support for programs addressing minority preparedness has also gained momentum, particularly in the aftermath of 9/11 and Hurricane Katrina. Eor example, some state and local health departments are con- ducting surveys, interviews, and focus groups with their racial/ethnic communi- ties to identify barriers to communication, preferred content areas on prepared- ness, preferred channels of communication, and opportunities for collaboration. Others have developed surveys to collect and monitor data on the capacity of pub- lic health agencies and health clinics to respond to these communities.”

Private organizations. Increased program initiatives have also emerged among pri- vate organizations. The Henry J. Kaiser Eamily Eoundation, for example, has sup- ported an evaluation study of Hurricane Katrina, which addresses warning infor-

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mation and evacuation behavior by race/ethnicity.^” Similarly, the California Endowment has provided support for programs focused on bioterrorism pre- paredness and outreach to vulnerable populations, including those located in bor- der regions.’^

Directions For The Future Our study was intended to provide a review and synthesis of information as

well as a status report on current research and interventions for integrating ra- cial/ethnic communities into emergency preparedness planning and execution. However, because the field is dynamic, projects in progress and emerging studies or initiatives are likely not captured here. In particular, state, local, and communi- ty efforts that are rapidly evolving—for example, the growing involvement of ra- cial/ethnic community leaders in communication planning for pandemic flu plans since Hurricane Katrina—are likely to add content and experience to the field.̂ ^

Nonetheless, results from our review covering three decades reveal gaps in planning as well as promising programs or critical resources that offer directions for future research, initiatives, and policy development. We identified five areas of focus for integrating diverse communities into emergency preparedness. Two as- sumptions underlie this focus: First, to be effective in reaching these populations, programs and policies will require adaptation not just at the community level but also at state and national levels; and second, the needs of diverse populations must be integrated not only with more self-evident areas, such as risk communication and community engagement, but also with many other preparedness priority ar- eas within public health such as surge capacity, quarantine, and isolation.

• Emergency risk communication strategies. Conclusions from our review reinforced the belief that informing diverse communities will require agencies and providers to tailor pubhc health messages, use trusted messengers, and use channels likely to result in populations that are knowledgeable and woUing to undertake and adhere to recommendations.̂ ^ To achieve this objective will require not only transla- tion of related materials but also adaptation to ensure their accuracy and acceptabil- ity. Simply translating materials might not suffice if language is offensive, unaccept- able, or perceived differently by people of different race/ethnicity. Expanded use of audio/video tools, printed materials with pictograms (especially for people with low hteracy), interpreters, and other channels of communication might need to be part of this repertoire.

Einally, who delivers the message and where that message is delivered are criti- cal to its acceptability and comprehension among diverse residents. Eor example, a federal government official might not be the best source for communicating on preparedness before immigrants or among African Americans familiar with the legacies of Tuskegee and especially with Hurricane Katrina. Alternatively, trusted sources in or familiar with these communities might be much more likely than other sources to have preparedness communications received, understood, and ac-

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cepted. This includes both individuals and channels such as media controlled by racial/ethnic groups, faith-based organizations, community leaders, and commu- nity-based outreach workers.̂ ^ To that end, community engagement is essential for fully integrating diverse populations into programs that traverse the spectrum of preparedness requirements. Resources such as the American Medical Associa- tion’s report on the dimensions of communication in health care as they affect vul- nerable populations may have considerable relevance and applicability for emer- gency risk communication as well.^’

• Pubilc iieaith training content. People charged v̂ dth carrying out public health preparedness planning and implementation participate in a variety of train- ing activities. Identified government- and community-based programs offer some direction for involving diverse communities. These and other programs should ex- pand or adapt their protocols to include general as well as strategic practical educa- tion, tailored to the needs of training participants. Eor example, tabletop exercises for the American Red Cross or emergency responders should be constructed to present how an event would unfold in a neighborhood composed primarily of Span- ish-speaking residents, or where there may be a mix of minority and white residents. Training programs also should consider adding specific content to incorporate unique circumstances of their diverse communities. Eor example, overcoming dis- trust may be of paramount importance, if not a first step, in immigrant or other com- munities with prior negative experiences with government programs.”” Similarly, assuring availabihty of interpreters or language lines is likely critical for those wdth limited Enghsh proficiency. In addition, lessons learned from diversity and health as in the issuance of National Standards of Practice for Interpreters in Health Care may offer guidance in assuring adequacy of interpretation in emergencies.’” These and other racially and culturally relevant content should be considered in the context of core preparedness functions and, unlike most current programs, should occur more than one time and beyond introductory levels.

• Coordinating federal, state, and iocai resources, roles, and responsibiii- ties. The documented lack of information and guidance on coordinating responsive- ness and responsibilities is a major barrier to implementing effective preparedness programs for diverse communities. Given the complexity of population need in the context of emergencies, coordination at all levels of preparedness will need to occur. Agencies and groups representing diverse constituents at the local level, for exam- ple, can facilitate critical linkages between service sectors such as health care pro- viders, public health, and housing or emergency rehef. Guidance from representative organizations can help states and federal agencies in formulating effective strategies for reaching racially/ethnically diverse vulnerable populations. Part of this coordina- tion effort should include centralizing information, resources, and initiatives and of- fering a related e-mail information and discussion hst that can link expertise and experience with the needs of agencies and organizations charged with preparedness responsibilities.

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• Evidence-based measurement and evaluation. Efforts to assess the effec- tiveness of preparedness programs can benefit from including measures to deter- mine the presence of disparities in both processes and outcomes. For example, some locahties that have developed sociodemographic profiles of their communities can evaluate their risk communication strategies in planning for an event both generally and for specific culturally diverse communities whose Enghsh proficiency is low by asking questions around comprehension and acceptability of translated materials. Similarly, locahties can determine the differential effectiveness of their programs for subgroups by assessing adherence to evidence-based service and treatment protocols and access to care, in addition to traditional measures of morbidity and mortahty.

• National and state preparedness policies and program priorities. State and community agencies and organizations are the primary players in implementing related interventions; however, state pohcymakers and the federal government play critical roles in bringing attention to and supporting the full engagement of diverse residents. The emerging state and federal leadership offers an important opportu- nity to identify and advance critical diversity objectives. For example, for monitor- ing and measurement, discussions around racial/ethnic disparities for state and fed- eral governments have suggested that they estabhsh standards and expectations in the effectiveness of risk communication. Deviations from those standards as they af- fect varied populations can offer measures determining equality of application and effect.”̂ Federal and state governments (as well as foundations and other private- sector organizations) can direct specific support to address the major gaps in coor- dination and shortcomings in risk communication and other areas, while also test- ing and expanding the application of innovations.

Finally, there is a need to draw on the expertise and integrate the perspectives of key organizations and individuals in the fields of cultural competence and dis- parities reduction with public health preparedness. Engaged communities can share their experiences to assist related initiatives elsewhere. Bringing together these resources will help incorporate diversity more fully into emerging initiatives and policies for communities across the nation.

Initial and selected findings were presented at the ‘National Emergency Management Summit in New Orleans, Louisiana, 5 March 2007.

NOTES 1. N. Lurie, J. Wasserman, and CD. Nelson, “Public Health Preparedness: Evolution or Revolution?” Health

Affairs 25, no. 4 (2006): 935-945. 2. M. Pastor et al., In the Wake of the Storm: Environment, Disaster, and Race after Katrina (New York: Russell Sage

Foundadon, 2006); D.K. Messias and E. Lacy, “Katrina-Related Health Concerns of Latino Survivors and Evacutes,” Journal of Health Care for the Poor and Underscrved 18, no. 2 (2007): 443-464; and O. Carter-Pokras et al., “Emergency Preparedness: Knowledge and Perceptions of Latin American Immigrants,” Journal of Health Care for the Poor and Underserved 18, no. 2 (2007): 465-481

3. Pastor et al., In the Wake of the Storm; and M. Brodie et al., “Experiences of Hurricane Katrina Evacuees in Houston Shelters: Implications for Future Planning,” Americanjoumal of Public Health 96, no. 8 (2006): 1402- 1408.

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4. Ibid.; K. Elder et al., “African Americans’ Decisions Not to Evacuate New Orleans before Hurricane Ka- trina: A Qualitative Study,” American Journal of Public Health 97, no. 1 Supp. (2007): S124-St29; and PR. Spence, E.A. Lachlan, andD.R. Green, “Crisis Communication, Race, and Natural Disasters,” Journal o/Blcicfe Studies 37, no. 4 (2007): 539-554.

5. Pastor et al., In the Wake of the Storm; and Spence et al., “Crisis Communication, Race, and Natural Disasters.” 6. B. Mufliz, In the Eye of the Storm: How the Government and Private Response to Hurricane Katrina Failed Latinos, 2006,

http://v’ww.nclr.org/content/publications/detail/36812 (accessed 28 February 2007); and National Coun- cil of Asian Pacific Americans et al., “Katrina and the Asian-American Community Congressional Brief- ing,” Press Release, 29 September 2005, http://www.navasa.org/PressReleases/2005/Katrina%20 Congressional%20Briefing.doc (accessed 14 June 2007).

7. See, for example, R.W. Perry, M.K. Ondell, and M.R. Greene, “Crisis Communications: Ethnic Differentials in Interpreting and Acting on Disaster Warnings,” Social Behavior and Personality 10, no. 1 (1982): 97-104; R.W. Perry and M.R. Green, “The Role of Ethnicity in the Emergency Decision-Making Process,” Sociologi’ cal Inquiry 52, no. 4 (1982): 306-334; and A. FothergiU, E.G. Maestas and J.D. Darlington, “Race, Ethnicity, and Disasters in the United States: A Review of the Literature,” Disasters 23, no. 2 (1999): 156-173.

8. Ibid.

9. R.W. Perry and M.K. Lindell, “Preparedness for Emergency Response: Guidelines for the Emergency Plan- ning Process,” Disasters 27, no. 4 (2003): 336-350; and Texas Department of Health, Barriers to and Facilitators of Effective Risk Communication among Hard-to-Reach Populations in the Event ofa Bioterrorist Attack or Outbreak, 1 February 2004, http://www.dshs.state.Dc.us/riskcomm/documents/Research.pdf (accessed 14 June 2007).

10. Centers for Disease Control and Prevention, “Emergency and Risk Communication: Overview,” http:// www.bt.cdc.gov/erc (accessed 14 June 2007).

11. See the ECHO home page, http://www.echominnesota.org. 12. M. Leyva, I. Sharif, and P.O. Ozuah, “Health Literacy among Spanish-Speaking Latino Parents with Um-

ited English Proficiency,” Ambulatory Pediatrics 5, no. 1 (2005): 56-59; and D.P. Andrulis and C. Brach, “Inte- grating Literacy, Culture, and Language to Improve Health Care Quality for Diverse Populations,” American journal of Health Behavior 31, Supp. 1 (2007): S122-S133.

13. PA. Bolton and WM. Weiss, “Communicating across Cultures: Improving Translation to Improve Com- plex Emergency Program Effectiveness,” Prehospital and Disaster Medicine 16, no. 4 (2001): 252-256.

14. FothergiU et al., “Race, Ethnicity, and Disasters”; Mumz, In the Eye of the Storm; and Pastor et al.. In the Wake of the Storm.

15. M.S. Wingate et al., “Identifying and Protecting Vulnerable Populations in Public Health Emergencies: Addressing Gaps in Education and Training,” Public Health Reports 122, no. 3 (2007): 422-426.

16. See the CPHP Resource Center home page, http://www.asph.org/acphp/phprc.cfm. 17. Wingate et al., “Identifying and Protecting.” 18. See the CARD home page, http://vrww.FirstVictims.org. 19. See NICOS, “Chinatown Disaster Response Project,” http://www.nicoschc.com/cdrp.html (accessed 14

June 2007). 20. Although a comprehensive review of international sources was beyond our scope, reports and guides pub-

lished by Canada and Australia illustrate that critical resources are being developed on diversity and pre- paredness by other nations. See Emergency Management Australia, Guidelines for Emergency Managers Working with Culturally and Linguistically Diverse Communities, July 2002, http://www.ema.gov.au/agd/EMA/ rwpattach.nsf/viewasattachmentpersonal/AFD7467016783EA8CA256CB30036EF42/$file/CALDSept 2002.pdf (accessed 2 August 2007); and G.Y. Sohs, H.C. Hightower, and J. Kawaguchi, Guidelines on Cultural DiversityandDisasterMflnagement, Final Report, December 1997, http://dsp-psd.pwgsc.gc.ca/Collection/D82- 45-1997E.pdf (accessed 18 June 2007). An example of a U.S. guide is CDC, “Pubhc Health Workbook to Define, Locate, and Reach Special, Vulnerable, and At-Risk Populations in an Emergency (Draft),” 16 Feb- ruary 2007, http://www.bt.cdc.gov/workbook (accessed 14 June 2007).

21. J. Athey and J. Moody-WiUiams, Developing Cultural Competence in Disaster Mental Health Programs: GuidingPrin- ciples and Recommendations, March 2004, http://mentalhealth.samhsa.gov/pubhcations/allpubs/SMA03- 3828/default.asp (accessed 14 June 2007).

22. CDC, “Public Health Workbook.”

23. Office of Pubhc Health Preparedness, Michigan Crisis and Emergency Risk Communication: A Guide for Developing Crisis Communication Plans, October 2003, http://www.michigan.gov/documents/Michigan_Crisis_

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Emergency_and_Risk Communication3_82364 7doc (accessed 14 June 2007); and Texas DOH, Barriers to and Facilitators of Effective Risk Communication.

24. Wingate et al., “Identifying and Protecting.”

25. CDC, State Public Health Preparedness and Response Capacity Inventory: A Voluntary Rapid Self-Assessment, Version 1.1, December 2002, http://www.astho.org/pubs/inventorystate.pdf (accessed 14 June 2007); and CDC, Local Public Health Preparedness and Response Capacity Inventory: A Voluntary Rapid Self-Assessment, Version 1.1, December 2002, http://www.astho.org/pubs/inventorylocal.pdf (accessed 14 June 2007).

26. T.S. Ghosh, J.L. Patnaik, and R.L. Vogt, “Rapid Needs Assessment among Hurricane Katrina Evacuees in Metro-Denver,” Journal of Health Carefor thePoorand Underserved 18, no. 2 (2007): 362-368; D.M. Krol et al., “A Mobile Medical Care Approach Targeting Underserved Populations in Post-Hurricane Katrina Missis- sippi,” journal of Health Carefor the Poor and Underserved 18, no. 2 (2007): 331-340; M.L. Ridenour et al., “Dis- placement of the Underserved: Medical Needs of Hurricane Katrina Evacuees in West Virginia,” journal of Health Carefor the Poor and Underserved 18, no. 2 (2007): 369-381; S.R. Rodriguez et al., “Rapid Needs Assess- ment of Hurricane Katrina Evacuees—Oklahoma, September 2005,” Prehospital and Disaster Medieine 21, no. 6 (2006): 390-395; and Brodie et al., “Experiences of Hurricane Katrina Evacuees.”

27. Ghosh et al., “Rapid Needs Assessment.” 28. Rodrigues et al., “Rapid Needs Assessment.” 29. Wingate et al., “Identifying and Protecting.”

30. See, for example, CDC, “FY 2005 Collaboration Groups,” 3 November 2006, http://www.bt.cdc.gov/ train- ing/cphp/2005_06_Collaboration Groups/Preparedness_Education_for_Special Populations.asp (ac- cessed 28 June 2007); and Department of Health and Senior Services, “Emergency Preparedness Tool Kit for Special Needs Population Resources for Cultural Literacy and Planning,” 15 February 2006, http:// www.dhss.mo.gov/SpecialNeedsToolkit/Pages/Contents.htm (accessed 2 August 2007).

31. See Office of Minority Health, “HHS’ Office of Minority Health Announces $3 MiUion in Emergency Plan- ning Grants Focused on Minority Populations,” Press Release, 22 January 2007, http://www.omhrc.gov/ templates/content.aspx?ID=4851 (accessed 14 June 2007).

32. D. Mack, K.M. Brandey, and K.G. BeO, “Mitigating the Health Effects of Disasters for Medically Under- served Populations: Electronic Health Records, Telemedicine, Research, Screening, and Surveillance,” Jour- nal of Health Carefor the Poor and Underscrved 18, no. 2 (2007): 432-442.

33. See, for example, Nevada State Health Division, Department of Human Resources, “Community and Tribal Health Clinic Emergency Response Preparedness in Nevada: 2004 Report,” http://health2k.state.nv.us/ php/pdf/HealthClinicAssessment.pdf (accessed 30 January 2007).

34. See, for example, Brodie et al., “Experiences of Hurricane Katrina Evacuees.” 35. See, for example. National Latino Research Center, The Border That Divides and Unites: Addressing Border Health

in California, October 2004, http://www.calendow.org/reference/publicarions/pdf/disparities/TCE1001- 2004_The_Border_Tha.pdf (accessed 27 February 2007).

36. Pandemicflu.gov, “State and Local Government Planning and Response Acdviries,” 24 May 2007, http:// www.pandemicnu.gov/plan/states/index.htmMstateinfo (accessed 7 June 2007).

37. Pastor et al.. In the Wake oftheStorm; Perry et al., “Crisis Communicarions”; Perry and Nelson, “Ethnicity and Hazard Informarion Disseminarion”; Perry and Green, “The Role of Ethnicity”; and FothergiU et al., “Race, Ethnicity, and Disasters.”

38. Texas DOH, Barriers to and Facilitators of Effective Risk Communication; FothergiU et al., “Race, Ethnicity, and Di- sasters”; Pastor et al.. In the Wake of the Storm; and Mufiiz, In the Eye of the Storm.

39. American Medical Association, An Ethical Force Program Consensus Report: Improving Communication—Improving Care, 2006, http://www.ama-assn.org/ama/pub/categoryA6245.html (accessed 14 June 2007).

40. Mufliz, In the Eye of the Storm.

41. National Council on Interpreting in Health Care, “A National Code of Ethics for Interpreters in Health Care,” July 2004, http://www.ncihc.org/NCIHC PDF/NadonalCodeofFthicsforlnterpretersinHealthCare .pdf (accessed 14 June 2007).

42. D. Stone, “Reframing the Racial Dispariries Issue for State Governments,” journal of Health Politics, Policy and Law 31, no. 1 (2006): 127-152.

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