The challenges of responding to the H1N1 influenza pandemic underscore the value of strong preparedness partnerships. On the Mille Lacs Band of Ojibwe reservation in East Central Minnesota, nine years of meetings and planning significantly improved preparedness for and response to the pandemic.
Monte Fronk, the Mille Lacs Emergency Management Coordinator with the Department of Public Safety, attributes the band's response to the strength of the band's Tribal Emergency Response Committee (TERC).
Created in 2000, the TERC brings together 25 people with key roles in the 4,000-plus member band. TERC members include tribal commissioners, as well as leaders within tribal health, public safety, health and human services, and communications. From its inception, the TERC members took their response duties very seriously, Fronk said, urging him and the public health director to collaborate with their local, regional, and state emergency response counterparts and communicating often.
The intervening years were marked by many meetings and conference calls, even trainings and tabletop exercises. "We were preparing. We had care sites planned and how to do vaccination sites," he said.
Having the leadership infrastructure in place for response allowed the band to adjust to quickly changing scenarios. Take the initial H1N1 vaccine allocation, for example. Prior to the pandemic, the TERC had identified maintaining community operations as a top priority and developed a plan to allocate 100 doses of an influenza vaccine for that purpose. Those priorities had been discussed at community meetings and written as an action plan.
When the H1N1 vaccine became available, the TERC anticipated receiving 100 doses. Then that figure was dropped to 70, Fronk said.
"We got the TERC together to decide which 70 people should receive it. We decided based on who would be the minimum level of employees to maintain government operations and the reservation clinic," he said.
The vaccine did not arrive as expected. Instead, planners got a call from a satellite health clinic on the reservation. Instead of 70 doses in the central community, 1,500 doses had arrived at the satellite clinic, Fronk said.
"We were ready to do minimal amounts, and had our public information officers (PIOs) ready to give out information about why we dedicated it to government operations," Fronk said. "Then we got this huge amount."
"We had an incident command meeting, and sent people to retrieve the vaccine," he said. Some was distributed in the two satellite health clinics for employees and some tribal members. The remaining doses of the vaccine were brought to Vineland, where most of the band's administrative offices are located. Within two days, all of the initial group members identified to receive doses had been vaccinated, and a number of additional key staff had been offered vaccine.
From that point, the band followed state guidelines for vaccine priority groups. For instance, diabetes is highly prevalent among band members, Fronk said, so routine diabetes clinics on the reservation included a lot of education about vaccination, preventing influenza and caring for people who developed it. The band also reached out to planning partners in a local county and shared vaccine.
Uptake among tribal members was initially strong. In addition to hearing from members on the reservation, tribal members living in the Twin Cities were calling the reservation clinic about obtaining vaccine, Fronk noted.
"The commissioner decided to bring vaccine down to the (Minneapolis) clinic, and we had two clinics," he said.
"I think our TERC is really a model. They took this seriously and prepared very well for this. We were constantly sending information to the commissioners. Elected officials were getting phone calls from the community and we were able to answer questions," he said.
The response to date has offered a number of valuable lessons, Fronk said, including:
*Strong public information programs will make or break any tribal government. Keeping officials and community members informed on a timely basis is crucial. On tribal lands the moccasin telegraph can be so fast, and then rumors are spreading that are harder to dispel. For us, communication has worked well. We knew who to contact.
*Tribal members wanted to talk with the local clinic even though there was a statewide flu information line.
Despite the TERC's accomplishments to date, Fronk anticipates additional challenges, including:
*Quarantine practices. "We're still working to create our own tribal quarantine statute because state quarantine laws don't apply to tribes, due to tribal sovereignty," he said. A draft is under review.
*Mass casualties. "What we are trained and taught to do in the state (emergency response) system won't apply to tribal governments because of our cultural beliefs about how to have funerals," he said. "Very few tribal members can conduct traditional ceremonies for when a person passes. We have less than 5. A traditional wake and funeral is almost a four-day process. If you have less than a handful of folks who can conduct a funeral and a lot of casualties for any reason-house fire, car fire, influenza-and everybody is bringing tobacco to the traditional person for funerals, how do you prioritize which ones you do?"
"Normally when a person passes, the family would approach a spiritual person with tobacco and ask them to conduct a traditional funeral for a loved one. That person would be given information on what the family would need to bring to prepare the body for the journey into the spirit world. The state says if you have a mass casualty, you get a refrigerator truck, and that just doesn't work here….We're still looking at how to handle that."
Fronk noted that the TERC processes and activities have become second nature to many members. "It has become very ingrained. We have seasoned TERC members and commissioners who even train in the new members," he said.