Addressing the Needs of People with Disabilities in Public Health Emergencies - Transcript

Moderator: Haley McCalla
Presenters: Cynthia Hinton, PhD, MS, MPH, Health Scientist
Date/Time: November 28, 2018, 2:00 – 3:00 pm ET

>> Hello, everyone.
We will officially begin at 1:03.
Thank you.
Good afternoon, everyone.
My name is Haley McCalla from the Center for Preparedness and Response, Division of Emergency Operations.
Thank you for joining us for today’s EPIC webinar titled “Addressing the Needs of People with Disabilities in Public Health Emergencies.”
Today we will hear from CDC’s Cindy Hinton.
This presentation will be series of questions and answers with my colleague, Jonathan Lynch asking Cindy questions a bout the topic.
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We are fortunate to have Dr. Cindy Hinton as our speaker today.
She is a health scientist in the Disability and Health Branch in the Division of Human Development and Disability at CDC. She has worked in this branch for three years, focusing on topics such as disability inclusion in emergency preparedness. She also oversaw the development of CDC’s online Emergency Preparedness Catalog for People with Disabilities. Additionally, Cindy has experience leading CDC’s At-Risk Task Force, particularly for natural disasters like hurricanes.
Thank you so much for joining us today, Cindy, I will get your PowerPoint on the screen and then we will begin.
Jonathan, are you ready for the first question?

>> I am, thank you everyone.
Thank you, Cindy.
Our first question that we came up with is to help us understand what is a disability and what kind of legislation addresses disability issues?

>> Next slide.
This is just a great place to start.
Disability, it’s a pretty broad topic and it’s an umbrella term that we use that covers impairments, activity limitations and participation restrictions.
So, if you think of an impairment it would be a problem or a part of your body that’s not working the way it would be intended.
Hands are meant to grasp and they can’t.
Ears are meant to hear but for some reason it’s not working the way it should.
So that would be an impairment.
Now this would be an activity limitation if you had difficulty executing activities of daily living.
You have a hard time getting ready for the day, making breakfast, cleaning yourself or other activities.
And then participation restriction is one that really will impact your ability to work, out and engaging social or recreational activities or obtain health care, prevent sieve services, go to school.
Now for public health surveillance, we use disability categorized by level of difficulty with six functions.
That is mobility, vision, hearing, cognition, self-care and independent living.
Next slide.
This is atable that represents recent data that CDC has put together, this is disability status among U.S. adults here.
And what you can see here is that people who self reported any disability, so this could be one or more, is about 5% of the adult population, that is one in four adults reporting any type of disability.
And the mobility limitations are the highest, it’s close to about 13% of the population reports mobility limitations and close to 11% self report cognitive disability.
Next slide.
And I also wanted to show distribution of disability across the United States.
So we can see that overall in the United States it’s 25% of the population has a disability but that’s not uniformally distributed.
You can see that there are some areas, some states that have a higher population of people with disability.
Some as much as almost 40% of the population and some that are lower, 18, 19%.
So this is just important to keep in mind because when you’re working within your own state and your own community it just really drives home the idea that you need to know the population that existing in your own state.
Next slide.
What is the impact this has especially when we think about emergency response, emergency preparedness.
If you’re thinking about response this is going to impact the way people communicate, whether they are able to evacuate they are able to understand.
So with mobility impairments, can a person leave home, can they evacuate and get to the shelter and function in a shelter.
If someone is deaf or hard of hearing will they be able to hear emergency communications or instructions?
If someone is blind or has low vision, seeing communications that might be released, seeing signs, knowing where to get to transportation.
And for people that have intellectual and cognitive disabilities and mental health and even post traumatic stress disorder, they’re going to have some difficulty understanding the situation, following instructions.
So, understanding how people with disability may interact in this environment of an emergency response is very important to know.
Next slide.
I want to step back a little bit in history to hurricane Katrina, now disasters have been occurring over time, people have had disabilities over time but it really was the experience of hurricane Katrina, the magnitude of the disaster that occurred during that — that highlighted for people I think in a way that hadn’t before, just the level of social disparities that existed and how that resulted in different outcomes in an emergency situation.
The national council on disability released a reported specifically on disability and hurricane Katrina, I’ve included the link at the bottom of the slide.
And they reported that in the three cities that were hit the hardest by Katrina, Biloxi, mobile and New Orleans, about 155,000 people they estimated were in pact by that.
They used estimates from census data and they estimate there were about 155e people who were impacted looking specifically at New Orleans, 73% of the hurricane Katrina related deaths were among people age 60 and over.
Although that population only comprised 15% of the population in New Orleans.
So you can start to see that this group was impacted at a much greater level than others.
More over, at least 50% of people with disabilities in New Orleans who were of working age were not employed, this is going to make recovery from disaster much more difficult.
And many were also relying on variety of programs such as supplemental security income and Medicaid to meet their daily service and support needs.
That is beginning to give us a picture of disability in a disaster situation and what is going to be the impact and what is going to affect recovery.
Next slide please.
More than just this is the right thing to do to take care of our neighbors, it’s the law.
The Americans with disability act is the law that really sets out that people with disability need to have access to aspects of life here in the United States.
As you look down this list I’ve included various executive orders, other acts, all that have been put out and some of them specifically address individuals with disability, some of them will cover transportation, petty vac could you wakes can also refer to service animals, but I want to show you is that there is a body of legislation that is commenting on and directing people to take into account the needs of people with disability.
I have added a new act down here at the bottom of the slide that I just really wanted to point out to everyone, this is the disaster recovery and reform act of 2018.
Recently signed.
Just this past fall.
This is going to really make a tremendous difference in how FEMA can help people after an emergency.
There’s usually a cap on how much money you can get back, but if people with disabilities would find themselves at a disadvantage if you are taking into account how to make your home accessible or to replace the accessible features of your home or you have lost a wheelchair, an expensive piece of durable medical equipment this will no longer count against the cap in requesting funds from FEMA.
So that addresses more to how communities recover, how a community becomes resilient.
But it’s so new I really wanted to make people aware that have.
Next slide, please.
Let’s look specifically at the Americans with Disabilities Act this is the act that comes into play when we look at emergency response, title II prohibits discrimination against people with disabilities and mandates that accommodations be provided.
Now the ADA does not specifically address emergency preparedness so you will not find anything specifically about emergency preparedness in the ADA but what you are looking at is the legislation that sets the entire framework for emergency preparedness and for accessibility.
And what we’ve seen is that emergency planning including people with disability has really started to develop through litigation against governments and schools.
Next slide please.
Recent example that have would be Hurricane Sandy or super storm sandy and the impact that it had on disabled New York City residents.
Tremendous storm and in 2012-2013 the Brooklyn center for independence of the disabled took the city to court and they filed under ADA violations that their rights had been violated.
And the court ruled in their favor and in that ruling said that New York City has violated the rights of 900,000 of its residents with disabilities failing to accommodate for their needs during emergencies.
It was cited as a violation of the Americans with disability act and some of the specific violations were, there were no evacuation plans from highrises.
There was a lack of water, heat and power.
There were inadequate shelters that could accommodate people who had disdisabilities and people with disabilities lacked information about availability and the location of emergency services.
Next slide, please.

>> Cindy, thank you, that’s remarkable.
It shows how much different localities and different organizations really do need to plan ahead.
Stow the next question we prepared for Cindy was this: How should people with disabilities or their caregivers prepare for and handle emergencies?

>> Next slide.
Thanks, Jonathan.
There are a lot of different levels in preparing for emergencies, so what we’re doing right now is we are looking at what an individual or a family or caregiver might be able to do F. you attending that webinar are involved in health education or working in your communities, there will somebody good resources here that can help you reach out to people in your community to help educate them about what they can do.
These are the questions that people think about what types of disasters might occur locally and for someone with disabilities you’re going to want to think, what are my abilities at this time and where do I need help.
What medications or equipment or other supplies will I need to stockpile and, who should I inform of my plans when I’m coming up with this.
Next slide.
And of course, you’re going to be thinking, gosh, I have a lot of things that I need to be pulling together, this is starting to seem a little overwhelming to me.
Next slide.
Next slide.
Actually click forward.
Thank you.
What I want to show you here is that there are a number of resources that are available that can help people walk through this process and begin to prepare themselves and prepare their families in the event of an emergency.
I’ve included the website for this resource, this is the online catalog that Haley mentioned in the beginning of the webinar.
Our motto, CDC, get a kit.
Make a plan.
Be informed.
And there are a number of kits online tools to help people think about just these topics, what do I need to be prepared for.
Who do I need to talk to.
What are the steps I need to go through.
I’ve just included a few of them here.
In the next slide, actually if you can just click to fill up the slide.
I have gone specifically into just some of the pages from ready now, one of the tools that I showed you before.
It outlines seven steps for personal emergency preparedness this is know the types of emergencies, assess your own abilities and where you need help.
Develop your support network, building your community, get your papers and medical information together, make your supply, get the supply kit.
And just look at things you can do to make yourself and your environment safer.
It says down there, you know, you can do it, it seems overwhelming, but as you can see just in these few examples there’s lists to help walk people through it so they don’t feel completely overwhelmed by it.
This is the website that I have been referring to, this is our emergency preparedness catalog including people with disabilities.
That is going to have information that you can go to that addresses what individuals may want to know, what caregivers might want to know and what emergency managers may want to know in thinking how to be prepared for an emergency, how to take into account the needs of people with disabilities.
Next slide.

>> Thank you.
It’s one of those situations where a little bit of work to get prepared is not that bad and could pay off hugely if the situation arises, thank you for that.

>> Exactly.

>> The next question we had prepared for you is this: What is caregiver stress and how can people minimize it?

>> Thank you, next slide.
We just talked about some of the ways that people might want to help mitigate some of their stress by being prepared.
But regardless of that, if you find yourself out of your normal routine and if you are the caregiver of someone who has a disability, you may be feeling a little stress.
Everyone reacts differently to stressful situations and soy the way one person may react to the situation may not be the same way that someone else is demonstrating the stress or experiencing the stress.
So, you may have anxiety about the situation, normal.
You may worry family members will be separated from caregivers.
If you are someone and let’s say your family member is living in another facility.
Say a group home for people with intellectual disability or you may be thinking about an older family member who may be living in assisted living, you’re concerned and worried because you are not able to be right there with your family member.
Or you may be a professional who has a person that you are actually working with and will not be able to be with them and help them attend to their daily needs.
You may be feeling guilt about not being able to perform regular caregiving activities.
Feeling lonely, isolated, sad or bored.
And worrying about the future.
You are worrying about loss of income and how are you going to take care of your family and fulfill these responsibilities that you have.
Next slide.
Just some tips for self care for caregivers.
I think this is just really good information to have outright now anyway.
We have a number of situations going on around in the United States.
But some good advice.
Stay informed from reliable sources.
There are going to be people from your state, from the local government.
From the merge enhe see management.
Those are going to be your reliable sources about where to go and what to do.
Avoid excessive media coverage.
It’s not going to help you, it’s not going to make you feel any more in control of the situation.
And can really keep that stress level going.
Keep your connection with others, with friends, with family, just find those ways to make the connection to support yourself, support others.
I’ve included two numbers here, one is for SAMHSA’s free 24 hour disaster distress help line.
For people who feel like they’re lonely or need support.
And also if people are feeling like they could hurt themselves or hurt others, I do have the number here for the national suicide prevention lifeline.
Next slide, please.
I also wanted to include the website for SAMHSA, the substance abuse mental health services administration, this website for disaster preparedness has been great resources on resilience and stress manage management.
There is the hotline number again.
They offer technical assistance to support state and local governments and they have ha behavioral health disaster response mobile app.
There are some tools there that can help the individual and can help states and local governments manage the caregiver stress.
Manage that emotional and psychological response to a disaster.
Next slide.

>> Thank you, that’s such an important part of response for people with disabilities, caregivers are also affected.
Our next question is this: What should response organizations and their employees do to be ready to help people with disabilities during emergencies?

>> Thank you.
I’ve included here just some suggestions and these are more of like the immediate response.
And I have drawn these from some materials that we have in our online catalog.
People are looking nor ways to learn more about this, you can go back to that catalog and look for resources for emergency managers.
Someone is coming into a shelter, don’t assume anything about the abilities of the person in front of you.
They may look like they have a disability and are perfectly capable of hamming themselves.
Or they may not have obvious disability and really need some help.
Look for any type of special health instructions, there may be bracelets or other information that a person has.
People with disabilities oftentimes have equipment that enable them to walk with mobility, this is a part of their person, their wheelchair, their walker, oxygen, communication devices, do not separate the person from the wheelchair.
Do not separate the person from the walker.
Also keep in mind that a person may be coming in with a service animal.
Next slide, please.
And I do want to add a special word on service animals.
I know oftentimes we hear there’s a service animal then there are support animals and there have been some examples say with airplanes that people are wondering, what’s the difference between the two.
A service animal is an animal that has been individually trained to work with and perform task for the benefit of a person with a disability.
So, a service animal has been trained to perform a specific task.
It may be pulling a wheelchair, it may be retrieving dropped items for that person, alerting a person to sound, reminding them that they need to be doing something at a certain time or pressing elevator buttons.
This is a trained working animal that has specific tasks to help their person get around in the world.
They are not pelts.
Again, you would not separate an individual from their service animals, they are allowed into the shelters, and always ask owners for permission to touch their animals — touch their service animals, don’t go petting them.
These are some things that people can keep in mind when you’re thinking about our immediate response and again to learn more about the things you might want to do to prepare yourselves or to take some training there are some courses listed in that online catalog I mentioned.
Next slide please.
Some great tools that you may want to have on hand for first responders or shelter workers.
The show me and the — that’s a laminated booklet then there are couple of apps are really great for people, whatever reason have some limited language and this can help bridge that communication gap.
Over here tips for first responders, this was developed in New Mexico at the university of New Mexico and it’s a wonderful product for people who are in a first responder situation, it just gives you really quick tips, if you encounter someone, service animals, mobility, autism, cognitive disabilities, what are some things to keep in mind when you are interacting with that person immediately.
Next slide.

>> Thank you.
The next question we prepared for you is this: What can communities do to be inclusive of people with disabilities.

>> Thank you.
Next slide.
Building partnerships, this is really where things come together.
Let’s look back to that case where the independent living brought a case against New York City and they won.
Talked about some of the things that where their rights had been violated but what the court also said is, you do not have people with disabilities involved in your processes.
They are not on your planning committees.
They are not part of your network.
They have to be part of your network.
Building partnerships is key for a resilient community.
And what I’ve included here is a photo from FEMA and it’s showing one of their regional meetings you have someone there in a we’ll chair, you’re there at the table.
The best person to provide information about what they need in an emergency situation is someone with a disability.
Next slide.
I wanted to show this because it starts to get at the different facets of what it takes to prepare and what FEMA says is to mitigate disaster.
And I wanted to specifically have this.
Mitigation is the effort to reduce loss of life and property by lessening the impact of disasters.
So, if you take a look at this figure that they have in their mitigation, their national mitigation framework you have community resilience.
You have public information and warning you have reducing long term vulnerability.
Planning, understanding threats, people with disabilities can be involved at every level of this response from a local response up to the state level.
And by having people with disability involved, you’re really going to be addressing that whole community and you are going to be working to mitigate the impact of disaster on your community and people with disability whom we’ve seen have been impacted at a greater level than people without disability.
Next slide.
Here is just examples of the types of partnership groups that you could be including in a network.
That is government agencies, all levels.
We have stuff going on at the federal level but if you’re talking about your state, you have your state, county, local levels.
Every state has independent living councils.
Another great resource to partner with and get people with disability involved in a network.
Every state has a council on developmental disabilities.
There are nonprofit organizations that work with people with disabilities, academia, every state has university centers of excellence on developmental disabilities.
You will have business and business organizations, faith-based organizations, advocacy groups including advocacy groups for people with disabilities and just building that neighborhood support.
Next slide.
I wanted to include this example of a network that has developed after hurricane Maria hit Puerto Rico.
It was devastated the island.
Hurricane Maria hit Puerto Rico on September 20th, 2017.
It was a category 4 hurricane with sustained winds of 155 miles per hour.
Really catastrophic devastation there.
Shortly after the hurricane hit and the island was kind of assessing just, you know, what had happened to their island to their community, a network started to develop.
It started with the university center for education on development, this is an academic medical center and they started reaching out to their partners.
So I just want to point out who all has become involved in this network.
You have the Movimiento Para El Alcance, their independent living.
The protection and advocacy system of Puerto Rico.
The Puerto Rico assistive technology program.
States have this type of program.
The development disabilities council.
You have the university center and you have the national association of voluntary organizations active in disaster or VOAD.
They became active shortly after the hurricane hit.
They are still active.
They have oftentimes gone in and made a seat for themselves at the table and are fully integrated, working on being fully integrated in developing the response plan, wanting to help people who have been impacted now but to look to the future and make sure that they can lessen that impact, they can mitigate that impact.
I have included a link to a presentation where members from the network are talking about what happened to Puerto Rico after the hurricane, specifically how this impacted people with disability.
How this network came together and the types of things that they are working on.
I thought it was very interesting and I think it would be something that folks could learn a lot from.
Next slide please.
I’m going to leave you with resources, I feel like this is just scratching the surface but for people that are thinking about how do I start to do this in my own states or I want to get involved, I want to find out who is working with this.
I want to make sure that people have resources that they can use.
First of all, talk about some of the CDC resources here we have our emergency preparedness and response.
I’ve included the link to our online catalog.
CDC has a social vulnerability index, this is very useful if you are trying to determine where vulnerable populations are in your specific locale.
And likewise, CDC has public health professionals in each of the states, they are working with cooperative agreement and that is a group of people who will be very interested in reaching out and working with people with emergency response.
Next slide.
Additionally here are some resources each of these websites has great information about emergency preparedness and people with disabilities.
Down at the bottom I’ve included the ADA national network learning sessions.
These are monthly webinars.
They usually have presentations from people in the community who are working to incorporate people with disability into emergency response.
They are archived, you can back and look at them and a lot of good information there and also the website for the national association of voluntary organizations.
Next slide please.
There are a number of ways that you can start pulling people together at that state level.
That first link I have here is the association of university centers on disabilities.
This is an umbrella organization for EDDs.
Like the center in Puerto Rico that started to activate this network.
There is at least one UCEDD in every state and so there are people there who are interested in emergency preparedness, have resources, a great place to start a connection.
Also has a nice website with other emergency preparedness resources these are all geared towards people with disability.
Every state has a council of developmental disability.
Website is there that can link you then to individual states, likewise I’ve included the link for the overall centers for independent living.
This will get you the directory to the centers for independent living in your state.
Of course, state emergency managers, state disability and health programs, then another organization nonprofit that is instrumental in working at the state level is portlight strategies.
Their purpose is to help people at the community level involve people with disabilities in planning for response.
Next slide.
I believe that is what we have.
So thank you.

>> Thank you so much, Cindy, for that wonderful presentation.
We will now transition into our Q&A session.
If you have a question for Cindy, you can enter your question in the Q&A box by clicking on the Q&A button on your screen and entering that.
While people are entering their questions, do we already have some ready to go?

>> Yes, we do, Cindy.
Our first question is, do you know if there’s a requirement for group homes to have an emergency preparedness plan?

>> I am not aware if there is a requirement for a group home to have an emergency plan.
But I would — if you have someone who is in a group home, I would definitely be asking about an emergency plan, if they do not have one then I think there’s some tools here to help them start to develop that.

>> Thank you very much.
We have another question from Alex W.
Asking about service animals and training.
Could you speak to that with regards to service animals and training in shelters and emergency preparedness, and such.

>> I think this is really a good opportunity for people to think about when a local community is having real life emergency drills, you can work with some of these organizations and actually have people who work with service animals to have them there.
Of course there are a number of slides, presentations, webinars where someone can learn more about what are the requirements, how do we interact with service animals, but I think what it really comes down to is having people there in the drills.
If you are someone who works in an emergency management program and this is something that you haven’t done, I think there’s a good opportunity now to reach out, say to the centers for independent living and indicate that this is something that you would like to do and how can you work together to snake this happen.
Work together to make this happen.

>> Thank you very much, our next question is how can public health drill an exercise with a disability community?

>> I think this is going back to the partnerships.
I’ll just share an anecdote here.
This is something that I heard in one of the national preparedness summits.
These are people who worked in emergency management and worked with disability and had a shelter set up where they thought they had accessible showers, accessible beds, accessible areas.
And they felt like they were good to go but they had really built a relationship with their centers for independent living so they were able to have people who were in wheelchairs come and actually try out their accessible facilities.
What they found is, they were not accessible.
And this was really good feedback for them and they could start to plan, change, plan ahead.
It’s not the norm to have people with disabilities involved in drills and training, but it’s something that could become that by reaching out to some of the organizations that I talked about previously.
Also going back to the online catalog there is an example in there where one of the states developed some table top exercises.
You’re not going through the actual exercises but you’re walking through what we we do and encountering various scenarios and they created a scenario for a situation that was mentioned earlier, group home.
What would a group home do in a flooding situation.
It’s a great tool to look at see if that is something that you could use in your own drills.
Or you can look at it, think about the type of disasters that may occur in your own locality and try and adapt that to something that might make more sense for you.

>> My apologies if it is outside your scope of expertise but does person with PTSD have a service animal or emotional support animal?

>> It’s a little outside my area of expertise.
But what I would point to is a service animal is trained to do a specific task.
If it is an animal — with the PTSD there is something about activities of daily living that a person is having difficulty with and the service animal is there to remind them of things, I mean there’s a wide range in which a service animal can be trained to help someone with activities.
If it has a task that has been trained to do to help that person go through specific activities.
Or a certain ability they just need some help with, that is a service animal, it’s been trained to do that.
People do have support animals.
It’s not covered in the same way and it doesn’t fall under the same type of — it’s not in the same category as a service animal and unfortunately would not — it might not be allowed into the shelter because shelters have to allow service animals.
But I think a support animal, it doesn’t have — it doesn’t fit that criteria.

>> Thank you very much.
Question regarding the data in your slides.
Do they include — do they classify mental illness such as depression as a disability?

>> The ones that I used that I showed from the table of disability and the slide, it’s broad.
It doesn’t specifically ask about mental illness, there are six questions that Health and Human Services uses to categorize disability.
There is a question about cognitive ability.
That is your ability to remember or ability to follow through on tasks or your ability to live independently.
So while those may not capture mental illness, say depression specifically if there is something about the depression that is keeping someone from being able to accomplish those activities of daily living and they answered in that way, this is a self report, it would fall underneath that.
You wouldn’t necessarily be able to draw that out of this particular survey that was used.

>> Thank you very much.
Again, a question that may — that you may feel — how do you suggest dealing with language barriers and cultural issues in addition to disability concerns in an emergency.

>> Right.
I think, for the language issue, I think the best tool would be one of those things that I showed earlier such as the show me booklet or the show me apps.
There are a number of tools, if you were to go online and look at things so they’re universal photos, maybe about illness or time, things that someone may have a question about.
If you go on to the CDC website and are looking under the emergency response, there is a guide that CDC developed and I I have included a link to it, but reaching out to vulnerable populations.
Part of that is reaching out to people where there may be cultural differences in your community.
And there are some really nice steps in there about how you build those partnerships, how you identify, how you build those partnerships.
So again, in the immediate course of a disaster I think you’re going to be looking at those communication barriers and I think trying to do the best you can would be my response.
But if we’re really talking about planning ahead and including people, that’s a nice resource to go to and I think might be helpful for people who have those concerns.

>> Cindy I’m just going to add one thing to that.
The E.P.I.C. team works frequently with this issue.
It is extremely helpful to have connections with organizations that serve different communities, different language communities ahead of time.
Have, for example, Spanish language documents ahead of time and connections within a local Spanish speaking community so that you have a mechanism to get that information to people.
That same principle applies to other services as well.
It requires preplanning.

>> Here we’re talking about preplanning for people with disabilities.
You have a wide range of disabilities, it could be mobility, cognitive, hearing, vision, a lot of different things to take into account and yet building those partnerships, reaching out to the people in your state, in your community who specifically work with those groups and having that accomplished beforehand is really going to help in that long term mitigation of the impact of a disaster of people with disability.

>> All right.
We’re just going to give people couple more seconds if you have any additional questions.
I see another question.
This person’s Q&A isn’t functioning.
Cindy, you mentioned how social class has come into play with the New Orleans disaster, could you elaborate a bit more about that?

>> With New Orleans in general or just in general, but social class I think, Katrina was a disaster where we saw that sort of play out like in realtime on the news.
Perhaps in recent history, aside from 9/11, but this was — it went on for weeks and days as people saw the the Superdome and people trying to get out of the city.
There was really a lot of interest and response after the hurricane where people in the United States, whether it was in say, departments of sociology, in public health both at the national and state level but people noticed, there’s different groups of people who are in the Superdome versus people who managed to evacuate the city.
We saw the death rates.
People with disability were disproportionately affected.
People who are older.
If you are looking at say population with disability which oftentimes really closely alliance with poverty, you are talking about groups that have a number of disadvantages.
So it may be physically difficult for someone to evacuate a city.
But also not working or not having the resources, say the saved wealth that someone in a higher social class might have.
It’s hard tore draw upon that then harder to get yourself back up and back on your feet afterwards.
And there have been some long term studies just looking at the impact of hurricane Katrina and sort of seeing children in different social classes and kind of what was the long term impact of children who experienced hurricane Katrina.
Where you can just start to see that if people are in different social classes, have different resources available to them and long term outcomes can be better for people that have more access to resources.

>> Thank you.
We have another question.
When discussion — emergency preparedness with caregiver or individual with a disability what would be an approach to have the initial discussion without invoking fear?

>> I think possibly it could come from that sense of empowerment.
Not being afraid of what is going to happen and you could even think of it as something small, like we had an ice storm here in Atlanta several years ago and that really gave people something to think about.
It was just, I could not get to work for several days and it was a good thing that I have food at home just even taking a small example of, what if we have a storm and we just can’t get out for a while are we going to be prepared for it?
That might be a way to just take something and look at a very manageable, what seems more manageable than catastrophic hurricane or tornado coming through.
But I think just working from that aspect of, we can be — you are empowered.
You have the ability to do this.
And it’s not fear, but it’s just really taking control.
I think taking control and taking action, knowing that there’s something you can do and that will be effective is something that has been shown to really help people.

>> Thank you so much, Cindy, for that wonderful presentation.
Thank you all for your participation.
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