JEM V20 N7 COVID-19 Special #3

43 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 already covered by SETRAC at that stage. Moreover, SETRAC received requests from facilities (mainly free-standing ERs) wanting access to the reporting platform to include their numbers. SETRAC facilitated Just in Time training with facilities to get them set up and trained on the EMResource data collection platform. Finally, in October 2020, state requirements31 further highlighted the importance of data collection and reporting responsibilities. On October 14, 2020, GA-32 was released by the Governor that directed as follows: for “Areas with high hospitalizations which means any Trauma Service Area (TSA) that has had 7 consecutive days in which the number of COVID-19 hospitalized patients as a percentage of total hospital capacity exceeds 15 percent, until such time as the Trauma Service Area has 7 consecutive days in which the number of COVID-19 hospitalized patients as a percentage of total hospital capacity is 15 percent or less.”31(p3) The impact of this EO meant that if a TSA had 7 consecutive days in a row above the 15 percent-mark, elective surgeries that were ordered stopped, and businesses were ordered to scale back operating capacity to 50 percent. The County Judges became especially engaged in helping to enforce data collection requirements. The SETRAC Leadership Team held regular calls with the Judges in the different TSAs to explain how the 15 percent was calculated and the importance of accurate and timely information. Misinformation or failure to report data by the healthcare community could cause a false elevation of the capacity percentage, resulting in economic effects to the county business communities. Judges quickly became champions of the data collected by SETRAC and would regularly monitor the website for variances. If they saw unusual data on the website, they would call for an explanation and then start calling the hospital leadership in their county asking for explanations as to why they were not reporting and encouraging them to become compliant. Collection In HSE and DHS specifically, collection is “best described as gathering,” and unlike national security intelligence, it occurs with knowledge and cooperation of “targets and target owners” typical of acquiring OSINT. SETRAC’s data collection was virtual and relied on self-reporting.28(p219) Every single hospital was contacted in the 25-county region and asked to provide capacity numbers, surge capacity, and overall capabilities. These are the numbers SETRAC used and later displayed to the public. The decision was made by SETRAC leadership that all data displayed must come directly from the hospitals/healthcare facilities as reported. Originally, there were 12 questions which all pertained to the number of suspected COVID-19 patients and what type of bed they were occupying. On March 17, 2020, the report expanded to 21 questions. The new questions added were to gauge hospital capacity and to address concerns outside of COVID-19. On March 18, 2020, SETRAC added another set of EEI known as a bed report. The bed report originally was 19 questions on bed availability by bed type (available ICU beds, med surge monitored, med surge nonmonitored, PICU, isolation rooms, Emergency Department beds, OR beds, etc.). Eventually, the final data collection set was expanded to 137 questions including 29 questions on a bed report, 36 on a COVID-19/Flu surveillance report, 24 on a capacity report, and 48 on a PPE report (only collected once a week). The collection of items comprises the EEI started at 6 am when reporting opened and concluded at 1:00 pm, giving facilities 7 hours to complete the reports. Once the reports were submitted at 1:00 pm, the SETRAC Planning Section would run a report and retrieve every number and every facility submitted for the day. An example of data reports generated by SETRAC/DSHS/HSS included the following: total hospital patient census, available ICU beds, available general beds, confirmed COVID-19 patients admitted to ICU beds, confirmed COVID-19 patients admitted to general beds, and confirmed COVID19 hospitalized and ventilated. A data dictionary was developed by the DSHS defining each category (Table 1). Originally, there were two state platforms used by reporting entities for data submission: EMResource and WebEOC. Moreover, facilities had to separately report data to the federal government via Teletrack. 04-SA-Weston-JEM#210066.indd 43 12/03/22 7:18 PM

44 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 During the summer of 2020, SETRAC had inquired with DSHS if it would be possible to set up an Automated Program Interface (API) in EMResource. In August, DSHS approved the use of an API. This, in turn, allowed hospitals or hospital systems to connect directly to their records system, and the data fields would be mapped to EMResource so daily the numbers would auto populate. One drawback was that not every facility could use this process. It required a robust IT infrastructure and a large amount of time to set up, but it was provided as an option for facilities. As mentioned previously, in October, requirements changed, and facilities had to report in EMResource and two additional platforms. Depending on the type of question, ie, capacity, vaccine, bed availability, and PPE, the questions were in different platforms. Throughout this entire process, hospitals were providing feedback daily about what was and was not working. SETRAC gathered the concerns and conveyed them to the Texas DSHS who relayed them to HHS. Then, the responses would make their way back to SETRAC and to the facilities. The process gave a high degree of confidence in what was not only being reported to the public but to the individual decision makers, to make the decision on reliable sound data. If anything, this identified the importance of collaboration and standardization of data collection. Processing/exploitation The next step of the intelligence process, referred to as processing and exploitation, involves sorting, verifying, deconflicting, and separating collected data to render them ready for analysis.22 To that end, daily reports were pulled from EMResource and sorted by SETRAC planning staff assisted by an external consultant to create visuals, look up tables, and reference tables in Excel. Notably, this phase had to occur within a compressed timeframe from 1:00 pm when the reports were available in EMResource until 4 pm when the data had to be displayed to stakeholders. This validation and processing included 1-2 hours of daily phone calls for clarification or follow-up on data that were conflicting or missing all together; this was an iterative process that occurred daily. Only when all data were processed and verified, would the final reports be sent out to SETRAC. Eventually, Excel’s functionality was not sufficient for processing and exploitation, and stakeholder’s feedback indicated a need for a more robust reporting platform as well as a public-facing report. Consequently, SETRAC switched to using Power BI (a business intelligence solution by Microsoft®).40 The transition occurred in early April 2020 and took 1 week to streamline the processing/exploitation of raw data. Most importantly, it allowed SETRAC to open data for public viewing. After going public with the new data graphs, feedback was provided by the public as well as SETRAC stakeholders, asking to see visuals sorted by county, inclusion of different data points, and/or different types of graphs. SETRAC used the feedback obtained, to make updates to the data display that proved meaningful and easy to understand. Frequently, SETRAC Table 1. Definitions of specific questions on daily reporting48 Category Definition Total hospital patient census The total number of hospital patients at the time of the report including admitted to general, isolation or ICU beds, and all overflow and surge/ expansion beds with patients Available ICU beds As total number of staffed adult ICU beds available Available general beds Available general beds (med surge) as beds available for patients who do not require intensive care Confirmed COVID-19 patients admitted to ICU A person has received a positive test result and has admission orders to the ICU Confirmed COVID-19 patients admitted to general beds A person has received a positive test result and has admission orders to a general bed Confirmed COVID-19 hospitalized and ventilated The total number of patients either confirmed or suspected of COVID-19 and is on a mechanical ventilator at the time of the report Note: Adapted from Ref. 5. 04-SA-Weston-JEM#210066.indd 44 12/03/22 7:18 PM

45 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 leadership would work with stakeholders to come up with alternative solutions to fill gaps or provide clarity in interpreting the data. For example, when a facility reported the questions in EMResource, the report covered the previous 24-hour period but was coded as the following day report. Hence, the stakeholders in the 25 counties did not understand how SETRAC could not have data for the same day and considered data outdated. SETRAC then switched the display date to show the same day and put a disclaimer that all questions represent the previous day (midnight to 11:59 pm), thus clarifying the process. Overall, under the new system, the pulling and exporting reports and verifying columns were narrowed to 1 hour, and SETRAC used the remaining 3  hours for verification. Rather than go data point by data point vs the previous day, an internal report in PBI that verified data was created. Thus, the data would be exported from EMResource, “cleaned,” and put into the test PBI report. Once in the test PBI report, metrics that made up the GA-32 executive order31 were integrated into a newly created table in Power BI, so each county would get a GA-32 individual percent rather than just by TSA. At this point, the numbers would be compared to what had been reported on previous days. All numbers were flagged if they increased or decreased in an abnormal fashion. Those facilities were then contacted and asked to provide justification or the correct number. During this time, all facilities that did not report were contacted and given 2 hours to report. Once the numbers were verified at an individual facility level, they were then put into the dataset and aggregated into a daily number for each question, which would be displayed to the public. Each number was than verified as an aggregate to make sure no abnormal numbers were missed. If any question displayed a large increase or decrease, all data for that question would be pulled, to find the individual facility(s) causing the issue. The same process of contacting the facility(s) was followed for justification or correction. In order to standardize any deviation, SETRAC leadership held a conference call with hospital CEOs to gauge their need for change fluctuation reporting and agreed on 5 percent standard deviation from 1 day to the next. This allowed for flagging all facilities that had a 5 percent change and determine further details (hospital census, available beds, lab-confirmed COVID-19 patients). That process, in turn, allowed SETRAC to narrow the list of 137 questions for 202 facilities (27,674 questions per day) to approximately 40 facilities a day. Of those 40 facilities, SETRAC removed the obvious ones (meaning if a facility went from having one available bed to zero beds that is a 100 percent change). In most instances, the remaining facilities either did not report or had experienced a “fat finger syndrome” (inaccurate typing or mistyping), and an example of that is if a facility had 10 beds yesterday and 100 today. Once all data were verified, records were updated and moved from the test environment to the live environment (the public site). The last step was to take all updated records and e-mail them to the state because they used an API to pull the data from EMReource daily. SETRAC would send an e-mail with all the corrections, so that the state could make them as well. The last task was to send out a daily situation report comprising information on community lifelines, a 7-day view of specific data points—a task completed by SETRAC staff. With the number of doctors, data analysts, researchers, elected officials, or concerned citizens throughout the United States and the World that viewed this report, it would take literally minutes for someone to identify any issues and contact SETRAC directly. Any errors that were discovered were corrected and disclosed along the way as soon as they were identified. The goal was to provide reliable data in a timely fashion. Dissemination From the perspective of crisis and risk communication, this was the most relevant step in the process adopted by SETRAC. Dissemination and visualization occurred concurrently with analysis; in the environment of information-sharing, parallel processes in OSINT production are common.32 The website was created with an Executive Summary on the landing page (Figure 1). The executive summary details new COVID-19 admissions in a 24-hour period, the COVID-19 Census (represented by bar graphs and displaying 04-SA-Weston-JEM#210066.indd 45 12/03/22 7:18 PM

46 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 7 consecutive days’ trends), bed availability (represented by a pie chart), patient census, operational beds, and the percent of COVID-19/census and percent COVID-19/operational beds. This page was created for decision makers at businesses, hospitals, and counties who did not have time to peruse additional pages and to filter what was most relevant to them, ie, COVID-19 numbers, bed availability numbers, and the percent that determined the status of the county. From there, the public and stakeholders could filter data by the specific TSA and county level. The additional six pages included COVID-19 tracker, general bed usage, ICU bed usage, vent usage, COVID-19- related census, and hospital/COVID-19 census. From March 10, 2020 onward, data could be accessed and disaggregated by TSA or county. The COVID-19 tracker page represented by Figure 2 was integrated with USAFacts, which aggregates data from federal, state, and local public health agencies. Specifically, in Texas, USAFacts33 pulls COVID-19 data from all 254 counties in Texas to maintain accurate numbers. That page contains a map of Texas with the 25-county region highlighted and a table for each county displaying confirmed cases, deaths, and case facility rates. Linkages to reputable data beyond our collection supplied additional information for situational awareness. The general bed usage page displays the total number of general beds in use and the number of suspected and confirmed COVID-19 patients in general beds. Included were two static lines—one for operational general beds and one for general bed surge (this number was 20 percent of the operational general beds consistent with the mandate that all facilities possess the ability to surge at 20 percent). The ICU beds in use page followed the same design as the general beds in use page. The ventilator usage page (Figure 3) contains two stacked bar graphs—one for pediatrics and one for Figure 1. Executive summary landing page. 04-SA-Weston-JEM#210066.indd 46 12/03/22 7:18 PM

47 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Figure 2. The COVID-19 tracker page. Figure 3. Ventilator user page. 04-SA-Weston-JEM#210066.indd 47 12/03/22 7:18 PM

48 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 adults. Each stacked bar graph showed ventilators available and those in use, respectively. This page was particularly critical to mitigate “breaking news” reports of ventilators’ depletion, which became a major public concern. Overall, the 25-county region did not experience a situation when every facility was out of ventilators, although at times an individual facility may have run out. The hospital/COVID-19 census page (Figure 4) depicts a line graph with three lines: patients in general beds (suspected and confirmed), patients in intensive care beds (suspected and confirmed), and total hospital patient census. The goal of this page was to show worst case scenario for COVID-19 status of the healthcare entities. The goal was to offer insights into worst-case scenario, whereby all suspected patients would be positive vs the census of patients who were in the hospitals overall. The COVID-19-related census page (Figure 5) portrays two graphs—one for suspected and confirmed cases in ICU and one for suspected and confirmed cases in general beds. It replicates the executive summary and general/ICU bed usage pages but was added because the scale was so drastic throughout the response that it was difficult to discern trends among other graphs. This was another effort to be completely transparent and let users see data at a more granular level. Overall, the dissemination process aimed to present the data exactly how they were received from the healthcare entities and to let the public and decision makers exploit them and make decisions based on the trends they saw in their counties. Universities, health researchers, jurisdictions, and other professional organizations frequently requested SETRAC’s raw data. SETRAC reviewed all requests, executed agreements, and set up a means for providing updated raw data weekly to partner requestors. Data shared were provided at a county level without releasing specific health institution identifiers. Overall, SETRAC received feedback from universities and professional organizations that use PowerBI, Microsoft, private practice doctors, the public, county judges, county public health officials, the State of Texas, local health departments, and other professional organizations on the value of the data shared and displayed in order to make personal or business decisions. Figure 6 depicts public access/views in July 2020 alone. Analysis of SETRAC data Whereas the dissemination and visualization stage allowed for public entities to access relevant evidence-based information and it permitted researchers and practitioner to conduct their own analyses, SETRAC further engaged in the analytical processes to create relevant public health OSINT. Indeed, as proposed by Greenberg, “intelligence reflects a more expansive analytical treatment  .  .  .  the information gathered is most useful when analyzed to reveal trends and developments in the data itself”.28(p220) We discuss the most salient OSINT outcomes/findings below. Pervasive data Pervasive data became a major concern to SETRAC early on during the COVID-19 pandemic. The three areas that were considered pervasive when examining trends and developments in data provided were (a) the prison population, (b) pediatric data, and (c) ILI data. Those data points became a concern throughout the COVID-19 response and were not initially priority data points compared to the growing number of adult cases. However, as analysis progressed, they became critical to track because they all affect surge in the healthcare continuum. The first population that was considered pervasive was the prison system. The SETRAC region is home to 34 Texas Department of Criminal Justice (TDCJ) facilities and one federal prison. The analysis focused on the prison system was warranted because incorrect picture could have completely overwhelmed the healthcare system in Southeast Texas. As beds were filling up, the real concern was in the number of prison-designated beds/wards and the staffing the TDCJ requires for each prisoner. On April 28, when SETRAC first collected prisoner COVID-19 data, there were 359 COVID+ prisoners, 7,138 under monitoring, and 387 in medical isolation across the 35 penal facilities. By June 5, the numbers exploded to 2,317 COVID+, 12,482 under monitoring, 2,369 in medical isolation, and 80 prisoners admitted to area hospitals.34 04-SA-Weston-JEM#210066.indd 48 12/03/22 7:18 PM

49 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Figure 4. Hospital COVID-19 census. Figure 5. COVID-19-related census. 04-SA-Weston-JEM#210066.indd 49 12/03/22 7:19 PM

50 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Another outcome of trend and data development analysis revealed pediatric data as pervasive. Similarly, those were not originally the main area of focus because COVID-19 was affecting the adult population at a much greater rate, but as school started and more youth were being exposed, those became salient. Indeed, because “any hospital could be asked to support the medical surge needs of a pediatric medical surge,”35(p1) SETRAC’s analysis of trends triggered the need for all healthcare providers to fill out bed and COVID-19 reports data, including pediatric facilities as a separate function of reporting to keep ahead of any growing trends in the pediatric population. The last area of pervasive data was ILI data. Once again, these data were not prevalent early on because it was not a flu season, but SETRAC wanted to be able to determine a baseline for influenza admissions and ED visits. As the analysis continued, these early baseline readings became extremely important, given that COVID-19 and influenza require similar supplies and equipment. Thus, with hospitals accommodating COVID-19 patients, ILI numbers could greatly affect surge capacity as flu season progressed.36 Beyond OSINT outcomes related to pervasive data, in-depth trends in data development were needed for decision-making and policy formation. Some areas of analytical scrutiny are discussed briefly as snapshots. For example, the average hospital census between March 19, 2020 and December 31, 2020 was 11,981. The maximum census was 15,004 on December 15, 2020, and the minimum census was 4,134 on March 21, 2020 (when the push for reporting started). For hospitalized and ventilated, it is important to note the first day this question was asked was April 21, 2020 (Figure 7). The max number of patients either suspected or confirmed on a ventilator was 751 on July 26, 2020 with the minimum 102 on May 22, 2020. The average number of ventilated suspected or confirmed patients was 276 between April 21, 2020 and December 31, 2020 (Figure 8). Figure 6. SETRAC COVID-19 report views for July. Note: This graphic is a snapshot of the month of July, to provide information on where the SETRAC report was being viewed. The report indicates that data were not only viewed locally, but nationally and even internationally. 04-SA-Weston-JEM#210066.indd 50 12/03/22 7:19 PM

51 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 When analyzing bed availability between March 19, 2020 and December 31, 2020, the maximum number of ICU beds available was 513 on April 29, 2020, and the minimum was 49 on July 16, 2020. The average number of available ICU beds was 219 (Figure 9). For general beds between the same date range, the maximum number of general beds was 3,646 on April 5, 2020, and the minimum was 586 on July 16, 2020. The average number of general beds available was 1,607 (Figure 10). The confirmed COVID-19 question was not initially asked and started April 3, 2020. For confirmed COVID-19 in ICU and in general beds, the date range will be between April 3, 2020 and December 31, 2020. The maximum confirmed COVID-19 patients in ICU beds was 1,093 on July 18, 2020, and the minimum was 169 on May 2, 2020. The average was 418 COVID-19 positive patients in ICU beds (Figure 11). The confirmed COVID-19 question for general beds was not initially asked and started April 3, 2020. For confirmed COVID-19 in general beds, the date range will be between April 3, 2020 and December 31, 2020. For the same date range, the maximum for confirmed COVID-19 in general beds was 2,444 on July 14, 2020, and the minimum was 206 on April 3, 2020. The average for COVID-19 positive in general beds was 886 (Figure 12). DISCUSSION The purpose of COVID-19 data driven planning— the Texas approach was to share the SETRAC’s experience in collecting, processing, disseminating, visualizing, and analyzing COVID-19 data during the pandemic. This case study started as one excel sheet of 25 Texas counties, and through a series of improvements, evolved into 15 individual business intelligence reports powered by PowerBI. These public-facing datasets were shared with Regional HPP Coalition Coordinators, County Judges and City Mayors, DSHS executive leadership, the Offices of the Texas Governor, Figure 7. Total hospital patient census. Figure 8. Total of hospitalized and ventilated COVID-19 patients. 04-SA-Weston-JEM#210066.indd 51 12/03/22 7:19 PM

52 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 and the Federal Pandemic Task Force led by the US Vice President to provide a foundation for situational awareness, inter-regional collaboration, allocation of scare resources, and local, regional, and state policy decisions. Most importantly, they became a cornerstone of risk and crisis communications in the region and as such represent best practices. From the standpoint of CERC communications during the pandemic, one of the main purposes of the SETRAC reports was to provide information to elected offices and the public, so that their risk and crisis communications to the publics could be data driven, reliable, and actionable. An example of this was in Harris County, where County Judge Hidalgo used the SETRAC reports and graphics in her news briefings to the public. “The county judge said she uses the SETRAC data to make Figure 10. Available general beds. Figure 11. Confirmed COVID-19 patients admitted to ICU. Figure 9. Available ICU beds. 04-SA-Weston-JEM#210066.indd 52 12/03/22 7:19 PM

53 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 decisions about stay home orders as it shows whether or not the curve has been flattened enough to avoid overwhelming the local healthcare system.”37 In tandem, institutions that are trusted by the publics and to which the publics turn for CERC communications such as churches reached out to the ask@setrac e-mail that was set up stating they depended on the data. For instance, a Pastor in Beaumont Texas wrote “I am a pastor in Beaumont and depend heavily on the data you provide in making day-to-day decisions about our congregation’s ministry during this pandemic.” Other examples included City and County Health and Human Services departments who used the SETRAC data to communicate crisis situation during briefings and to make critical situational decisions. An example was Fort Bend County Health and Human Services who e-mailed SETRAC stating “We rely on the SETRAC COVID-19 Hospitalization Dashboard to hospital usage surveillance for our county and neighboring counties.” Furthermore, Institutions of Higher Education (IHEs) reportedly trusted by students as source of risk communication during public health emergencies31 leveraged SETRAC data to tailor their crisis and risk communications. Specifically, a PhD student at Texas A&M and University of Texas at Austin COVID-19 Modeling Consortium had reached out and requested weekly exports of SETRAC data to assist in creating IHEs COVID-19 modeling for those IHEs. Moreover, organizations traditionally involved in crisis and emergency management and trusted by local publics such as Harris County Fire Marshal’s Office, whose COVID-19 mission has been to monitor compliance under non-general fund division, used SETRAC data to provide COVID-19-related orders, ensure social distancing protocols, educate the public and businesses, and provide health and safety order(s). Most importantly, the concerned publics, whose questions regarded available ventilators, hospitalization numbers, PPEs, and the overall hospital medical surge, could verify public officials’ messaging through open access to the source of data itself. Moreover, CERC based on SETRAC COVID-19 reports constituted trusted and authoritative voice because of the degree of collaboration and feedback. Since SETRAC allowed and encouraged constant feedback across all phases of our OSINT production process, the coalition has been able to identify, thus, far in the COVID-19 response, four notable areas of collaboration. First was the joint effort between SETRAC and Texas DSHS to create a dynamic report that was not a static dashboard. Second, SETRAC worked with other HPP providers to create similar reports that fit their populations needs. Third, SETRAC consulted with existing stakeholders to give a framework on using PowerBI. Finally, an open line of communication with the Texas Medical Center (TMC) led to a successful understanding of public reporting in Southeast Texas. All factors above contributed to create a common operating picture and synchronize subsequent public risk and crisis messaging. With the successful implementation of the SETRAC COVID-19 report, SETRAC offered to do the Figure 12. Confirmed COVID-19 patients admitted to general beds. 04-SA-Weston-JEM#210066.indd 53 12/03/22 7:19 PM

54 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 same for the State of Texas, and the State accepted. At this point, it was identified that every region in the state asked the same questions in a different way. This is when DSHS worked to take over reporting requirements, so every facility was asked the same questions, in the same way. Once the state was able to standardize questions, reporting (which happened quickly) and creating visualizations for the data were easy. This was an important move by the state because it brought all partners together to speak the same language or be interoperable, whereas before this was not the case. Indeed, interoperability has been consistently identified in research as critical to effective risk and crisis communications,39-41 especially in healthcare systems.42,43 From a data analysis perspective, interoperability provided another layer of validity because once SETRAC checked the data, the state went through a similar process and sent back questions on numbers. The importance of collaboration with respect to interoperability is especially prevalent in the modern era of technology. As the reporting process started, and the decision was made to create a public report, SETRAC’s IT director considered the solution of PowerBi. The issue was that SETRAC personnel had not used it to the level it was about to be used. This is where collaboration came in; SETRAC personnel reached out to the stakeholders, and Harris County linked us to a PowerBi user who, in turn, was able to give us a crash course and guide us through issues encountered. Without leveraging relationships and collaboration efforts made on the preparedness front, the SETRAC report would not be what it is today. Another area of collaboration was among HPP providers. SETRAC leadership reached out to the other HPP providers and let them know that SETRAC was able to create a public report, and, if they wanted, we offered to do the same for them. Because two separate providers engaged with us, their ideas illuminated new solutions for reports since leadership from the different providers wanted visualizations presented in different ways or wanted to see comparisons between different questions. Once the reports were completed, an URL was sent to the HPP providers to do with them as they pleased. The last critical area of collaboration was with the TMC. The TMC is an organization with a 2.1 square mile geographical footprint that contains the largest medical complex in the world44 and with that comes many challenges and advantages. With the TMC’s resources, they were able to also create their own reports for TMC-affiliated facilities and display them to the public. For example, for SETRAC, one clear benefit of public facing reporting for risk and crisis communication was a creation of a separate PPE report, which addressed concerns and rumors of publics throughout the region concerned about not receiving PPEs. The report evidenced that SETRAC had approximately 4,000 LTACs, EMS agencies, jurisdictions, doctor offices, pharmacies, funeral homes, hospitals, free standing EDs, dentists, home health, and long-term care facilities who were being supplied throughout the 25-county region on a biweekly basis. Thus, by filtering by county, stakeholders and concerned publics could assess PPE distribution, and SETRAC was successful in monitoring public misinformation issues before they became a crisis.45,46 However, this created some confusion in the beginning because the TMC and the SETRAC reports did not match perfectly. It took getting the right messaging out that the SETRAC data cover 25 counties, and although you can filter down to the county level, the facilities that display in Harris County are more than just the TMC, granted the TMC members data would cause the greatest impact on data due to the sheer size of the facilities. After working together, the TMC and SETRAC were able to deconflict data, so local leaders understood why differences existed (if they did), and the entire system had confidence in data reliability. Taken together, OSINT’s production, collaboration, and integration of feedback by SETRAC suggests that its crisis and risk communication processes (a) aligned both with the whole community right to know and with the professional community, and healthcare system needs to share, (b) positioned it as one firm voice and as a source of clear and accurate information, (c) leveraged scientific evidence, (d) promoted health literacy, and (e) contributed to the overall system’s resiliency in the region during this unprecedented crisis. 04-SA-Weston-JEM#210066.indd 54 12/03/22 7:19 PM

55 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Adam Lee, MS, Regional Training and Exercise Coordinator, SouthEast Texas Regional Advisory Council, Houston, Texas. Lori Upton, RN, BSN, MS, CEM, Vice President, Disaster Preparedness and Response, SouthEast Texas Regional Advisory Council, Houston, Texas. Magdalena Anna Denham, EdD, Clinical Associate Professor, Department of Security Studies, College of Criminal Justice, Sam Houston State University, Huntsville, Texas. ORCID: https://orcid. org/0000-0003-4504-2485. Jeremiah Williamson, Director of Information Technology, SouthEast Texas Regional Advisory Council, Houston, Texas. REFERENCES 1. Covello VT: Risk communication: An emerging area of health communication research. In Deetz SA (ed.): Communication Yearbook, vol. 15. Newbury Park, CA: Sage, 1992: 359-373. 2. Walaski FP: Risk and Crisis Communications: Methods and Messages. Hoboken, NJ: John Wiley & Sons, 2011. 3. US Department of Health and Human Services Centers for Control Disease and Prevention. CERC Introduction. [Update]. 2018. Available at https://emergency.cdc.gov/cerc/ppt/CERC_ Introduction.pdf. Accessed December 2, 2021. 4. Burton-Jeangros C: Epidemics and risk communication: Why are lessons not learned? In Managing the Global Health Response to Epidemics. New York, NY: Routledge, 2019: 105-125. 5. Laajalahti A, Hyvärinen J, Vos M: Crisis communication competence in co-producing safety with citizen groups. Soc Sci. 2016; 5: 13-15. DOI: 10.3390/socsci5010013. 6. Heath RL, O’Hair DH: Handbook of Risk and Crisis Communications. New York, NY: Routledge, 2009. 7. Coombs TW: Public sector crises: Realizations from COVID-19 for crisis communications. Participatzione Conflitto. 2020; 13: 990- 1001. DOI: 10.1285/i20356609v13i2p990. 8. Ratzen SC, Sommarivac S, Rauh L: Enhancing global communication during a crisis: Lessons learned from the COVID-19 pandemic. Public Health Res Practice. 2020; 30(2): 1-6. DOI: 10.17061/phrp3022010. 9. Hills TTL: The dark side of information proliferation. Pers Psych Sci. 2018; 14(3): 323-330. DOI: 10.1177/1745691618803647. 10. Glick DC: Risk communication for public health emergencies. Ann Rev Public Health. 2007; 28: 33-54. 11. Fischhoff B: The realities of risk-cost-benefit analysis. Science. 2015; 350: Aaa6516. DOI: 10.1126/science.aaa6516. 12. Cvetkovich G, Lofstedt R: Social Trust and the Management of Risk. London, UK: Eartscan, 1999. 13. Renn O, Levine D: Credibility and trust in risk communication. In Kasperson R, Stallen P (eds.): Communicating Risks to the Public. Dordrecht, Netherlands: Kluwer, 1991: 175-218. 14. Fessenden-Raden J, Fitchen JM, Heath JS: Providing risk information in communities: Factors influencing what is heard and accepted. Sci Technol Hum Values. 1987; 12(3/4): 94-101. 15. Lundgren R: Risk Communication: A Handbook for Communicating Environmental, Safety, and Health Risks. Columbus, OH: Batelle Mem. Institute, 1994. 16. United States Department of Homeland Security: NIPP 2013: Partnering for critical infrastructure security and resilience. 2013. Available at https://www.cisa.gov/publication/nipp-2013- partnering-critical-infrastructure-security-and-resilience. Accessed December 2, 2021. 17. United States Department of Homeland Security: Target capabilities list: A companion to the National Preparedness Guidelines. 2007. Available at https://www.fema.gov/pdf/government/training/ tcl.pdf. Accessed December 2, 2021. 18. White House: National Strategy for Information Sharing and Safeguarding. 2012. Available at https://obamawhitehouse.archives. gov/sites/default/files/docs/2012sharingstrategy_1.pdf. Accessed December 2, 2021. 19. Fynn SE: Higher ground: The sophisticated healthcare response of the SouthEast Texas regional advisory council to Hurricane Harvey [report]. Northeastern University, Global Resilience Institute. 2018. Available at https://globalresilience.northeastern. edu/higher-ground-the-sophisticated-healthcare-response-of-thesoutheast-texas-regional-advisory-council-to-hurricane-harvey/. Accessed December 2, 2021. 20. Texas Department of State Health Services: Regional Advisory Councils. 2021. Available at https://www.dshs.texas.gov/emstraumasystems/etrarac.shtm. Accessed December 2, 2021. 21. SETRAC: Regional healthcare preparedness coalition our mission. 2021. Available at Regional Healthcare Preparedness Coalition – SETRAC. 22. Lowenthal MM: Intelligence: From secrets to policy. (8th ed.). Thousand Oaks, CA: CQ Press. 2019. 23. Chang H, Ngunjiri FW, Hernandez KA: Collaborative Autoethnography. Developing Qualitative Inquiry, Book 8. New York, NY: Routledge, 2016. 24. Denham MA, Baker N: Harvey unstrapped: Experiencing adaptive tensions on the edge of chaos. WIT Transaction on Built Environment Disaster Management. 2019; 190: 1-18. 25. National Defense Authorization Act: Washington, DC: H.R. 1815, 2006. Available at https://www.congress.gov/bill/109th-congress/house-bill/1815. Accessed December 2, 2021. 26. Hubbs C, Moran M, Salisbury D: Open-Source Intelligence in the 21st Century: New Approaches and Opportunities. New York, NY: Palgrave Macmillan, 2014. 27. Bernard R, Bowscher G, Milner C, et al.: Intelligence and global health: Assessing the role of open-source and social media intelligence analysis in infectious disease outbreaks. J Public Health (Berl). 2018; 26: 509-519. 28. Greenberg HM: Is the Department of Homeland Security an Intelligence Agency? Int Nat Security. 2009; 24(2): 216-235. DOI: 10.1080/02684520902819644. 29. Ferguson NM, Laydon D, Nedjati-Gilani G, et al.: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. [Report 9]. Imperial College COVID-19 Response Team, London, UK. 2020. Available at https:// www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gidafellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020. pdf. Accessed at December 2, 2021. 30. Abbott G: Governor Abbott Issues Executive Order to Strengthen Reporting Capabilities. Austin, TX: Office of the Texas Governor, 2020. Available at https://gov.texas.gov/news/post/governor-abbottissues-executive-order-to-strengthen-reporting-capabilities. Accessed December 2, 2021. 31. Abbott G: Executive Order No. GA-32 relating to the continued response to the COVID-19 disaster as Texas reopens. 2020. Available at http://EO-GA-32_continued_response_to_COVID-19_ IMAGE_10-07-2020.pdf. https://www.dshs.state.tx.us/coronavirus/ execorders.aspx. Accessed December 2, 2021. 32. Bean H: No More Secrets: Open-Source Information and the Reshaping of US Intelligence. Santa Barbara, CA: Praeger, 2011. 33. USAFacts: Texas coronavirus cases and deaths. 2021. Available at https://usafacts.org/visualizations/coronavirus-covid-19-spreadmap/state/texas. Accessed December 2, 2021. 04-SA-Weston-JEM#210066.indd 55 12/03/22 7:19 PM

56 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 34. Texas Department of Criminal Justice: Texas Department of Criminal Justice COVID-19 case counts. ArcGIS Interactive Map. 2021. Available at https://www.tdcj.texas.gov/covid-19/mac_dashboard.html. Accessed December 2, 2021. 35. Regional Emergency and Disaster Healthcare Coalition: Pediatric medical surge annex. 2020. Available at https://srhd.org/ media/documents/REDi-HCC-Pediatric-Medical-Surge-Annex.pdf. Accessed December 2, 2021. 36. Blackburn CC, Natsios A, Ruyle L: What happens when COVID-19 and influenza collide? Can hospitals handle the strain? The Conversation. 2020. Available at https://theconversation.com/ what-happens-when-covid-19-and-influenza-collide-can-hospitalshandle-the-strain-144046. Accessed December 2, 2021. 37. Kamath T: Harris County Judge says hospital admissions rose slightly in past few days, peak not reached. Click2Houston. 2020. Available at https://www.click2houston.com/news/local/2020/04/21/ watch-live-harris-county-judge-lina-hidalgo-gives-update-on-coronavirus-response/. Accessed December 2, 2021. 38. Callahan M: Faced with a daily barrage of news, college students find it hard to tell what’s real and what’s ‘fake news’. 2018. Available at https://news.northeastern.edu/2018/10/16/faced-with-a-daily-barrage-of-news-college-students-find-it-hard-to-tell-whats-real-andwhats-fake-news/. Accessed December 2, 2021. 39. Comfort LK, Haase TW: Communication, coherence, and collective action: The impact of Hurricane Katrina on communications infrastructure. Public Works Manag Policy. 2006; 10: 328-343. DOI: 10.1177/1087724X06289052. 40. Mayer-Schoenberger V: Emergency communications: The quest for interoperability in the United States and Europe. KSG Working Paper No. RWP02-024. 2002. Available at https://www.hks.harvard. edu/publications/emergency-communications-quest-interoperability-united-states-and-europe. Accessed December 2, 2021. 41. Minnis CW: Data Communications with the Emergency Services: A Mixed Methods Study of Attempts to Improve Data Communications Systems Interoperability and Information Sharing Issues [doctoral dissertation]. Ann Harbor, MI: Proquest, 2010. 42. Balka E, Whitehouse S, Coates ST, et al.: Ski hill injuries and ghost charts: Socio-technical issues in achieving e-Health interoperability across jurisdictions. Inf Syst Front. 2012; 14: 19-42. DOI: 10.1007/s10796-011-9302-4. 43. Walker J, Pan E, Johnston D, et al.: The value of health care information exchange and interoperability. Health Affairs, 19. 2005. Available at https://www.researchgate.net/publication/8072860_The_Value_of_ Health_Care_Information_Exchange_and_Interoperability. Accessed December 2, 2021. 44. Texas Medical Center Corporation: TMC facts and figures [report]. 2016. Available at https://www.tmc.edu/wp-content/ uploads/2016/08/TMC_FactsFiguresOnePager_0307162.pdf. 45. Coombs TW, Halladay SJ: The paracrisis: The challenges created by publicly managing crisis prevention. Public Relat Rev. 2012; 38: 408-415. DOI: 10.1016/j.pubrev.2012.04.004. 46. Igoe KJ: Developing public health communication strategies and combatting misinformation during COVID-19. Harvard T. H. Chan School of Public Health. 2021. Available at https://www. hsph.harvard.edu/ecpe/public-health-communication-strategiescovid-19/. Accessed December 2, 2021. 47. PowerBI [Software]: Microsoft, 2021. Available at https:// www.zoho.com/analytics/?campaignid=14852238448&adgrou p=127569738203&keyword=bi%20software&network=g&devic e=c&matchtype=p&placement=&adposition=&creative=54988- 3636970&gclid=Cj0KCQiA-qGNBhD3ARIsAO_o7ymZZ9lxe9M29wZqk7jx71r7nTV6EiNq1KZuchOgNYZMBaZ0LvvnORcaApATEALw_wcB. Accessed December 2, 2021. 48. Texas Department of Health State Services: COVID-19 hospital bed reporting data dictionary. 2020. Available at https://www.dshs. texas.gov/coronavirus/docs/HospitalBedReportingDataDictionary. pdf. Accessed December 2, 2021. 04-SA-Weston-JEM#210066.indd 56 12/03/22 7:19 PM

JEM 57 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Nonprofit capacities and emergency management during the COVID-19 pandemic: Insights from a Taiwan-based international nonprofit organization Chin-Chang Tsai, PhD ChiaKo Hung, PhD Wei-Ning Wu, PhD ABSTRACT During the COVID-19 pandemic, some nonprofit organizations (NPOs) have been struggling to maintain their operations, while others are able to coordinate with partners to provide programs and services locally and globally. This study explores how NPOs are able to survive and actively engage in local and global COVID-19 responses by investigating the organizational capacities of the Tzu Chi Foundation, a Taiwan-based international NPO. This study employs interview data and secondary data from a variety of sources to answer the research questions. Through this case study, we find that Tzu Chi Foundation’s capacity to coordinate local and global COVID-19 issues quickly, broadly, and effectively can be attributed to three main factors: (1) clear mission and charismatic leadership, (2) rich experience of disaster relief and recovery strategies, and (3) committed and active volunteers. Moreover, we find that financial management capacity and adaptive capacity are two crucial kinds of capacity for enabling the Tzu Chi Foundation to survive and continuously engage in emergency responses during the pandemic. We conclude with implications for future nonprofit capacity and emergency management research. Key words: emergency management, nonprofit capacity, collaboration, pandemic response INTRODUCTION The ongoing COVID-19 pandemic is a modern, invisible leviathan that strikes numerous individuals and organizations around the world, greatly challenging current modes of governance. Amid such an unprecedented crisis, governments around the world seek to cope using different emergency management strategies.1,2 Nevertheless, because the pandemic crisis has resulted in significant impacts on various aspects of society, a country’s emergency management strategy to tackle COVID-19 issues entails not only government actions but also collective efforts from other sectors and ordinary citizens.3-5 Specially, the nonprofit sector is vital to effective emergency management because of its social missiondriven nature and capacities that compensate for the government’s insufficient public service delivery.6,7 The voluntary, philanthropic-driven, and ordinary citizens-based characteristics of nonprofit organizations (NPOs) enable them to serve as key actors in contemporary public governance.8,9 Moreover, prior studies also demonstrate the importance of nonprofit or community-based organizations in collaborative emergency management.4,5,10 As a crucial part of the nonprofit sector, volunteers also contribute significantly to various aspects of disaster relief activities.11 Therefore, this study seeks to examine emergency management during the COVID-19 pandemic from the perspective of the nonprofit sector. Amid the COVID-19 pandemic, the capacity crisis of the nonprofit sector is evident12-14 and to some extent, manifests typical features of “voluntary failure.”6 Some NPOs struggle to maintain operations and services, while others even fail to weather the crisis due to insufficient resource supports. For example, a recent survey focusing on Indiana NPOs12 finds that DOI:10.5055/jem.0647 05-SA-Weston-JEM#210070.indd 57 11/03/22 1:00 PM

58 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 71 percent of respondents report a decline in various sources of revenues since the coronavirus outbreak; moreover, over 60 percent of surveyed NPOs experience different levels of difficulties in operating their programs (from ending programs to operating with limited capacity). Furthermore, some NPOs may not survive in the pandemic due to funding shortages. For example, a recent survey of 424 NPOs worldwide shows that one-fourth of respondents would be forced to close down within 12 months if funding conditions do not change.15 Another recent report points out that half of US NPOs do not have cash for 6 months of operations.16 Related to funding issues, being considered as less essential services (such as the arts)17 and failing to transfer to new service modes (such as online services and fundraising)18 could also be reasons why some NPOs fail to survive amid the pandemic. This study asks the following research questions: in the face of tremendous challenges during the COVID-19 pandemic, what kinds of capacity are crucial for enabling NPOs to survive and engage in the emergency management process? Also, in the face of the pandemic, which dimensions of nonprofit capacity are especially important for NPOs to be able to offer local and global responses? To answer these questions, we first go through prior studies to identify key themes in current nonprofit capacity research. Next, we use the case of Buddhist Compassion Relief Tzu Chi Foundation (Tzu Chi) in Taiwan to demonstrate the importance of nonprofit capacity in current emergency management facing the challenges of COVID-19. As the largest Taiwan-based philanthropic organization, Tzu Chi has previously taken various relief actions to deal with many natural disasters in Taiwan and other countries.19-21 The case of Tzu Chi manifests how a nonprofit can survive in this pandemic and still continue to offer services locally and globally. We address how Tzu Chi has engaged in both local and global emergency management during this pandemic. Furthermore, we summarize the key themes regarding why Tzu Chi is capable of performing these actions. We then discuss how this research case could inform emergency management research and conclude with implications for future research directions. Nonprofit capacity and emergency management The concept of nonprofit capacity has received increasing attention in recent studies.22-25 This topic is important in that scholars, and practitioners seek to understand and build core capacities that enable NPOs to survive and grow in challenging social contexts.26 In particular, current research focuses on identifying and measuring the dimensions of nonprofit capacity24-26 and tries to connect capacity with effectiveness evaluation.22,27 For example, adopting the classic notion of Frumkin,28 Daniel and Moulton29 develop a conceptual framework that links capacity with nonprofit roles and related service objectives, including (1) service delivery; (2) innovation; (3) individual expression; and (4) civic engagement, political advocacy, and social capital creation. Moreover, Brown et al.26 utilize a nonprofit value framework to explore key capacity factors: resource portfolio (human capital, financial capital, physical capital, and social capital) and management functions (human relations, internal processes, open systems, program, and services). Other recent studies also seek to identify and measure nonprofit capacity.24,25 For example, Shumate et al.25 have developed an eight-factor instrument, including financial management, adaptive capacity, strategic planning, external communication, board leadership, operational capacity, mission orientation, and staff management. NPOs are regarded as one of the crucial actors in emergency management.30,31 NPOs’ engagement in disaster events can enhance the effectiveness of emergency management because those organizations share their expertise and information with governments. NPOs with resources for emergencies also can supplement and complement the emergency management strategies of public organizations by sharing the resources which those public organizations lack.32 For example, voluntary organizations cooperate with public organization for emergency management by helping victims and refugees in disaster events.33 In particular, volunteers have a positive impact 05-SA-Weston-JEM#210070.indd 58 11/03/22 1:00 PM

59 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 on their local communities because of their deep commitments.34 Moreover, prior research has addressed the importance of preparedness for NPOs to function well in emergency responses. For instance, Smith holds that NPOs can have a positive impact on emergency situations when organizations are better prepared for emergency management.35 Curnin and O’Hara also have emphasized the importance of prepared and organized volunteer management because scattered and unprepared voluntary organizations lack cohesiveness with emergency plans of government and face difficulties in accessing networks and resources on short notice, while prepared voluntary organizations are trained and educated for collaboration and cohesiveness in emergency management.36 The literature has shown significant efforts to identify various dimensions of nonprofit capacity; however, in times of crisis such as the current COVID-19 pandemic, the research community needs to revisit the concept of nonprofit capacity and examine what nonprofit capacity means when it comes to emergency management in times of pandemic. METHODS We employ an exploratory, single-case case study research design37 to address our research questions. Specifically, we choose Tzu Chi, the largest faith-based NPO in Taiwan, as the research case. We choose Tzu Chi for our study because its actions help us explore how a NPO can conduct local and global responses to COVID-19. Indeed, since Tzu Chi is an international religious NPO and Taiwan was not seriously impacted by the pandemic until May 2021, the case of Tzu Chi cannot represent small-tomedium-size NPOs and nonreligious organizations that have been struggling with the global disturbance. However, exploring Tzu Chi’s actions could shed light on the practices of international religious NPOs that provide disaster relief services. According to Baumgart-Ochse,38 as of 2012, there were around 339 international religious nonprofits that engage in activities related to development and humanitarian aid across the world. Tzu Chi’s capacities and experiences in disaster relief are especially useful for increasing our understanding about the patterns of similar international religious organizations. As an exploratory case study, this paper does not seek to examine causal relationships among variables. This study seeks to identify main themes regarding how international religious NPOs coordinate local and global emergency management. The exploratory findings from this study can be tested by future quantitative research. Our data sources include two major aspects. First, we collected information and secondary data from news, social media, literature, and the official websites of Tzu Chi and its overseas branches. In particular, we focused on gathering information related to Tzu Chi’s COVID-19 relief efforts since the pandemic’s outbreak in 2020. Second, we conducted semistructured interviews with Tzu Chi’s deputy chief executive officer, one scholar who conducted research about Tzu Chi’s disaster relief patterns, and six stakeholder representatives (including Tzu Chi’s target agencies, collaborative organizations, and members of the community that Tzu Chi serves). Table 1 shows the interviewee list. We selected those interviewees to reflect more comprehensive perspectives from Tzu Chi itself, key stakeholders, and academia. Based on these selection Table 1. Interviewees Interviewee type Interviewee description Stakeholder–target agency Local government official (A1) Local fire department official (A2) Stakeholder–collaborative organization Local hospital supervisor (A3) Local hospital supervisor (A4) Face mask company owner (A5) Stakeholder–communities that Tzu Chi serve Local village manager (A6) Scholars who study Tzu Chi Taiwan’s emergency management scholar (A7) Tzu Chi internal member Deputy chief executive officer (A8) 05-SA-Weston-JEM#210070.indd 59 11/03/22 1:00 PM

60 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 criteria, we employed the snowball sampling method to identify initial interviewees from our personal networks, conduct interviews, and ask interviewees to help identify or introduce other interviewees. In particular, we were able to interview Tzu Chi’s deputy chief executive officer, who helped summarize information from different units inside Tzu Chi, to understand more about how Tzu Chi conducts its local and global responses to COVID-19. For data analysis, we utilized the thematic analysis approach.39 First, we went through interview data and secondary data to identify initial codes. Second, we categorized those codes into meaningful themes. Third, based on those themes, we constructed three thematic maps to manifest Tzu Chi’s local and global responses as well as its capacities in responding to COVID-19. All authors were involved in the analysis process and reached a consensus together to ensure more objective findings. Tzu Chi: Local and global responses to the pandemic Founded by Master Cheng Yen in 1966, Tzu Chi was once a small faith-based charitable organization located in Hualien, Taiwan; over the past decades, Tzu Chi has evolved from a local organization in Taiwan to an international humanitarian organization that serves people in need around the world.21,40 It has four major missions: charity, medicine, education, and culture. Following these missions, Tzu Chi has conducted various charitable actions and established hospitals, education systems, and media channels.41 In particular, beginning from Bangladesh’s floods in 1991, Tzu Chi has since conducted numerous disaster relief actions in 97 countries and regions as of 2018. Therefore, Tzu Chi has rich experience in helping people in need who suffer from disasters around the world.21,42,43 The current COVID-19 pandemic is no exception. Since the coronavirus outbreak in China in early 2020, Tzu Chi’s affiliated organizations and volunteers have devoted significant efforts to respond locally and globally to help those in need. For domestic responses, as of June 2021, Tzu Chi has donated epidemic prevention materials to more than 157 organizations in Taiwan. Table 2 shows the detailed information. In 2021, Tzu Chi has focused more on offering medical gloves and helping establish screening stations, mainly due to the increasing number of cases in Taiwan since May 2021. For international responses, as of June 2021, Tzu Chi has donated epidemic prevention materials to 92 countries and regions, according to its official website. Table 3 shows data at two stages: April 2020 (the beginning stage of the pandemic) and June 2021 (the most recent Table 2. Tzu Chi’s domestic donation of epidemic prevention materials Epidemic prevention materials Numbers in 2020 Numbers in 2021 (as of May 2021) Medical face masks 52,400 items 3,190 items Protective suits and clothing 25,010 items 2,200 items Disinfectant or hand sanitizers 17,211 L 2,160 L Fabric face masks (for community use) 236,905 pieces Goggles and head covers 18,544 pieces 54,020 items Medical gloves 61,000 gloves 861,000 gloves Healthy vegetarian meals 13,486 meals Multipurpose beds 138 beds 315 beds Blankets 2,429 Shoe covers 15,500 items Instant noodles 454 packs Ethanol for disinfection 110 barrels Porridge 1,214 packs Forehead thermometer 274 items Blessing bags and food boxes 42,650 items 16,690 items Screening station 13 stations Source: Tzu Chi’s Facebook page. https://www.facebook. com/tzuchi.org/posts/4533360100011478. 05-SA-Weston-JEM#210070.indd 60 11/03/22 1:00 PM

61 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 situation). In addition to material donation, so far Tzu Chi has also offered various kinds of community care actions, benefiting more than 5 million people (2 million households).44 In the next section, we first discuss Tzu Chi’s efforts in Taiwan and then its global emergency relief actions. Tzu Chi’s local engagement Tzu Chi’s engagement in Taiwan’s efforts in fighting against COVID-19 can be categorized into three dimensions: collaboration with governments, community care, and the utilization of medical expertise (Figure 1). First, in addition to complying with governmental epidemic prevention regulations to adjust its regular activities, Tzu Chi collaborates with Taiwan governments in many aspects. For example, since local governments need more assistance to conduct care measures for those who are in quarantine, Tzu Chi’s volunteers step into help governments do telephone interviews for home quarantine care and offer food packets for those who need to quarantine. Moreover, during the period when Taiwan governments need more face masks, Tzu Chi’s volunteers participated in the operation of face mask factories that collaborate with the government. In addition, Tzu Chi also donates epidemic prevention supplies to various levels of the Taiwan government, especially border security management agencies. Tzu Chi’s effort represents part of the collaborative emergency management that enables Taiwan to perform relatively well in fighting the pandemic.45 Based on our data, we find that Tzu Chi does not engage in political activities. Collaborations between Tzu Chi and governments mainly focus on disaster response and recovery, environmental protection, and public health Figure 1. Tzu Chi’s pandemic responses in Taiwan. Table 3. Tzu Chi’s global donation of epidemic prevention materials As of April 22, 2020 As of June 6, 2021 Countries or regions that have received distributed relief aid 36 countries/ regions 92 countries/ regions Medical face masks 4,977,944 pieces 13,616,378 pieces Protective suits and clothing 447,856 items 1,663,645 items Disinfectant 37,422 L 68,480 L Fabric face masks (for community use) 197,882 pieces 322,255 pieces Face guards and goggles 159,312 items 678,180 items Medical gloves 6,144,400 gloves 10,598,100 gloves Blessing bags 61,816 bags 80,519 bags Healthy vegetarian meals 82,897 servings 85,561 servings Multipurpose beds 5,175 beds 6,290 beds Total numbers of donated materials 12,114,704 27,970,916 Source: Tzu Chi’s monthly reports (https://web.tzuchicul ture.org.tw/). 05-SA-Weston-JEM#210070.indd 61 11/03/22 1:00 PM

62 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 issues. Tzu Chi’s rich experience of disaster response is the key factor that various levels of Taiwan governments choose to work with Tzu Chi. More recently, another example of Tzu Chi-government collaborations is that, with the authorization of Taiwan’s government, Tzu Chi has signed a deal in July 2021 to buy five million doses of BioNTech’s COVID-19 vaccine and will donate them to the government for subsequent distribution.46 Given the emergency need for vaccines for people in Taiwan, Tzu Chi’s effort to purchase vaccines is remarkable. Second, community care has long been a central part of Tzu Chi’s charity efforts in Taiwan.40 Since the pandemic outbreak, Tzu Chi has conducted multidimensional community care actions, such as offering emergency assistance to vulnerable people struck by the crisis, helping students, and donating epidemic prevention supplies and food boxes to local healthcare workers.43 In particular, Tzu Chi’s volunteers and social workers utilize telephone interviews to evaluate the conditions of case families and conduct on-site visits of many schools. After that, Tzu Chi offers various forms of financial aids to those who face economic plights and to help students to study without worries. By conducting various community actions, Tzu Chi plays a role in stabilizing the community and helping the vulnerable, which is an important part of crisis governance during the pandemic. Third, because Tzu Chi has its own hospitals and university, it has the capacity to offer services that go beyond the scope of traditional philanthropic organizations. For instance, doctors in Tzu Chi hospitals serve as volunteers to participate in epidemic prevention affairs that help border security management agencies. Furthermore, in May 2020, Tzu Chi University and Taipei Tzu Chi hospital collaborated with Taiwan’s Academia Sinica to successfully develop COVID-19 rapid testing kits. These efforts illustrate Tzu Chi’s utilization of its medical expertise in responding to the pandemic. Tzu Chi’s global engagement We categorize Tzu Chi’s global engagement in COVID-19 responses into three dimensions: global collaboration, donation, and community care (Figure 2). First, Tzu Chi’s collaborations with various public, private, and NPOs around the world initiate its engagement in COVID-19 governance at the global level. As for collaborations with international organizations, Tzu Chi collaborates with the Office of the UN High Commissioner for Refugees to help deliver financial assistance in Malaysia. In terms of collaborations with individual countries, Tzu Chi donates medical supplies to Italy and the Vatican to help the clergy and healthcare workers, demonstrating interreligious collaboration and a common mission to serve people in need. Moreover, due to different restrictions in many countries, Tzu Chi strives to communicate, negotiate, and collaborate with various organizations (including local NPOs, companies, and governments) Figure 2. Tzu Chi’s global pandemic responses. 05-SA-Weston-JEM#210070.indd 62 11/03/22 1:00 PM

63 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 to distribute food and medical supplies to those in need.47 These collaborations demonstrate Tzu Chi’s endeavors to overcome social and cultural differences, paving the way for their global donation and community care actions. Second, based on the above-mentioned collaborations, Tzu Chi’s major global COVID-19 response is to donate food and epidemic prevention supplies to people in need around the world. Specifically, Tzu Chi has delivered those materials to countries that face serious COVID-19 challenges (such as the United States, Brazil, and Russia) and remote areas in other countries (including the Philippines, South Africa, Malaysia, and Indonesia). Tzu Chi donates materials not only to local people but also to organizations that have urgent needs for supplies, such as police agencies, hospitals, nursing homes, and food banks.48 These donations help compensate for the deficiency of many countries’ COVID-19 responses—especially the inability to take care of the vulnerable caused by the pandemic. Third, apart from donating food and supplies, Tzu Chi also conducts various community care actions in many countries. In particular, volunteers go to local communities in different countries to visit vulnerable groups of people, such as single-room occupancy residents in San Francisco, the underprivileged in Malaysia, and foreign workers in Singapore. Moreover, Tzu Chi conducts public health education, eg, wearing face masks, washing hands, and keeping social distancing, in some local communities where residents do not have sufficient epidemic prevention knowledge, such as areas in Mozambique. These efforts go beyond material support, providing other forms of aid and comfort to those affected by the pandemic crisis. DISCUSSION AND IMPLICATIONS FOR FUTURE RESEARCH Tzu Chi’s capacities in responding to COVID-19 How can Tzu Chi initiate various types of local and global responses to the COVID-19 pandemic? Based on our case study, we identify three major features and related capacities shown in Tzu Chi’s COVID-19 responses: clear organizational missions and charismatic leadership, rich disaster relief experience, and committed volunteers around the world (Figure 3). First, clear organizational missions and charismatic leadership are essential for Tzu Chi’s efforts.40,49 Tzu Chi’s founder, Master Cheng Yen, set up a righteous example for her followers to carry out Tzu Chi’s simple but clear mission—“To help those in need with love and care: We’re all one family on this Earth.” Because of Cheng Yen’s leadership and clear mission, Tzu Chi attracted numerous followers, earned great public trust, and then grew as an organizational system with solid fundraising capacity as well as strong human and social capitals. Clear missions and charismatic leadership led to Tzu Chi’s strong resource and management foundations.26 According to our interview with a scholar (interviewee A7) who previously studied Tzu Chi activities, we find that people who voluntarily participate in Tzu Chi are highly Figure 3. Tzu Chi’s capacities in responding to COVID-19. 05-SA-Weston-JEM#210070.indd 63 11/03/22 1:00 PM

64 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 committed to the organization’s missions. This, in turn, makes Tzu Chi’s emergency management much easier. Moreover, Tzu Chi’s deputy chief executive officer (interviewee A8) highlights that Cheng Yen’s value system makes her a charismatic leader. Her effective leadership not only affects the organization positively but also helps it contribute tremendously to the world. Second, another niche for Tzu Chi to conduct local and global responses to the COVID-19 pandemic is its rich disaster relief experience both in Taiwan and many other countries.50 In particular, through previous experiences, Tzu Chi has developed a wellorganized disaster relief system that consists of local community volunteers and professional groups (including entrepreneurs, healthcare professionals, and rescue teams).21,42 This system has operated even without crises to conduct preparedness activities. More importantly, while Tzu Chi has rich international disaster relief experience, it has developed associated expertise, including how to collaborate with different public, private, and NPOs in different countries.21 These experiences also enable Tzu Chi to know how to adaptively utilize various types of resources to conduct short-term rescue and long-term recovery activities, which highlights the importance of adaptive capacity.25 Our interview with Tzu Chi’s deputy chief executive officer (interviewee A8) shows that Tzu Chi has long been collaborating with many NPOs, universities, and government agencies on disaster management, environment protection, water resources, and post-disaster reconstruction. Since 2019, Tzu Chi has signed memorandums of understanding with four NPOs, two universities, and 20 government agencies to work on the above-mentioned four areas (interviewee A8). A scholar also points out in our interview that Tzu Chi plays quite an important role in emergency management in Taiwan. Many local governments invite Tzu Chi to participate in their meetings for pre- and post-disaster management (interviewee A7). A healthcare professional whom we interview reports that Tzu Chi sent its people to his hospital for medical training. The collaboration between Tzu Chi and his hospital has a positive effect on public health in the community (interviewee A3). Again, these experiences strengthen Tzu Chi’s reputation and contribute to its recent responses to the COVID-19 pandemic. Third, a significant advantage for Tzu Chi in conducting local and global actions is its committed and active volunteers around the world.21,51 Specifically, its volunteers have conducted various direct community-care field actions, especially in poor areas in other countries. These direct actions include significant efforts and selfless contributions. They also utilize personal networks to make international disaster relief actions possible. These volunteers’ longterm participation and service provision in different countries not only help express their personal faith but also enhance social capital, fulfilling three roles of NPOs in Daniel and Moulton’s framework.29 First, NPOs’ service delivery role means they offer services that governments and markets fail to provide. Tzu Chi’s volunteers’ actions fulfill this role, especially in some countries that do not have sufficient resources to help people in need. Second, NPOs’ individualexpression role means that NPOs conduct activities and prioritize outcomes that reflect the values of its key stakeholders (including volunteers). This role is fulfilled since Tzu Chi’s volunteers’ global actions enable them to express their value of charity. Third, NPOs also have a social-capital creation role that facilitates collaborations and social cohesion. This role is fulfilled because Tzu Chi’s volunteers’ community-care actions increase collaborations among different organizations and strengthen the networks helping local communities. Overall, these three features and related capacities enable Tzu Chi to engage in COVID-19 responses not only in Taiwan but also in many other countries. Amid the pandemic crisis, NPOs could offer significant contributions to successful crisis management.3,4 Collective emergency management is essentially a governance process that entails collective efforts to confront great uncertainties and resource limitations.5,52 That is to say, the government (offering guidelines and regulations for the people) and its people (through participation in NPOs’ efforts) play different roles in the collaborative process to fight with the pandemic. Prior research has demonstrated that, due to limited capacities and organizational fragility, 05-SA-Weston-JEM#210070.indd 64 11/03/22 1:00 PM

65 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 the government cannot by itself conduct emergency responses without the involvement of citizens.53 Active citizen participation in the emergency management process enhances the possibility of coproduction, complementing the service-delivery capacity of public organizations.54,55 In our cases, governments around the world design related guidelines and policy regulations to cope with the pandemic. Citizens’ participation (such as donation and volunteering) in Tzu Chi could enable Tzu Chi to offer services and goods that governments need or fail to provide (such as community care or epidemic prevention materials). Hence, governments and citizens play different roles in the collaborative emergency management process. Our study aims to explore how Tzu Chi performs local and global responses to COVID-19. There are some similarities and differences between Tzu Chi and other Taiwan-based NPOs. In terms of similarities, some NPOs also offer emergency aids and services during and after disasters, as Tzu Chi does. For example, like Tzu Chi, the Red Cross Society of Taiwan and World Vision Taiwan have also helped offer permanent housing for those who suffer from natural disasters.56 Moreover, some Taiwanese NPOs also have international disaster relief experiences. For instance, based on their experiences in the Sichuan earthquake, the Red Cross Society of Taiwan formed the 88 Flooding Service Alliance to integrate various NPOs’ post-disaster relief efforts that help people affected by Typhoon Morakot.43 In terms of differences, unlike those Taiwanese NPOs that offer disaster relief responses, because of its four major missions, Tzu Chi offers more diverse services, including disaster relief, environmental sustainability, social education, and public health issues, enabling Tzu Chi to develop multiple dimensions of knowledge that could be useful in COVID-19 responses. In addition, Tzu Chi’s flexible but strong volunteer groups distinguish Tzu Chi from other disaster relief NPOs. Furthermore, there are also some Taiwan-based international religious NPOs, such as the Buddha’s Light International Association. Although those organizations also offer social services, they do not have rich disaster relief experiences as Tzu Chi did. Thus, other Taiwanese faith-based NPOs may not be able to conduct both local and global COVID-19 responses. Nonprofit capacities for survival and service engagement during the pandemic The aforementioned discussion has addressed one of our two research questions: what key capacity dimensions enable NPOs to offer local and global responses to the pandemic? Furthermore, by analyzing the case of Tzu Chi, we are able to answer the other question regarding crucial kinds of capacity for enabling NPOs to survive and still be able to engage in the emergency management process. As noted earlier, previous studies have identified various dimensions of nonprofit capacity, including organizational resources, eg, social capital, human capital, and financial capital, and different aspects of management capacity, eg, adaptive capacity, external communication, board leadership, and mission orientation.24-26 Moreover, the literature has begun to examine the pandemic’s impact on NPOs’ service continuity and resilience strategies.12-14 By analyzing the case of Tzu Chi, we contend that under the pandemic’s threat, two kinds of capacity are especially critical to NPOs’ survival and continuous engagement in the emergency management process: financial management capacity and adaptive capacity. First, to survive during the pandemic, NPOs need to have strong financial management capacity to ensure their survival and continuous service delivery. The case of Tzu Chi shows that fundraising capacity and funding diversification are two important aspects of financial management capacity for NPOs facing the pandemic. Tzu Chi is arguably the largest NPO in Taiwan in terms of “membership, assets, budget, and social influence.”21 According to its most recent annual report,57 Tzu Chi received approximately 193 million USD in charitable donations in 2019. Tzu Chi has a successful fundraising strategy “developing a network of donors committed to small amounts of planned monthly or yearly donations.”58 Tzu Chi’s fundraising capacity is also related to its positive reputation for actively engaging in disaster responses.21,42,43 Furthermore, the literature has pointed out the importance of funding 05-SA-Weston-JEM#210070.indd 65 11/03/22 1:00 PM

66 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 diversification for NPOs during the pandemic.14 Tzu Chi serves as a good example of diversifying funding sources. According to its annual report, Tzu Chi’s headquarters’ income sources are diverse, including charitable giving, investment income, eg, interest and stock, earned income, eg, product sales, associated organizations’ income, and other income. Moreover, per our interview with Tzu Chi’s deputy CEO (A8), we find that the majority of Tzu Chi’s overseas branches are financially independent. Thus, as an international NPO, Tzu Chi does not rely totally on its Taiwan headquarters to financially support global responses to the pandemic. Second, NPOs need to increase their adaptive capacity to continue engaging in the emergency management process. As Shumate et al. argue, adaptive capacity “refers to the way organizations adapt to changes in their environment, and consists of organizational learning, responsiveness, innovativeness, and motivation.”25 The pandemic has significantly changed various aspects of our lives, and different countries encounter different problems in the midst of the pandemic. Therefore, adaptive capacity is very important for enabling NPOs to offer services during the pandemic. Tzu Chi has shown evidence of strong adaptive capacity. Its four major missions (charity, medicine, education, and culture) enable it not only to offer traditional disaster responses but also to utilize medical expertise to deal with the pandemic. Moreover, as our interviewee (A7) and the literature42 point out, Tzu Chi’s flexible organizational structure is one of the key features of its emergency responses. Because of such organizational flexibility, Tzu Chi’s local volunteer teams are able to have more autonomy in adjusting their actions to suit local needs. Tzu Chi’s international collaborations also demonstrate its organizational flexibility. For instance, as Tzu Chi’s deputy CEO (A8) noted, even though Tzu Chi does not have an India branch, it works with local NPOs and manages to deliver epidemic prevention materials to India. Consistent with what Shi et al. argue,13 Tzu Chi’s long-term engagement in Taiwan and global disaster relief actions enable Tzu Chi to be familiar with local needs and adapt itself to the changing environment caused by the pandemic. Implications for future research The aforementioned discussion has demonstrated how international religious NPOs, such as Tzu Chi, can serve as active responders in emergency management locally and globally. The case of Tzu Chi is unique in terms of pandemic responses in the global context. First, because of its well-earned reputation in disaster response, Tzu Chi has received significant donation support from Taiwan and other countries.21,57 A strong headquarters and financially independent overseas branches do enhance Tzu Chi’s overall resilience during the pandemic. Second, service professionalization distinguishes Tzu Chi from other Buddhist organizations in the world. While other Buddhist organizations are limited in traditionally charitable services (such as donating to professional humanitarian groups),21,59,60 Tzu Chi’s development of its own professional disaster response teams and experts is unique.21 Professional expertise and rich experience enable Tzu Chi to continue disaster response activities at both the domestic and international levels during the pandemic. Given the aforementioned discussions about Tzu Chi’s capacities to perform local and global responses to the pandemic, we have identified some challenges or limitations regarding Tzu Chi’s actions from our interview data. First, the services and goods offered by Tzu Chi may not always fit the needs of target organizations and communities. As two interviewees (A2 and A3) point out, some target organizations and communities may not need the materials Tzu Chi donates. Therefore, we suggest that Tzu Chi contacts target organizations and communities in advance to understand their needs. In particular, as a Taiwan-based Buddhist NPO, Tzu Chi needs to be careful when dealing with different cultural (Western and Eastern) and religious (Buddhist and Christian) contexts in Taiwan and other countries. Offering services or goods that do not appropriately fit the needs of target organizations or individuals could result in negative perceptions toward Tzu Chi. Previous studies61,62 and the opinion of our interviewee A7 also demonstrate that Tzu Chi’s good intentions could end up being controversial. The key point is to respect cultural and religious contexts 05-SA-Weston-JEM#210070.indd 66 11/03/22 1:00 PM

67 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 of target organizations and communities, and a full communication process involving Tzu Chi and beneficiaries is needed. This is an important issue for international religious NPOs that seek to offer global responses to COVID-19. Second, offering global responses brings about various types of challenges. As Tzu Chi’s deputy CEO (interviewee A8) told us, different countries have different regulations about customs clearance and procurement processes, which makes it difficult for Tzu Chi to prepare epidemic prevention materials. Moreover, unlike natural disaster-relief actions, COVID-19 responses entail more professional medical knowledge and strategies. To meet this challenge, Tzu Chi’s own hospitals help the headquarters to make decisions. However, Tzu Chi’s ability to initiate local and global responses to COVID-19 does offer some implications for future emergency management and nonprofit capacity scholarship. First, future nonprofit research could further identify nonprofit capacity for emergency management in times of pandemic. While prior research on nonprofit capacity mainly focuses on identifying and measuring nonprofit capacities during regular conditions,24-26 the literature has not yet documented whether these capacities can enable NPOs not only to survive but also to provide services to people in need during a global-scale pandemic crisis. Second, NPOs’ missions matter in terms of NPOs’ involvement in emergency management. Our study finds that a main reason why Tzu Chi is able to quickly, broadly, and effectively respond to this COVID-19 pandemic is associated with the fact that its leader who gives the organization a clear mission. Good leaders are hard to find, but good missions are often available. In their study of nonprofit performance, Pandey et al.63 conclude that it is important for NPOs to craft missions that convey the activities of their organizations. We, thus, encourage future studies to investigate whether crafting mission statements with clear rescue activities improves disasterrelief NPOs’ capacities to respond to crises. Finally, the case of Tzu Chi shows that effective collaborations among NPOs are crucial to effective emergency management. Thus, having good connections with other partner organizations could also serve as a key dimension of nonprofit capacity.64 While many NPOs are suffering due to the COVID-19 pandemic, some NPOs have rich disaster-relief experience and the capacity to work with others to deliver services. Future research could explore and examine how NPOs build connections with other NPOs to improve their own capacities and how collaborations among NPOs can help them to engage effectively in emergency management. Chin-Chang Tsai, PhD, Institute of Public Affairs Management, National Sun Yat-Sen University, Kaohsiung, Taiwan. ChiaKo Hung, PhD, Public Administration Program, University of Hawaii at Manoa, Honolulu, Hawaii. Wei-Ning Wu, PhD, Institute of Public Affairs Management, National Sun Yat-Sen University, Kaohsiung, Taiwan. ORCID: https://orcid. org/0000-0002-7113-7923. REFERENCES 1. Rajan D, Koch K, Rohrer K, et al.: Governance of the Covid-19 response: A call for more inclusive and transparent decisionmaking. BMJ Glob Health. 2020; 5(5): e002655. DOI: 10.1136/ bmjgh-2020-002655. 2. Comfort LK, Kapucu N, Ko K, et al.: Crisis decision-making on a global scale: Transition from cognition to collective action under threat of COVID-19. Public Adm Rev. 2020; 80(4): 616-622. DOI: 10.1111/puar.13252. 3. Comfort LK: Crisis management in hindsight: Cognition, communication, coordination, and control. Public Adm Rev. 2007; 67(Suppl. 1): 189-197. 4. Kapucu N: Collaborative emergency management: Better community organising, better public preparedness and response. Disasters. 2008; 32(2): 239-262. 5. Wachhaus A: Bootstrapping disaster: The challenge of growing and maintaining a cross-sector collaborative network. J Emerg Manag. 2016; 14(6): 397-411. 6. Salamon LM: Of market failure, voluntary failure, and thirdparty government: Toward a theory of government-nonprofit relations in the modern welfare state. Nonprofit Volunt Sect Q. 1987; 16(1-2): 29-49. 7. Berlan D: Understanding nonprofit missions as dynamic and interpretative conceptions. Nonprofit Manag Leadersh. 2018; 28(3): 413-422. DOI: 10.1002/nml.21295. 8. Bingham LB, Nabatchi T, O’Leary R: The new governance: Practices and processes for stakeholders and citizen participation in the work of government. Public Adm Rev. 2005; 65(5): 547-558. 9. Salamon LM: America’s Nonprofit Sector: A Primer. New York, NY: Foundation Center, 1992. 10. Murphy H, Pudlo J: Bridging cultures: Nonprofit, church, and emergency management agency collaboration after the May 2013 Oklahoma tornado outbreak. J Emerg Manag. 2017; 15(3): 157-174. 11. Fernandez LS, Barbera JA, van Dorp JR: Spontaneous volunteer response to disasters: The benefits and consequences of good intentions. J Emerg Manag. 2006; 4(5): 57-68. 05-SA-Weston-JEM#210070.indd 67 11/03/22 1:00 PM

68 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 12. Grønbjerg KA, Mcavoy E, Habecker K: Indiana nonprofits and COVID-19: Impact on services, finances, and staffing. Bloomington, IN, 2020. Available at https://nonprofit.indiana.edu/doc/publica tions/covid-19-impact.pdf. Accessed July 22, 2021. 13. Shi Y, Jang HS, Keyes L, et al.: Nonprofit service continuity and responses in the pandemic: Disruptions, ambiguity, innovation and challenges. Public Adm Rev. 2020; 80(5): 874-879. DOI: 10.1111/ puar.13254. 14. Hutton NS, Mumford SW, Saitgalina M, et al.: Nonprofit capacity to manage hurricane-pandemic threat: Local and national perspectives on resilience during COVID-19. Int J Public Adm. 2021; 44(11-12): 984-993. 15. CAF America: The Face of Charities during COVID-19 Worldwide. Vol. 5. Alexandria, VA: Charities Aid Foundation of America, 2021. Available at https://www.cafamerica.org/wp-content/ uploads/5_CV19_Report_9_22.pdf. Accessed July 22, 2021. 16. Candid, Center for Disaster Philanthropy: Philanthropy and COVID-19: Measuring One Year of Giving. Washington, DC: Candid and the Center for Disaster Philanthropy, 2021. Available at https:// www.issuelab.org/resources/38039/38039.pdf. Accessed July 22, 2021. 17. McCartney R: Nonprofits in trouble: One-third of organizations may not survive pandemic, recession. The Washington Post, 2020. Available at https://www.washingtonpost.com/local/non-profits-coronavirus-fail/2020/08/02/ef486414-d371-11ea-9038-af089b63ac21_ story.html. Accessed July 22, 2021. 18. Strub C: 1 in 4 nonprofits “not sure” how to approach events in 2021. Report. Forbes, 2021. Available at https://www.forbes.com/sites/ chrisstrub/2021/03/29/1-in-4-nonprofits-not-sure-how-to-approachevents-in-2021-report/?sh=55706e272d0a. Accessed July 22, 2021. 19. Montlake S: Taiwan charity has global reach. The Wall Street Journal. 2010. Available at https://www.wsj.com/articles/SB100014 24052748704353404575114661869717700. Accessed July 22, 2021. 20. Santiago JSS, Manuela WS, Tan MLL, et al.: Of timelines and timeliness: Lessons from Typhoon Haiyan in early disaster response. Disasters. 2016; 40(4): 644-667. 21. Lee C, Han L: Becoming INGO: A case study on Taiwan’s TzuChi in the United States. VOLUNTAS. 2020; 31(6): 1201-1211. DOI: 10.1007/s11266-020-00270-1. 22. Bryan TK: Toward a contingency model for the relationship between capacity and effectiveness in nonprofit organizations. Nonprofit Volunt Sect Q. 2019; 48(4): 885-897. 23. Christensen RK, Gazley B: Capacity for public administration: Analysis of meaning and measurement. Public Adm Dev. 2008; 28(4): 265-279. 24. Despard MR: Can nonprofit capacity be measured? Nonprofit Volunt Sect Q. 2017; 46(3): 607-626. 25. Shumate M, Cooper KR, Pilny A, et al.: The nonprofit capacities instrument. Nonprofit Manag Leadersh. 2017; 28(2): 155-174. 26. Brown WA, Andersson FO, Jo S: Dimensions of capacity in nonprofit human service organizations. VOLUNTAS. 2016; 27(6): 2889-2912. 27. Eisinger P: Organizational capacity and organizational effectiveness among street-level food assistance programs. Nonprofit Volunt Sect Q. 2002; 31(1): 115-130. 28. Frumkin P: On Being Nonprofit: A Concept and Policy Primer. Cambridge, MA: Harvard University Press, 2002. 29. Daniel JL, Moulton S: Beyond cans and capacity: Nonprofit roles and service network objectives in an emergency food network. Nonprofit Manag Leadersh. 2017; 28(1): 47-64. 30. Brudney JL, Gazley B: Planning to be prepared: An empirical examination of the role of voluntary organizations in county government emergency planning. Public Perform Manag Rev. 2009; 32(3): 372-399. 31. Wu W-N, Chang S-M, Collins BK: Mobilizing voluntary organizations in Taiwanese emergency response: Citizen engagement and local fire branch heads. J Contemp East Asia. 2015; 14(2): 45-55. 32. Waugh WL, Jr., Streib G: Collaboration and leadership for effective emergency management. Public Adm Rev. 2006; 66(S1): 131-140. 33. Aggarwal VRK: The role of oral health in complex emergencies and disaster rehabilitation medicine. Disaster Med Public Health Prep. 2018; 12(6): 772-777. 34. Musso JA, Young MM, Thom M: Volunteerism as co-production in public service management: Application to public safety in California. Public Manag Rev. 2019; 21(4): 473-494. 35. Smith SL: Coping with disaster: Lessons learned from executive directors of nonprofit organizations (NPOs) in New Orleans following Hurricane Katrina. Adm Soc Work. 2012; 36(4): 359-389. 36. Curnin S, O’Hara D: Nonprofit and public sector interorganizational collaboration in disaster recovery: Lessons from the field. Nonprofit Manag Leadersh. 2019; 30(2): 277-297. 37. Yin RK: Case Study Research: Design and Methods. 5th ed. Thousand Oaks, CA: Sage Publications, 2013. 38. Baumgart-Ochse C. Introduction. In Baumgart-Ochse C, Wolf KD (eds.): Religious NGOs at the United Nations: Polarizers or Mediators? London: Routledge, 2018: 1-25. 39. Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2): 77-101. DOI: 10.1191/1478088706qp063oa. 40. Huang CJ: Charisma and Compassion: Cheng Yen and the Buddhist Tzu Chi Movement. Cambridge, MA: Harvard University Press, 2009. 41. Leonard HB, Chu YK. The Tzu Chi Foundation’s China Relief Mission. Harvard Business School Case 311-015, 2011. 42. Han CC: Exploring self-organizing processes of the disaster relief system: Implications from Tzu Chi’s experiences [in Chinese]. Chinese Local Gov. 2013; 66(11): 23-48. 43. Wu W-N, Chang S-M: Collaboration mechanisms of Taiwan nonprofit organizations in disaster relief efforts: Drawing lessons from the Wenchuan earthquake and Typhoon Morakot. Sustainability. 2018; 10(11): 4328. DOI: 10.3390/su10114328. 44. Update for Tzu Chi’s distribution of COVID-19 relief materials. Available at https://www.tzuchi.org.tw/featured/help/2019新型冠狀 病毒防疫. Accessed June 6, 2021. 45. Huang IYF: Fighting against COVID-19 through government initiatives and collaborative governance: Taiwan experience. Public Adm Rev. 2020; 80(4): 665-670. DOI: 10.1111/puar.13239. 46. Hsin-Fang L: Tzu Chi foundation inks vaccine deal. Taipei Times. 2021. Available at https://www.taipeitimes.com/News/front/ archives/2021/07/22/2003761256. Accessed July 22, 2021. 47. Djalante R, Lassa J, Setiamarga D, et al.: Review and analysis of current responses to COVID-19 in Indonesia: Period of January to March 2020. Prog Disaster Sci. 2020; 6: 100091. DOI: 10.1016/j. pdisas.2020.100091. 48. Whitaker J: Buddhist compassion relief Tzu Chi foundation offers coronavirus aid to the Vatican and beyond. Buddhistdoor Global. 2020. Available at https://www.buddhistdoor.net/news/bud dhist-compassion-relief-tzu-chi-foundation-offers-coronavirus-aidto-vatican-and-beyond. Accessed July 22, 2021. 49. Yan H: Social entrepreneurship of the Buddhist Tzu Chi Movement. Am J Entrep. 2012; 1: 37-57. 50. Eadie P, Su Y: Post-disaster social capital: Trust, equity, Bayanihan and Typhoon Yolanda. Disaster Prev Manag. 2018; 27(3): 334-345. DOI: 10.1108/DPM-02-2018-0060. 51. Brummans BHJM, Hwang JM: Tzu Chi’s organizing for a compassionate world: Insights into the communicative praxis of a Buddhist organization. J Int Intercult Commun. 2010; 3(2): 136- 163. DOI: 10.1080/17513051003611610. 05-SA-Weston-JEM#210070.indd 68 11/03/22 1:00 PM

69 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 52. Kapucu N, Ustun Y: Collaborative crisis management and leadership in the public sector. Int J Public Adm. 2018; 41(7): 548-561. DOI: 10.1080/01900692.2017.1280819. 53. Bosomworth K, Owen C, Curnin S: Addressing challenges for future strategic-level emergency management: Reframing, networking, and capacity-building. Disasters. 2017; 41(2): 306-323. 54. Wu W-N, Chang K, Tso Y-E: If only we knew what we know: Factors for mobilizing citizen participation in community-based emergency preparedness. Chinese Public Adm Rev. 2016; 7(1): 77- 109. 55. Pyles L, Svistova J, Ahn S, et al.: Citizen participation in disaster recovery projects and programmes in rural communities: A comparison of the Haiti earthquake and Hurricane Katrina. Disasters. 2018; 42(3): 498-518. 56. Lai AYH: Towards a collaborative cross-border disaster management: A comparative analysis of voluntary organizations in Taiwan and Singapore. J Comp Policy Anal Res Pract. 2012; 14(3): 217-233. 57. Taiwan Buddhist Tzu Chi Foundation: 2019 annual report [in Chinese]. 2020. Available at https://www.tzuchi.org.tw/ financial/2019financial/. Accessed July 22, 2021. 58. Lo K-T, Wu S-Y: Giving in Taiwan: On the rise following economic growth and political democratization. In Wiepking P, Handy F (eds.): The Palgrave Handbook of Global Philanthropy. New York, NY: Palgrave Macmillan, 2015, 455-472. 59. McLaughlin L: Japanese religious responses to COVID-19: A preliminary report. Asia-Pacific J Jpn Focus. 2020; 18(9): 1-23. 60. Salguero CP: Buddhist responses to the COVID-19 pandemic in historical perspective. Buddhistdoor Global. 2020. Available at https://www.buddhistdoor.net/features/buddhist-responses-tothe-covid-19-pandemic-in-historical-perspective. Accessed July 20, 2021. 61. Tsai Y-L: Trojan horses of neoliberalism: The case of Tzu Chi’s Da Ai village [in Chinese]. Community Dev Q. 2010; 131: 261-276. 62. Wang FTY: Helping relations and subjectivity of indigenous peoples in post-disaster recovery: Returning to whose home? [in Chinese]. Taiwan: Radic Q Soc Stud. 2010; 78: 437-449. 63. Pandey S, Kim M, Pandey SK: Do mission statements matter for nonprofit performance? Insights from a study of US performing arts organizations. Nonprofit Manag Leadersh. 2017; 27(3): 389-410. 64. Gazley B, Guo C: What do we know about nonprofit collaboration? A comprehensive systematic review of the literature. Nonprofit Manag Leadersh. 2020; 31(2): 211-232. DOI: 10.1002/ nml.21433. 05-SA-Weston-JEM#210070.indd 69 11/03/22 1:00 PM

Dr. Geoffrey Simmons, MD, CERT Trainer, applies this most uncommon of senses to the serious subject of disaster preparedness, giving an invaluable primer in an area where proactive may be the ideal, but reactive is oen the reality...sometimes with tragic consequences. With the chance of you being involved in a disaster during your lifetime one in four, this guide belongs in your home alongwith yourwell-equipped prep kit. Dr. Simmons designed Common Sense and Disaster Preparedness to be succinct, comprehensive, durable and sized (4”x9”)to fitright in your back pocket! is guide will show you how most life-saving preparatory steps are easy, logical and inexpensive. e guide is organized in several sections, before a disaster, during a disaster, aer a disaster and includes a special section for medical emergencies. islastsectionwaswritten to make it easy forthe non-medical person to deal with most life-threatening injuries during a disaster. e guide includes a comprehensive table of contents and a detailed index that allows the user to quickly find critical information. Order yourcopy today! Order 250 or more and we will customize the firstfourtext pages for you. Call for details. Perfectfor outreach to your at-risk citizen populations! Name________________________________________________________ Title ________________________________________________________ Company ____________________________________________________ Street Address ________________________________________________ City ________________________________________________________ State________________Postal/Country ____________________________ E-mail: ______________________________________________________ SPECIAL OFFER FOR JEM SUBSCRIBERS Being prepared is being informed! þ For faster service call our order department at 800-743-7206 x108, fax this form to 781-899-4900 or mail this form to: Common Sense and Disaster Preparedness, 470 Boston Post Rd, Weston, MA 02493 www.commonsenseanddisasterpreparedness.com *Volume orders include US ground shipping, Outside US-call for quote, Delivery 1-4 weeks for 1-200 copies, 3-6 weeks for custom orders. qCheck enclosed q Please call me for a custom quote on 250+ guides! qMasterCard qVisa qAMEX qPO#_____________________ Card No. ______________________________________________ Exp. Date _____________________________________________ Name on credit card _____________________________________ Address on credit card ___________________________________ X ____________________________________________________ Signature required Fed Tax ID # 20 882 8337 (Required to access online updates) 13129_JEM 04/16/14 Rev. B JEMV20N7 Common Sense and Disaster Preparedness A Quick Yet Comprehensive Guide for Staying Safe Before, During and Aer Any Disaster By Geoffrey Simmons, MD, CERT Trainer “Chance favors the prepared mind.” - Louis Pasteur ISBN: 9780932834508 210 pages Please rush my copy of Common Sense and Disaster Preparedness — Single Copy q $24.95, add $3.50 for USPS Postage Volume Pricing*-Each: 2-10 $23.95; 11-25 $22.95; 26-100 $21.95; 101-up $18.95 Total Copies Ordered__________ Total cost*:__________ Are you prepared? Scan here to order now Turn local residents into well prepared, self-reliant citizens! New Second Edition 13129_JEM_V20N7_CSDP_Layout 1 3/11/2022 10:00 AM Page 1

JEM 71 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Innovative public health staff augmentation concepts during a global pandemic Valerie Beynon, MA, CEM, FPEM Susan James, AA Amy Graham, BS Danielle Baxter, MPA Christina Stenberg, MPH, MEP ABSTRACT At the onset of the COVID-19 global pandemic, Florida’s State Emergency Response Team’s Emergency Support Function 8 (ESF-8) Health and Medical Staffing Unit faced a surge of personnel requests from the field. The unit found that, given the scope of requests, standard disaster staffing practices could not always accommodate the requirements of the requests. With full support of leadership, the ESF-8 Staffing Unit developed new and innovative practices to streamline the cumbersome hiring process including coordinating with internal and external partners to expedite staff identification and implementing just-in-time training. Key words: pandemic, COVID-19, disaster, staff augmentation, surge capacity, just-in-time training, public health, human resources INTRODUCTION A surge in personnel resources arises when the demand for a greater number of people with diverse skill sets materializes during operations.1 A surge may happen for a variety of reasons, including a natural or man-made disaster. Fulfilling disaster staffing surge needs during a hurricane, or related disaster, relies on established relationships with sources for skilled or trainable individuals. In contrast, the unpredictable nature of the waves of a global pandemic affects the government’s capacity to respond with sufficient resources. The pool of standard sources for additional support— internal personnel, contractors, staffing services, and consultants—becomes exhausted. The ability to treat a large increase in the number of persons requiring care following an emergency—an essential aspect of public health planning for surge capacity—involves supporting community public health systems. System partners’ services, including hospitals, local health departments, and community agencies, may experience the strain, causing a cascading effect emanating from the local to the state to the national level.2-4 With both scenarios, the need for additional staff becomes urgent, and responders must be deployed quickly. Used by organizations to increase agility and respond to changing needs when addressing surge capacity, staff augmentation utilizes personnel from outside the organization on a temporary basis to expand capacity for emergency or nonemergency operations to continue.5 Depending on the numbers, skillsets, and credentials needed, using a pool of temporary employees, staffing services, consultants, or contract workers may address this issue.5-7 Staffing professionals face new-hire and recruitment pipeline issues during emergencies including modifications to their hiring prioritizations and procedures. This may result in placing new hiring on hold or requiring new staff to start immediately to fill or backfill existing positions or operationalize new locations.6 Therefore, a lengthy hiring process to bring new staff onboard can severely affect the ability to respond appropriately. The skillsets, credentials, and trainability of potential staff play a crucial role in supporting community mitigation, including the implementation of nonpharmaceutical interventions. In an effort DOI:10.5055/jem.0672 06-SA-Weston-JEM#220002.indd 71 11/03/22 1:00 PM

72 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 to “build the bench,” predisaster training improves readiness for current personnel pools in preparation for an activation but may not be viable for some situations. Leveraging just-in-time (JIT) training to create a force multiplier utilizes personnel with the aptitude to quickly learn, adapt, and assist.7,8 SITUATION As a guide to how the United States responds to disasters and emergencies, the National Response Framework describes how Emergency Support Functions (ESFs) at the federal level primarily provide structure for coordinating interagency support for incident response and the ability to group functions during declared emergencies and disasters and nondeclared incidents to provide support to states. Fifteen ESFs comprise the federal structure.9 Similar to the federal and many state governments, Florida utilizes the ESF model to organize and manage response resources and capabilities. Florida’s State Emergency Response Team (SERT) provides disaster support to county emergency management agencies statewide. The Florida Department of Health (FDOH) and the SERT utilize the Incident Command System (ICS), comprised of eight branches and 18 ESFs staffed by skilled individuals from government agencies and partner organizations (Figure 1). These entities work together to fulfill county mission tasks and requests for direct aid to disaster impact areas.10 ESF-8 (Health and Medical), led by the FDOH, oversees Florida’s public health and healthcare response systems. Integrated with multijurisdictional emergency management efforts, the ESF-8 ensures execution of coordinated emergency response actions codified in statute, rule, policies, and plans.11 Located within the Logistics Section, the ESF-8 Staffing Unit’s responsibilities include assigning staff requested by counties or the SERT through missions during all phases of the event (Figure 2). Staffing requests during a “normal” response typically require immediacy and an increased quantity of resources for a short duration of time (usually less than one month) to a specific geographic area for hurricane, tornado, and flood missions supporting special needs shelters, incident management teams, environmental health, and epidemiology teams. During hurricanes, for example, the ESF-8 Staffing Unit often uses contractual service companies and the Emergency Management Assistance Compact (EMAC) to provide added staffing. As a national Figure 1. Chart of Florida State Emergency Response Team’s Emergency Support Functions.12 06-SA-Weston-JEM#220002.indd 72 11/03/22 1:00 PM

73 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 system enabling states to share resources during times of disaster, EMACs support staffing demands during incidents by “.  .  .  providing timely and costeffective relief to impacted states requesting assistance from assisting member states  .  .  .  .”14 EMACs from Mississippi and other states supported Florida response efforts in 2018 during Hurricane Michael, a Category 5 storm affecting nine counties. The ESF-8 Staffing Unit also provided 544 personnel from the department including staff from regions outside the affected area, and contractual services over a 4-week period to fill critical positions in the devastated area.15 In contrast, missions requesting staffing during the COVID-19 pandemic arrived from every county in the state after the Florida Governor Ron DeSantis declared a COVID-19 Public Health Emergency.16 This required support staff to work in the call and email centers responding to requests from the public, the long-term testing units to download test results from the laboratories and provide formatted data to the county health departments, and the State Emergency Operations Center. Resources unique to COVID-19 included testing sites, border screenings, airport screenings, laboratory support, and county health department COVID-19 activities in support of epidemiological teams. Weigh stations, laboratories, and airports were staffing mission areas not normally encountered during hurricanes. Also, since the response was of a global demand, the ESF-8 Staffing Unit found themselves in direct competition with other jurisdictions and organizations requesting contractual service staffing making mission fulfillment challenging. OUTCOME Innovative staffing sources As a result of the unique obstacles brought on by the pandemic, the ESF-8 Staffing Unit looked for new and innovative ideas to address these challenges. This search opened doors to other areas of the department for staffing support since the usual pool of response personnel was activated and assigned to other parts of the state. It also provided an opportunity to expand evolving relationships with external partners. Emergency duty policy The extended length of staffing needs during the pandemic—over 9 months, compared to the standard 2-4 weeks for hurricanes, tornadoes, or floods—and the increase in roles and duties to fill, required the ESF-8 Staffing Unit to utilize the Department’s Emergency Duty policy and procedures. Figure 2. Florida ESF-8 Staffing Unit responsibilities.13 06-SA-Weston-JEM#220002.indd 73 11/03/22 1:00 PM

74 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 FDOH staff throughout Florida may receive an activation notification for mandatory emergency duty in the case of a disaster or public health emergency. All staff complete their registration in the Department’s Health Alert Network, Alerting and Notification System upon their hiring. Emergency Duty group 1, under the emergency duty policy, denotes staff members with specific skills or training with the ability to respond and deploy outside of their county of employment, if needed.17 They also must maintain a current State of Florida Purchasing Card with travel and fuel provisions to ensure their readiness and preparedness for deployment. Emergency Duty group 2 includes secondary response personnel activated for support roles within their county of employment. Only those employees on Continuous Approved Medical Leave can request a permanent exemption from emergency duty. Although the supervisor or the Department’s Bureau of Personnel and Human Resource Management (BPHRM) may grant staff temporary exemptions from emergency duty activation or deployment as appropriate, preapproved annual and/or compensatory leave may be canceled or altered. Failure to comply with this policy may result in disciplinary action or dismissal.18 Internal partners Leadership’s support and guidance of the Department’s response efforts throughout the pandemic played a crucial role in fulfilling missions and providing needed support for the critical roles to be filled. Of particular importance: leadership support authorizing the BPHRM to prioritize the hiring of positions related to the pandemic. This authorization allowed human resources (HRs) staff to implement a targeted process for a specific group of positions, expediting the average hiring time frame from weeks to days by 75 percent while ensuring consistency with the recruitment process. This significant increase in hiring resulted in added capacity in mission critical areas, including testing sites, contact tracing centers, warehouses, and county health department support of COVID-19 activities. The Department’s Bureau of General Services used an existing state contract with a temporary general staffing company to secure staffing contractors for positions at the airport, weigh stations, and county health departments. The Florida Department of Management Services’ contract manager for the state-contracted rental car company worked closely with the ESF-8 Staffing Unit to help secure vehicles for responders statewide during the response because of the high volume of rental cars needed for deployments. EXTERNAL PARTNERS University system Early in the pandemic, Florida’s colleges and universities moved classes online from in-person settings.19 The Department reached out to 57 schools, colleges, and departments at 20 Florida institutions of higher education throughout the state by holding an interest call requesting staffing assistance in the areas of public health, nursing, and social work. As a result, the BPHRM created four positions for faculty and students to review and consider. These positions included three epidemiological positions at the student, intermediate, and senior level, as well as a health educator position. The ESF-8 Staffing Unit, in coordination with the BPHRM, developed an online survey for faculty and students to provide their contact information, knowledge, skills, and abilities to qualify for one of the four positions. BPHRM requested applicants provide confidential information, such as Social Security numbers, not collected through the survey, to complete the hiring process. Upon receipt of the required information, BPHRM personnel followed an expedited process by sending offer emails instead of offer letters by mail. The offer emails included verbiage to indicate the applicant’s interest in the position, provided new hires access to People First (the State of Florida’s online HR information system), the electronic timesheet system, and access to TRAIN Florida, the Department’s learning management system for JIT training. Providing a gateway to the national TRAIN Learning Network, a free service sponsored by the Public Health Foundation, TRAIN Florida offers a comprehensive catalog of public health training opportunities for Florida professionals. The BPHRM also supplied 06-SA-Weston-JEM#220002.indd 74 11/03/22 1:00 PM

75 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 the list of accepted hires to the Office of Information Technology to create email accounts and to the Office of Budget and Revenue Management for expenditure tracking. Once a mission was requested, clarified, and confirmed, the ESF-8 Staffing Unit reviewed available faculty and students and assigned them to a mission based on location and availability. The ESF-8 Staffing Unit then contacted the faculty and students with mission details and, upon acceptance of the mission, became FDOH new hires and received their responder orders. The BPHRM then forwarded a copy of the responder order to the applicable HR region manager to coordinate with the local county health department personnel liaison to establish the new hires in their system.20 Response agencies Staffing augmentation proved crucial in the State Emergency Operations Center where critical inventory and supply management decisions were being made. FDOH, the Florida Division of Emergency Management (FDEM), and the Florida National Guard (FLNG) formed a unified logistics team creating a force multiplier. This involved each agency learning each other’s systems and complementing each other’s strengths. FDOH provided JIT training to members of the FDEM and FLNG to provide support for receipt and distribution processes. FDEM staff member’s ability to obtain supplies in bulk and FLNG’s robust transportation network and access to staffing contracts with trucking companies provided FDOHs strategically positioned distribution points with the added capacity to quickly move resources to the field. CONCLUSION By utilizing new and innovative resources to address surge capacity issues in disaster staffing, the ESF-8 Staffing Unit filled 440 positions with university faculty and students, utilized 1,311 internal FDOH positions, and 4,365 positions from staffing agencies over a 9-month period (Figure 3). The ESF-8 Staffing Unit also built upon and developed new relationships with internal and external partners and streamlined the onboarding process for temporary staff reducing the processing time by 75 percent. Described as an invaluable resource that provided the necessary influx of staff for mission critical tasks, the ability to hire university faculty and students on short notice rapidly filled and backfilled positions in areas including contact tracing and onsite testing at Figure 3. Weekly average number of staff by date and type.21 06-SA-Weston-JEM#220002.indd 75 11/03/22 1:00 PM

76 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 the county health departments. With guidance and assistance from leadership, the BPHRM onboarded 7,169 people over a period of 9 months. As a result, the updating of existing staffing surge capacity guidance and processes and the development of JIT training materials continue to address future disaster scenarios. Many of the lessons learned by the ESF-8 Staffing Unit during the early months of the COVID19 pandemic response continue to improve the processes used to keep responders safe while deployed. Valerie Beynon, MA, CEM, FPEM, Florida Department of Health, Tallahassee, Florida. ORCID: https://orcid.org/0000-0003-4231-8036. Susan James, AA, Florida Department of Health, Tallahassee, Florida. Amy Graham, BS, Florida Department of Health, Tallahassee, Florida. Danielle Baxter, MPA, Florida Department of Health, Tallahassee, Florida. Christina Stenberg, MPH, MEP, Florida Department of Health, Tallahassee, Florida. REFERENCES 1. LMI Insights: Planning for disasters: Staffing as a major component of emergency planning. Available at https://www.lmi.org/blog/ planning-disasters-staffing-major-component-emergency-planning. Accessed December 1, 2020. 2. Landesman L: Public Health Management of Disasters. Washington, DC: American Public Health Association, 2005. 3. Clements B: Disasters and Public Health: Planning and Response. Burlington, MA: Elsevier, 2009. 4. US Department of Health and Human Services: Office of the Assistant Secretary for Public Affairs: Public Health Emergency Response. Washington, DC: US Department of Health and Human Services, 2007. 5. Topical Research: Harnessing global power—What is staff augmentation? Available at https://www.toptal.com/insights/future-ofwork/what-is-staff-augmentation. Accessed December 1, 2020. 6. Society for Human Resource Management: Managing through emergency and disaster. Available at https://www.shrm.org/resourc esandtools/tools-and-samples/toolkits/pages/managingemergency anddisaster.aspx. Accessed December 1, 2020. 7. US Department of Health and Human Services: ASPR-TRACIE: COVID-19 workforce virtual toolkit: Resources for healthcare decision-makers responding to COVID-19 workforce concerns. Available at https://asprtracie.hhs.gov/Workforce-Virtual-Toolkit. Accessed December 1, 2020. 8. Kearns R, Cairns B, Cairns C: Surge capacity and capability. A review of the history and where the science is today regarding surge capacity during a mass casualty disaster. Front Public Health. 2014; 2: 29. DOI: 10.3389/fpubh.2014.00029. 9. Federal Emergency Management Agency: National response framework (NRF). Available at https://www.fema.gov/sites/default/ files/2020-04/NRF_FINALApproved_2011028.pdf. Accessed October 14, 2021. 10. Florida Division of Emergency Management: State emergency response team. Available at https://www.floridadisaster.org/sert/. Accessed December 1, 2020. 11. Florida Department of Health: Emergency response system. Available at http://www.floridahealth.gov/programs-and-services/ emergency-preparedness-and-response/disaster-response-resources/ emergency-response-system/index.html. Accessed December 1, 2020. 12. Florida Division of Emergency Management: Emergency support functions. Available at https://www.floridadisaster.org/sert/esf/. Accessed December 1, 2020. 13. Florida Department of Health: Florida SERT ESF-8 public health and medical standard operating procedure. Version 4.0. Available at http://www.floridahealth.gov/programs-and-services/ emergency-preparedness-and-response/_documents/esf8-sop.pdf. Accessed December 1, 2020. 14. Federal Emergency Management Agency: Emergency management assistance compact (EMAC). Available at https://www. fema.gov/pdf/emergency/nrf/EMACoverviewForNRF.pdf. Accessed December 1, 2020. 15. Florida Department of Health: 2018 Hurricane Season Public Health & Medical Response After-Action Report. Tallahassee, FL: Florida Department of Health, 2019. 16. Executive Order Number 20-52-Re: Emergency Management— COVID-19 Public Health Emergency. Tallahassee, FL: Florida Office of the Governor, 2020. Available at https://www.flgov.com/ wp-content/uploads/orders/2020/EO_20-52.pdf. Accessed December 1, 2020. 17. Florida State Emergency Response Team: State ESF-8 deployable resources capability summary. Available at http:// www.floridahealth.gov/PROGRAMS-AND-SERVICES/emergencypreparedness-and-response/disaster-response-resources/emergencyresponse-system/logistical-systems-deployable.html. Accessed December 1, 2020. 18. Florida Department of Health: DOHP 310-2-18 Emergency Duty Policy. Tallahassee, FL: Florida Department of Health, 2018. Available at https://floridahealth.sharepoint.com/sites/ EMERGENCYPREPAREDNESS/Policies/DOHP%20310-2-18%20 Emergency%20Duty%20Policy.pdf. Accessed December 1, 2020. 19. State University System of Florida: State University System Statement on COVID-19. Tallahassee, FL: State University System of Florida, 2020. Available at https://www.flbog.edu/2020/03/11/ state-university-system-statement-on-covid-19/. Accessed December 1, 2020. 20. Florida Department of Health: COVID-19 Recruitment/ Separation Process. Tallahassee, FL: Florida Department of Health, 2020. 21. Florida Department of Health: Weekly COVID-19 Response Staffing Reports. Tallahassee, FL: Florida Department of Health, 2020. 06-SA-Weston-JEM#220002.indd 76 11/03/22 1:00 PM

JEM 77 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Applying the novel IDEA model for instructional health risk and crisis communication to explore the effectiveness of the COVID-19 crisis communication in Cameroon Henry Ngenyam Bang, PhD ABSTRACT This paper utilized a new novel framework, the Initialization, Distribution, Explanation, and Action (IDEA) model, for Instructional Health Risk and Crisis Communication (IHRCC) to investigate the effectiveness of the COVID-19 crisis communication (CC) in Cameroon. This contemporary research is empirical, qualitative, exploratory, and novel in the field of CC. Based on the findings, the COVID-19 CC in Cameroon could be ranked mediocre-fair. This is informed by an analysis of the IDEA elements in the framework that reveals that “Internalization” (messages on timeliness, compassion, and impact) was poor, “Distribution” (messages, guidance/protocols, and sources/distribution of messages) and “Explanation” (accuracy of messages, updated messages, and CC languages) were fair, and “Action” (instructional messages on infection control) considered as mediocre. This paper contributes to literature in the field, including concept development in health CC. The novel IDEA framework for IHRCC can enable health crisis managers gain context and better apply best practices to health CC. A structured recommendation on how this can be done has been proffered. Key words: crisis communication, IDEA model for instructional health risk and crisis communication, Cameroon, COVID-19 pandemic, health crisis INTRODUCTION Crisis communication (CC) is a critical and indispensable component of an organized crisis response to a range of crises.1 While facing crises, governments may encounter real uncertainties, concerns, and challenges. Consequently, the communication strategies employed may be ineffective.2 Nevertheless, the authorities have a short reaction time to gain control of the crisis,3 especially in this era of information and communication technology where messages can be transmitted to millions of people instantaneously. Contemporary CC is happening in an environment where regular communication is happening within and between the public, different communities, families, and individuals, fueled by social media in an online interconnected world.4 While innovative social media practices can positively affect communication, they can also plunge the populace into the vortex of social media misinformation.5 In such a frenzied backdrop, quick response is essential to mitigate the negative consequences of social media/networks, which influences the populace during crises.6 Consequently, communication stakeholders need to dispel any unfounded rumors and provide accurate instructional messages and guidance to the populace. An empathetic and open communication style that arouses public trust is imperative to galvanize public action to respect instituted safety measures.7 Governments must ensure that messages are clear, accurate, open, and transparent since people are looking for reassurance from sources they trust.8-10 Under ideal circumstances, governments would rollout their CC plan when hit with a crisis. Notwithstanding, during an unprecedented crisis like the ongoing COVID-19 pandemic, information may be unavailable or inconsistent, leading to the desire of the population for transparency and guidance to understand the unfolding situation. Yet, the COVID-19 pandemic is unprecedented as shown by the speed of its spread and wide-ranging effects that DOI:10.5055/jem.0648 07-SA-Weston-JEM#210071.indd 77 14/03/22 7:39 PM

78 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 caught many governments off guard. In such situations, even the best CC plans may not be deployed effectively. Governments will have to make tough decisions, including on communicating complex issues to diverse sectors of the population.9 As a result, novel CC frameworks like that applied to this research10,11 will be required to inform the heightened communication that may exist across numerous communication channels,8 especially in developing countries where CC has not been sufficiently incorporated into their crisis/disaster management frameworks. As the COVID-19 pandemic accelerated around the world, Cameroon recorded its first confirmed cases in February, and by December 28, 2020, that number had risen to 26,277 cases with 488 deaths.12 The actual number of cases/deaths, however, is much higher since testing was not scaled-up, and several issues with data collection and reporting abound.13 Is spite of the government’s endeavor to fight the disease, Cameroon is not resilient to the COVID-19 pandemic due to several constraints including CC.14 Hence, the need for a novel framework that can provide clarity and guidance for effective CC in the country. This article has utilized the tenets of CC adapted from the novel Initialization, Distribution, Explanation, and Action (IDEA) model of instructional risk and crisis communication (IRCC)10,11 (Figure 2) to develop a new model for health CC. The newly developed IDEA model for Instructional Health Risk and Crisis Communication (IHRCC) (Figure 3) has been used to examine CC during the COVID-19 pandemic in Cameroon. The paramount aim is to assess Cameroon government’s instructional CC and diagnose challenges therein for improved messaging in crisis response. This is a worthwhile enquiry considering legitimate concerns abound on the potentially harrowing ramifications of the COVID-19 pandemic on resource limited nations with fragile health systems like Cameroon.14,15 BRIEF CONTEXTUAL BACKGROUND This paper addresses CC within a developing country context with a focus on Cameroon, a bilingual country located in the “armpit” of Africa (Figure 1). Cameroon’s two official languages of colonial heritage are French and English. French is the dominant language in eight of Cameroon’s 10 administrative regions in a country with a population of around 26 million according to the World Bank’s 2019 estimate. Effective CC is enshrined in Cameroon’s legislative framework for Disaster Risk Management. The government’s strategy for managing disasters stresses the importance of information flows and CC in all the disaster management phases, and inter/ multi-agency cooperation at the local, regional, and national levels. Notwithstanding, effective CC leaves much to be desired16 as demonstrated during past disasters/crises in the country.17-19 This could be partly due to the fact that stakeholders have limited knowledge on the theoretical underpinnings of CC. CRISIS COMMUNICATION THEORETICAL FRAMEWORK Conceptualizing crisis communication: A brief review Several disciplines have informed theoretical approaches for risk and CC,4 and in the twenty-first century, the scope has broadened to encompass communication measures that address public health crisis20,21 like the COVID-19 pandemic. The context of “communication” in CC varies enormously in the aim, content, and form, making a concise definition of the term difficult. CC is defined by Reynolds and Quinn7 as efforts to disseminate information that would enable the populace/stakeholders make informed decision about their well-being under limited time constraints. According to FearnBanks,22 CC is the transfer of information to publics to either help avoid or prevent a crisis, recover from a crisis, and maintain/enhance reputation. Coombs and Halladay23 conceptualize CC from a broad perspective of collecting, processing, and disseminating information necessary to address a crisis. The concept has disciplinary and/or context definitions that explain the efficacy of the activities employed, the manner in which they are carried out, and in many instances, the difficulties or challenges involved.24,25 The empirical focus of CC in this paper concerns the dissemination of information/instructional messages from response agencies/government to the populace. The role of instructional CC in mitigating messaging 07-SA-Weston-JEM#210071.indd 78 14/03/22 7:39 PM

79 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 has been articulated in contemporary disaster management frameworks. Crisis communication paradigm The Sendai Framework for Disaster Risk Reduction (SFDRR) emphasizes the role of disaster risk reduction (DRR) communication practices/plans to enhance disaster resilience. The framework underscores innovations in information and communication technology, including data collection, analysis, and dissemination; geographical information systems; early warning systems; emergency communication networks; and the utilization of various media (social, traditional, and mobile phone networks) to support CC strategies. There is emphasis for the media to be involved in public awareness raising and disseminating accurate hazard/disaster information. The SFDRR also urges governments to collaborate with other stakeholders to adopt DRR policies that articulate CC.26 As signatory to the SFDRR, Cameroon could improve CC, albeit significant challenges still exist as the findings of this paper will reveal. Arguably, this is due to the fact that the government is yet to understand the main principles of effective CC. Figure 1. Map of Cameroon showing the 10 administrative regions. Source: Author, adapted from Cameroon’s National Institute of Statistics. 07-SA-Weston-JEM#210071.indd 79 14/03/22 7:39 PM

80 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Key attributes of crisis communication Many suggestions for effective CC exist, including regular practice and preparedness of the crisis management/communications teams; fact check; monitor different media to know what is being communicated; messages should be simple, clear, honest, frequent, and evolve with people’s information needs; and be transparent to build trust and loyalty and be optimistic to restore confidence.8,9 To reach a wide audience, utilizing various communication channels, like verbal messages, blogs, online magazines, letter/emails, social media platforms, web portals, and the distribution of physical material like posters and pamphlets to continually exchange information among government/health authorities, the media, and populace, is essential for effective crisis management.27,28 Crisis messages tended to be shared in scattered subgroups via social media/networks, which can also impede information diffusion.6 Rumors may create problems such as discrimination and/or stigmatization for vulnerable populations.29 In public health criFigure 2. The IDEA model for IRCC. Adapted from sis, stigmatization may have appalling consequences Sellnow and Sellnow.10,11 Figure 3. The newly developed novel IDEA model for IHRCC. Source: Author (inspired by Sellnow and Sellnow10,11). 07-SA-Weston-JEM#210071.indd 80 14/03/22 7:40 PM

81 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 on those affected; people may shy away from testing for infections or to seek treatment.30 Public risk perception can influence adherence to crises/DRR measures, and what the public perceives as acceptable/unacceptable risk are underpinned by economic and cultural factors that shape individual mitigation strategies.31 In the context of epidemics/ pandemics, this includes adhering to orders requiring social distancing or wearing facemasks. Indeed, perception and response to crises/risk communication are shaped by social and cultural factors, including trust, uncertainty, immediacy, familiarity, and personal control.32 These attributes have implications for the COVID-19 CC analyzed in this paper. Well-planned CC can be instrumental in mitigating epidemics/pandemics in several ways: assisting the public to respect preventive measures; enhancing medical interventions and minimizing anxiety.28 Hence, the need to scrutinize messages for detrimental elements that may lead to negative consequences and communication should not facilitate the dissemination of myths or rumors.20 Having a framework that can guide understanding of these attributes will facilitate operational CC. CONCEPTUAL FRAMEWORK: THE IDEA MODEL FOR EFFECTIVE INSTRUCTIONAL RISK AND CRISIS COMMUNICATION This article applies a novel communication model— the IDEA model for effective IRCC10,11 (Figure 2) to the COVID-19 CC in Cameroon to better understand how simple, effective, and strategic communication underpins effective response to health crisis. Underpinned by decades of empirical, theoretical, and experimental learning research on CC, effective instructional risk and crisis messages must address the four central elements of IDEA that constitute the essential building blocks of the framework explained here. “Internalization” constitutes the main components required to encourage recipients to address and easily recall messages communicated to them. This includes timeliness, compassion, proximity, and impact. “Distribution” is concerned with the essential constituents required to reach the “at risk” audiences. Establishing consistent messaging from diversified sources to reach different audiences in different locations falls in this category. “Explanation” covers attributes that can enable recipients understand correct information. This includes providing accurate and updated information regularly; translating scientific information into an easily understandable manner for various populations/communities with different educational levels; and ascertaining receiver’s trust in information sources. Finally, “Action” involves the main features to get receivers of messages to the right measures. It should be noted, however, that the other three building blocks of the conceptual framework have implications for Action.10,11 The IDEA model for IRCC is an easily understandable, situationally generalizable, and applicable framework that can help emergency managers/ communicators design effective crisis, high-risk, and disaster response messaging.10,33 The model can be applied as a learning theory-based framework where messages can appeal to affective, cognitive, and behavioral learning/outcomes and used to design messages in any emergency, crisis, and risk context including a novel health crisis.11 Consequently, the model has been adapted to investigate CC during the COVID-19 pandemic in Cameroon. Introducing the IDEA model for Instructional Health Risk and Crisis Communication The IDEA model for IRCC has been adapted to develop a new model for health crises as shown in Figure 3. The key features of the new IDEA model for IHRCC have been discussed in the context of a novel health crisis like the COVID-19 pandemic. 1. “Internalization” in the IDEA model of IHRCC has the following elements: n “Timeliness” could imply the speed to detect virus and inform the health system and populace; the speed to implement containment, safety, and/or lockdown measures; time/duration taken from contact with virus to infection; and speed to detect new virus strain and/or wave of virus spread. 07-SA-Weston-JEM#210071.indd 81 14/03/22 7:40 PM

82 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 n “Compassion” in messaging to let the “at risk” populace know the government care about their sufferings and/or challenges caused by the health crisis/pandemic. Indeed, “people don’t care what you know until they know you care about the victims and losses.”11(p1) This could be the impact of the pandemic on the health/ death of family members, income generating activities, and welfare or social networks or socializing with family and/ or friends. n “Proximity” entails mentioning the locations/areas with the highest infection rates, where infections are spreading fastest; nearest location of test and health/ medical centers/facilities with capability to treat various severity of sickness caused by the virus including locations to obtain vaccines and closeness to infected persons. n “Impact” of the pandemic is considered in the light of the effects/impact of the pandemic on the health/death of people/ family members, the country’s health system/infrastructure, livelihoods, jobs, community social structures, the culture and traditions of the affected populace, and the local, regional, and national economy. 2. “Distribution” in the IDEA model of IHRCC could imply messages on: n “Virus Symptoms or Infection” like having high temperatures, new continuous coughing, loss and/or change of smell, difficulty breathing. n “Virus Transmission” modes from person to person and how it spreads like respiratory droplets, physical/close contact with cases, confined spaces, nonsocial distancing. n “Sources/Distribution” of messages through different mainstream media sources (public/private TV and radio stations), social media platforms (Twitter, Snapchat, WhatsApp, Facebook, etc.), community/ religious gatherings (churches, mosques, and social meetings/gatherings), and personal communication via emails, leaflets, letters, and public announcement like posters and billboards. The motive is that communication should reach all audiences in different locations of the country. 3. “Explanation” in the IDEA model of IHRCC implies the following characteristics on messaging: n “Accuracy of Messages” on the virus/ pandemic to the populace on issues like infection rates, speed of virus spread, and daily death rates/infection. Guidance and treatment protocols to frontline health workers must also be accurate. n “Constantly Updated Messages” to the public on different aspects of the pandemic/ virus (epidemiological evolution) and heath treatment protocols to the populace and healthcare workers, respectively, when new information is acquired is necessary. n “Simplified Messages” on the scientific information of the virus should be communicated in a simple language that can be understood by different audiences. In particular, scientific information should be disseminated in a nonscientific language, so that the populations with varying degrees of literacy can understand. n “Language of Communication,” messages should be translated or conveyed in languages that the populace can understand. This is important in countries with many local/indigenous languages like developing countries. 07-SA-Weston-JEM#210071.indd 82 14/03/22 7:40 PM

83 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 4. “Action” in the IDEA model of IHRCC would imply: n “Communicating” to get the “at risk” populace to implement the right infection prevention and control measures like: n “Social Distancing” by restricting the number of persons in social groupings in various settings (indoors, outdoors, homes, or in restaurants/pubs). n “Wearing face coverings” like face masks/ shields outdoors in public transport, shops, schools, and when performing other specified activities. n “Regular hand washing” with soap and water for at least 20 seconds regularly. n Use “hand sanitizers” to clean hands before and after entering or leaving public spaces. n “Quarantine” by self-isolating for a specific duration of time if told to do so or fall in a category of people who have or might have the disease. n “Lockdowns” by respecting restrictions in place like closure of international/ regional borders; closures/prohibitions of activities (schools/universities, businesses, sporting events, and travel/movement of people). n “Motivation” to inspire the required behaviors from the populace, so that they can obey instruction or become less aversive, and to mitigate the instituted measures that might hurt financially. This article has applied the IDEA model for IHRCC to assess the COVID-19 CC in Cameroon. The model informs and also aligns with the methodology. METHODOLOGY This is a mixed methods principally qualitative and exploratory research that adopts a blended paradigm—multiple perspectives and viewpoints from empirical, primary, and secondary data. In crisis, emergency, and disaster management, qualitative methodologies aim to explore complex phenomena encountered by governments, organizations, and other stakeholders, inclusive of CC.22,23 Embracing this methodological approach entails a commitment to in-depth understanding of the research enquiries by gauging participant’s perspectives in a real-life situation—the evolving COVID-19 pandemic. The epistemological paradigm underpinning this article follows an inductive research trajectory,34,35 informed by salient CC theoretical perspectives and the novel IDEA model for IHRCC, which also informed the research aims, objectives, and the structure of this article. Empirical data were generated by conducting a standardized online survey via google in June and July 2020. The survey had inputs from two sets of respondents: 143 respondents from the public/community (“Questionnaire administered to the population” in Appendix A) and 38 healthcare professionals (“Questionnaire administered to health workers” section in Appendix A) living in eight of Cameroon’s 10 administrative regions (Figure 1). A random sampling selection strategy was adopted for the public/ community informants. The author, assisted by other collaborators (acknowledged), developed/designed the questionnaires (“Questionnaire design/development” section in Appendix A) and utilized their networks of friends/family both in Cameroon and in the diaspora to rollout the survey questionnaires to people living in Cameroon during the pandemic (“Questionnaire administration process” section in Appendix A). Sampling for the health professionals was initially purposive and snowballed. Likewise, known medical professionals/practitioners in Cameroon were initially contacted to inform the research. Those who consented were urged to cascade links to the survey questions to their peers all over the country. Since data collection was done during the pandemic when all the universities were shut down to 07-SA-Weston-JEM#210071.indd 83 14/03/22 7:40 PM

84 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 control the disease, internal review board’s approval could not be obtained and was therefore, not needed for the study to be undertaken. Indeed, the research was viewed to be low risk since it only required obtaining responses from informants. Nevertheless, ethical considerations of voluntary participation and confidentiality were enshrined in the data collection and analysis.35 The informants were not coerced to take part in the survey. They were aware that even after receiving the enquiries, they could not respond if they changed their mind. By agreeing to participate in the research, they were assured of their confidentiality and anonymity in the data analysis. For instance, the research ensured there were no identifiers in the survey questionnaire such as the names of the respondents that could link them to the survey responses. The survey was designed to elicit responses on key CC themes/enquires mentioned in the findings— “Questionnaire design/development” section in Appendix A for more information. CC themes that inform the IDEA model for IHRCC were sieved from the responses, whose depth and breadth generated sufficient data for adequate analysis,36,37 which have informed the findings. Primary data on CC were derived from various sources particularly official communiques, speeches, press releases, and statements openly available on the websites of government agencies/ministries. For instance, all the 23 press releases of Cameroon’s Prime Minister (PM) for 2020 were assessed and analyzed for CC messaging. Secondary data were sourced from the few scholarly articles published on COVID-19 in Cameroon and gray sources of information from different media outlets also informed the research. This article utilized a content analysis approach to data analysis. Content analysis is suitable for conducting research in a relatively new research area where not much is known and facilitates reporting of simple, regular, and/or common subjects/issues identified in data, hence, its application in this exploratory research since CC is a relatively new research area in Cameroon. Furthermore, content analysis is appropriate to analyze important, sensitive, and multifaceted phenomenon36,37 like CC, not least in this research (Appendix A, “Data analysis” section) that introduces a new multifaceted CC model for heath pandemic (Figure 3). A blended approach that utilized qualitative and quantitative techniques (basic statistics) for data analysis was used, informed by responses from open-ended and close-ended questions, respectively (Appendix A, “Data analysis” section). Both manifest and latent content of data were instrumental in the analysis. Manifest content informed the findings as compelling extracts of text or information from identified themes/categories. Conversely, latent content based on the researcher’s perspective informed the recommendation and ranking of the IDEA elements in Table 1. The research has also employed techniques of reflexivity, verbatim quotations, and triangulation across the different data sources to support interpretations and establish validity and credibility of the findings. The individual elements of the content analysis method employed, demonstrated by a flow diagram of the process, have been qualified in “Data analysis” section in Appendix A. A richer empirical data set could have been generated if the survey covered all 10 regions of Cameroon; enquiries were initially designed to specifically address elements of the IDEA model; and the enquiries targeted a wider audience, including in areas without internet access. That would entail face-to-face administration of questionnaires/interviews, which is not possible during a pandemic, not least due to social distancing and other measures restricting travel and physical contact. In addition, pretesting of the questionnaire could have enhanced its design. This did not happen to save time since the health respondents had hectic schedules dealing with COVID-19, and the populace were under duress trying to respect restrictive measures amidst challenging social and economic conditions (Appendix A, “Questionnaire design/development” section). Furthermore, the recommendations and/or observations and their ranking have been informed by the researcher’s perspective, which is subjective and could be disadvantageous in its reliability and specificity. Despite these potential limitations, the philosophical methodological approaches and perspectives 07-SA-Weston-JEM#210071.indd 84 14/03/22 7:40 PM

85 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Table 1. Summary of findings and recommendations/observations The key IDEA elements Key IDEA subelements Key findings Recommendations/observations Rank* Overall ranking Internalization Timely action to warn/ sensitize the population Slow pace to institute infection control measures Swift action to institute lockdown measures following the first detected cases will reduce infection spread Poor Poor The president delayed addressing the nation on the pandemic Presidential address immediately following the start of a health crisis important to demonstrate leadership and that the government is in control of the situation Awful Timely provision of treatment guidance Delay in providing treatment guidance/protocols Guidance/protocols should be provided immediately a pandemic is imminent to expedite healthcare provision for sick patients Mediocre Messages on compassion There are few compassionate messages Compassionate messages demonstrate concern and attention to the audiences and encourage the populace to respond positively to instituted measures Poor Messages on pandemic impact The few messages mostly focused on the economy and businesses More messaging should contain the impact of the pandemic on the lives/ livelihood of ordinary citizens who form the bulk of the population Mediocre Messages on proximity Proximity is not very visible in messages Information on proximity helps in risk avoidance of physical contact and locations with high infection rates Poor Distribution Public messages and guidance on infection control Most respondents are familiar with COVID-19 symptoms, means of transmission and infection While this is encouraging, the authorities should do an assessment in rural areas to know if this finding is the same Fair Fair Most healthcare workers had received treatment protocols albeit some were obtained from colleagues While this is encouraging, the authorities should do an assessment in health facilities in rural areas to know if this finding is the same Treatment guidance/protocols should be sent to all medical facilities/frontline workers all over the country immediately a pandemic outbreak is detected Fair Treatment guidance not very comprehensive Guidance documents should be concise, clear, have all the required information and be mindful of volume Fair Sources and/or distribution of messages Social media is the most trusted source of information Publics should be cautioned not to take information on social media as gospel truth The government should also utilize social media platforms to inform the populace Poor 07-SA-Weston-JEM#210071.indd 85 14/03/22 7:40 PM

86 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 Table 1. Summary of findings and recommendations/observations (continued) The key IDEA elements Key IDEA subelements Key findings Recommendations/observations Rank* Overall ranking Distribution Sources and/or distribution of messages Private TV channels are the second most trusted source of information The government should liaise and coordinate messages with private TV channels/radio Mediocre Fair CRTV is the third most trusted source of information The government needs to instill more trust and confidence in that state broadcaster and ensure its crisis messaging is apolitical and credible Poor Multiple platforms have been used to sensitize the populace The messaging sources seem to benefit urban/city dwellers the most. There is need to explore messaging sources that can reach rural populations Fair The conflict-ridden Anglophone regions have limited access to information The government should institute a ceasefire with separatist fighters during a health crisis to enable the afflicted population to have easy access to safety information and follow recommended measures Mediocre Explanation Accuracy of messages Alleged contradictory and conflicting messaging The government should coordinate and streamline its messages and ensure its clear and void of speculation Mediocre Fair The government stopped regular live updates without providing reasons A change in any medium of communication should be accompanied with reasons to avoid speculations on the motive Fair Alleged insufficient transparency and credibility The sources of figures/data on COVID-19 communicated should be mentioned and verifiable Fair Updated messages COVID-19 messages were regularly updated on the MPH’s website and press releases While this is encouraging, the authorities should assess knowledge of updated information in rural areas to know if this finding is the same Good Languages used for COVID-19 CC French and English languages were used most to convey messages While most educated Cameroonians and those living in urban areas will understand French and/or English, others in rural areas may not Fair Local languages should be used for CC All indigenous languages spoken in Cameroon should be used to sensitize/ educate the respective local populations Mediocre Elderly people would better comprehend indigenous languages Targeted messages to vulnerable demographic groups like the elderly using their native languages would facilitate CC Poor 07-SA-Weston-JEM#210071.indd 86 14/03/22 7:40 PM

87 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 employed render this research open to adaptation, replication, and repetition if similar protocols are followed (Appendix A, “Questionnaire design/development” section). These provide credibility and validity to the findings, enabling the research to achieve rigor.35,37 FINDINGS Internalization Timeliness action to warn/sensitize the populace. Cameroon’s initial response to the COVID-19 pandemic was relatively slow. The virus was first confirmed in a French citizen who arrived Yaoundé on February 24, Table 1. Summary of findings and recommendations/observations (continued) The key IDEA elements Key IDEA subelements Key findings Recommendations/observations Rank* Overall ranking Explanation Languages used for COVID-19 CC Treatment guidance/protocols are provided in French to some English-speaking health workers All protocols/guidance documents should be provided in both the English and French languages and given to health workers in their preferred language Mediocre Fair Foreign languages should be used when required The language needs of foreigners/ refugees in Cameroon should be considered in health CC Fair Action Instructional messages There is evidence of understanding of personal infection control measures While this is encouraging, the authorities should do an assessment in rural areas to know if this finding is the same Good Constraints Mediocre on taking preventive and safety action Insufficient sensitization and/or poor communication More resources should be poured into the provision of health education to the populace especially in rural areas Mediocre Some patients are avoiding hospitals Health counseling services and specialized educational services are required to encourage infected patients seek treatment Mediocre Data on spread of virus/deaths are alleged to be unreliable Government should explain its source of data and how it is collated Mediocre Doubts about COVID-19 deaths Evidence of COVID-19 should be provided to relatives Mediocre Alleged politicizing of COVID-19 response Politization of CC should be avoided. Communication specialists could be consulted or utilized to facilitate CC Poor Some COVID-19 patients are stigmatized Aggressive educative public campaigns against the consequences of stigmatization on infection transmission is required Mediocre Lack of trust in government The government should engage in building trust even in noncrisis times via demonstrating that its messages are correct and credible Poor * Ranking of the different CC themes is based on a subjective scale comprising of Abysmal, Awful, Bad, Poor, Mediocre, Fair, Good, Great, and Excellent. Source: Author. 07-SA-Weston-JEM#210071.indd 87 14/03/22 7:40 PM

88 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 2020.38 Yet, the initial official government response to the pandemic began on March 17, 2020 (23 days later), when the PM announced a number of containment measures.39 Delays to institute lockdown measures after the first cases were detected may have caused the virus to spread further.14 On April 30, 2020, the restrictive measures were eased (just after 6 weeks) amidst concerning the infection rate was escalating.40 Swiftness to show leadership on the pandemic was also a concern. According to the government, Cameroon’s President (87-year-old Paul Biya who has ruled the country for 38 years) was in charge of the crisis response. However, the president was inconspicuously absent for 35 days after the PM announced the initial COVID-19 containment measures. The president made his first public appearance on April 16 with the French Ambassador to Cameroon supposedly discussing about managing the COVID-19 response.41 The president’s silence on the pandemic and his delay to appear in public for close to 2 months after the first cases were detected raises issues of a gaping void in political leadership amidst a novel health crisis with implications for citizen’s trust in governments to expedite treatment or virus control. Timeliness provision of guidance/protocols for COVID19 treatment. The survey for healthcare professionals had a question on whether they had received guidance documents for COVID-19 care and if the guidance was given in a timely manner (question 12 in section “Questionnaire administered to health workers” of Appendix A). 90.5 percent (n = 19) of the survey takers confirmed having received guidance from the Ministry of Public Health. Nevertheless, most respondents complained of delays in receiving the documents, which some said were not comprehensive. This research also learned that there was difficulty implementing the protocols at the beginning of the pandemic due to challenges in the provision of adequate medical and other resources needed to treat patients. Sluggishness in the provision of treatment guidance/protocols also impacted empathetic messaging. Messages on compassion. Compassion has been assessed from speeches/statements, and press releases by senior government officials managing the pandemic. Cameroon’s PM leads the COVID-19 response in the country. The website of the PM’s Office has statements, messages, or press releases on government’s response to the coronavirus, which is openly accessible to the public. An examination of all press releases/speeches on the website shows that in 2020, there were 23 press releases, of which 20 (87 percent) were about the COVID-19 pandemic. In-depth analysis of the press releases on COVID-19 reveals that just three (15 percent) have messages with some elements of compassion. The messages, though, were not directly addressed to the populace but presented as measures to mitigate the impact of the pandemic to the populace, for instance, messages like: “These are difficult but necessary measures . . .” (press release of March 17, 2020); message to decongest prisons as a means to mitigate the impact of the pandemic on the prison population (press release of April 23, 2020)— based on presidential decree No. 2020/193 of April 15, 2020 to commute and remit prison sentences42 and statements on measures to protect the most socially vulnerable population like women, children, and the elderly (press release of August 27, 2020). The president’s first and only speech on the pandemic was delivered on May 19, 2020—more than 3 months after the first case was detected in February. During the 18-minute speech canceling the 2020 traditional May 20 National Celebration, three sentences captured messages on empathy: “ . . . my main concern is to preserve the health of my fellow compatriots . . .,” “ . . . extend my sympathy to the families that have lost loved ones to this terrible disease . . .,” “  .  .  . heartfelt encouragement to patients admitted to our hospitals . . . I wish them a speedy recovery.”43 The president’s speech to the populace, like the press releases of PM, placed more emphasis on government measures/determination to combat the pandemic, and persuading Cameroonians to respect the instituted infection control/safety measures. Generally, the messages/speeches are scarce of messages with compassion and/or empathy. This is a limitation on Cameroon’s CC, which could affect effective response to the pandemic if the citizens feel the government is not concerned about their well-being. Like messages 07-SA-Weston-JEM#210071.indd 88 14/03/22 7:40 PM

89 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 on compassion, the populace expect to understand the impact of the pandemic to their lives. Messages on pandemic impact. The few messages on the impact of the pandemic have centered mostly on the effects/impacts of the country’s economy and businesses. An analysis of the 20 COVID-19 messages on the PM’s website also revealed that three (15 percent) indirectly address the impact of the pandemic. The press release of May 7, 2020 mentioned economic support measures for business sectors in difficulty. That of June 25, 2020 mentioned the negative impact of containment measures on production, trade, and imports/exports and support measures for small/medium sized enterprises (press release of August 20, 2020). Furthermore, in an address to the nation on state TV and radio on April 30, the PM said measures taken to fight the coronavirus have had socioeconomic effects, particularly in the trade, transport, hotel, and restaurant sectors.41 The President’s COVID-19 speech briefly acknowledged the economic effects of the pandemic on the global economy and the country. A passive comment was made about government’s effort to preserve jobs.43 The messaging did not directly address the concerns of the majority of Cameroons working in the informal sector. Like the potential impact of the pandemic, knowledge of proximity to virus spread is invaluable. Messaging on proximity. The research did not capture much evidence of proximity. Government messages to the population do not specify geographical locations with the highest infection rates or where infections are spreading fastest. COVID-19 messages on the website of the MPH and the PM’s press releases urge the population to test for the virus and seek treatment but do not specify the locations of the treatment facilities. This may be due to the limited health facilities capable of testing and treating patients in the country. At the onset of the pandemic, the few health facilities with intensive care units were concentrated in Yaoundé and Doula, the country’s political and economic capitals, respectively, and gradually scaled up in the regional capitals. This has implications for populations in the rural areas seeking COVID-19 care.14 Distribution Messages and guidance on virus control. One question to the populace gauged key messages received on the transmission of COVID-19 (question 11 in “Questionnaire administered to the population” section of Appendix A). Of the two answers provided to guide the response, 91.6 percent (n = 131) of the community respondents mentioned that the most potent message was respiratory droplets generated by coughing and sneezing. 67.3 percent (n = 96) reported contact with contaminated surfaces. A few mentioned contacts with infected and/or asymptomatic persons. Another question was with regard to key messages received on COVID-19 symptoms (question 12 in “Questionnaire administered to the population” section of Appendix A). The most responses were elevated temperature (88.1 percent, n = 126), continuous coughing (67.8 percent, n = 97), loss/change to sense of smell (47.6 percent, n = 68), and breathing difficulties (6.3 percent, n = 9). The remaining 5.6 percent (n = 8) responses mentioned other symptoms like running nose, loss of appetite, sore throat, cold/feverish, increase in tiredness, and sneezing. There was an inquiry on the relevance of the guidance and its usefulness (question 13 in “Questionnaire administered to health workers” section of Appendix A). Health worker assessment of COVID-19 treatment protocols provided by the MPH was overwhelmingly positive (89.3 percent, n = 25) from those who responded. Many said the protocol instituted by the MPH was received in their health facility, while others obtained them from colleagues in the nation’s capital, Yaoundé. The research also learned that there was difficulty implementing the protocols at the beginning due to challenges in the provision of adequate medical and other resources needed to treat patients. Insufficient resources might have also affected the variety of platforms through which instructional messages were disseminated. Sources/distribution of messages. An inquiry on where the population got the most credible information on COVID-19 (question 10 in “Questionnaire administered to the population” section of Appendix A) uncovered multiple sources as shown in Figure 4. The 07-SA-Weston-JEM#210071.indd 89 14/03/22 7:40 PM

90 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 state-owned Cameroon Radio and Television (CRTV) broadcasting corporation is third on the list (34.5 percent, n = 49) behind private TV channels (47.9 percent, n = 67) and social media (66.2, n = 94). The expectation was that the population would have more confidence in CRTV, which dominates the airwaves in the country and regarded as government mouthpiece.44 It is worrying that the populace prefer social media to official government sources. There is an elevated risk that a sizeable population may not be getting accurate information since social media is abound with distorted information, myths, a conspiracy theory about the pandemic.45 A majority of health workers who responded to enquiries on government’s effort to sensitize the populace (questions 30 and 31 in “Questionnaire administered to health workers” section of Appendix A) gave positive answers. Their responses corroborate that of the community informants in terms of the multiple channels they said were used to sensitize the population. The identified channels were radio, newspapers, TVs, flyers, posters, websites, and community sensitization programs. However, they mentioned shortcoming-like contradictory messages, suboptimal community sensitization due to insufficient funds, improper coordination of messages, and limited access to COVID-19 information in the conflict-ridden Anglophone regions. Explanation Accuracy of messages. The accuracy of messaging was sieved from responses to a question requesting the populace or community respondent’s perception of government’s limitations in managing the pandemic (question 21 in “Questionnaire administered to the population” section of Appendix A). 15.4 percent (n = 22) of the respondents mentioned CC-related short comings including inaccurate messages. Notable responses were as follows: “unreliable statistics/information on the rate of spread of COVID-19,” “they are not truthful in their figures,” “wrong and incredible figures for either the number of patients or number of deaths,” “doubtful information on COVID-19,” and “figures of confirmed and recorded cases are at times questionable.” These concerns have been substantiated by communication specialist in Cameroon who asserted that the abrupt termination of live COVID19 regular briefings could be attributed to constant manipulation of the epidemiological data to conceal the real impact of the virus.46 The reliability of messages cannot be divorced from the frequency in which the messages were updated. Updated messages. The community informants were also asked what they perceived were the good aspects of government’s COVID-19 response (question 20 in “Questionnaire administered to the population” Figure 4. Most credible sources of information for the COVID-19 pandemic. 07-SA-Weston-JEM#210071.indd 90 14/03/22 7:40 PM

91 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 section of Appendix A). Among the responses, themes on CC received 27.3 percent (n = 39). The research captured a few positive responses on updated messaging, in verbatim: “ . . . constant updates . . .,” “ . . . regular updates . . .,” “ . . . frequent general sanitization of public places . . .,” and “ . . . daily report on CRTV about the virus . . ..” At the onset of the pandemic response, the Public Health Minister provided daily updates on the evolution of the pandemic (infections, deaths, treatment, etc.).47 The briefings, however, stopped abruptly on April 9 with no reasons provided.46 The MPH then resorted to providing the latest information on COVID-19 on its website.12 Additionally, almost all press releases about COVID19 on the PM’s website (except those signed on March 31, April 1, and June 16) have updates on the epidemiological evolution of the virus in the country. Since Cameroon is a multilingual country, the languages used for communication are important if most of the populace have to understand crisis messages. Languages used for COVID-19 crisis communication. In response to the question “Which languages are being used for sensitization and/or to educate the population on Covid-19” (question 7 in “Questionnaire administered to the population” section of Appendix A), the public informants responded as shown in Figure 5. The majority (25.4 percent, n = 36) said English and French (Cameroon’s official languages), and pidgin or creole (a lingua franca) was used most to communicate the pandemic. The next three sets of data consecutively mentioned English and French, French, and English. Analysis of the data shows that English and French were used most to disseminate pandemic information. Nevertheless, the informants also had preference for other languages. Other preferred languages/translation of messages. Another question stated that “Which other language(s) will you want to be used for sensitization and/or community education on Covid-19? Please also explain this preference” (question 8 in “Questionnaire administered to the population” section of Appendix A). In response, most community respondents recommended that indigenous languages and pidgin be added to the official languages (Figure 6). The response captured reasons for their preference. More than 95 percent said old people would better comprehend in their words, “indigenous languages,” “local dialect,” “vernacular,” or “their mother tongue,” and some argued that elderly people are more vulnerable to COVID-19 and need to be prioritized during sensitization using the language they understand best. For instance, an informant stated that “COVID-19 attacks mostly old age persons and most of them do not understand pidgin either, so native language or vernacular will be the best language to make them understand.” Most respondents informed the research that indigenous languages were useful in rural/local areas where most older people live. The populace residing in rural areas are generally low Figure 5. Languages used to communicate the COVID-19 pandemic. 07-SA-Weston-JEM#210071.indd 91 14/03/22 7:40 PM

92 Journal of Emergency Management Vol. 20, No. 7 Special Issue on COVID-19 in literacy and, therefore, not very conversant in the official French and English official languages. In-depth analysis shows that respondents in the Francophone regions wanted English to be used in the French regions and vice versa, acknowledging the necessity to communicate in both national languages in all regions of the country. The basis for this, according to a few respondents, was that the French regions were hosting internally displaced persons from the Anglophone regions who did not understand French. The “Sango” language—a foreign language—was justified for use by a lone respondent (0.7 percent, n = 1) who emphasized its necessity to communicate with refugees from Central African Republic in Cameroon. Empirical data from the healthcare informants also revealed that treatment guidance/protocols were provided in French to English speaking health workers. This was mentioned in response to an enquiry on treatment protocols or guidance provided to health workers (question 12 in “Questionnaire administered to health workers” section of Appendix A). Action Instructional messages on prevention/safety. Based on the question “What key messages on prevention of Covid-19 were passed on?” (question 13 in “Questionnaire Administered to the Population” section of Appendix A), the dominant messages conveyed on how to get the populace to do the right actions to prevent COVID-19, according to the respondents, were social distancing (93.7 percent, n = 134), washing hands with soap and water often (93 percent, n = 133), wearing face masks (92.3 percent, n = 132), using hand sanitizer gel if soap and water are not available (78.3 percent, n = 112), stay at home if possible (3.5 percent, n = 5), and avoid touching one’s face, cough in one’s elbow, avoid handshake and cold food, observe hygienic conditions, and always wear hand gloves outdoor (4.2 percent, n = 6). These responses seem to align with those recommended by the government. The government first responded to the pandemic by instituting 13 containment measures—closed Cameroon’s borders and educational establishments; restricted the opening times for bars/restaurants to 6 pm and urban-interurban travel; government to requisition private facilities and equipment for implementing COVID-19 plans; meeting for more than 10 persons to be held online; prohibition of gatherings with more than 50 people; and the public to strictly observe hygiene measures like social distancing, regular hand washing, and covering the mouth when sneezing in order to contain the virus spread.39 In fact, most government communication on the pandemic has included instructional safety/prevention messages (PM’s press releases on COVID-19).40,43 It is one thing to disseminate messages on safety and/or containment measures, and it is another thing to respond appropriately or take mitigating action based on the messages. Constraints on taking preventive/safety action. By asking the question “What are some of the challenges that affected the ability of the population to comply Figure 6. Other languages that should have been used for messaging. 07-SA-Weston-JEM#210071.indd 92 14/03/22 7:40 PM