Motivation for participation
Many BENS members have had prior careers in the military, and they value the opportunity that BENS offers to "continue to serve." The motivation of BENS members is broadly shaped by the realization that governments and business each have resources that, if combined, could enhance emergency preparedness for the benefit of governments, communities, and businesses. Business respondents appreciate that public health officials have expert knowledge about biological and other health threats, unique access to information and resources in crisis situations, and skills and authorities essential for responding to public health emergencies. BENS members emphasize that their organization is geared to providing community service, not to advancing short-term business interests. The experience of one member is typical of the motivation of business participants:
"...I looked at opportunities and ways I could get involved...I heard about BENS and saw that this was one where I could help lead and make some change...I attended a conference in Washington DC about the response to 9/11. There was a presentation on BENS and I got hooked...When I got home a few days later I called and asked 'How can I get involved?'"
While the principle of community service is fundamental to BENS, many members readily acknowledge that their participation is not purely altruistic. In addition to the good publicity that can accompany community service, many view their involvement as an extension of business continuity planning. The survival of businesses during and following a disaster depends on the survival of communities and vice versa. Business respondents were keenly aware of the potential for government systems to be overwhelmed and the attendant consequences. "Fear of failure and a clear understanding of the limits of government" combined with a sense that "We're a part of the community and should be a part of the solution" were perspectives that exemplify the motivation of BENS members.
From the perspective of public health agencies, the motivation to work with businesses is simple. Public health officials recognize their limitations and see the value of business resources for emergency preparedness and response. With respect to SNS dispensing, this includes logistics expertise, access to large numbers of potential volunteers, and business infrastructures for training, organizing, and communicating with volunteers. The motivation for public health to work with an organization such as BENS also reflects a desire for simplicity because BENS has ties to multiple businesses, reducing the need for public health to cultivate links independently with different businesses. BENS represents many of the largest companies in metropolitan Atlanta, as well as smaller firms with specific expertise relevant to emergency preparedness. The ability to reach these companies through BENS is clearly valuable to public health, given both the assets these companies can enlist in an emergency and the number of people they can reach. As one respondent observed, "We are surrounded by opportunities."
Challenges to collaboration
Differences between the cultures of business and government in general and public health in particular represented the most frequently cited challenge to collaboration. Manifestations of these differences included a lack of familiarity with one another's values, metrics, resources, constraints, lines of accountability, management styles, lingo, and modes of operation. As a result, business leaders and public health officials often do not know how to approach one another or whom to call to establish a relationship.
Additionally, there is a stereotypical view that people in business and public health have of one another. Many in public health are suspicious of the profit motive of businesses and are thus guarded when approached by business representatives. Entrees from business representatives may be viewed with suspicion, e.g., "What is this guy trying to sell me?" This perspective was amplified after September 11, 2001 and the subsequent anthrax attacks, when government officials felt besieged by entrepreneurs seeking to promote new security or health protection products. From the business perspective, suspicion of government reflects a perception that government officials typically want "something for nothing," often seek to impose burdensome regulations, and have a bureaucratic mindset. As one BENS staff member noted:
"We need to get past the image of the public employee as someone resistant to change, just works 9-5...couldn't get a real job"
There is also a perception among some business executives that government management styles are at times inefficient and wasteful. This latter concern is a manifestation of differences in the ways that business and government value efficiency and effectiveness. While both are important to businesses and governments, one business respondent characterized the difference in the following way.
"In business, you are constantly trying to shift dollars from the cost to the profit side of the ledger. The way you do that is to improve efficiency. If something costs you a dollar, the first question a good manager asks is whether you can get that cost down to ninety-five cents. When you get it down to ninety-five cents, the next question is how to get it down to eighty-seven point five. If you don't do that, your competitors will do it for you, and the next thing you know you're out of business. In government, the priority is making sure you can get the job done [effectively], and it is less important that you do it at the lowest possible cost. That's why...when public health approaches business and asks for 200 volunteers for an exercise, the first reaction from someone in business person is likely to be, 'Why wouldn't 100 volunteers be enough?"'
This difference, viewed from the perspective of a public health official was described in the following way:
"Public health and business people speak a different language. Business people...focus on measurable outcomes based on dollars. Public health people are [concerned about the] well-being of humanity, but you can't reduce that to dollars..."
Historically, business-government interactions have often centered on regulation or investigations that may lead to regulation, casting business and public health people into adversarial positions. From this perspective, business people are apt to worry about misinformed or unnecessary government regulation, while people in public health may see their role as constraining businesses from promoting unhealthy products, polluting the environment, or threatening the health of workers. This perspective has also blinded many in public health from recognizing the critical role of businesses in assuring community continuity. The notion that perceptions of business are shaped by adversarial engagements with governments is troubling to BENS members:
"Most business leaders cringe when tobacco is held up as an example of business in public health...You only hear about business when there's fraud. Our members are the first to argue that bad actors [should] get what they deserve."
As cultural gaps have narrowed through the establishment of trust and collaborative efforts to act in response to shared objectives, other issues have become apparent. These include concerns about the following:
Government procurement regulations
Business leaders perceive that procurement regulations force government officials to maintain a defensive posture in order to avoid risking a future conflict of interest, or appearance of conflict of interest. Both may be concerned that collaboration could poison opportunities for future contractual interactions, especially if a business partner is perceived as having unfair insight into government contracting opportunities as a result of voluntary collaborations.
Potential for shifts in government priorities
At times, business partners were frustrated by shifts in public health priorities, which some BENS members described as a "flavor of the month" mentality. For example, over the course of the SNS project, public health and other government agencies in Georgia had to divert part or all of their attention to the Group of Eight (G8) summit conference in June 2004, pandemic influenza planning, and other preparedness mandates from CDC and HRSA. While these diversions are understandable, many business leaders have a "Lets get it done" attitude, they value adherence to timelines, and they are concerned when competing demands on public health officials force project delays. People who work in government are familiar with such political realities and have at times been frustrated by the impatience of business partners. In addition, many in business have been surprised to learn that state and local public health agencies lack sufficient staff and resources to manage their multiple preparedness responsibilities simultaneously. As one public health official noted:
"It was hard for business leaders to even imagine that public health was not well funded and did not have the tools we need given our responsibilities...They think we have more money than we do."
Anxiety about the timeline for exercises was felt most acutely by some in local public health departments:
"BENS wants to do more exercises. We're exercised to death. They don't understand how much work it is for us to put on an exercise."
"It's too soon to have another exercise...we needed more time to train...These timelines are crazy. We have other exercises and other responsibilities"
Business respondents had a different reaction to delays, but also demonstrated a growing understanding of the constraints affecting their public health partners:
"If planning for SNS is delayed, business partners ask, 'What if we have an anthrax attack? If we postpone the exercise then we're postponing our ability to be prepared...'"
"Putting on my military hat, you don't back up or postpone. You make it happen. The tendency of public health to shift priorities and postpone projects is frustrating...But public health said 'Slow down' and BENS has to understand that...At least we're moving forward."
Different management styles
Business leaders observed that company chief executive officers often exercise greater authority than government officials to mandate changes or enforce adherence to policies and standards across locations. Public health managers put greater emphasis on consensus-based decision making, and they value flexibility in adapting programs to local circumstances. This partly reflects the sharing of public health authority in Georgia between the state health officer (the Director of the Division of Public Health) and directors of the state's 18 local public health districts. As a consequence, public health districts in Georgia are apt to develop SNS dispensing procedures that are more independent and variable than a company's operations in different locations.
Occasional but memorable instances of government disorganization
The state's experience in responding to Hurricane Katrina, which directly affected nearby states and resulted in evacuation of affected people to Georgia, was largely viewed as an example of the benefits of positive links between business and government agencies. There were, however, instances when government officials asked BENS staff to request resources from members, and business leaders responded quickly, only to be told that needs had shifted and their resources were not needed. In another instance, a Georgia BENS member offered to provide a critical service at no cost to the Federal Emergency Management Agency (FEMA), but FEMA did not have an administrative mechanism to accept the offer. While this episode reflected an interaction with a federal rather than Georgia agency, the perceived lack of flexibility or imagination by a government agency unavoidably shaded perceptions of governments in general, including state government, among some business leaders.
Confidentiality of proprietary information
Concerns about the confidentiality of information that businesses share with governments and vice versa have been an ongoing challenge, despite progress in clarifying laws and regulations that govern information sharing and access. Much of the critical infrastructure required to support community functioning is privately owned. Maintaining an inventory of these assets is essential to emergency planning, but information about these resources may be highly sensitive for either security or proprietary reasons. Businesses' enthusiasm for sharing such information with government agencies in advance of crises is diminished if it is susceptible to widespread access via open record laws. Likewise, government agencies may acquire intelligence that would be valuable to businesses in protecting assets, and businesses may be uniquely positioned to assist governments in interpreting intelligence reports, especially if they relate to potential threats against businesses. Despite the potential benefit of sharing intelligence information, government officials may feel compelled to withhold it, erring on the side of making sure they adhere to security regulations as they understand them. The status of efforts to address these concerns was summarized by one government respondent in the following way:
"The current mindset is 'Hold onto your information'...We're chipping away at that..."
Another major concern for businesses is liability, especially with regard to collaboration in exercises. For example, if a company offers space to conduct an exercise or allows its employees to serve as volunteers, a host of questions arise about potential liability in the event of an injury. While Good Samaritan laws typically protect people engaged in supporting an emergency response, they generally do not protect preparedness activities, nor do they protect companies. Moreover, the level of protection may be narrowly defined by the specifics of an emergency declaration. Both liability and confidentiality concerns tend to evaporate during an actual crisis, but, in the absence of advance planning, governments have been unprepared and unable to accept valuable offers for help during crises. Ironically, current open record and Good Samaritan laws deter some business from engaging in such pre-event planning.
Ongoing differences in perspective
Despite successes in bridging cultures, managing differences in perspective remains an ongoing challenge. For example, the July 2005 SNS dispensing exercise was widely viewed as successful by business and public health respondents, both for providing proof-of-concept for the collaborative dispensing model and for evaluating specific procedures. Despite this shared view, several public health respondents expressed frustration because BENS member companies did not meet initial targets for the number of volunteers they could recruit:
"I had to do a lot of volunteer recruiting that I had expected them [BENS] to deliver..."
"Show me the volunteers."
For others, this shortfall was immaterial, as exemplified by the following observation from a business respondent:
"What is the question? Is the question Can we get the number of targeted volunteers to an exercise?... Or is it can you learn a lot real quick?... We set a goal of 2000 volunteers and got 1200. I don't see that as a failure. The exercise truly flexed the process...We had enough to truly stress the operation and learn where the flaws were in the design of the operation..."
While this inventory of challenges may seem daunting, none of these obstacles was viewed as insurmountable, nor were they viewed as a deterrent to planned expansions of the SNS dispensing model or extension of the partnership to pandemic influenza planning. To the contrary, respondents emphasized that their growing understanding of one another's concerns and their increased ability to be frank with one another about these issues were important signs of progress. Identifying potential barriers to growth in collaboration has enabled the partners to target these concerns, including ongoing work to address legal questions surrounding confidentiality and liability.
Facilitators to collaboration
The ability of business and government partners to establish personal relationships has been fundamental to the success of the partnership. The accompanying growth in trust and respect and the ability of participants to enjoy working together have enabled the partnership to take on increasingly complex activities. As one business respondent observed at the conclusion of the interview, "It's just been fun" and as one state official observed:
"They're good people. Their hearts are in the right place...They're rich guys but they're down to earth...very patriotic, they want to help."
There are also attributes of BENS business model that have facilitated collaboration with public health, including their:
Focus on national security and emergency preparedness
BENS' mission-level focus is on national security, and its Business Force program is dedicated to collaboration with state and local governments to advance emergency preparedness. This focus has attracted a membership that includes representatives of very large companies with a sizeable stake in community continuity, as well as people from smaller companies with relevant expertise.
Commitment to service
BENS' non-profit and non-partisan status is critical to establishing and maintaining links to governments given potential differences across areas or over time in political leadership. In addition, BENS' firm commitment to being a service-oriented organization is perhaps its single most valued attribute among government partners. BENS zealously guards its reputation in this regard. In a rare instance when a BENS member appeared to government partners as self-promoting, BENS leadership removed that person from the project team.
Strategic engagement of senior business and government officials
BENS leadership is strategic in its outreach to government partners at federal, state, and local levels, and BENS staff explicitly identify building personal links as a strategic priority. As part of this approach, BENS is able to leverage the seniority of its members into contacts with senior business and government officials. Business respondents often cited the support of top-level executives in their companies as critical; likewise, government respondents repeatedly cited the governor's support for collaboration with BENS as an essential catalyst for the partnership.
The BENS business model for collaboration includes a)identifying partners' needs and assets, b) developing focused priorities and project concepts that are consistent with its overall mission, and c) initiating projects that can be tested and measurably evaluated. This has been a workable model that has been embraced by both government and business partners.
Conceptual link between business and community continuity
As part of its Business Force model, BENS has successfully linked the concept of business continuity planning, an activity that is familiar to business, to the concept of community continuity. Simultaneously, collaboration with BENS has enabled public health leaders to better understand the role of businesses in community continuity as essential to disaster response and recovery.
Links to multiple government agencies
The collaborations that BENS has with emergency management, public safety, and homeland security agencies in Georgia have facilitated links with public health. As one public health official noted, "We all go to each other's meetings." For example, public health has the lead on SNS dispensing, and officials from other state agencies participate in SNS workgroups. In turn, the Georgia Emergency Management Agency has the lead for projects that address protecting critical infrastructures, linking business partners to the state's emergency operations center, and hurricane preparedness, but public health is represented at these meetings. The credibility that BENS has established and maintains with other agencies "makes it easier for public health to work with BENS."
Benefits of business and public health collaboration
Identifying benefits that have arisen from the collaboration involves two questions: 1) Has the collaboration led to more effective responses to actual emergencies, and 2) Is Georgia better prepared to address a future large-scale emergency?
The most dramatic emergency to occur during the course of the partnership was Hurricane Katrina in August 2005. Although Georgia was not directly hit by the storm, Georgia was the destination for thousands of evacuees from the Gulf coast; and Georgia government agencies and businesses contributed to recovery and relief efforts in directly affected states. The response to Hurricane Katrina did not involve mass dispensing from the SNS in Georgia, the focus of the BENS-public health collaboration, but respondents provided multiple anecdotes describing BENS members' support for the response. As several respondents observed, the director of the BENS Metro Atlanta Region was "on the phone 24/7" fielding requests for assistance from government officials and offers of assistance from businesses and making connections to match resources to needs. For example, as the result of business contacts, BENS staff made connections with the airline company that transported evacuees from New Orleans, resulting in better information for public health and healthcare providers about flight arrival times in Georgia and passengers' health status. Other contacts through BENS enabled support for transportation of people and supplies to the Gulf region, assistance in restoring critical telecommunications links, and donations of warehouse space to store and distribute clothing and other donated materials.
Regarding preparedness for a future large-scale public health emergency, all respondents felt that response capacity, particularly in the metropolitan Atlanta area, has been strengthened. Nonetheless, they cautioned that the impact of the collaboration is difficult to quantify, they varied in how they gauged readiness, and they agreed that substantial work remains. Perspectives included the following comments:
"If we had a massive anthrax exposure in the middle of Atlanta tomorrow, we'd probably have a fiasco. But the response would be much more effective than it would have been several years ago, and we are much better positioned to prepare for a future attack than we were several years ago."
"Are we better prepared? Absolutely, but we're not ready. We're halfway through the first quarter."
"We're not done... but if something happened today, we could really help. We have the relationships and a model for corporate involvement. We could get the business commitment. "
Advances in preparedness were also described in more personal terms:
"I can speak straight with him [a colleague in business] in a way that couldn't be done earlier."
"Now we have access to the top folks in business..."
"...People are on one another's speed dials."
"When I call to offer help in a crisis, they [senior government officials] know who I am and they'll take my call."
"We're learning to think like them and they're learning to think like us."
More tangible benefits to public health include the engagement of logistics expertise and volunteers from businesses in the July 2005 SNS dispensing exercise and the commitment of businesses to expand the model to all five metropolitan Atlanta health districts. In addition, the success of the partnership has enabled expansion of its agenda to include pandemic influenza planning. For example, the Division of Public Health has involved BENS in encouraging the business community to participate in regional pandemic planning groups throughout the state and in developing procedures for corporate occupational health systems to support home healthcare in the event of a pandemic. Altogether, these activities represent substantial, although un-tallied in dollar terms, investment of private resources into emergency preparedness in Georgia.
Limits of Business-Public Health Partnerships
Discussion of limitations of partnerships between business and public health fell into the following categories:
Limits of volunteerism and pro bonoengagement
As BENS is being asked to do more by its government partners, the partnership is facing the limits of volunteerism and of pro bono member engagement. In this regard, BENS is a "victim of its own success" resulting both from the value that government agencies in Georgia have gained from the partnership and from the ongoing efforts of BENS to promote business-government partnerships. In addition, CDC views the BENS-public health collaboration in Georgia as a model for SNS dispensing that should be emulated by other states, and CDC has enlisted BENS members to consult with businesses and public health officials in other states. As BENS staff or members have observed:
"A few people have donated a lot of time. We need to wrestle with how much time we can ask people to give."
"Potential is unlimited, but we are limited by resources and ability"
"We're being asked to do a lot. It's now more than what we can do. We're being included in everything [regarding emergency preparedness]."
Limits are also shaped by the lines of accountability and procedures within businesses and governments. Ultimately business managers are accountable to investors or shareholders, and actions must be compatible with companies' long-term interests. For example, a company may endorse the principle of supporting SNS dispensing, but there are limits to how many employees a company may be willing to dismiss from work to participate in a dispensing exercise, which can represent a significant cost. Similarly, public health officials "live in a political world" and must act in ways that are politically feasible. Despite the potential value that may be gained from such collaboration, some respondents expressed concern that the partnership may be constrained if the public perceives the SNS dispensing model as a form of favoritism for business.
There are limits to the speed at which business-public health partnerships can take on projects. Efforts to expand the collaboration beyond the Atlanta region within Georgia or to replicate the Georgia experience in other states may not be successful if the scope of projects does not match the status of relationships.
"It has taken five or more years to move from casual 'handshake' relationships to one where people are on one another's speed dials. Relationship building cannot be rushed."
Keeping focus on preparedness
Some in public health would like to extend the scope of the partnership to address other health problems, such as promoting workplace obesity prevention or smoking cessation programs. But, there is recognition that pushing in this direction could strain the still-developing relationship with BENS. Noting that attention to emergency preparedness has enabled public health to strengthen infrastructure generally, one public health official cautioned against over-reaching: "The homeland security dividend only works so far." While workplace health promotion is certainly a worthy cause, BENS members advised that other business organizations would be a better fit for such efforts.
Respondents were consistent in recommending that the partnership between BENS and government agencies, including public health, in Georgia be sustained and expanded and that businesses and governments elsewhere initiate similar partnerships. As one public health official noted:
"I see the public health-business relationship as one of the most useful new relationships for public health that has come onto the horizon".
In addition to recommendations to attend to the challenges, facilitators, and limits described above, other recommendations included:
Make a start
Cautions against pushing relationships too quickly were offset by a counter-recommendation against moving too slowly.
"You need to make a start, so pick something and get going."
Obtaining new funding would enable BENS to push beyond the limits of volunteerism, and both the national office and the Metro Atlanta Region of BENS are exploring potential opportunities for additional funding. Several respondents cautioned that such an expansion could present new challenges for the partnership. Given the long-standing context of BENS' role as an organization that offered volunteer services to governments, initiating contractual arrangements with governments would change the dynamics of BENS-government interactions. For example, expanded funding would allow BENS to pay members whose services are needed beyond the limits of what they can offer pro bono. Alternatively, government agencies may be interested in contracting for additional services from BENS members, including those who have previously provided pro bono services and who would likely continue to serve as BENS volunteers. This will require defining the line of propriety for members who are both volunteers as well as potential contractors for BENS-related work.
Avoiding complacency and overstatement
Despite the achievements to date, substantial work remains to expand the SNS dispensing model to all five metropolitan Atlanta health districts. Beyond Atlanta, where many large companies are based, this model may be less replicable in other, more rural parts of the state. Proponents of the BENS-public health partnership must carefully navigate the boundary between reasonable promotion and overstatement. Public health officials are typically grounded in the scientific tradition, which involves carefully qualifying observations. In contrast, business people are more accustomed to the role of marketing in achieving goals. These differences in perspective can lead to discomfort on both sides of the partnership, another example of the inevitable and ongoing differences in the business and public health cultures.
No respondent challenged the lead role of government in planning or executing emergency response activities, nor did any recommend that government authorities be transferred to businesses. Nonetheless, concern was expressed by some in government about the ability of public health officials to maintain their leadership role. For example, one official noted:
"People in public health tend to have less assertive personalities than people in business. We're dealing with people who run major companies, and they are aggressive and like to take charge. If we're not careful, we could end up handing over control of things that are our responsibility."
"We need to keep in mind, public health is the lead. Public health cannot allow others to be the driving force – partners yes, but not lead. Public health should not turn it over to business to manage. I don't see that happening, but..."
A related recommendation from some public health officials was to assure that governments maintain an option to work directly with businesses that are BENS members, not having to "go through" BENS, or to work with other business organizations, without feeling obliged to consider BENS as the sole conduit for business partnerships. Some business respondents anticipated these concerns by emphasizing that BENS should not aim to usurp government authorities or position itself as a gatekeeper for business and public health links, but rather it should continue its role in supporting government programs and facilitating links. As one BENS staff member commented, "We don't have all the answers, there's room for others." Another dimension of respecting government and business roles was expressed by a company executive in the following way:
"It is important for all parties involved to understand the 'value proposition' for the other parties. If we are not creating value for other members, the team will not survive. If we can to that, we can sustain our effort."