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Saturday, December 9, 2023

State of Public Health: Emergency Management in a World of Increasingly Complex Disasters

Emergency planners cannot change someone's genetic code, but they can change the conditions in a zip code.

Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe

Traditional disasters with an acute phase and a relatively finite timeline for the immediate response are becoming a thing of the past. Emergency management and public health must now, instead, pivot to a new reality of multiple complex and simultaneously ongoing disasters. In early September 2021, the United States is managing droughts and wildfires on the West Coast, devastation from Hurricane Ida in multiple locations from the Gulf Coast up the Eastern seaboard, a refugee crisis, and the sudden conflagration of new COVID-19 variants within the slow-burn of a persistent pandemic. These situations, while all clearly falling into the realm of emergency management, also clearly fall into the realm of public health. As the earth continues to warm, increasing the reach of both storms and diseases, this will become our new normal. To be prepared we must recognize the overlap between these two critical fields and begin to integrate them more fully. Public health begets emergency management and emergency management begets public health.

In the two decades since the deadliest terror attack on American soil, emergency management has modernized its approach to disaster management. The Federal Emergency Management Agency (FEMA) and its local, state, territorial and tribal level counterparts shifted to a new understanding of emergency management: the all-hazards approach. In this heuristic, emergency managers should account for all possible hazards to a region and plan accordingly. In these plans the health of the public is included but has not yet been fully integrated. We need to do better; emergency management and public health have often been seen as two separate entities with emergency management often focused on response to an acute time-bound event and public health dealing with long-term health issues or response to health issues after the hurricane or other disastrous event has happened. Notably, emergency management agencies could dramatically reduce morbidity and mortality during disasters by understanding and improving public health. Nascent partnerships have been established between FEMA, the Assistant Secretary for Preparedness and Response (APSR), the National Emergency Management Association (NEMA), and the Association of State and Territorial Health Officials (ASTHO), but the meeting of these groups requires further prioritization and investment to flourish. Public health is often treated as an adjunct to emergency management; it is not. Public health is the raison d’être of emergency management.

After all, what disaster does not impact the health of a community? When COVID-19 was first emerged many in emergency management felt that “FEMA doesn’t do pandemics.” Administrator Pete Gaynor initially soon realized, however, FEMA was the one agency that COULD coordinate and lead the response – shortly thereafter FEMA became the lead federal agency for the COVID-19 response. As long-term climate change becomes a threat of greater significance than only one hurricane or terrorist event the mindset of public health and emergency management must be reevaluated and revised. FEMA will continue to be tapped for an increasingly broad range of missions as the nature of disasters changes. The Incident Command System (ICS) has proven to be such a powerful tool in leading through complex situations that FEMA, and other emergency management agencies, will be turned to as the go-to resource in a world in which more and more communities are susceptible to calamities. This broadened scope of emergency management will increasingly overlap with the scope of public health work.

When both public health and emergency management are examined through an equity lens the connections between the two fields become explicit: nothing happens in a vacuum. As described by Dr. Eric Noji in his seminal text The Public Health Consequences of Disasters, disasters are never the events themselves; disasters are how an event interfaces with a society. Without vulnerable human populations, a hurricane is just an interesting meteorological phenomenon. When populations are able to evacuate, and their houses are built in an appropriate location with a building code that accounts for storm conditions a hurricane is just a storm and not a disaster. The question now is how to change the status quo from adverse events, be they hurricanes, wildfires, terrorist attacks, etc., being disasters to a status quo in which these events are just that — events.

There needs to be a systems-based approach for mitigating disasters into events, rather than the current piecemeal approach as problems arise. Since 2010, FEMA has introduced the concept of the Whole Community into their emergency management planning. Humbly accepting that local organizations know the most about their communities and are prepositioned on location in the event of a disaster, FEMA is empowering leadership at the most local level possible. Although FEMA aims to make itself e pluribis unum it maintains a role as the national tone-setter on emergency management topics. FEMA should use this platform to encourage using public health lenses and frameworks across all levels of government. Vulnerabilities are created by the complex interactions of all levels of society, therefore all facets of society must be at the table to efficiently ameliorate them.

“There needs to be a systems-based approach for mitigating disasters into events, rather than the current piecemeal approach as problems arise”

Poverty and inequality are both well-recognized contributors to vulnerabilities in both emergency management and public health. It is no mystery which populations will be the worst affected in disasters – it will be the same communities that have the worst health outcomes today because the same systemic forces that compel people to live in hazardous areas are the same forces that lead to worse health outcomes. To help communities prepare for disasters, FEMA has designated $5 billion for multiple mitigation programs like the Hazard Mitigation Grant Program (HMGP) and Building Resilient Infrastructure and Communities (BRIC) grant programs dedicated to helping communities develop programs to address self-identified needs. This program is exactly the kind of systems-level approach the United States needs to address impending catastrophes, but even this program cannot fund projects in every location and leaves populations at risk unless their state and local governments take the initiative to apply for grants. Sadly, this is not a guarantee for communities whose leaders are still denying the reality of climate change.

Despite FEMA’s acknowledgement that much resilience happens on the level of societies; American society still places a heavy burden of responsibility on individuals to be resilient and to be responsible for their health and well-being in normal times and in times of disaster. Despite the clear population trends delineating that the majority of these impacts stem from forces greater than the individual. Our built environment and social zeitgeist create the vulnerabilities we see to both forces. Individual responses to society-wide problems will often be ineffective and continue to favor those with the greatest resources, a situation that can further exacerbate societal tensions. To see lasting change systems must be altered.

The old public health adage applies: “Every system is perfectly designed to get the results it gets.” However undesirable or unintentional the outcomes of that system may be, the results are still a direct outcome of its design. As Louisiana struggles to recover from the impact of Hurricane Ida, we can see that axiom at play. The aftermath of disasters often leads to rebuilding in more “resilient ways,” but this resilience often focuses on critical infrastructure and not the resilient health infrastructure that communities need to reduce the conditions that make people vulnerable to disasters. Many breathed a sigh of relief as the improved levees held against a Category 4 storm, but as the storm abated, the same social conditions that created vulnerabilities in Hurricane Katrina remain. The social safety net was not strengthened like the levees in the intervening years. A public health framework can help emergency managers work upstream to find the predictable points of failure in social systems and mitigate them like they do with hard infrastructure.

While the Pelican State has geographic conditions that make it uniquely vulnerable it can still act as a national “canary in the coal mine” to the effects of climate change. Hurricane Ida showed that planners must now account not only for a strong hurricane, but also they must plan around a new more complex milieu. The city of New Orleans was unable to implement its citywide evacuation plan due to how quickly the hurricane gathered strength. Shelters were unable to handle the planned capacity of residents because of COVID-19 restrictions, hospitals in the entire region were already fully at capacity from the ongoing Delta surge, NGOs and federal agencies had to divide their resources between Louisiana and all along her destructive path as well as myriad other ongoing disasters. While the details may change by state and over time the core challenge will remain, disasters are becoming more frequent and more complex.

The data exists to tell policy makers, public health practitioners, and emergency managers who will be at risk of future disasters. When we do not act on that information the results are predictable points of failure. In New Orleans, the poorest residents have been struggling in crippling heat without power for more than a week after Ida made landfall. Many suffered and it should come as no surprise that those suffering are the same segment of the population that was unable to evacuate during Hurricane Katrina. While the length of the power outage is unprecedented, the precedents set by previous hurricanes and known health and resource disparities meant that this outcome was by no means surprising. Any system that requires residents to be privately responsible for evacuation and lodging is destined to leave behind those without transportation, funds, or other necessary resources. The system gets the results it was designed to get.

State of Public Health: Emergency Management in a World of Increasingly Complex Disasters Homeland Security Today
25 staffed ambulances from FEMA arrived at Camp Ripley Nov. 20, to help hospitals transfer patients to other medical facilities. (Minnesota National Guard photo by Sgt. Mahsima Alkamooneh)

The intersection of emergency management and public health must be strengthened to fix the flaws in the system. Epidemiological data is one of the most powerful tools society has to understand which communities will be vulnerable to disasters. In Chicago’s 1995 heat wave, the areas that experienced the most heat-related deaths mapped perfectly onto the areas that were also experiencing poverty. Although Chicago developed improved response strategies for similar events in the aftermath many of the societal inequities that created the vulnerabilities prevail. Should a similar heat wave occur in the future (an increasingly likely event due to climate change) the same populations that were impacted before will be disproportionately impacted again – the evidence is in the data of ongoing structural disparities.

In the past decade, public health has developed a robust literature on the social and behavioral determinants of public health. This data can be and should be co-opted by emergency management to better plan to meet the needs of a population pre-disaster and address them post-disaster. The health of a population is a sentinel signal of how a population will fare in a disaster. A person’s genetic code is less of a predictor of their health than their zip code. And while this is a damning indictment of inequalities in the United States, it also offers hope. Planners cannot change someone’s genetic code, but they can change the conditions in a zip code. Emergency organizations have begun to see the power of using this data in response. Team Rubicon, a disaster response organization, chooses its deployment locations based on the social vulnerability index of neighborhoods because they have recognized this to be a relevant proxy for who will be at risk in a disaster. FEMA, too, has begun using health data for response but can expand its capacities. To create systems, change, this data must be part and parcel of the entire disaster cycle – not just during responses. Improving the health of people who are vulnerable to disasters will inherently make them less vulnerable to disasters because the conditions that put people in harm’s way are the same conditions that make them more likely to experience worse health outcomes.

The importance of public health has been demonstrated time and time again over the past 18 months of COVID-19. Emergency management has also played a critical role in protecting the nation from existing and emerging threats. But what is still missing is fully integrating the two disciplines so that they can function as more than the sum of their parts. Disasters are getting more complex and both fields must modernize to fulfill their missions of population protection. These changes must include steps like expanding BRIC and to encouraging communities to utilize COVID-19 relief funding in ways that both diminish chasms between emergency management and public health and take steps toward addressing the underlying systems that lead to vulnerabilities in the first place. Both careers draw from a population that has a profound calling to help people and improve the human condition – we must use the tools at hand the channel that shared calling into a shared understanding of challenges communities face, why they face them and, ultimately, a unified vision of how to respond to these challenges.

Richard Serino and Ellen Chappelka
Richard Serino and Ellen Chappelka
The Honorable Richard Serino is currently a “Distinguished Visiting Fellow” at Harvard University, National Preparedness Leadership Initiative. Mr. Serino was appointed by President Obama and confirmed by the Senate as the Federal Emergency Management Agency’s 8th Deputy Administrator in October 2009 and served until 2014. Prior to his appointment as Deputy Administrator, he served as Chief of Boston EMS and Assistant Director of the Boston Public Health Commission. As Chief of Boston EMS, Mr. Serino served as Incident Commander for over 35 mass casualty incidents and for all of Boston’s major planned events. During his time at FEMA, he oversaw 60 disasters from flooding in the Midwest, tornado devastation in Missouri, tsunami destruction, and numerous hurricanes. Mr. Serino was on scene at the Boston Marathon bombings in 2013 as the highest-ranking official of DHS. Under Mr. Serino’s leadership, FEMA has started the following initiatives such as FEMA Corps, FEMA Stat, the FEMA Think Tank, a detailed budgetary process, and a Disaster Workforce and Workplace Transformation. Ellen Chappelka is an MPH student in the Healthcare Management. Her research interests include rural healthcare, health and the built environment, and transportation health. She completed her undergraduate studies at Tulane University with a BS in Public Health and a minor in urban studies. Prior to Harvard, Ellen also worked as an EMT for New Orleans EMS and as a health systems specialist for the Air Force with a focus on health optimization and military readiness.

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