Kennedy, George MD; Richards, Michael MD, MPA; Chicarelli, Michael RN; Ernst, Amy MD; Harrell, Andrew MD; Stites, Danniel MD
* The assessment of vulnerabilities and likely events in a community can help establish the foundation for planning appropriate responses.
* The best opportunity for the development of resilient structures is during new construction.
* The strategic development and maintenance of memoranda of understanding can assist in the development of external resources that can be mobilized when needed.
* The overall goal is to develop a plan for a sustainable response that will carry a community through an event and into recovery.
Each year, natural and manmade disasters occur around the world, and how individuals or communities react has lasting effects on families, neighborhoods, and communities. The resilience of a community overwhelmed by a disastrous situation may be measured in the difference between a response with a sense of hope, community pride, and resourcefulness and one filled with despair, hopelessness, and blame. A community’s assessing vulnerabilities, developing resilient infrastructure, establishing memoranda of understanding, and planning for a sustainable response leads to mitigation of an event long before the actual impact.
In the post–September 11, 2001 decade, an all-hazards approach to the known threats in an area can be appended into a response to an unforeseen event such as a terrorist attack or a hazardous materials event. A community having an unexercised plan is not ready.1 If a community remains safe and unchallenged by events for a period of time, then a response plan may become obsolete through attrition of key players and changing resources. Preventing the stagnation of complacency and mitigating its impact through planned reviews and drills should be part of ongoing community readiness,2–6 and the growth of populations into previously unoccupied areas should be seen as an opportunity for community leadership to foster honest debate about disaster mitigation. Conflicts regarding removing vegetation in opposition to the green/ecology movement,7 blocking controlled burns during unfavorable conditions, repairing damaged levees, or building structures that are more resilient should be recognized and overcome.
Vulnerability assessment is a vital step in disaster preparedness. No amount of planning or preparation can avert the devastating impact to a community, and lack of knowledge about endemic hazards by citizens and governmental planners will contribute to poor preparation.8 A well-designed and thorough vulnerability assessment can strengthen the existing infrastructure and focus response and recovery efforts. Vulnerabilities include loss of basic survival needs, communication, and infrastructure. The extremes of age and more fragile segments of the population including poor people, people with disabilities, and those with unique needs for daily living are representative of the vulnerable elements of the community. A preevent analysis should provide an appendix of responses for damages incurred and anticipated recovery. Taking an all-hazards approach to an area may assist in the development of further event-specific responses and define recovery planning. The anticipated variety of vulnerabilities depends on the community affected, the type and duration of the hazard, the time of year, and other important factors.
Food and water are among the basic necessities that must be addressed quickly and efficiently. Provision for the safety of local food and water supplies in the absence of electrical power needs to be considered. Identifying individuals who have the ability to sustain themselves and shelter in place as opposed to more vulnerable segments of the population who do not have that capacity should be a cornerstone of planning. Response may include backup generators at a local water treatment plant or locating alternate sources. If local resources are not adequate or are highly vulnerable, then planning for storage, routes of delivery, and distribution is essential.2
Shelter mitigation planning includes establishing building codes and code enforcement for likely local events such as hurricanes and tornadoes. This assessment should include individual homes, local businesses, and designated shelters at the local and regional levels. Disaster planners can encourage programs for building safe rooms into existing homes and businesses, as well as cooperative education through local home improvement centers.2,3,5
Communication is the foundation of effective human interactions, and its role in disaster preparation, planning, and response is no exception. The chaos and lack of coordination through ineffective communication may blunt early effectiveness. Communication assessment includes the emergency warning system, interagency communications, media communications, and public information dissemination. Component assessment includes cellular telephone towers, radio towers, dispatch and emergency operations centers, landline telephone systems, Internet, and networking systems.
Most communication systems are rendered useless when electrical power is interrupted; therefore, planning must include effective backup communication devices or methods. Examples of backup devices include weather radios, public address speakers, and patrols by fire or police personnel using bullhorns to disseminate information or door-to-door notification. Amateur radio clubs can provide communication support in the event of catastrophic area-wide infrastructure failure and power loss, and the media can play an important part in disseminating instructions and providing information to the affected population. One can foresee that the media’s response to an event often will be faster than other agencies. It is important to recognize this phenomenon and develop strategies that will provide useful information to survivors, the public, and outside agencies planning to offer assistance. Thoughtful use of the media can prevent sensational reporting and attempts to set the agenda. These assessments are crucial to each community’s response.2,4,9,10
Electrical power is essential for maintaining a functional community, and the provision of a sustainable source of power takes planning. Without power, communication systems, automated teller machines, and gasoline pumps are inoperable, and perishable food storage becomes finite. The ability to shelter in place becomes more challenging.
A disaster can have an enduring and widespread impact on the economy of a community, from the individual level to small businesses, agriculture, and industry throughout an entire area. An economic vulnerability assessment should include the social impact, transportation of goods and commodities, bank and automated teller machine infrastructure, the loss of businesses and industry, and other potential areas that will affect recovery.
It is also important to recognize that most response will occur at the local level during the first 72 hours; furthermore, there will be a flood of well-intentioned offers of help from outside sources. Preplanning should encompass how to address these offers, including potentially blocking offers of assistance that will burden the response unnecessarily and facilitating needed offers of mutual aid.
The incident command system has provided a uniform platform for disaster response. Over time, individuals with variable levels of understanding of their specific duties may be assigned to roles for which they are not prepared. Providing up-to-date guidelines and exercises will allow opportunities for training community leadership in a response.2,5,8
Developing Resilient Local Infrastructure
In the predisaster development of infrastructure, the best opportunity for building resilience is during new construction. The differences in casualties, from earthquakes in California compared with an event in underdeveloped areas such as southwest Asia, are a testimony to the benefit of infrastructure development. Focusing community resources toward the most likely, foreseeable situations provides safety and response capabilities when and where they are needed most. These efforts also build in area-wide resources that can then be used for other unanticipated events.1,2,11
Events may have varying areas of size of impact. Discrete, localized disasters such as a long, although narrow, tornadic touchdown event through sparsely populated country will differ from a large-scale metropolitan event such as flooding after a hurricane. A disrupted regional response will create the need for state or even federal resources.
The local governmental infrastructure for disaster responses needs to cover a broad range of resources. The conventional local fire, emergency medical systems, law enforcement, and emergency services are crucial components. Just as important are those entities that can work to restore crucial public services such as water and electricity. During the colder months, natural gas and fuel oil sources for heating must become available as soon as possible and planning activities must involve area public works and power generation infrastructure early in any response.2 The integration of area social services, transit departments, municipal animal control services, public schools, and even parks and recreation departments should be included. This disparate group can provide a wealth of resources that can aid in population relocation (transit), coordination of contact information and support for separated families (social services), assistance with transport and safe treatment of family pets and other animals (animal control), and provide safe shelter and entertainment (parks and recreation, public schools).
Local nongovernment resources for disaster planning purposes should start first and foremost with the residents of any given area. Individual preparedness efforts should aim to have all capable people create and maintain the ability to shelter in place for at least 72 hours; although some experts have suggested that this timeframe may need to be increased. Recent events in the United States and throughout the world have supported 2 weeks of self-sufficiency.6 Businesses and industry need to consider sheltering in place those employees who are unable to return home, in addition to mapping out their own recoveries.
Other resources from nongovernment entities (volunteer organizations active in disasters) such as the Red Cross and Salvation Army or other faith-based agencies should be factored into disaster preplanning considerations. Furthermore, private organizations such as home health and home meal delivery agencies may play a vital role in reaching out to the most vulnerable members of a community. These groups often have a formidable and well-proven record of response capabilities that can augment local governments’ efforts in extenuating circumstances.
Thinking unconventionally about the utilization of nongovernment resources in a given area event will provide additional resources. Disaster response improvisation to solve problems is greatly amplified with small amounts of preevent preparedness and may allow for enhanced response flexibility postevent.5 Local corporations that have large, warehouse-style commercial presences could provide much-needed supplies and materials for rescue operations and other community needs if outside transit routes prove impassable. Mirroring their government counterparts, private utility contractors and electrical, gas, plumbing, and transit entities can supplement local area governments’ response when the scope of disaster events outstrips the ability of the local response capacity. Any government resource should be integrated with a private sector counterpart.
Another area of focus is healthcare delivery and treatment locations for a given locale. All municipalities must plan for worst-case scenarios when experiencing the loss of either government or private hospital–based patient centers or for continuing to support the healthcare needs of the area. Schools, churches, health clubs, warehouses, empty commercial space, and performance facilities that can serve as surge capacity for displaced population housing and healthcare facilities should be identified. Whether using private networks of clinics, urgent care clinics, freestanding emergency departments, or other resources, communities must build in redundancy to provide for loss of community healthcare resources in large-scale disasters. Predetermining multiple possible patient care rally points throughout an area allows for the distribution of patient volumes and minimizes the loss of backup planning locations.3,5,11 Arrival of state and federal resources such as state medical assistance teams, state urban search and rescue teams, disaster medical assistance teams, and urban search and rescue teams assets are seldom expected within 12 hours of an event unless there is prepositioning of the resources in conjunction with tracking of a large hurricane in the United States.
Collaborating on Memorandum of Understanding
The memorandum of understanding (MOU) is an integral and key piece of a robust emergent response. The strategic development and maintenance of MOUs can assist in a community’s utilization of key external resources instead of an uncoordinated flood of offers for assistance. The MOU process offers an opportunity for organizations to prepare well in advance of an actual event. A well-designed MOU creation and implementation plan must contain a realistic assessment of organizational needs and potential required resources. Considered resources should include human resources, supplies (including medical and infrastructure), and space. Developing MOUs between local or regional hospitals can improve collaboration during a significant surge of patients in emergency department or inpatient units.
Full disclosure regarding how the MOU will be executed must be predetermined and written into the agreement, and the developer of the MOU must be clear about how the resource will be used and returned. The classic example of an MOU for refrigerated trucks used for mass fatality storage demonstrates how disclosure is paramount. Once used as a temporary morgue, a truck offers little use for food transportation by the company from which it was borrowed. This example, although dramatic, illustrates why disclosure is critical during the initial development of the MOU.
The development and use of MOUs can present some unique and interesting challenges. Many MOUs are written as legally binding documents, which creates unwillingness in both parties to participate in the agreement. Companies may be reluctant to be bound to an agreement based on the potential unknowns created by a disaster or emergency. To avoid confounding issues during an actual disaster, it is wise to randomly test the MOU to the furthest extent possible; simulating the needs listed in the MOU can quickly determine whether potential barriers may exist during actual implementation. An emphasis on solid development of the MOU will reduce the number of potential issues that may be realized in an actual event.12,13
Creating a Sustainable Response
Some events such as hurricanes and floods may allow for the early initiation of response and evacuation of vulnerable segments of the population. Other disasters such as earthquakes, tornadoes, and terrorist-initiated events may require a response to begin at zero hour. Once the event has occurred, an early, honest assessment of damage, injury, and needed response for the incident commander can initiate the mobilization of assets. Individuals can decide whether they can self-rescue, shelter in place, provide self-care, and remain self-reliant for at least the next 72 hours. Contrary to popular notion, most communities respond positively to adverse events. Neighbors helping each other with rescue, first aid, food, water, and shelter are more likely to be the norm than the exception; however, planning security and prevention of predatory behaviors such as looting must be included.
Developing and controlling access into the affected area may require multiple agencies, including law enforcement, fire, emergency medical services, utilities management, and engineering capacity.2,11 Containment of the impact area and security of essential services are critical. Operational needs and logistics should evolve continuously as plans are implemented. Rescue operations should be delineated and ongoing, hazards contained, and services restored by local and nearby agencies. Community leadership needs clarity regarding the capacity for mobilization and utilization of all local assets relevant to the event, as well as establishing communication with the media and outside agencies offering help. The release of instructions and information through the media can be coordinated with overall operations at a high level. Disaster declarations from the state level should be initiated if appropriate to mobilize additional response.
Anticipating an overwhelming surge of injured people during medical planning can help with the distribution of patients. There should be plans for a nearby diversion site with appropriate staffing to examine these patients, the goal being to prevent flooding the system and to keep any single institution from becoming overwhelmed. Congregating local assets into an orchestrated response and matching needs with the utilization of resources will grow and change during the course of the disaster. Initial triage, treatment, and the evacuation of casualties to appropriate facilities are evolving responses that continue into recovery.
There is an overlap of ongoing response and recovery in disaster mitigation. Removing debris, clearing roads and bridges, establishing communications, and providing utility service are part of the early recovery from a disaster. Some individuals may shelter in place and should be assisted with their own efforts. Long-term revitalization of a community by rebuilding local businesses and industry to stimulate economic growth becomes part of the mitigation process by increasing a community’s overall resilience. Mitigation also continues with the reevaluation of vulnerabilities, the assessment of MOUs, the need to rebuild resilient infrastructure, and the postdisaster evaluation of the community’s disaster planning.
1. Rocha JL, Christoplos I. Disaster mitigation and preparedness on the Nicaraguan post-Mitch agenda. Disasters 2001; 25: 240–250.
2. Coule PL, Mitas JA, eds. CORE Disaster Life Support Course Manual. Version 3.0. Chicago: American Medical Association; 2012.
3. McCaffrey SM, Stidham M, Toman E, et al.. Outreach programs, peer pressure, and common sense: what motivates homeowners to mitigate wildfire risk? Environ Manage 2011; 48: 475–488.
4. Godschalk DR. Disaster mitigation and hazard management. In: Drabek TE, Hoetmer GJ, eds. Emergency Management Principles and Practices for Local Governments. Washington, DC: International City Managers Association; 1991: 131–160.
5. McEntire DA, Myers A. Preparing communities for disasters: issues and processes for government readiness. Disaster Prev Manage 2004; 13: 140–152.
6. Simpson DM. Community emergency response training (CERTs): a recent history and review. Nat Hazards Rev 2001; 2: 54–63.
7. Poudyal NC, Johnson-Gaither C, Goodrick S, et al.. Locating spatial variation in the association between wildland fire risk and social vulnerability across six southern states. Environ Manage 2012; 49: 623–635.
8. Kreps GA. Organizing for emergency management. In: Drabek TE, Hoetmer GJ, eds. Emergency Management Principles and Practices for Local Governments. Washington, DC: International City Managers Association; 1991: 30–54.
9. Romo-Murphy E, James R, Adams M. Facilitating disaster preparedness through local radio broadcasting. Disasters 2011; 35: 801–815.
10. Barnes M, Hanson C, Novilla L, et al.. Analysis of media agenda setting during and after Hurricane Katrina: implications for emergency preparedness, disaster response, and disaster policy. Am J Public Health 2008; 98: 604–610.
11. Dajer AJ, Lopez FA, Baker T, et al.. Disaster preparedness 10 years after 9/11: the experts weigh in. Emerg Med 2011; 43: 6–16, 24–26.
12. Institute of Medicine. Guidance for Establishing Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: National Archives of Science; 2010.
13. Hodge JG, Anderson E, Kirsch TD, et al.. Facilitating hospital emergency preparedness: introduction of a model memorandum of understanding. Disaster Med Public Health Prep 2011; 5: 54–61.