So nigh is grandeur to our dust
So near to God is man;
When duty whispers low, “thou must.”
The youth replies, “I can.”
—Voluntaries, Ralph Waldo Emerson (1803–1882)1
This special issue on disaster response in the United States includes a number of excellent articles examining how best to prepare physicians and other healthcare workers to plan for, respond to, and mitigate the effects of a variety of disasters. A key point to remember, however, is that for most disasters of any type, the majority of the response work, including health-related activities, is performed by unpaid volunteers. For example, the American Red Cross, which has a Congressional mandate to serve as one of the primary local disaster response coordinators for shelter and public health, has just a handful of paid positions in any given state (and in my state, none of them are doctors). Planning models indicate that a large-scale biologic event may quickly outstrip the capabilities of local hospital personnel. Extended work hours and increased manpower requirements may create the need for an essentially volunteer workforce, with healthcare workers remaining at their posts, primarily from a sense of duty. In some scenarios, a large proportion of the affected population may never make it to a hospital and their care depends on courageous volunteers willing to work close to the dangerous edge of the disaster or outbreak.
Where will these medical volunteers come from? Do we know whether the hospital’s doctors and nurses will answer duty’s low whisper? In my experience, disaster planners at the local and regional level tend to make overoptimistic projections about the number of medical and service personnel that will report for duty and remain on the job despite threats to self and family. Disasters affect everyone in a given region, including those tasked with responding to the crisis, leaving healthcare workers to make difficult choices concerning the sense of duty to their profession and their personal obligations.
If we use community volunteerism as a proxy for willingness to respond to emergencies, the outlook is not good. Prior studies on volunteerism have found that physicians in particular were unlikely to commit time to community service outside their daily practice, and the trend is worsening.2 Gone are the days when medical schools emptied out so that young “doctors” could support disaster relief efforts (or calls to war) and the bustling halls of charity hospitals were filled with local physicians donating their time. A 2011 Department of Labor survey on volunteerism found that physicians volunteer fewer hours than almost any other group, and much of the volunteer work that was done was connected to children’s school activities.3 The few academic studies that have examined the issue indicate that younger physicians are less likely to volunteer, despite the professed level of volunteer activity of nearly 100% among applicants to medical school.4 The factors behind this lack of community service have yet to be adequately investigated, but research indicates that excessive work hours at every level (with accompanying burnout) and a decline in altruism and community spirit in general are important factors.5 Residency programs are considering ways to increase and sustain volunteer efforts among new physicians, and perhaps involving them in disaster preparedness and response would be a good area of investigation.
Is willingness to volunteer in peacetime an important indicator of what would happen during a disaster? Surely once a flood inundates a region or a bioterrorism agent is unleashed, local healthcare workers will step up to do what is necessary—“so nigh is grandeur”—right? Perhaps not. Imagine an early-career physician or nurse with a new family watching media reports on the advance of lethal pandemic influenza. When a physician is called to leave his or her family to go into the hospital, possibly to remain there until the disaster abates, do we really believe the response rate will be 100%? When I consult with disaster planners, I tell them to use any number for absenteeism they want: We are just making it up and we will not know until faced with a real emergency. In general, we settle on a conservative 20% absentee rate, which is in line with results from surveys sent to physicians in 2003,6 but imagine trying to run a hospital with one-fifth of the staff gone and then add the demands of disaster response and mass casualties. Preparedness drills may duplicate a realistic level of absenteeism for a short time, but no drill can continue for the days and weeks that an actual bioterrorism event or large-scale disaster may require. Fewer still adequately duplicate the loss of ancillary staff, technicians, and often overlooked workers in industries such as food service, custodial, or supply. Perhaps more worrying is that almost no research has been done on how support personnel may respond to a medical emergency. With cutbacks and reduced pay already straining relationships between workers and administration in many healthcare systems, the idea of loyalty to the organization as a significant motivator in emergency response may be erroneous.
Research indicates that the character of the disaster may affect the type and level of response. In years past, natural disasters such as earthquakes and floods brought out the best in a society, with more than enough volunteers in all sectors of response; however, when sociologist Kai Erikson investigated how communities respond to “manmade disasters” such as a nuclear accident or chemical spill, events he called “a new species of trouble,” he found less community cohesion and a general unwillingness to participate in response and cleanup.7 This was most prominent in events in which government or industry was perceived as causing or contributing to the disaster, and as Hurricane Katrina and the 2011 earthquake and subsequent tsunami in Japan showed, even an event that once was commonly thought of as a natural disaster can be perceived as somehow made worse through government incompetence, negligence, or corruption, with a corresponding breakdown in orderly response. Healthcare workers are not immune to this reaction and it may play a role in whether they choose to come to work or self-evacuate. Perceived threats to safety at work or at home during a response may also become a factor when emergency medical providers decide to respond.
Media accounts of disasters such as the 2010 earthquake in Haiti tend to focus on volunteers from outside the disaster area clamoring to get in, making discussions about volunteerism seem moot; however, disaster organizations around the world overstress the importance of ensuring that local providers are trained and motivated to remain in place to provide the best possible care during emergencies. A deluge of uncoordinated and untrained volunteers can add to the complexity of a disaster and hinder effective response. For example, most medical specialty societies, including the American College of Emergency Physicians, discourage unsolicited medical volunteers from entering a disaster area and encourage anyone wishing to participate in emergency response to plan ahead and become integrated into the response incident command structure. Hospitals and community emergency planners are researching creative ways to integrate local providers into immediate response, such as developing precredentialing databases, liaising with Medical Reserve Corps units (discussed elsewhere in this issue) and Volunteer Organizations Active in Disasters.8 In most areas, these efforts are still in the early stages and challenges remain in finding local providers willing to donate their time before the emergency to receive and maintain training, integrate into the established response framework, and prepare themselves and their families to respond when needed.
Is there a way now to identify who may be more likely to respond during a crisis? The motivations of those who do and do not respond in disasters are surely complicated and multifactorial, and for the most part are poorly understood. One study found that fewer than 75% of healthcare workers would respond to an unknown chemical agent emergency, and other studies indicate ranges of from 35% to 55%. The main reasons given for not responding were fear of personal safety and the safety of their families.9 Organizations and institutions may be reluctant to even ask the questions, but discussion of the subject is not an indictment of healthcare providers’ lack of courage or character. In fact, although there were numerous articles on the ethics of response during the bioterrorism events of 2001, it may no longer be reasonable to say medical personnel have an absolute duty to respond in an emergency that threatens their well-being or that of their family. The American Medical Association’s Principles of Ethics, which are not binding but are considered “essentials of honorable behavior,” do not mandate emergency response service, although they do suggest that physicians “shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”10
Perhaps Emerson’s views are no longer relevant in contemporary society and concepts of a physician’s “duty” need to be evaluated critically. Research is urgently needed so that we may clearly understand how individual medical providers decide to commit precious off-duty time in their community and how best to support and sustain their efforts. In the meantime, medical disaster planners need to take into account what little is known thus far and look for creative ways to identify, motivate, train, and integrate those people who are most likely to respond. As this special issue of the Southern Medical Journal shows, we can learn from past events so that we can more realistically prepare for future disasters. In most cases, effective disaster response will depend on the willingness of dedicated, trained medical personnel to sacrifice their time and efforts before and during an emergency. It still may be that grandeur is nigh, but we also should remember the caution Emerson included in that same poem (apologies for its gender specificity)1:
In an age of fops and toys,
Wanting wisdom, void of right,
Who shall nerve heroic boys
To hazard all in Freedom’s fight—
Break sharply off their jolly games,
Forsake their comrades gay
And quit proud homes and youthful dames
For famine, toil and fray?
1. Emerson RW. The Complete Works of Ralph Waldo Emerson: Poems. New York, Houghton Mifflin, 1904.
2. Grande D, Armstrong K. Community volunteerism of US physicians. J Gen Intern Med 2008; 23: 1987–1991.
4. Isaacs S, Jellinek P. Is there a (volunteer) doctor in the house? Free clinics and volunteer physician referral networks in the United States. Health Aff (Millwood) 2007; 26: 871–876.
5. Romano M. Looking for volunteers. With the number of uninsured on the rise, the proportion of physicians willing to provide free care is on the decline. Mod Healthc 2006; 36: 6–7,16,1.
6. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff (Millwood) 2003; 22: 189–197.
7. Erikson K. A New Species of Trouble: The Human Experience of Modern Disasters. New York, WW Norton, 1995.
8. Schultz CH, Stratton SJ. Improving hospital surge capacity: a new concept for emergency credentialing of volunteers. Ann Emerg Med 2007; 49: 602–609.
9. DeSimone CL, Response of public health workers to various emergencies. AOHN J 2009; 57: 17–23.